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A Unified Theory for Physical Therapy and the Treatment of Pain

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  • #46
    Originally posted by EricM View Post
    The scientific community must be paying attention to your thread Cory. I found this abstract today. Does unconventional medicine work through conventional modes of action?

    eric
    :thumbs_up

    Here is the full text.
    Last edited by bernard; 22-09-2006, 04:20 PM. Reason: Added link to Sound Of Silence
    sigpic Kay'1
    "Ce qu'il y a de meilleurs dans les religions, ce sont leurs hérétiques" Nietzsche

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    • #47
      Hi Gil,

      So sorry about the Packers.

      Now that I’ve got that out of the way, after I read your post I opened Richard Brodie’s classic Virus Of The Mind – The New Science of he Meme and found this passage: “ According to the new paradigm of memetics, the mind works as a combination of instinct and memetic programming…A cultural institution that programs people with self-serving memes is a virus of the mind. That doesn’t necessarily mean it’s a bad thing, but if I were you I’d want to know what mind viruses were competing for use of my life so I could at least pick and choose among them, if not invent my own…It’s possible to consciously choose your own memetic programming to better serve whatever purpose you choose, upon reflection, to have for your life.”

      The words “upon reflection” struck me, and I think they directly connect to the dilemma we all face along with our patients. It seems to me that it’s our job to help people reflect upon their problem and the naturally occurring biologic resolution rather than the culturally imposed “rightness” of some other behavior.

      I tell my patients that the culture is out to control them and sell them stuff and, upon reflection, they typically agree. This agreement grows the more they think about it. Once that meme is in place getting them to behave "counter-culturally" isn't that hard.
      Last edited by Barrett Dorko; 22-09-2006, 01:50 AM.
      Barrett L. Dorko

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      • #48
        What happens when the biologically appropriate response does not feel appropriate? Surely this would have a negative influence on the process. This is a real tough situation that I see regularly. What do we do?
        Barrett's answer was in the context I believe you were aiming for, Gil. I would like to approach it in another way though, working through some other issues that will bring us into that context more fully.

        If a biologically appropriate response, or movement, is carried out in a context that remains threatening (perhaps by a physical therapist, like the one that hurt my mom, and is standing next to that scary looking machine) then this would have a negative influence on the process and I don't think it would be likely to meet the need state.

        We must intervene in ways that decrease the threat value. We must provide stimuli that are not associated with the threat. Nari's example is a great example of one way in which this can be accomplished in the scary PT problem. Don't fulfill their worries. Gain their trust that you won't harm them.

        Thinking in terms of the discussion thus far, we must create new somatic markers with non-threatening associations, and integrate them with the previously threatening stimuli. I imagine this happening in a successful way in PT interventions through the 1) environment we create, 2) novel stimuli, and 3) graded exposure.
        Cory Blickenstaff, PT, OCS

        Pain Science and Sensibility Podcast
        Leaps and Bounds Blog
        My youtube channel

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        • #49
          The environment we create:

          Think about all of the associations that could possibly be working against us for a threat. The layout of our clinic, the colors of the room, the temperature of the room, the tone of our voice, whether we are male or female, our reputation, their social situation.

          Robert Saposky writes in Why Zebras Don't Get Ulcers on p. 403:

          More predictive information about impending stressors can be very stress-reducing.
          Too much of a sense of control can be crippling, whether the sense is accurate or not.
          He says this in the context of saying a sense of control is a good thing, but not when it is to the degree that the person feels at fault. Sapolsky's book is all about the stress response and its chronic and acute effects. These are from the end of the book when he is giving advice based on the evidence of how to reduce the stress response.

          The take away message for me here is that the stress response (which will always be present with a threat and is synonymous with a sympathetic state) can be reduced through education. The ways in which we present ourselves, our clinics, our approach, what our intervention is about, what is pain, even our cleanliness is allowing the patient to re-evaluate their environment, how much control they have in what will be done to them, and allowing them to predict what the outcome will be.

          The bad news here is that some things we just can't change about their environment which might explain why often we fail. We can't change the fact that they have 15 cats, 8 kids, 3 jobs, and are going through a divorce. Although, we can point them in the direction of a professional who can help them cope. Hopefully, if you have a patient who is threatened by males, there is a female co-worker or colleague that can be pulled in.
          Cory Blickenstaff, PT, OCS

          Pain Science and Sensibility Podcast
          Leaps and Bounds Blog
          My youtube channel

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          • #50
            Novel Stimuli:

            By novel stimuli, I mean a stimulus that is not currently associated with the threat. This could include a movement, an external input through touch, a new functional context, etc.

