SomaSimple Discussion Lists  

Go Back   SomaSimple Discussion Lists > Physiotherapy / Physical Therapy / Manual Therapy / Bodywork > Barrett's Forums
Albums Quiz PubMed Gray's Anatomy Tags Online Journals Statistics

Notices

Barrett's Forums This discussion is devoted to the latest advances in neuroscience and the clinical phenomena it explains.

Reply
 
Thread Tools Display Modes
Old 14-10-2011, 02:26 AM   #1
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default A simple case

Consider the legs pictured below. What questions would you like answered? How would you ask them? What would you do and why?

More pictures to come.
Attached Images
File Type: jpg Feet 001.jpg (1.62 MB, 118 views)
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 03:31 AM   #2
byronselorme
Senior Member
 
byronselorme's Avatar
 
Join Date: Jan 2011
Location: Hamilton, Ontario
Age: 41
Posts: 1,691
Thanks: 1,325
Thanked 443 Times in 242 Posts
Default

I really just like to jump in so my first question is why is he so close to the edge of the bed? It looks as though he is about to fall off.

Is he supposed to get some kind of feedback from the laptop?

I know this is a very rudementary bit but like I said I like contributing.
__________________
Byron Selorme -SomaSimpleton and Science Based Yoga Educator
Shavasana Yoga Center

"The first principle is that you must not fool yourself - and you are the easiest person to fool" Richard Feynman
byronselorme is offline   Reply With Quote
Old 14-10-2011, 03:34 AM   #3
Clark
Senior Member
 
Clark's Avatar
 
Join Date: May 2011
Location: Monroe, WA
Posts: 127
Thanks: 10
Thanked 6 Times in 5 Posts
Default

Are the pillows under the knees providing some sort of relief for LE or back pain? Is the left hip more comfortable in external rotation? (It appears to be situated that way in this picture)
__________________
Lauren Clark

'Tis a poor craftsman who blames his tools.
Clark is offline   Reply With Quote
Old 14-10-2011, 04:30 AM   #4
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

Don't worry about how close to the edge he appears. No one's in danger here.

Forget the computer and the pillow. Clark's onto something.

What does the hip position result in?
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 05:19 AM   #5
keithp
SomaSimpler
 
keithp's Avatar
 
Join Date: Jun 2011
Posts: 1,545
Thanks: 1,381
Thanked 1,591 Times in 578 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
What does the hip position result in?
Postural Restoration says that this patient presents with a typical L anterior interior chain from poor zone of apposition in the L thoracic cage...but I doubt that is what you are looking for...so...I offer you a more serious answer:

ER and Abd of the L hip would reduce neural (sciatic) tension, no?

(Cannot tell clearly if the R hip is in "neutral" or is IR'd b/c of the pillows).

Thanks for this thread.

Respectfully,
Keith
__________________
Blog: Keith's Korner
Twitter: @KeithP_PT
keithp is offline   Reply With Quote
Old 14-10-2011, 05:29 AM   #6
gilbert
Senior Member
 
Join Date: Mar 2008
Posts: 336
Thanks: 154
Thanked 93 Times in 42 Posts
Default

My first question would be, does the patient have a painful problem on the (R) side of the body somewhere? What's causing the observed asymmetry in the lower limb position.
gilbert is offline   Reply With Quote
Old 14-10-2011, 05:57 AM   #7
weni888
Senior Member
 
weni888's Avatar
 
Join Date: Aug 2008
Location: Adelaide, South Australia
Posts: 352
Thanks: 538
Thanked 351 Times in 105 Posts
Default

Well,

1. My first Q: what was this guy's main complaint??
2. It seems to me:
a. R side in neutral (does this guy have any deformity in R tibia??)
b. L side in ER: unload the lateral cutaneous N tension+ in hip sl. F further unloading whole Femoral N tension
3. Barett, di you really think that a pillow did not make any positional change???
And why you put him in this position??

