This morning my secretary told me that there was a man lying beneath the tree in our front yard. She thought that there could be something wrong with him but wasn’t sure. I looked out onto a beautiful summer day and then over toward an older man lying supine with his legs crossed at the ankle. I saw him idly drumming his fingers on his chest wall, keeping the beat to some tune in his head. At that moment I knew he was okay.
The woman I saw this afternoon complained of cervical discomfort that has worsened over the course of the past three weeks. As she stood her chest rose with every breath and she said her hands were “…freezing, as usual.”
Aside from the problems peculiar to central sensitization, neurogenic pain cannot exist without chemical irritation or mechanical deformation and, in my experience, the mechanical problems are by far the most prevalent. Fortunately, these lend themselves to movement of a certain sort. Every therapist and every patient searches for it, and I think the man beneath the tree and the woman struggling to catch her breath offer perfect examples of this movement’s elusive nature.
There is a persistent effort in our community to understand and resolve painful problems by delving ever deeper into the biomechanical intricacies of human movement. But I’ve never found this information especially relevant to my life in the clinic. I know that this is heresy. Though my problems with intricate biomechanics may have their origin in my lack of mathematical sophistication (and I admit this freely), I feel that in our effort to assess and understand human movement from this perspective we ignore something fundamental: the willingness to move at all.
“Whenever a movement unhesitatingly and immediately follows upon the idea of it, we have ideomotor action. (This is not a curiosity), but simply the normal process…and we may lay it down for certain that every mental representation of a movement awakens to some degree the actual movement which is its object; and awakens it in a maximum degree whenever it is not kept from so doing by an antagonistic representation present simultaneously to the mind.”
William James in Principles of Psychology. New York, NY: Holt; 1890
The man beneath the tree appeared to be in his mid-sixties and I noticed later that he rose from the ground effortlessly. His gait was easy and unhurried and his smile perfectly natural as he greeted his wife coming out of my office. I never spoke to him, but watching him lie on his back in the grass with a busy street twenty yards away told me a lot about his sense of physical authenticity and his willingness to seek comfort. What he did makes perfect sense when viewed from the perspective of our instinct, but it was so unusual in a cultural sense that my secretary felt certain that “there must be something wrong with him.” This man saw shade from the tree, felt the summer breeze, assessed his mood and followed his desire. How strange. This was an especially unusual act given that passers-by could see him clearly. He’s probably lucky someone didn’t stop their car, run up and begin to perform CPR. He’s lucky it wasn’t me.
Now my freezing lady later in the day: Simply put, she refuses to let her gut out while she’s standing. When she’s supine I could see free, full diaphragmatic breaths expand this region quite easily. She reported an immediate easing of her cervical pain and her hands begin to warm. We find that she can reproduce all of her pain with two successive upper respiratory breaths. Her subsequent struggle to breathe painlessly while standing makes it clear that although this pattern of use is contributing massively to her discomfort and cooling, some part of her is unwilling to allow her stomach to swell. She thinks that the appearance of obesity is too great a cost for comfort and I know I’ve got some very careful explaining to do if I’m going to help her.
The difference between the man and the woman struck me today and reminded me of the description of ideomotor movement William James wrote over a century ago. He understood that our desire to move was always present but that the manifestation of that desire was also dependent upon messages to the contrary emanating from another part of the brain. This “antagonistic representation” is a result of our enculturation, not our basic instinct for comfort and thus takes forms that are much more likely to be geared toward an appearance of normalcy and attractiveness than health. Remember, neurons get many signals at once and the total effect is determined by adding those that are excitatory and subtracting those that are inhibitory. In my afternoon patient the inhibitory signals to the diaphragm are winning whenever she stands. Thomas Moore, my favorite modern day philosopher says, “The need to be normal is the predominant anxiety disorder in modern life.” Moore is a counselor, and I would rephrase that slightly from my perspective as a physical therapist to read, “The desire to appear normal effectively inhibits our naturally occurring tendency toward healthful, corrective movement and posture and thus contributes to painful function.” Well okay, maybe I rephrased that a bit more than slightly, but you get the idea.
Let’s return to the basic premise that movement of a corrective sort is required for pain relief secondary to mechanical deformation and then look carefully at the cultural norms. I contend that they commonly keep us from behaving like the man beneath the tree and instead encourage the postural straining seen in my afternoon patient. We (and when I say “we” I mean the culture and that part of the therapy community that mirrors its attitudes) look at the man on the grass and assume he’s sick in some way when in fact he’s healthier than those of us who wouldn’t dare follow our instinctive desire for comfort. We look at the woman standing with a flat stomach and assume she’s healthy in some way when in fact her stomach isn’t flat at all; it’s been “flattened” by a breathing pattern known to be deleterious to our health. Of course we’d rather she did that than breathe normally.
By ignoring the desire to move in an ideomotor fashion (or even knowing such a thing exists) and by reinforcing purely cultural admonitions against anything unique or idiosyncratic, traditional physical therapy has failed to apply common sense and the known properties of instinctive movement for care and bowed to the cultural norm instead. They preach bodily symmetry and some imagined biomechanical ideal and attempt to prove that pain relief will result from this. One look at the statistics of chronic pain and it’s evident that this has been a tragically ineffective approach.
The man beneath the tree knows nothing of ideal biomechanical functioning. He only knows what he wants to do, and then he does it.
He doesn’t need a therapist-we need him.