Thursday, December 13, 2007

"Tree of Knowledge" : Part V "On the Razor's Edge"

The authors want there to be no mistake about what they intend to convey about the observer role. They provide an analogy:
Imagine a person who has always lived in a submarine. He has never left it and has been trained how to handle it. Now, we are standing on the shore and see the submarine gracefully surfacing. We then get on the radio and tell the navigator inside: "Congratulations! You avoided the reefs and surfaced beautifully. You really know how to handle a submarine." The navigator in the submarine, however, is perplexed: "What's this about reefs and surfacing? All I did was push some levers and turn knobs and make certain relationships between indicators as I operated the levers and knobs. It was all done in a prescribed sequence which I'm used to. I didn't do any special maneuver, and on top of that, you talk to me about a submarine. You must be kidding!"

All that exist for the man inside the submarine are indicator readings, their transitions, and ways of obtaining specific relations between them. It is only for us on the outside, who see how relations change between the submarine and its environment, that the submarine's behavior exists and that it appears more or less adequate according to the circumstances involved. If we are to maintain logical accounting, we must not confuse the operation of the submarine itself and its dynamics of different states, with its movements and changing positions in the environment. The dynamics of the submarine's different states, with its navigator who does not know the outside world, never occurs in an operation with representations of the world that the outside observer sees: it involves neither "beaches" nor "reefs" nor "surface" but only correlations between indicators within certain limits. Entities such as beaches, reefs, or surface are valid only for an outside observer, not for the submarine or for the navigator who functions as a component of it.

What is valid for the submarine in this analogy is valid also for all living systems: (...) for each one of us human beings.
My bold.
This is second nature for physiotherapists, and others who work with human function, like sport coaches, trainers, etc. We are steeped in observation and evaluation of movement in a context. We can communicate with the person performing the movement, behavior, function we are observing, but we can never quite share their inner world, or see things quite the same way they do, or have quite the same feelings at quite the same time. And we cannot literally feel someone else's pain. We can only infer how they feel based on how their movement, behavior, their description.

If we treat pain, we cannot be so presumptuous as to think we have very much at all to do with its resolution. Instead, the patient will draw from their encounter with us what they need for self-resolution of their own pain. Let me be clear: they will take from the encounter only what they need. Whatever that might be. All one can do is offer up what one knows, and be willing to handle someone's skin and body parts in a boundaried, caring manner, learn to sense change that goes on inside that "submarine". Learn to sense when response has slowed, and it's time to move on, change position, change grip, change part, change vector..

Most of this "learning" to sense how and when, is in one's own "submarine". There is no way to really abstract it, test it, subject it to algorithms, define it precisely, dose it. It's a relationship - it's a bodily relationship more than it's a social relationship - yes, it has therapeutic value, but it is more in the realm of two nervous systems communicating than it is two people. It is as ephemeral and non-verbal and in the moment as pain itself is. And that big neuroplastic adaptive continually changing entity known as the patient's nervous system, will learn something from this encounter; if we are careful to set up the encounter right, it will move itself in a direction that is favorable.

Patrick Wall stated that he viewed pain as a "need" state that required a "consummatory movement" to quench it. The movement has to come from the patient. In order to create, to produce that required movement, their brain, their nervous system needs to find the right moment while assessing and adopting (learning from, neuroplasticizing around) the right sort of "input". This takes time. It can be provision of a movement illusion, as from mirror therapy, or it can be provision of a kinesthetic illusion, as in manual treatment of that midline zone without a great deal of sensory-motor mapping that we call the "back", for example. If someone can see an illusion of their painful body part moving freely in a mirror, great. The back is a bit harder to set up mirror therapy for, but some day someone might rig something up. Until that day I think manual therapy will never go extinct. There will always be people around needing physical contact from another nervous system in order to find that elusive mix required to create THE movement that can resolve their distress, and it seems to me there will always be some chunk of the population willing to become the next generation of human primate social groomer, capable of supplying boundaried human contact backed by some degree of understanding, be it conceptual or kinesthetic or both.

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