Thank you,

Weni
weni888 is offline   Reply With Quote
Old 14-10-2011, 10:30 AM   #8
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 8,753
Thanks: 2,116
Thanked 643 Times in 459 Posts
Default

Compensatory (L) hip ER for the apparently kinky (R) tibia?
Plus some dodgy neurodynamics.

Nari
nari is offline   Reply With Quote
Old 14-10-2011, 01:01 PM   #9
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

The pillow's there because the patient's knees won't extend fully. It doesn't affect the most important issue: Where do the legs rest when the patient lies supine? This is the position he chose. And my interest is in the hip's affect upon the foot position.

Of course I want to know whether the patient can alter their pain with position or use. Otherwise, how can I determine anything about the origin of their pain?

Forget the tibia. As you can see in the picture below, taken ten minutes later, treatment has already resulted in an alteration of position that couldn't have come from any change there.

How might I have tested him manually prior to employing Simple Contact?

P.S. The picture's blurry because I'm not Ansel Adams
Attached Images
File Type: jpg Feet 003.jpg (1.58 MB, 58 views)
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com

Last edited by Barrett Dorko; 14-10-2011 at 01:06 PM.
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 01:34 PM   #10
Bas Asselbergs
Physiotherapist
 
Bas Asselbergs's Avatar
 
Join Date: Jul 2004
Location: Canada
Age: 62
Posts: 4,679
Thanks: 2,046
Thanked 1,589 Times in 688 Posts
Default

His initial position appears to be tense and protective compared to his post-treatment position - both hips have rotated more externally. Apparent reduction of defense/neural stress.

Pre-treatment manual testing may have been neurodynamic testing of femoral and sciatic complexes (with, for me, a strong suspicion of both left sciatic tension and right femoral tension - but just vissual clues can be deceiving. He may simply be asymmetrical).
__________________
We don't see things as they are, we see things as WE are - Anais Nin
I suppose it's easier to believe something than it is to understand it.
Cmdr. Chris Hadfield on rise of poor / pseudo science

Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

We don't need a body to feel a body. Ronald Melzack
Bas Asselbergs is offline   Reply With Quote
Old 14-10-2011, 01:56 PM   #11
keithp
SomaSimpler
 
keithp's Avatar
 
Join Date: Jun 2011
Posts: 1,545
Thanks: 1,381
Thanked 1,591 Times in 578 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
How might I have tested him manually prior to employing Simple Contact
Quote:
Originally Posted by Bas Asselbergs View Post
Pre-treatment manual testing may have been neurodynamic testing of femoral and sciatic complexes
This is what I was thinking as well.

Quote:
Originally Posted by Bas Asselbergs View Post
with, for me, a strong suspicion of both left sciatic tension and right femoral tension
Before the second pic, I was thinking about how the sciatic n. is sensitized with SLR/Slump testing via IR/Add and that the patient might be displaying defense (rather than defect, as I have read mentioned before) via ER/Abd the L hip to reduce tension. But there appears to be less "defense" in the later pic, and we are to assume that the pics are presented chronologically, right?

If so, even if my thought had been correct (sciatic n. tension) my logic had been poor, or else the patient would NOT have been "guarding" by positioning himself in a position of increased neural tension (IR/Add on the L) in the first pic compared to the second.

Again, thanks for this learning opportunity.

Respectfully,
Keith
__________________
Blog: Keith's Korner
Twitter: @KeithP_PT
keithp is offline   Reply With Quote
Old 14-10-2011, 02:21 PM   #12
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

Personally, I wouldn't do any neurodynamic testing. Heresy, I know.

I would have already determined that use of the right leg increased his pain so the origin is obviously mechanical deformation. At least, the origin I can most readily deal with given what I do for a living.

The obvious choice of internal rotation and adduction of the right hip is something I want to see given the patient's history. It means I have something obvious to treat. I need to help him find a path toward external rotation and abduction. In this position that's where gravity would take him and that's where the left leg can go easily. That, I assume, is why it doesn't hurt.

