Monday, May 14, 2018

Starting in the middle

Todd Hargrove wrote a new post based on his talk in Oslo recently, in which he described systems thinking, and how it can be helpful for complex problems like treating pain; here is a link:
The Big Picture of Pain

From the blogpost:

"At the “lower” levels, you can view the health status of cells and organs like muscles, tendons, discs or nerves. For example, maybe your foot hurts because of a stress fracture. This is where you can find "issues in the tissues", which is where traditional pain treatment has focused most of its attention. This is often called the "biomedical approach" or the "bio" part of the biopsychosocial model. You find the structure that is damaged and work to repair it.
"At the “higher” levels of analysis, such as the person or the environment, you are looking at more complex phenomena – the role of thoughts, emotions, or social relationships. These are the “psychosocial” issues that are known to have very important effects on chronic pain. Problems in these areas are often relatively subtle, more about dysregulation or imbalance than something being broken or injured. These issues are also invisible if you look for them at a lower level. For example, you can't see catastrophising by assessing a foot - you need to talk to a person."
In between "lower" and "higher", there are threads that must connect. After all, people are individuals, aren't we?
What about "middle" levels?
As a PT I aim mostly at the middle levels, which I define as how someone habitually inhabits their own "bio", and which give me options of exploring to either side, either bio* or psychosocial. 
*(And when I consider "bio" I'm really only thinking about the 72 km of peripheral neural tree, most of the time. The fact that neurons need physiology to get their groceries and drainage. Neurodynamics.) 

Lest we forget, people are physical entities. They have mass.
They are constantly being operated on by the "environment," which, to make life simple, let's reduce to the most basic of physics, air pressure and gravity.

Most of the time, they can re-arrange their relationship to these two things, by simply arranging their bodies differently with respect to them.

People adopt default resting positions, that IMO have a lot more to do with eventual mysteriously-arising "pain problems" than anything else in life, be it strictly bio or strictly psychosocial. (I like to stay away from these two polarized extremes. I always have.)

Sometimes the reasons people do what they do with their own body stem from psychosocial reasons, sometimes for clear bio reasons, most of the time for reasons that are probably completely innocuous and seem to have been lost in the fog of time. 
Examples: why someone crosses their left leg over their right, but never the right over the left. Why someone leans on the right elbow on the couch, but never their left. 
In the case of leg crossing, it could be a bio reason (one hip is actually shaped differently than the other), or it could be a choice (perhaps the patient is a psychotherapist and "learned" or taught herself or himself that crossing one leg, not the other, led more easily to a sense of security and boundary between them and whatever their client was saying to them). 
In the case of leaning on one elbow, there might be a bio reason (the patient has only one elbow!), but usually there is a psychosocial reason (territorialism at home "this is my spot on the couch") or a context reason ("The way I have my furniture arranged, this is the easiest way to watch TV"). 

Helping people spot their own physical behaviours (mostly lop-sided usage) is often a revelation for them. They have been mostly unconscious about these, all their lives. Becoming aware (of anything) is the first step toward change (of anything).

No comments: