A Unified Theory for Physical Therapy and the Treatment of Pain

[BB]

We've established that Patrick Wall's research indicates an appropriate motor response needs to be fulfilled to resolve pain. We've discussed what an appropriate motor response consists of.

We've considered that the motor response depends upon the context.

In order for the appropriate motor response to be expressed, the appropriate context must be present.


At this point it is helpful to review our general statement:

Those treatments which satisfy the needed action sequence in the context of resolving pain, which is synonymous with eliminating threat, will be successful.

Ways in which the threatening contexts are reduced were presented. Now, we need to talk about the actual expression of the motor plan.

It is time to discuss ideomotion.

From an earlier post:

The carrying out of a non-conscious motor plan, such as we have been describing, is called ideomotion. Wall calls it "overt motor movements."

First, let me provide a very clear cut instance of ideomotion. Experiments have been carried out on people with parietal lobe lesions. This lesion does not allow a person to percieve an object in their visual field. The problem is not with the eyes, so they can make a neural map of the object, but they cannot process it. Therefore, they do not percieve the object. If you hold up an apple in front of them and ask what or where it is, they won't know. But an interesting thing happens: p12 "Bypassing the Will":

those with lesions in the ventral-visual system could not recognize or identify the item but were nonetheless able to reach for it correctly when asked in a casual manner to take it from the experimenter.

In their mind, they thought they were just guessing. But they guessed accurately. They were able to carry out a motor plan correctly but could not percieve it. Ideomotion...non-consious movement.

You might now say, "Well that's great, but a normal person could percieve the apple, and the motion would therefore be concious."

That seems logical, but the truth may surprise you: p. 14-15

A person cannot possibly think about and be consciously aware of all of the individual muscle actions in compound and sequential movements – there are too many of them and they are too fast (see, e.g., Thach, 1996). They therefore can occur only through some process that is automatic and subconscious. Empirical support for this conclusion comes from a recent study by Fourneret and Jeannerod (1998). Participants attempted to trace a line displayed on a computer monitor, but with their drawing hand hidden from them by a mirror. Thus they were not able to see how their hand actually moved in order to reproduce the drawing; they had to refer to a graphical representation of that movement on a computer monitor in front of them. However, unknown to the participants, substantial bias had been programmed into the translation of their actual movement onto that which was displayed on the screen, so that the displayed line did not actually move in the same direction as had their drawing hand. Despite this, all participants felt and reported great confidence that their hand had indeed moved in the direction shown on the screen. This could only have occurred if normal participants have little or no direct conscious access to their actual hand movements.

So, it turns out that the movements we think we have conscious control of, are actually ideomotion.

From p. 13:

Jeannerod (in press) has similarly argued that there exist two different representations of the same object, one “pragmatic” and the other “semantic”. The former are actional, used for interacting with the object; the latter are for knowing about and identifying the object.

Throughout this article, Bargh shows that the motor plans are determined by context. What we see, for example, creates a motor plan (remember that you can only sense those things to which you can make a motor plan). If we had no consciousness we would be very impulsive. Bargh describes a patient who had a brain lesion in which every environmental stimuli caused the corresponding output of the motor plan. If he saw a bed in someone else's house, he would get naked and go to sleep in it. He did not possess the inhibitory ability of consiousness.

Remember that we discussed the core self as it compares to the autobiographical self, which supplies context based on past experience. This patient did not have access to the autobiographical self which would have supplied the contextual clues that it is inappropriate to climb into someone else's bed that way. We are not consiously changing the motor plan, the inhibitory context used a different motor plan, the carrying out of which was still ideomotion.

That is an example of a useful inhibitory context provided by the autobiographical self. For those in pain however, it is this inhibition of the expression of the appropriate motor response through ideomotion that frustrates the progression through the action sequence.

So the mystery behind ideomotion is not how to elicit it, it is how to allow ideomotor expression within the correct context.

Next generality: those interventions which allow the ideomotor expression of the appropriate motor response will be successful

I'm not sure I've made my point clearly here, so please bring the comments.

[Barrett Dorko]

Cory,

This thread seems too good to be true, and I mean that in several different ways. I’ll let the collective minds here figure out the ways.

When you speak of “context” I’m reminded of how I often say that “ideomotion will emerge from the patient when the therapist creates a culture (read context) between their hands that permits it.” To me this is clear and obvious but I know it’s often not to others. Therapists insist on knowing why touch elicits such an unexpected and often odd movement and that’s understandable.