My test? "Lie on your back. Here's a pillow for your knees." Now I observe - takes about 3 seconds. Then I see how the limbs respond to passive movement toward the position I'd prefer - the one the left leg is already in external rotation.

I don't handle the limb as if I'm trying to start a lawnmower.

Twenty minutes later you see what is depicted below.

How did we get there?
Attached Images
File Type: jpg Feet 009.jpg (1.65 MB, 46 views)
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com

Last edited by Barrett Dorko; 24-02-2013 at 03:49 PM.
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 03:11 PM   #13
Bas Asselbergs
Physiotherapist
 
Bas Asselbergs's Avatar
 
Join Date: Jul 2004
Location: Canada
Age: 62
Posts: 4,679
Thanks: 2,046
Thanked 1,589 Times in 688 Posts
Default

Quote:
Pre-treatment manual testing may have been neurodynamic testing of femoral and sciatic complexes
I did not mean to imply that you actually did. By now, I know that you observe these and appreciate them as effect of mechanical deformation somewhere. It has only been in the past 5 years that I have really started to appreciate this phenomenon of rotated leg positions.

Heresy? In many circles: yes. Not in my eyes.


"start a lawnmower" - I now have that image stuck in my head......Funny (and it should be sad)
__________________
We don't see things as they are, we see things as WE are - Anais Nin
I suppose it's easier to believe something than it is to understand it.
Cmdr. Chris Hadfield on rise of poor / pseudo science

Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

We don't need a body to feel a body. Ronald Melzack
Bas Asselbergs is offline   Reply With Quote
Old 14-10-2011, 03:28 PM   #14
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

Thanks Bas. I appreciate how neurodynamic testing is required to satisfy those who insist upon such things. I don't. and I doubt they're as telling as we hope they'd be. The nervous system is too complex.

Still, I love that they've been invented.

I like that "starting a lawnmower" thing too. Elaine told Kramer that this is the way she intended to "pull the plug" if he ever needed that (Seinfeld).

I tap gently. This tells me what I need to know.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 04:11 PM   #15
keithp
SomaSimpler
 
keithp's Avatar
 
Join Date: Jun 2011
Posts: 1,545
Thanks: 1,381
Thanked 1,591 Times in 578 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
I like that "starting a lawnmower" thing too.
It does resonate...similar to when I (if I remember correctly) you told a student that she wasn't "sweating to the oldies" in one of the "Diamonds" vids.

Quote:
Originally Posted by Barrett Dorko View Post
I tap gently.
I am picturing you gently tapping the foot, to determine how readily/easily the lower limb moves into rotation, but I am uncertain if I am taking from this what you intend.

Quote:
Originally Posted by Barrett Dorko View Post
This tells me what I need to know.
The operator in me is frustrated by this and needs more information than a "tap" will provide. The interactor in me is still learning that all that extra information can just be window dressing, anyway.

Respectfully,
Keith
__________________
Blog: Keith's Korner
Twitter: @KeithP_PT
keithp is offline   Reply With Quote
Old 14-10-2011, 04:24 PM   #16
gary s
SomaSimpler
 
gary s's Avatar
 
Join Date: Dec 2005
Posts: 68
Thanks: 0
Thanked 2 Times in 2 Posts
Default

Barrett,
Not that it's really relevant, but out of curiosity, where on the ocean did the seagull intially land?
__________________
___________________
GARY
" I speak Spanish to God, French to women, English to men, and Japanese to my horse."------Buckaroo Banzai
gary s is offline   Reply With Quote
Old 14-10-2011, 04:57 PM   #17
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

Gary,

Always the enigmatic question. I think the answer would be: On the surface.

Glad to see you here.

Yes, I tap toward external rotation. It's a quiet conversation, not a command.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 04:57 PM   #18
zimney3pt
life long learner, clinician, and instructor
 
zimney3pt's Avatar
 
Join Date: Dec 2009
Location: Sioux City, IA
Age: 44
Posts: 2,160
Thanks: 267
Thanked 1,233 Times in 417 Posts
Default

How long has this individual been having this adverse neural tension?

