The Analgesia of Movement

[Barrett Dorko]

In Wall's last text, "Pain-The Science of Suffering," he makes it clear that the three stages of motor response to painful sensation are in sequence, withdrawal, protection and resolution. If all three are instinctive, what would the last stage (resolution) look like and how might it be promoted?

My work seeks to answer these questions through the study of ideomotor activity, neurodynamics and manual methods of care. I've written of this extensively on my own web site, barrettdorko.com and elsewhere. I am hoping that this site might become yet another place where analgesic movement can be discussed. Perhaps the question above will help us get started.

Barrett

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[perfphysio]

Resolution hmmmmmm,

I would say it is mainly inattention. If a painful stimulus is there, we feel it, withdraw from it, we protect from it and then our brain tries mechanisms to "ignore" or dissociate from it. Sometimes breathing exercises, sometimes rubbing the pain, sometimes other techniques are used to dampen our conscious awareness of the "Pain". I would think that this happens before resolution.

Any comments? There are numerous examples of war hero's running into battle shooting with one arm after having the other one blown off during the assault. Movie footage from front line journalists have shown repeatedly that the injured person does not register the pain, does not withdraw from the pain, certainly does not resolve their pain, but rather increase from no pain to excruciating pain as soon as another person draws to their attention the fact the have no arm any more.

We postulate about endorphin etc releases in the heat of battle and that this masks pain pathways.....hmmmmm it's only theory. Perhaps wall was generalizing a framework but it appears a bit to simple to me.

:smokin

[Barrett Dorko]

I'm not referring to pain from injury necessarily, and equating the two is obviously a mistake (as Wall makes clear). I'm talking about pain secondary to mechanical deformation, the sort we see in the clinic rather than the battlefield.

The suppression of ideomotor activity is commonly seen in people who express that they feel the pain but are not moving as any other animal would. Wall cites brain imaging that demonstrates a large amount of motor planning but no motor activity. What do you suppose is the impediment if not a lack of awareness?

Barrett
barrettdorko.com

[Physiobase]

Barrett, are you taling about "emotional" pain? e.g. being dumped or losing a loved one? Perhaps you be slightly more specific as many of us do not read as specifically as you on pain in general.

many thanks

<img border=0 src="http://www.ezboard.com/images/emoticons/nerd.gif" />

[Barrett Dorko]

I'm surprised that anyone would think I was referring in any way to emotional pain. Dealing with that is, of course, beyond my expertise.

I'm talking about pain secondary to mechanical deformation below the level of injury. Think of a hammerlock applied by a policeman-no injury, but the neural tension produced exceeds our tolerance for its presence fairly easily. Sympathetic tone rises and the motor planning necessary for its resolution will be converted to motor activity when the policeman finally lets go. Movement without volition (ideomotor) follows and the mechanical deformation is reduced.

Is it possible that a similar movement might resolve pain at the center of the body? Is it possible that all the cultural restrictions imposed upon us in an effort to promote "proper" posture proximally are enough to keep this from happening naturally?

Barrett
barrettdorko.com

[Physiobase]

Many thanks for your clarification <img border=0 src="http://www.ezboard.com/images/emoticons/ohwell.gif" />

[somasimple]

Hi All,

If all three are instinctive? Perhaps because they involve autonomic system and homeostasis but assuming that we haven’t any control over some reflexes is actually denied by science. Many of our chronic pains are the results of conscious but inappropriate actions over the reflex ones.

[Physiobase]

Not sure of the relevance to your comments Barrett, but I have been discussing with some fellow PT's the work done with phantom limb pain and pain associated with the absence of sensory input in the hemiplegic arm.

Some fellow Pt's have told me about work done using a mirror placed to the side of the absent limb/inattention or limb with sensory loss. In this way the eyes see a reflection of the good limb when moved and are tricked into believing it is the injured limb.

Some have postulated that where there is an absence of sensory input the brain tends to a representation of contracture and that the brain may believe the limb is contracted even when it is flaccid. Using the mirror has been suggested to influence this by letting the brain think the limb is not contracted and therefore the pain reduces.