I tell them, “It isn’t your touch that elicits the motion, it’s the patient’s unconscious that does that. What your touch does is assist them in becoming aware of that inclination and then the movement itself. Your way of being present is what creates the context (the culture) within which the movement is expressed. If you know what modern neuroscience has discovered (a BIG if), this movement and the consequent pain relief reported by the patient won’t surprise you. Not being surprised, you won’t react to it like Dracula to the Cross nor will you explain it in a magical and absurd manner. The theories proposed by those who sell myofascial release or craniosacral therapy are precisely what I’m speaking of, and my distain for them has its origins in the willful ignorance that forms their basis.”

“Ultimately it is the therapist’s way of being that determines how the patient will react to touch, and that way of being is a consequence of their knowledge. Far too often accurate and up-to-date information regarding how humans actually exist and function is unknown to the therapist. I think that this is common, tragic and reversible all at once.”

Nari,

I agree that patients are easier than therapists to instruct regarding the theory and practice of Simple Contact. It’s a matter of memetics and the powerful effect of the memes that are already present in the minds of others. After all, patients aren’t usually possessed by a “mesodermal monster” nearly to the extent that our colleagues are.

I always carry a picture of Homer Simpson with me, his arms crossed and staring glumly ahead. The caption reads, “Every time I learn something new, it pushes some old stuff out of my brain!” Of course Homer wouldn’t know it, but this is often a good thing.

[Diane]

Hi Cory,
I love how your agile mind is pulling together all these lines of thought into a big braid.
Two things came to mind.
1. Work with "blind sight" in monkeys, and (I think) Ramachandran's work with a blind woman, to whom he threw a ball and she instinctively caught it; even though she had no conscious sight, some part of her brain was still catching visual information and moving her to protect her.
2. I made posts on RE and in my blog, yesterday, about something I call "cognitive hemi-neglect," which I think the whole profession has habituated to, currently thinks it's normal to only investigate one side of a picture, the mesodermal side.

Keep going, I'm getting so much from this amazing thread.

[EricM]

Cory you should be collecting royalties everytime someone reads this. It's fantastic.

Barrett, in Not In Kansas Anymore, re-introduced me to the children's tale The Wonderful Wizard of Oz, and the parallels between it and aspects of the therapy community. Cory and Barrett's last posts reminded me of this for some reason and in particular of this quote from Chapter 16 The Magic Art of the Great Humbug.

Oz, left to himself, smiled to think of his success in giving the Scarecrow and the Tin Woodman and the Lion exactly what they thought they wanted. "How can I help being a humbug," he said, "when all these people make me do things that everybody knows can't be done? It was easy to make the Scarecrow and the Lion and the Woodman happy, because they imagined I could do anything. But it will take more than imagination to carry Dorothy back to Kansas, and I'm sure I don't know how it can be done."

The wizard came close in assigning his success with the scarecrow, lion and woodsman to their imaginations. Had he read this thread he'd understand that it was actually their non-conscious 'imagination.'

There's also a lesson to be learned when the Wizard admits his inability to help Dorothy.

I am ashamed to say that I cannot keep my promises."
"I think you are a very bad man," said Dorothy.
"Oh, no, my dear; I'm really a very good man, but I'm a very bad Wizard, I must admit."

Cory your thread has the potential to make great wizards out of all of us or expose the wizards out there for what they are, humbugs. It will depend on whether one is hiding behind a giant head or not.

Eric

[Gil Haight]

Cory,
I would like to describe the following anecdote in hopes that it supports your discussion. A Pt. Dx. with fibromyalgia told me that she struggles with her condition because her pain is so different or complicated. After surgery for a bunion and with a cholecysectomy she did not experience a lot of pain and in fact did not require typical levels of postoperative medication. This is a woman who has been on a fentanyl patch for years. Her postoperative pain made perfect sense (appropriate context) to her and she therefore allowed the appropriate neurological response (non-conscious) to occur. Her fibro pain of course does not have a context from which to ease into and she therefore assumes one needs to be identified or discovered. The protracted process of insisting that an appropriate dx or context be identified has actually become the impediment to allowing any chance of an instinctual response to emerge.
Gil

[Barrett Dorko]

Gil,

As I read your last post Joseph Heller's classic novel Catch-22 came to mind. Described as a "no-win, no-win" situation, many of our patients find themselves there when they are waiting for somebody to tell them "exactly what's wrong."

Education about the origins of pain and some consideration for the physiologic markers of the tissues possibly responsible for the complaint would help, but I don't see that kind of thinking emerging from the medical or therapeutic professions any time soon.