            Thinking in terms of the somatic marker again, a novel stimulus would allow for an input to be processed and percieved, determined to be threatening or not, and then associated with whatever else is avaible to create context.

            Once a novel input is percieved as non-threatening, the association/context making hippocampus can be used to our advantage. Previously threatening contexts can be processed with the novel input that has been deamed non-threatening. This combined input is then processed and percieved and, if sufficiently associated with the non-threatening aspects, can become non-threatening itself. A previously threatening input now is non-threatening in whatever context was used.

            Think about some of the potential novel stimuli that are provided by the myriad of manual therapy techniques that provide proprioceptive, stretch, pressure, vibration, temperature input. We'll actually talk about this again in the outside-in neuromodulation discussion when we talk about peripheral neural sensitivity.

            It would be interesting, in a discussion of better practice (instead of best practice, which implies perfection and is therefore unachievable), to discuss the relative benefits of many types of novel stimuli in comparison. I'll leave that to another discussion on another day.
            Cory Blickenstaff, PT, OCS

            Pain Science and Sensibility Podcast
            Leaps and Bounds Blog
            My youtube channel

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            • #51
              Graded Exposure:

              As novel inputs generate non-threatening contexts for previously threatening stimuli, they must be associated with progressively more difficult scenarios. This process must be graded. If too big of a jump is made, the existing associations won't be able to recognize enough similarities, and the new input will not be deemed similar to the non-threat.

              In this manner, progress is made in duration, intensity, frequency, amplitude, and eventually generalizability of the stimulus.

              These terms should be pretty familiar to all therapists. It is reminiscent of the progression ladders we were taught in school and in pretty much all continueing education classes, and may represent, in part, why sometimes people get better with the strength and conditioning approach. It does provide graded exposure. However, I think more often the gains seen in that style are more due to habituation, which we will discuss in the outside-in section. I would love to speculate on what would be better practice graded exposure, but my goal is to provide a model of explaining why the things we do work, not what is better.
              Cory Blickenstaff, PT, OCS

              Pain Science and Sensibility Podcast
              Leaps and Bounds Blog
              My youtube channel

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              • #52
                One example of a novel stimulus is explaining pain - their pain perception, as far as we can interpret it by being with them. For them, it is novel to have this information, relevant to their current state.

                Nari

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                • #53
                  Yes, Barrett did answer my question and very well at that. Adopting a counter-cultural perspective is not difficult for me, but I do wonder about others. I hope you're right Barrett.
                  A reflection on Cory's dress code comment may be interesting here. About three years ago the dress code where I worked was changed to include only shirts (usually Polo) with the corporate logo. I refused to wear them and was transferred to a facility within the system where the policy did not apply. Thank God. It is easy to see why leadership went with the policy however. They want us to look like trainers because that is what they think we are. I wish I had Cory's comments to offer at the time. Maybe then they wouldn't see me as radical.
                  Gil
                  Last edited by Gil Haight; 22-09-2006, 04:03 PM.

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                  • #54
                    Nari,

                    Brilliant. I have forgotten (if I'd ever before considered it) that my very words and the way they are imparted are novel for the patient. Rarely a day passes when I don't ask a few patients odd questions they never expected - probing them for their general knowledge regarding something so that I can decide how best to write about it or use it for some strategy as I teach. Often it has no evident relation to their painful issues, or at least it doesn't seem so. Now I can see that this questioning is probably therapeutic in its own way - and in a way neuroscience can explain.

                    Almost without exception people are drawn to this and appreciate my asking their opinion or testing their knowledge. Not always, of course.

                    In the end, they have been stimulated in a variety of novel ways that they find non-threatening. I hope.
                    Barrett L. Dorko

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                    • #55
                      Hi Cory,
                      Thanks for all the time and thought you put into this thread!
                      I've been thinking about graded exposure and its role in decreasing our patients' fears, be they fear of the physical--more pain--"You're making me hurt" (even though I may be quite clear that they are doing the moving) or fear of some other monster, like reflection (or, as Barrett put it in his beautiful essay reflecting on 9/11, "internal conversation"). My most difficult patients seem to be ones with the most fear, and it remains a challenge and certainly a learning experience for me, to discover ways to grade their exposure, whether to movement or to an idea, in such a way that their fear is turned down enough for learning to occur.
                      Thanks again, Cory.
                      Cheryl

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                      • #56
                        Hi Cheryl,
                        You are very welcome. It actually feels quite a relief to get some of these thoughts out into words. So, thank you for reading.

