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Re: Blindness and Manual Assessment

 
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Re: Blindness and Manual Assessment - June 11, 2005 11:19:00 PM   
Jon Newman

 

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Hi Nari,

Funny you should ask that. I just recently starting treating in our pediatrics room because it has a reasonable sized mat table and is out of the way of the buzz and hum of the gym. When someone is on their backs they end up staring straight up into the lights. Since it is the peds room and we seem to appreciate how environment is important to children, the room was equipped with recessed lighting and a dimming switch. I use it all the time.

Barrett, it sounds familiar and excellent advice. Thanks for posting it.

The direction this thread has taken has reminded me of one of the first books I read from your book list.

[URL=http://www.rehabedge.com/ubb/ultimatebb.php?/ubb/get_topic/f/11/t/000006.html]The Hand: How it shapes the brain, language, and human culture[/URL] by Frank Wilson. It informs this topic quite well in my opinion. For example, from the book, on page 117, Frank Wilson examines a narrative by a fellow named David. This is the passage
[QUOTE] I raised horses, and much of my relationship with my horses happened through my hands. I had a little Appaloosa, raised several foals out of her, and I remember touching her and being close to her and guiding her with my hands. When you work with a horse, your hand is what controls the whole horse. Horsemen talk about people who have "light hands." You can guide a horse and communicate with a horse through a very delicate hand. You can build trust with your hand and your touch more than you can with any amount of whipping or yelling or anything else. There is tremendous power there. [/QUOTE]I see this as the horse training us but that is, in my opinion, how it most often happens when coercion is minimized and paradoxically what accounts for David's sense of power and Gary's sense of awe. I'm also humbled by it. Something I could use more of.

jon

_____________________________

[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]

(in reply to Barrett)
Post #: 21
Re: Blindness and Manual Assessment - June 12, 2005 3:12:00 AM   
Lukey

 

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Hi all,

Did you know that for many centuries in Japan the only jobs available to the blind were as an acupuncturist or massage therapist? Even today there are 94 acupuncture schools and only 25 of them are for normal sighted students.

Nari,
I love walking in the dark, especially in the bush when the moon is new. I find the slowness and increased awareness needed quite exhilarating. It's even better with bare feet.

Luke

(in reply to Barrett)
Post #: 22
Re: Blindness and Manual Assessment - June 12, 2005 6:50:00 AM   
Barrett

 

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From: Cuyahoga Falls, Ohio
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Great stuff here, but I?d like to take the blindness motif a step further by suggesting that we needn?t create a darkened environment in order to appreciate what a lack of visual stimulus might produce, we are already blind to the processes within the patient and will always be so. It is this sort of blindness that we can use to alter our sensibilities if we choose to do so. Consider this passage from ?A Sense of Things? on my site:

?We don?t see with our eyes, we see with our brains.? The speaker is Paul Bach-y-Rita, a physician and neuroscientist at the University of Wisconsin . I first read of his work in the June 2003 issue of Discover magazine in an article entitled ?Can you see with your tongue?? After watching his profoundly impaired father recover from a stroke that was known to have severely injured his brain tissue, Bach-y-Rita turned his attention to research designed to reveal and enhance the brain?s apparent plasticity. He developed electronic devices capable of stimulating tactile sense when a camera ?saw? an object move. When the stimulation was applied to the tongue of a blindfolded subject they quickly learned to ?see? with their tongue. This sounded a great deal like the production of synesthesia to me and I asked him about that in a personal communication. He replied: ?I consider that what we are doing is completely different. The tongue becomes merely a relay, and no sensations are experienced on the tongue; this is much like a blind person with a long cane, who perceives the door, chair, foot, etc as being at the cane tip but feels nothing at the hand which has become the relay.? Fair enough, but in the Wiley Encyclopedia of Biomedical Engineering, he also says: ?Synesthesia is the experiencing of one sense as if it were another; for example, the experience of tasting shapes, has been known for at least 300 years. When it arises unbidden and operates uncontrolled, it can be a serious and disabling pathology. Nevertheless, it leads to remarkable insights in the understanding and control of cognitive function. A controlled form of synesthesia may have parallels to the sense display unit (invented and developed in his laboratory)?

It appears that while naturally occurring synesthesia and the neurologic adaptation induced by means of Bach-y-Rita?s training and instrumentation are not precisely the same, the difference is primarily that of control and the end result, the translation of one sense to another, is much the same. The lack of simultaneous experience, i.e. the blind person has no sense of their hand, may be at the root of its distinction from the naturally occurring condition.?

When our palpatory method becomes almost completely non-coercive and our attitude non-judgmental (read Simple Contact) we work with our hands as the blind do with their canes. According to Bach-y-Rita, what is this likely to produce?