In fact, as Eric and Chris can tell you, therapists who do this sort of thing are literally punished for it. I know you have been, as have I. We need to make this as large a club as possible, and we need to have somebody important join us. So far, that person hasn't arrived here.

[christophb]

I just started a new job and I am going through extensive training (and I mean over the top training) on documentation and all that mumbo jumbo so we can dance like monkey's for our insurance masters. The comment was made to minimize the use of pain in documentation as the only important variable was function and tissue dysfunction. I remarked that it seemed like that reflects a poor understanding of the mechanisms of pain... after the blank stare I received, training resumed. Yeah, the medical and therapeutic culture it seems is a ways off it from being able to effortlessly slide between the concepts of pain and dysfunction. And in order to stay employed in most places you have to approach things from a "mesodermal" tissue/joint perspective. It was actually one of the conditions for my hiring. So, I am now a simple contact, ectodermal, neuro-ninja.

Chris

[Diane]

in order to stay employed in most places you have to approach things from a "mesodermal" tissue/joint perspective. It was actually one of the conditions for my hiring. So, I am now a simple contact, ectodermal, neuro-ninja.

And subversive as well, I hope! Maybe we should start a group. The (ectodermal) PTs, united, will never be defeated.

[BB]

Before moving on to section 2, I want to bring together the general statement so far:

Those treatments which satisfy the needed action sequence, which is the ideomotor expression of the appropriate motor response, in the context of resolving pain, which is synonymous with eliminating threat, will be successful.

It is not a great sentence for readability, but is descriptive of what we've talked about so far.

OK, on to section 2!

[BB]

Section 2: explanations and the placebo response

I want to start section 2 by talking about a peculiar habit of our minds. Our minds don't like ambiguity. It seems that it must have a context from which to work, and therefore will always assign a context.

Let me give a few examples to clarify what I mean.

First let me use Ramachandran.

In the book, A Brief Tour of Human Consciousness by Ramachandran he talks about face blindness. It is a condition in which a person will, when they see their mother for example, recognize that the person in front of them looks exactly like, sounds exactly like, dresses exactly like their mother, however will say that it must be an imposter. It is a condition in which a person loses the ability to use emotion to mark context (I don't feel like I do when I see my mother).

(I couldn't find my Brief Tour of Human Consciousness book tonight, so this is from memory. Anyone who has the book and finds this passage feel free to post it. I'll do the same when I find mine.)

Next, an example from LeDoux's The Emotional Brain from work with split brain patients. These folks cerebral hemispheres had their connections cut. From p. 32:

It was well known from earlier work by Gazzaniga and others that information presented exclusively to one hemisphere of a split-brain patient is unavailale to the other. We capitalized on this as a model of how consciousness deals with information generated by an uncouscious mental system. In other words, we secretly instructed the right hemisphere to perform some response. The left hemisphere observed the response but did not know why the response was performed. We then asked the patient why he did what he did. Since only the left hemisphere could talk, the verbal output reflected that hemishphere's understanding of the situation . Time after time, the left hemisphere made up explanations as if it knew why the reponse was performed. For example, if we instructed the right hemisphere to wave, the patient would wave. When we asked him why he was waving, he said he thought he saw someone he knew. When we instructed the right hemisphere to laugh, he told us that we were funny guys.

What these two examples show, is that our concious minds needs to have an explanation to build context for our behaviour when it is conscious of that behaviour.

LeDoux says it well on p. 33

We concluded people normally do all sorts of things for reasons they are not consciously aware of (because the behavior is produced by brain systems that operate unconsciously) and that one of the main jobs of consciousness is to keep our life tied together into a coherent story, a self-concept. It does this by generating explanations of behavior on the basis of our self-image, memories of the past, expectations of the future, the present social situation, and the physical environment in which the behavior is produced.

Our explanations allow the coherence of our lives in our consciousness. And if we don't have information regarding our behavior we will make it up.

Warning: soap box moment ahead.

The "Why?" is absolutely important, and those who argue that "who cares why, as long as it works" will always raise my sympathetic response. The patients we work with are going to come up with a "why" of their own, because they have to if they are conscious, and they therefore deserve to be informed.

[Barrett Dorko]

Cory,

Your post brought a few things to mind. I was reminded of what I often say about the relative thinness of my course manual when compared to the amount of writing I’ve otherwise done. I say, “This isn’t a how-to book, it’s a why-to book.” This is an idea I took directly from Charles Hayes, and I give him credit for it.