Did you see or the patient experience any change in knee extension as well after the 20 minutes?
__________________
Kory Zimney, PT, DPT

http://koryzimney.blogspot.com

"Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

"All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei
zimney3pt is offline   Reply With Quote
Old 14-10-2011, 04:59 PM   #19
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

A couple of years as far as I can tell. Enough to prevent his painless walking anyway.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 14-10-2011, 05:16 PM   #20
proud
Senior Member
 
Join Date: Sep 2006
Posts: 1,660
Thanks: 403
Thanked 1,021 Times in 372 Posts
Default

I am really enjoying this thread. Barrett, I have no idea how you help someone towards ER and abduction.

I am interested in finding out.

Thanks for this.
proud is offline   Reply With Quote
Old 14-10-2011, 07:14 PM   #21
byronselorme
Senior Member
 
byronselorme's Avatar
 
Join Date: Jan 2011
Location: Hamilton, Ontario
Age: 41
Posts: 1,691
Thanks: 1,325
Thanked 443 Times in 242 Posts
Default

I agree with Proud.

This is a fascinating thread. Especially having the opportunity to attempt to figure it out. Way out of my leagues but really enjoyable. Is this patient an older gentleman? I just assume so from the shoes.
__________________
Byron Selorme -SomaSimpleton and Science Based Yoga Educator
Shavasana Yoga Center

"The first principle is that you must not fool yourself - and you are the easiest person to fool" Richard Feynman
byronselorme is offline   Reply With Quote
Old 14-10-2011, 07:51 PM   #22
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

It's nice to see how popular this has become.

Several thoughts:

I refer to this as a simple case because the management itself is simple - not the patient. Being human, he's got a lot going on as is common in the settings I frequent. I choose to focus.

Not being a doctor, nurse, OT, speech therapist or social worker, I'm not obligated to "fix" all kinds of things beyond the scope of my practice and my interest tends to flag anyway. All day long I hear other PTs asking questions about issues that are none of their business. I guess they think this means they are "holistic." If they actually knew anything about the neurobiology of pain, well, that would be nice. They don't. They're just nosey.

This, as it turned out, was an educable patient (to me, a much more important factor than age). Not everyone is. It makes a huge difference.

I didn't take this man's leg into the position last seen - I followed him there. To me, the pain is neither a defect or defense - it simply motivates him to change. The change itself is brought about by unconsciously generated processes that are easily palpated and promoted. The muscular activity present is the beginning of movement along the corrective path. The muscular activity (isometric in the main) is a defense and thus it should be amplified. (see this)

Combined with education about the characteristics of correction, metaphors the patient understands and the proper context, this can result in an enduring effect, as any learning might.

Think of this: instinctive movement toward a reduction in neural tension is inherent to life. That doesn't mean it is always obvious, just that it's always present.

Use it.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 15-10-2011, 01:28 AM   #23
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

As you can see below, better still, and this after 1/2 hour of treatment.

What you expect this new posture to provide?
Attached Images
File Type: jpg Feet 011.jpg (24.1 KB, 27 views)
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 15-10-2011, 04:39 AM   #24
zimney3pt
life long learner, clinician, and instructor
 
zimney3pt's Avatar
 
Join Date: Dec 2009
Location: Sioux City, IA
Age: 44
Posts: 2,160
Thanks: 267
Thanked 1,233 Times in 417 Posts
Default

See here.
__________________
Kory Zimney, PT, DPT

http://koryzimney.blogspot.com

"Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

"All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei
zimney3pt is offline   Reply With Quote
Old 15-10-2011, 07:09 AM   #25
Randy Dixon
Senior Member
 
Join Date: May 2006
Posts: 552
Thanks: 5
Thanked 83 Times in 45 Posts
Default

My question is, now that he has external rotation is the pain in his right leg gone?
Randy Dixon is offline   Reply With Quote
Old 15-10-2011, 08:02 AM   #26
weni888
Senior Member
 
weni888's Avatar
 
Join Date: Aug 2008
Location: Adelaide, South Australia
Posts: 352
Thanks: 538
Thanked 351 Times in 105 Posts
Default

This is a really interesting thinking process to me.