Comments?

[Barrett Dorko]

I often refer to this work while teaching in order to demonstrate the presence of "central sensitization" and the novel way therapy might affect it. The original clinical trials were conducted by Nancy Byl, a brilliant PT in San Francisco.

However, this work is not related to ideomotor activity, an active though unconsciously driven movement whose purpose is to reduce mechanical deformation; not to significantly alter cellular changes in the brain.

With Simple Contact an effort is made to "play" with the creative activity generated instinctively and produced by the patient in an effort to relieve the mechanical deformation from which the problematic sensation originates.

I find myself repeatedly saying "mechanical deformation" in these posts. Is there a problem with our profession's understanding of this simple concept as it relates to painful sensation?

A very interesting discussion regarding creativity, play, induction and therapeutic movement that may help here can currently be found on Rehabedge.com in "Barrett's Bullypit." Look for the tread titled "Induction."

[SuperFizz]

Hi Barret

I read that you are relating the situation to ideomotor (movement) that is "involuntary".

Movement without volition (ideomotor) follows and the mechanical deformation is reduced

I am not sure how the police hold fits in. Surely pain is conscious and then withdrawal from pain is conscious. There is some talk around suggesting that reflexes in fact are still under higher center control? But is that stimulus from deformation of a sensory organ and not pain itself.

It the response more about reducing the pain via the mechanical deformation to the sensory organ? Or is it simply the mechanical deformation. In a limb with sensory loss mechanical deformation may not induce the ideomotor activity as no pain is elicited yet the deformation still occurs. It is then the essence of pain itself (sometimes a learned behavior) that is under higher center control? Are there then ways to learn to deal with this behavior and as a result can behavioral approaches to that affect result in new coping mechanisms?

I think Lorima Moseley, an old colleague of mine at the Sydney University wrote something titled. "'What they don't know won't hurt them.' but then states in his concluding note - "The evidence to the contrary is mounting. It probably will!"

:hat

[Barrett Dorko]

I appreciate your joining in here but find your reply rather confusing. You put the word involuntary in quotes as if I said this. Would you please point out where I did so? I'm sure I've used the word in the past but having a context would be quite helpful.

Ideomotor activity is best described as instinctive rather than reflexive in that the latter implies great difficulty in our ability to suppress its expression. Consider the poker player who successfully bluffs for instance. This is an effective suppresion of ideomotor activity. You might also consider the fact that many people with a 20 minute sitting tolerance before experiencing pain remain in their seat long beyond this in a variety of situations wher standing is considered "improper." Both of these nonmovements represent a successful suppression of instinctive expression, and this is the very definition of domestication.

You say, "Surely pain is conscious and then withdrawal from pain is conscious." By this do you mean that we plan and willfully move with volition in this manner when stimulated painfully? Not according to Patrick Wall, who includes withdrawal as the first of three hard wired responses to painful sensation (the second being protection and the third resolution). Ideomotor movement (that which we use to achieve the third stage) is fairly easy to suppress if our "higher centers" deem it inappropriate, and I think they do so regularly.

The second paragraph doesn't quite make sense to me either. I don't know how you separate mechanical deformation of the sensory organ from mechanical deformation of, well, something else. What else but the former would be relevant to the painful experience? What is "the essence of pain"? Is pain a "thing" that has parts to you? The loss of sensory ability in a deformed limb presents us with well known problems and they are solved with procedures of care developed over many years. It is the deformation that produces pain in the normally sensitive tissue that concerns me. When the instinctive response to such a situation is suppressed therapists should come to understand how that is possible, what it looks and sounds like and how to handle patients in a way that changes the situation for the better.

[SuperFizz]

Thanks for the examples Barrett, this does help make things clearer. I have included a quote in my last response. Please take my use of "quotes" as meaning; perhaps/a postulated thought or many; of me; etc. not a dig or direct response to your words. I am simply not necessarily saying I agree or disagree with the words I am writing when I put "" around them. I am just offer up thought for comment.