                        Some thoughts on your comments about fear and the difficulty with proceeding with graded exposure. I want to bring back the quote from an earlier post from LeDoux:

                        during a traumatic learning situation, conscious memories are laid down by a system involving the hippocampus and related cortical areas, and uncounscious memories established by fear conditionaing mechanisms operating through an amygdala-based system. These two systems operate in parallel and store different kinds of informatinon relevant to the experience. And when stimuli that were present during the inital trauma are later encountered, each system can potentially retrieve its memories. In the case of the amygdala system, retrieval results in expression of bodily responses that prepare for danger, and in the case of the hippocampal system, conscious remembrances occur.
                        The hippocampus and the amygdala work very closely together and the amygdala's role in fear is profound, central even. The Emotional Brain is mostly about LeDoux's work on the amygdala and fear conditioning.

                        Your post will give me a great segway into section 2, explanatory mechanisms/placebo. I've one more topic I want to cover in this section, but for those interested in a bit of a preview try googling "learned helplessness" and "Martin Seligman."

                        Nari,
                        Yours gives me a great segway as well into the next section. When we educate about pain, we are not only providing a novel stimulus, we are creating an environment that is non-threatening. However, we are also diminishing ambiguity. In the next section I'll go on to talk about how our brains attempt to solve ambiguity and do so through explanations. The more we fill in the gaps with factual knowledge, the less ambiguity there is to explain away, and the more accurate our explanations become. Stay tuned.
                        Last edited by BB; 22-09-2006, 08:41 PM.
                        Cory Blickenstaff, PT, OCS

                        Pain Science and Sensibility Podcast
                        Leaps and Bounds Blog
                        My youtube channel

                        Comment


                        • #57
                          One more thought on graded exposure: Maybe this is the way to go about educating other health professionals about Simple Contact (which is the point of a unified theory, huh?).
                          Cheryl

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                          • #58
                            Another quick thought - it is far more difficult to educate other health professionals (qv PTs) than it is to educate patients on SC.

                            I have tried graded exposure with PTs and it hasn't worked...but that is probably me and my impatience with the brick wall which is virtually impervious to learning...

                            Perhaps the 'clean slate' concept vs the 'established meme' slate is the reason...

                            Nari

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                            • #59
                              What, if any, universal truths do the various philosophies of care, including Simple Contact, share?
                              Cheryl,
                              You posed this question in another thread recently, and it is basically what got me motivated to go ahead and start posting.

                              If we can unify, we can reduce ambiguity. If we can reduce ambiguity, we can have more accurate explanations. If we have more accurate explanations, we can provide better care.

                              A goal of this unified theory, is to give a satisfatory answer to your question. My hope is that we can provide a satisfactory answer upon which all educators and clinicians should be held accountable for their explanations. For those educators who are already holding themselves accountable, hopefully a unification will provide a bridge upon which graded exposure can progress in our profession.
                              Cory Blickenstaff, PT, OCS

                              Pain Science and Sensibility Podcast
                              Leaps and Bounds Blog
                              My youtube channel

                              Comment


                              • #60
                                I'm reading through "Bypassing the Will" by John Bargh from New York University while reviewing some info for the last topic.

                                I came across this passage on p. 11:

                                The brain structure that has emerged as the primary locus of automatic, nonconsciously controlled motor programs is the cerebellum, and specifically the neocerebellum (Thach, 1996). With frequent and consistent experience of the same behaviors in the same environmental context, this brain structure links the representations of those specific behavioral contexts with the relevant premotor, lower level movement generators. In this way complex behavior can be mapped onto specific environmental features and contexts and so be guided automatically by informational input by the environment (i.e., bypassing the need for conscious control and guidance). Critically, cerebellar output extends even to the main planning area of the brain, the prefrontal cortex, providing a plausible neurological basis for the operation of automatic, nonconscious action plans (e.g., Bargh & Gollwitzer, 1994). As Thach (1996) concludes from his review of research on the role and function of the cerebellum, “[it] may be involved in combining these cellular elements, so that, through practice, an experiential context can automatically evoke an action plan” (p. 428).
                                The neural basis of compulsion spelled right out, and since we talked about that a bit earlier, I thought it was worth bringing here. More evidence about how context driven we are as well. More will be coming from John Baugh.....
                                Last edited by BB; 24-09-2006, 07:19 AM.
                                Cory Blickenstaff, PT, OCS

                                Pain Science and Sensibility Podcast
                                Leaps and Bounds Blog
                                My youtube channel

                                Comment

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