So the problem is on the R hip???

" you can see in the picture below, taken ten minutes later, treatment has already resulted in an alteration of position that couldn't have come from any change there."

Barrett, what did you do in this 10 minutes......
Education...Metaphors....relaxing chat.... and putting your hand on certain area all together?? What made you to chose that area to start your simple contact??

as the Rx was done in lying, how you could transfer the effect of Rx into standing and walking? Any particular somatic exercises you would use to before this man got up?

Thank you,

Weni
weni888 is offline   Reply With Quote
Old 15-10-2011, 11:08 AM   #27
rkathryn
Senior Member
 
rkathryn's Avatar
 
Join Date: Jul 2009
Location: San Diego, CA by way of Huntsville, AL
Age: 41
Posts: 288
Thanks: 134
Thanked 161 Times in 62 Posts
Default

That's so funny b/c only a year ago if you'd presented that photo with question, I would have said something about his L hip being tight, maybe even specified the piriformis or somesuch.

Now, looking at the initial photo, I can see the R seems restricted (or protecting) at the hip or thigh somehow. I can't tell you anything more than that.

Your photo has shown me how far I've come and how much more there is to learn all at once.

I would expect the new sensation to provide a better sense of movement for the patient as he walks.
__________________
Rajam K. Roose, HHP

"The danger is not that the soul should doubt whether there is any bread, but that, by a lie, it should persuade itself that it is not hungry" (Simone Weil)
rkathryn is offline   Reply With Quote
Old 15-10-2011, 02:08 PM   #28
Bas Asselbergs
Physiotherapist
 
Bas Asselbergs's Avatar
 
Join Date: Jul 2004
Location: Canada
Age: 62
Posts: 4,679
Thanks: 2,046
Thanked 1,589 Times in 688 Posts
Default

I really like Kory's answer!
Weni, I can not speak for Barrett, but I would suggest that this
Quote:
transfer the effect of Rx into standing and walking?
is something "we" do not do. When the patient goes through the process of experiencing the changes, often if not most always, the changes they perceive during the process translate to their other "postures" .
I am not saying they are done treatment.
They have already taken a big step towards their resolution.

Looking forward to Barrett's answer.
__________________
We don't see things as they are, we see things as WE are - Anais Nin
I suppose it's easier to believe something than it is to understand it.
Cmdr. Chris Hadfield on rise of poor / pseudo science

Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

We don't need a body to feel a body. Ronald Melzack
Bas Asselbergs is offline   Reply With Quote
Old 15-10-2011, 02:16 PM   #29
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

At the end of four sessions in four days this gentleman could bear weight painlessly and take five steps with contact guarding. He told me that he no longer needed the nurse to help him from a supine position.

He was taught to simply draw up the right knee, his foot still in contact with the surface, and repeatedly externally rotate the hip while supine. He understood that he was not trying to stretch or strengthen anything.

I landed many places with my hands, didn't remove any clothing and always discovered more ideomotion waiting for a little help. This included the torso, head and neck. I wasn't treating his hip, I was treating his nervous system. He felt warmer, softer and was often surprised by these sensations as well as the movement evident to both of us.