I was also inspired to search out my copy of Captured by Aliens by Joel Achenbach. This is an amazing exploration of our search for additional biology in space. So far, nothin’. Still, the desire; the longing for this might be seen as the desperate creation of an artificial context. If we create a story that satisfies and/or explains our sensation, then the story - true or not, defendable or not – becomes more important than anything else.

The meaning-making mechanisms of our brain can’t be turned off, and without something we can understand to give our clinical experience some meaning or sense we will either believe that for which there is little or no evidence or make something up.

This accounts for so many of the myths that continue to drive and perpetuate mesodermal practice even in the absence of reason or success. These guys simply have a better story – a more compelling context – than we ectodermalists do. Yet, anyway.

Maybe this thread will eventually lead us to creating a better story. One therapists find irresistible.

Now, that would be something.

[Diane]

In Robert Sapolsky's book, The Trouble with Testosterone, he examines many social human behaviors he finds perplexing in a series of essays. (Full points for not allowing his own testosterone to soak his brain too much, but onward..)

In the last essay in the book he discusses the direct one-to-one ratio between OCD and extreme religiosity/ritual behavior, found across a wide spectrum of humanity and differing faith groups. It seems the more a religion is 'rule bound', the more numerology tends to play a role, i.e., the more ritual practices need to be "counted" to count, the more stereotypical the movements become - as a rule, the more likely an individual with OCD is behind the structure, one who found a rewarding, permanent, status-elevated role to play in a group.

The whole essay is fascinating and I highly recommend it, but I wanted to just mention it because of how it seems to me that mild forms of OCD might have found a home in PT; those with a fair bit of it, developing "systems" to try to control existance (the gurus), those who need outside reassurance needing to "buy" it from the developers, everyone feeling slightly better about themselves, for a little while at least, until along comes the inevitable patients who demonstrate to you that the system you bought isn't fool proof.

Maybe OCD is something we all have in varying amounts and must deal with as best we can, some more than others, tending to be worse when young, and best outgrown.

[christophb]

I have just returned from a mesodermal in-service and I could not help but think of how detailed the mesodermal theory is, vs. how deep it is. There was a lot of how and little of why. Also a lot of body snobbery IMHO. But, I came away from it not irritated but satisfied at my little improvement in critical thinking in seeing through some of the beliefs we as a profession have acquired. Not all of the information was bad, but no satisfying deep model. I see the potential for future deconstruction threads...

Chris

P.S. this could have gone in the "fear of being unskilled" thread as well

[BB]

It seems we all have certain explanatory styles. OCDers ending up being drawn to a profession such as ours where such a style fits with the popular systems would make sense to me.

I'll actually write next a bit about explanatory styles, but I think first returning to ideomotion and and explanations is important.

In Bypassing the Will, Bargh describes a second experiment involving reaching for an object (p 12).

those with lesions in the parietal lobe region could identify an object but not reach for it correctly based on its spatial orientation (such as a book in a horizontal versus vertical position)

Further on (p 13):

Decety and Grèzes (1999) and Norman (2002) concluded from this and related evidence that there are two separate cortical visual pathways activated during the perception of human movement: a dorsal one for action tendencies based on that information, and a ventral one used for understanding and recognition of it. The dorsal system operates mainly outside of conscious awareness, while the workings of the ventral system are normally accessible to consciousness. Jeannerod (in press) has similarly argued that there exist two different representations of the same object, one “pragmatic” and the other “semantic”. The former are actional, used for interacting with the object; the latter are for knowing about and identifying the object.

Our actions and our explanations for them do not arise in the same place, and accounts for the differences between our behaviour and the explanations we provide of them.

This becomes very important clinically for us. Think about the person needing to move to resolve their pain, but they are explaining their pain to themselves by thinking something is damaged (hurt equals harm). Since this is their explanation, they are afraid to move, so they don't and the threat remains unresolved.

The corrective pattern needs to be expressed, but the explanation provides an expectation of pain and damage with movement. Therefore the corrective ideomotion is inhibited, and a protective ideomotion is expressed. We could think of endless examples of this.

When we provide a means for the explanation to be congruent with the needed behavior, it will not be inhibited. The expectation based on the explanation will be that the movement is needed for resolution.

[Diane]

I can't recall how this paper on individuation ended up on my desktop, but I found it, took a look, and I think parts of it pertain to this thread. The first ten pages are a bit of review of Jung and a bit of a yawn, but things start to get good after that. It discusses contributions from all the researchers already mentioned earlier in the thread, and discusses "selves".. much in here that's quotable; one of my favorites (roughly): "The self is a circle with a center that is everywhere and a circumference that is nowhere." (Jung)