_____________________________

Barrett L. Dorko P.T.
http://barrettdorko.com

(in reply to Barrett)
Post #: 23
Re: Blindness and Manual Assessment - June 12, 2005 10:55:00 AM   
Diane

 

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[QUOTE]this is much like a blind person with a long cane, who perceives the door, chair, foot, etc as being at the cane tip but feels nothing at the hand which has become the relay.[/QUOTE]Exactly... One theory is that the brain has produced a "virtual" (i.e., phantom) body that includes the cane. Ramachandran has worked with these I think.. Certainly Wall, Melzack.. I read about this phenomenon in "The Burning House" by Jay Ingram. The phantom becomes very sensitive to input, can perceive the tiniest of irregularities. True for all sorts of mechanics, surgeons, dentists, carpenters, jewelers, painters, calligraphers etc., anyone devoted to a craft who extends their hands' capabilities by using a tool at the end of them.

Laying down the ultrasound wand and using our bare hands this way turns them into satellite dish like receivers of kinesthetic information. And minor attunments we might make (adjusting only the antenna, not the body of the patient) will help the feed.

Still doesn't explain, though, Barrett, your comment, [QUOTE]I knew I was in trouble with this man.[/QUOTE]

(in reply to Barrett)
Post #: 24
Re: Blindness and Manual Assessment - June 12, 2005 1:39:00 PM   
gary s

 

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Barrett,
Like Diane, I'm curious about the final outcome.

Gary

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Post #: 25
Re: Blindness and Manual Assessment - June 12, 2005 2:45:00 PM   
Barrett

 

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I ?thin sliced? this comment (See Gladwell?s ?Blink?) to mean that this man was of the opinion that another?s body could be both assessed and altered with the judicious use of passive testing and coercion by forces he had learned to generate over the years with dedicated practice and study. I had done the same, and, in fact taught all of that for several years early in my career. I knew that I could handle another in a fashion that elicited relaxation and permitted increasing provocation and increased range, albeit briefly. I learned enough anatomy to guide me through the surface and dwell upon the joint line. I was convinced if I did this with enough skill that no joint could resist me.

Of course, as you know, today I?m certain I was going after the wrong structure.

If you were sure about the consequences of skillful coercion and then someone stood in front of you and made the case for manual permission instead, someone who pointed out that neural irritation would account for the vast majority of complaints that you had previously thought were connective tissue problems and that you weren?t actually capable of assessing the problem manually or pushing things back where they belonged, well, wouldn?t that give you pause? I imagine that many would be able to make their way toward new knowledge simply because that?s how we progress, but our emotional attachment to hard-won skill is another thing entirely. For the work I teach, something like that must be abandoned. At least, while treating an abnormal neurodynamic.

My method doesn?t require the skills of the manipulator and though you must work to become cognizant of what the neurobiologic revolution has to teach us, the skills necessary to be ?good? as this don?t amount to much. (See ?Easy and Simple? elsewhere on this site)

This man was essentially silent the remainder of the day and left quickly after class. I?m only guessing at how he felt but despite early promises of continued contact I?ve yet to hear from him.

_____________________________

Barrett L. Dorko P.T.
http://barrettdorko.com

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Post #: 26
Re: Blindness and Manual Assessment - June 12, 2005 3:36:00 PM   
Diane

 

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Sometimes mental composting is a slow process. I think new cognitive layers take time to get used to. He may still get in contact. Did he volunteer for a demo? I'm guessing he didn't; he could have "got it" that way.

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Post #: 27
Re: Blindness and Manual Assessment - June 12, 2005 6:58:00 PM   
nari

 

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I have the feeling that the most well-intentioned and well-meaning PTs coerce without realising what they are doing.

Barrett, it is the emotional attachment to hard-won skills that is important; and after reading stuff on Rehab Edge for a while I have come to understand why I was so dissatisfied with orthopaedic work, going back years. It is the mechanical aspect, the technical application of techniques that nobody really knew much about except that they seemed to work, that bothered me.

I was a research technician for three years at our university, and loved it. This was different..I was quite happy talking to frogs and lungfish plus a few mice, Besides, all that I did with the assays and outcomes was evidence based.
Based purely on chemistry and biochemistry. As a PT we don't really have that solid background.
We learn all those subjects as PTs, but do not really apply them in any scientific way. Getting people to 'do quads' and funny exercises which had no functional application, drove me crazy.

Now I know why...I think.


Nari

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Post #: 28
Re: Blindness and Manual Assessment - June 12, 2005 7:43:00 PM   
Barrett

 

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Nari,

You're right, good intentions don't eliminate our tendency to impose our own idea of what's best for another, which would be a good idea if the therapist actually had a clue.

If I can just get my students to understand that we are all instinctively self-corrective their whole approach to palpation and manual treatment immediately changes. For some this is effortless and for others it simply cannot be believed. For the latter group, an attachment to their coercive skills is probably part of it, for others, it is simply that touching another remains a difficult and foreign act. I'm not kidding.

So, in the end, a revolution in manual care (if there is ever to be one) will only come about if we come to a new understanding of what's in our hands. As others here have suggested, when we appreciate that more than our own hands, things truly change.