He appreciated my humor and Nat King Cole from the computer.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com

Last edited by Barrett Dorko; 15-10-2011 at 03:43 PM.
Barrett Dorko is online now   Reply With Quote
The Following 3 Users Say Thank You to Barrett Dorko For This Useful Post:
AdamB (15-05-2012), Matt Arnold (27-02-2012), paradigmshiftfitness (10-03-2013)
Old 15-10-2011, 06:36 PM   #30
John W
"Mean Poopy-Pants" Club Founding Member
 
John W's Avatar
 
Join Date: Sep 2006
Location: Mandeville, LA
Age: 49
Posts: 6,296
Thanks: 1,899
Thanked 3,207 Times in 1,256 Posts
Default

I've got a patient right now with a very similar presentation, but she's only 42 years old, chases a 20-month-old around after she gets home from work, and has been told that she has a "bad disc". She frequently refers to her pain as synonymous with the disc: I lightly palpate over the lumbosacral junction and she replies, "That's my disc."

I could be under-estimating her, but for my patient, some level of "operative stance" is expected, and I'm afraid I'd lose the opportunity to help her if I didn't at least pretend to oblige. So I do. I have her do neural glides and activate her transversus abdominus (did I mention that she's had some plastic surgery to...um...restore her previously nubile female shape?).

Most patients live, to some extent, in a fantasy world, and I have to enter the fantasy in order to bring them back out through the "looking glass" to a place that is more consistent with the reality of being an aging human primate. This is the hardest part of the job. It's commonly and almost flippantly referred to as "patient education". Barrett describes using metaphors, humor, music and education about what correction might feel like. I try to do this without causing more confusion or worse suspicion from the patient, and, perhaps more precariously, alienation from my referral sources.

These acts of therapy, unfortunately, prove all too often fatal to the therapist. But, that has to be weighed against knowing what will happen to the patient if they continue down the biomedical path towards lumbar fusion where patients like this almost invariably end up.

It's just a shame that we have to continuously make these fateful decisions between our ethical duty to patients and our need to make a living.

Thank you very much for this thread, Barrett.
__________________
John Ware, PT
Fellow of the American Academy of Orthopedic Manual Physical Therapists
"Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
“If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
be carried on to success.” -The Analects of Confucius, Book 13, Verse 3
John W is offline   Reply With Quote
The Following User Says Thank You to John W For This Useful Post:
AnitaKB (21-03-2013)
Old 15-10-2011, 07:54 PM   #31
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

I hadn’t thought of this “entering a fantasy land” trope but it brings to mind countless movies for me.

Saving others often requires that the hero or heroine enter into a place that they would ordinarily avoid.

This thought deserves a thread of its own.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 15-10-2011, 09:17 PM   #32
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 23,249
Thanks: 3,351
Thanked 6,577 Times in 2,981 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
I hadn’t thought of this “entering a fantasy land” trope but it brings to mind countless movies for me.

Saving others often requires that the hero or heroine enter into a place that they would ordinarily avoid.

This thought deserves a thread of its own.
Yes. Everyone's/Anyone's mind is terra incognita. You do the best you can, knowing that anything you say has to go through a plethora of interpreters/interpretation. And that anything the person says has to go through yours. It's not a job for sissies.

And who is "saved"? the nervous system of the patient. Also the nerves of the therapist.

Saving the nerves of the therapist is IMO a matter of laying out the rules, clearly, at the start. "I assume you're here to let me help your nervous system get off the square it's been stuck on. Here's what nervous systems usually do, what pain is about, according to pain science: You are part of your own nervous system. You are part of it, not the other way round. It puts you to sleep and wakes you up when it gets hungry, or thirsty, or bored, it keeps your heart beating and your lungs breathing and makes you roll over at night without waking you up, under normal circumstances. It's not perfect - it's a story through time and isn't a finished project yet, by any means. It has ancient parts that have no problem taking over if they see fit, and will make you feel pain if they feel threatened. They can hijack your movement system. Treatment is not about fixing defects in your meat, it's more about helping your nervous system change its attempts at solving its own glitch. It's an operating system, very high maintenance, only 2% of your body but sucking up 20% of all your available resources; what it needs most in the world is food and oxygen (just like the rest of us). If we give it what it needs, it can then learn to stop giving you noxious input when you try to move. And you will have the reins back over your own movement. Here's what my mental map is. Here's how I plan to get from A to B: (blah-blah treatment approach). Do you agree?