By this do you mean that we plan and willfully move with volition in this manner when stimulated painfully?

I don't think we necessarily plan it, but we have learned it and I believe it is conscious and under our control. Mechanical deformation is as you say mechanical deformation, I am not trying to separate it but rather postulate is pain merely the symptom? Are with withdrawing from the symptom or the deformation/stretch/increase in threshold stimulus.

I think I can see your point now by your last sentence:

When the instinctive response to such a situation is suppressed therapists should come to understand how that is possible,

Is it that as a therapist we should seek to understand how to ignore pain and get on with it? Surely the pain does not go away, we simply decide that it is neither the time nor the place to do anything about it and just ride it out. Should we teach this to our patients as a first measure while trying to figure out in the medium term why the mechanical deformation is causing pain in apparently normal tissue?

I am a big supporter of normal movement and symmetry promoting normal tissue function and, in the absence of inflammation, thereafter a reduction in pain. Perhaps if you could really say what you are postulating, in simple terms, that therapists should do as a result of your current understanding. I suppose I am trying to add my general thoughts via a few words but might be missing your point like a few others above.
:hat

[Barrett Dorko]

I don't think we're actually getting any closer to understanding each other.

You say regarding withdrawal: "I don't think we necessarily plan it, but we have learned it and I believe it is conscious and under our control."

The fact that this is an instinctive reaction (Wall et.al.) means that we have in fact not learned it but were born knowing how to do this already. It is therefore unconsciously driven though we may be aware of its presence and not necessarily its origin in ourselves. We can certainly learn to suppress its expression though the motor planning remains and will probably show up minimally as an isometric contraction, but I'm going over old ground here.

Then you ask: "...is pain merely the symptom?"

When is pain anything other than a symptom? Deformation becomes symptomatic in all tissue eventually, that's why we shift positions in order to avoid the consequences of stasis. We do this instinctively. Is that beginnig to sound familiar? Why should we teach patients to ignore this? What's therapeutic about that?

You suggest: "Perhaps if you could really say what you are postulating, in simple terms..."

I have simply suggested that in the case of excess mechanical deformation pain relief follows instinctive movement, whether inflammation is present as a complicating factor or not. This is not a complicated issue nor have I stated it in an obtuse or vague manner. This point is expanded upon in hundreds of essays I've had published elsewhere (barrettdorko.com and rehabedge.com). Your inability to follow this surprises me.

The point you seem to be missing is that manual care might be more effective if it recognized that motion and promoted its expression-not if it sought "symmetry" or the thrapist's notion of normalcy. I seek self-correction as expressed by the patient. This movement has certain characteristics and those who provide gentle manual care usually have some sense of these. Perhaps you don't.

[SuperFizz]

Well Barret you seem to be putting alot of faith in Wall. Moving to avoid pain might as well be considered avoidance behaviour as much as a good thing for the organism. Such avoidance in order to shift away from pain can lead to postural abnormality such as scoliosis that in turn can lead to further deformation, further pain and further movement. In the end one might end up in a knot!

I don't think we are talked at crossed paths in this forum thread. I simply find that your thoughts are perhaps to general that one can easily present a different opinion. If you stick to a more specific example of client and their specific behavior to a specific problem, then we might all get walking in the same direction, not meandering away from it.

:hat

[Barrett Dorko]

You seem to have arbitrarily chosen to focus on withdrawal alone despite the fact that this thread was explicitly begun as a discussion of resolution. Your inability to see all three stages of instinctive behavior confounds me. Of course if we stop at withdrawal we'll appear deformed-the question is; What should be done next? How can the therapist know what the next unique, instinctive and personal movement should be? Should it be the one that *appears* right? Is the path out of trouble always a straight line full of effort?

Depending upon Wall's opinion is not something that I feel requires any sort of defense. Can you name anyone more highly regarded? On page 18 of Ramachandran's latest book he expresses skepticism at the very study you previously cited regarding recovery with mirror techniques-then he sees Wall is one of the authors and immediately accepts it. (see "A Brief Tour of Human Consciousness")

Is anyone else out there?