_____________________________

Barrett L. Dorko P.T.
http://barrettdorko.com

(in reply to Barrett)
Post #: 29
Re: Blindness and Manual Assessment - June 12, 2005 10:28:00 PM   
Diane

 

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From: Vancouver, B.C., Canada
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[QUOTE]I love walking in the dark, especially in the bush when the moon is new. I find the slowness and increased awareness needed quite exhilarating. It's even better with bare feet.[/QUOTE]Luke, after hearing Lorimer Moseley tell the story about his snake bite, there's no way I'd go walking around anywhere in Australia without thigh high boots..
[QUOTE]a revolution in manual care (if there is ever to be one) will only come about if we come to a new understanding of what's in our hands[/QUOTE]Ditto that. One therapist at a time.

I like this excerpt from something Ian sent, by a person who laments Western cultural attitudes to the body: [QUOTE]..as Richard Grossinger eloquently puts it, "The majority
treat their body like a date picked up at the singles bar. They hustle it,
punish it, and try to make it give them things they want" (Grossinger
1995, 1, 41).[/QUOTE]Sort of describes certain aspects of PT doesn't it?

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Post #: 30
Re: Blindness and Manual Assessment - June 12, 2005 10:53:00 PM   
Lukey

 

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Diane,

It's much safer at night - venomous snakes aren't nocturnal. Also, certain types of terrain don't have the aggressive ones.
I've had graded exposure and desensitization therapy too - my brother and I used to keep snakes and goannas as pets in our bedroom when we were kids. We lived in the city so it was quite a spectacle when we would take them down to the park for sun and exercise.

Luke

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Post #: 31
Re: Blindness and Manual Assessment - June 13, 2005 5:20:00 AM   
nari

 

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Diane

Snakes are really only a problem in the north and in very dry warm weather in the south. We live quite happily with our venomous critters and rarely come across many in our part of the country.
I will quite happily walk barefoot around bushy areas - the only real problem are burrs and broken glass from idiots. My daughter has always wanted to own a python...
Spiders are everywhere, but we live with them. We don't have funnelwebs like Sydney ( but we will soon with global warming) but redbacks live arond the house surrounds happily, and huntsmen, the big ones, come inside to visit. We never kill spiders - pick them up in a jar or a piece of paper and put them outside...

Yes, I think we hassle our own bodies, and certainly others in our care. I was out on an 18 km stroll today (OK, I have sore feet) discussing the state of physiotherapy with another PT. She was adamant that Australian physiotherapy, at least, is going to be in trouble justifying the huge costs of physio treatment for insurance purposes, and in the hospitals. When I see patients who go to physio 3xweek for years, I wonder why they have not complained before now.
But she also said we have spent so long doing detailed, complex, miniscule treatments to tiny joints( facet jts spring to mind) that we have lost ourselves in the academic mystery of detail and lost the plot completely....

On NOI there are quite a few posts around this subject. The art of using hands is full of untestables from placebo to CNS desensitisation stuff (which is more testable); but one day it may backfire when a trial is run using ultrasound on/off and fMRI or SPECT...and finds that steel heads are very effective desensitising treatment.
The catch is, patients can't take it home to use for 5 minutes every 1-2 hours...

Neurodynamics does win out in the end...I think.
Or, hands-on plus neuro stuff may be the ultimate winner.

Nari

(in reply to Barrett)
Post #: 32
Re: Blindness and Manual Assessment - June 14, 2005 1:24:00 PM   
Barrett

 

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From: Cuyahoga Falls, Ohio
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So, perhaps to finish up this thread I would say the following:

Palpatory assessment comes in two basic forms; those that seek to discover deficits by means of provocation and/or judgement based upon the therapist's knowledge of normal, and those that seek only to help the patient reveal how they actually exist. This second form is virtually unheard of, in my experience, and perhaps that's mainly because most therapists approach the system as if were primarily passive and silent when not provoked and truthfully responsive when it is. In my experience (and according to normal physiology) neither of these things are true.

The latter approach supposes that unique and telling expression-long known to be therapeutic in the world of psychology-often requires permission and a safe environment to come to the fore. Where in a modern therapy environment might such permission and safety be possible?

Blind people don't provoke their surroundings with their cane-they allow it to reveal itself in an important way. After all, physical obstacles, no matter how large, are generally silent. It is the tip of the cane that allows them to express their presence. Emptiness elsewhere is then revealed, and the blind can move forward into that space safely. You might say that to a blind person every room is completely empty until their cane proves it otherwise.

Perhaps our patients are similarly lacking in animation until touched in the proper fashion; in a way that helps them express the movements they don't normally dare express.

Rumi put it this way:

Reach your long hand out
to another door, beyond where
you go on the street
where everyone says, "How are you?"
And no one says, "How aren't you?"

_____________________________

Barrett L. Dorko P.T.
http://barrettdorko.com

(in reply to Barrett)
Post #: 33
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