That way I can bypass all their "beliefs" about what "treatment" could or should be. They have a choice. Leave and go to someone who'll ultrasound them or traction them or inject them or reiki them or whatever them. Or give this a try.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 16-10-2011 at 04:56 AM. Reason: spelling
Diane is offline   Reply With Quote
The Following 3 Users Say Thank You to Diane For This Useful Post:
AnitaKB (22-03-2013), mojohnson (16-03-2014), willowsofsaturn (14-05-2013)
Old 16-10-2011, 01:36 AM   #33
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,024
Thanks: 5
Thanked 59 Times in 45 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
I tap gently. This tells me what I need to know.
Barrett,

It's been awhile since I've been to one of your courses but I don't remember observing any tapping or you discussing it in course material. Is the tapping a new addition since Naniamo?
Jon Newman is offline   Reply With Quote
Old 16-10-2011, 04:13 AM   #34
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

I'm not sure. These things just show up eventually. They seem natural enough and I forget that I'm doing it. Hopefully, I start to teach it.

Naniamo was a long, long time ago.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 16-10-2011, 04:49 AM   #35
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,024
Thanks: 5
Thanked 59 Times in 45 Posts
Default

Yes it was. I can still remember how that weekend used to make me smile.

It's good to hear there are updates.
Jon Newman is offline   Reply With Quote
Old 18-10-2011, 03:49 PM   #36
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

Below you can see how this patient began his fifth session of therapy.

That day he walked 60 feet X3 in a front-wheeled walker with stand by assist. No sudden collapse of the knee (a two year old problem) and no pain. He had been non-ambulatory for three months prior and I hadn't suggested any strengthening.

I'm not claiming that this is worth as much as I'd like it to be. All I can do is describe the circumstances and my reasoning. I have no way of knowing what else might have conributed to his recovery.
Attached Images
File Type: jpg Case and Run 003.jpg (22.5 KB, 21 views)
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 18-10-2011, 03:57 PM   #37
keithp
SomaSimpler
 
keithp's Avatar
 
Join Date: Jun 2011
Posts: 1,545
Thanks: 1,381
Thanked 1,591 Times in 578 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
...and I hadn't suggested any strengthening.


Six months ago I would have found this story to be implausible.

This thread serves as a wonderful example of what is going on here (SS)...without earning a single CEU.

Respectfully,
Keith
__________________
Blog: Keith's Korner
Twitter: @KeithP_PT
keithp is offline   Reply With Quote
The Following User Says Thank You to keithp For This Useful Post:
AnitaKB (22-03-2013)
Old 18-10-2011, 04:16 PM   #38
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

Keith,

Aren't you supposed to be working? (Just asking because this often goes through my own head during the day)

As implied, I think that weakness secondary to under-use is over-rated. I figured that out reading Awakenings in '73. I still wonder why the PT schools haven't noticed what Sacks observed and reported there. They even made a movie out of it starring Williams and De Niro for cryin' out loud ("There's a movie?!! ref Sam Malone on Cheers).

The fact that we don't provide CEUs is actually a draw back here. Neither do we provide lunch.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Old 18-10-2011, 04:26 PM   #39
keithp
SomaSimpler
 
keithp's Avatar
 
Join Date: Jun 2011
Posts: 1,545
Thanks: 1,381
Thanked 1,591 Times in 578 Posts
Default

Quote:
Originally Posted by Barrett Dorko View Post
Aren't you supposed to be working? (Just asking because this often goes through my own head during the day)
I am. Stepped away while I have a patient on the leg press, one with my gym aide doing step-ups 3x10, and another on stim.

Just kidding, today I start at 10:30. (sad how that could be a legit response from a PT, though)

Quote:
Originally Posted by Barrett Dorko View Post
The fact that we don't provide CEUs is actually a draw back here. Neither do we provide lunch.
That explains my weight loss these last few months.

Thanks again for this thread.

Respectfully,
Keith
__________________
Blog: Keith's Korner
Twitter: @KeithP_PT
keithp is offline   Reply With Quote
Old 17-02-2012, 05:58 PM   #40
zendogg
Senior Member
 
Join Date: Jan 2012
Posts: 504
Thanks: 184
Thanked 228 Times in 84 Posts
Default

Hi Barrett,
THank you for all the great info and questions. I am really starting to see through the lens you are sharing with us and I have to say that it takes a huge burden off of my shoulders. Not only with my clients but for my body as well. Treating the nervous system as the intelligent, responsive system that it is, a system that has kept us as a species alive for millennia, rather than a stupid, misbehaving nuisance that needs to be forced or abused into obedience just makes sense.
Would you mind adding some thoughts on SC for me? I have been able to appreciate the movement that you have described within my own body and in my clients. I'll just bullet the questions.
1) Does the warmth you describe that accompanies SC have to be present to indicate a successful or correct response of the nervous system?
2) Sometimes I will only feel "the tissue" gliding and "churning" underneath my hands but no visible motion is detected. Again does this indicate an incomplete response of the clients' nervous system, or a less than desirable hand placement choice?

Thank you for opening my eyes to new possibilities.
Nathan
zendogg is offline   Reply With Quote
Old 17-02-2012, 06:13 PM   #41
ste5e
SomaSimpler
 
ste5e's Avatar
 
Join Date: Jan 2012
Location: Harrogate UK
Age: 46
Posts: 565
Thanks: 389
Thanked 397 Times in 178 Posts
Default Thanks.

Thanks for the class. Well recieved.
Please, Sir! Can we have more?
Steve
ste5e is offline   Reply With Quote
Old 17-02-2012, 06:57 PM   #42
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

The warmth is blood flow. It couldn't be anything else.

The work of the nervous system is never complete until we die.

Don't worry about hand placement. When the response diminishes go somewhere else.

A great deal of movement isn't visible but palpable nonetheless. Ask about and palpate for the characteristics of correction.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com

Last edited by Barrett Dorko; 19-03-2013 at 04:18 PM.
Barrett Dorko is online now   Reply With Quote
The Following User Says Thank You to Barrett Dorko For This Useful Post:
zendogg (17-02-2012)
Old 17-02-2012, 11:32 PM   #43
Mary C
Chronic Chrawler
 
Mary C's Avatar
 
Join Date: Jan 2008
Location: NB
Age: 68
Posts: 898
Thanks: 39
Thanked 34 Times in 19 Posts
Default

Quote:
Neither do we provide lunch.
Just food for thought.
__________________
Guess learning is a lifestyle, not a passtime.
Those people who think they know everything are a great annoyance to those of us who do. ~ Isaac Asimov
Mary C is offline   Reply With Quote
Old 17-02-2014, 02:55 PM   #44
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 63
Posts: 16,952
Thanks: 1,920
Thanked 3,182 Times in 1,809 Posts
Default

I wanted to bump this thread up because it is the subject of today's blog post.

If you want to see the images, which is largely the point, become a member.

It's free.
__________________
Barrett L. Dorko P.T.
www.barrettdorko.com
Barrett Dorko is online now   Reply With Quote
Reply

Bookmarks

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off

Forum Jump

Similar Threads
Thread Thread Starter Forum Replies Last Post
Case presentation gerry Clinical Reasoning 2 25-05-2011 11:00 PM
CT Taking over a case smikolic General Discussion 2 30-06-2010 01:10 AM
Complex Case bhawna Clinical Reasoning 11 01-03-2006 05:46 AM


All times are GMT +2. The time now is 01:25 AM.


Powered by vBulletin® Version 3.8.8
Copyright ©2000 - 2014, vBulletin Solutions, Inc.
SomaSimple © 2004 - 2014