Saturday, January 5, 2008

Psychology of the Tissue

Let me tell you two little stories as an introduction to this post :

The first one is, from what I remember, coming from a book written by Bernard Weber.
There is a farmer trying to push his donkey into a box and his son is observing them. The donkey doesn't really want to go into the box, infact it doesn't want to be forced into the box. The father pushes the donkey even harder, but the harder he pushes the harder the donkey resists from being pushed. The son starts laughing at the scene. After a while the father, frustrated and irritated by the obstinence of the "stupid" donkey and by the laughing of his son, shouts at him : "you do it if you think you can !"
The son approaches the donkey and pulls his tail. The effect is immediate, the donkey jumps forward into the box...

The second one was told to us (a group of students) from Mr Colum Gregory (Osteopath, teacher/Tutor at the ESO).
Mr Gregory was at that time a student practicing at the ESO teaching clinic under the supervision of a senior tutor clinic, Mr Gez Lamb.
Colum was in a room with a patient and was trying desesperately to "crack" her T9 (a thoracic vertebrae) but it was really restricted. Gez Lamb finally came in the room and told him to unwind T9 using one of the legs as a leverage... (dear reader, if you are not an osteopath please acknowledge that such a technique is as irrationnal as it is obscure for you to understand). Mr Gregory did so and after a few moment the patient started crying excessively. This is what we call a good somato-emotionnal release. Colum asked her what happened and she replied that she remembered a particular incident that had happened during her childhood when some boys attached her to a tree and were particularly nasty with her.
This T9 restriction couldn't be forced to shift with a HVT or a LVT technique, fascial unwinding was THE technique to use to release this restriction with this particular patient.

While we could have forced the donkey into the box by pushing it with a tractor or "cracked" this patient's vertebrae with the help of a professionnal wrestler, a different approach adapted to the patients particular needs seemed to have worked and done the trick.
We are constantly confronted in practice with multiple choices of techniques we can use on one patient and on one particular restriction.
On certain patients a structural adjustment will have fantastic results, while others will react by tensing up even more.
On certain patients deep tissue massage relaxes the contracted muscle whilst with others the muscle will contract even more.
On certain patients the cranial approach will have almost miraculous effects whilst others will take you for a quack.

Is it possible that for any patient's restriction there is one specific approach which will be the most effective with the less side-effects ?
Which one needs to be used ? GAT, GOT, HVT. LVT, Recoil, BLT, direct/indirect cranial approach, MET, PNF, A/P work, Unwinding, Strain/counter Strain, Trigger point inhibition, dry needles, Functionnal techniques...
Is there a reason why a patient may react better with a certain type of technique or approach ?

I believe there is one, and the reason could be explained due to the Psychology of the Tissue.

Psychology of the Tissue

What is a Tissue ?

I will employ this term to express living structures such as bones, ligaments, muscles, capsules, tendons, arteries, nerves, cells, fasciae...

If we want to talk about a "psychology of the tissue" we need to accept the fact that a tissue holds a memory. Memories of past experiences are an essential part of the psychology of an individual or a tissue.

Tissues have memory :

There are some debates about it. Some state that the memory resides exclusively in the brain and some others believe that the memory is also localised in the tissue itself at a cellular level. This memory is very important as it will influence the psychology and the comportement of the tissue. I would say that there are 3 major memory mechanisms, and certainly many more.

The somato-psychologic, the psycho-somatic and the somatic-somatic memory (please note that I use the term somatic in its broader sense including the visceral sphere).

The somato-psychologic memory:

When we hurt ourselves some afferent information coming from the injured area is sent to the brain. A part of this information analyses the type and quality of the pain felt while another part is sent to our limbic system where the brain will attach an emotion to this pain (in which circumstance this injury happened) and will compare it to previous similar injuries.

let's give some examples :
  • Let's take two similar injuries which happened to two different individuals :Imagine a soldier on a battlefield who whilst carrying and saving the life of one of his team mates, twisted his ankle. Now imagine another random person who whilst on stage live on TV, missed a step and twisted his ankle, and by this action, embarrassed himself in front of million of spectators. During a treament the practitioner will certainly notice this injury. Asking about the cause of this trauma will awaken a sense of pride and self-confidence to the ex-soldier whilst it will awaken a deep sense of shame to the other patient. The internal chemical secretion and the immediate reaction of these two patients will be totally different.
  • Imagine now a widower who just lost his wife. Every single one of his friends came to him and whilst putting their hand on his shoulder asked him : "How do you feel?" or "How are you?" This scene is repeated 100 times. It creates a deep anchor mixed with a pavlov reflex between the sensation of feeling the hand of a friend on his right shoulder, the sentence "how do you feel?" and the deep sadness. Six months later our widower starts recovering slowly. One of his friend innocently put his hand on his shoulder and asks him :"How are you?" Unconsciously, a voice will say : " I was feeling fine until you reminded me I lost my love 6 months ago by reactivating this anchor..." Internally the chemical reaction will lower his mood for the day.
It is interesting to note that this somatico-psycological link will have in return an influence on the soma.

The Psycho-somatic memory :

This is maybe one of the most well-known links. The effect on the body from this type of link is very important. It is often classified as "stress". Stresses influence our body function greatly , by playing with our cardio-vascular system, our respiratory system, digestive system, immunity system, mental health and will also influence the musculo-skelettal system.

In practice we mainly percieve it through the musculo-skelettal, digestive and respiratory system. From my experience constant repetitive stressful situations tends to manifest itself by a general increase of the muscle tone. It means that generally muscles are more tense than usual. A good victim and barometer of the stress level is the diaphragm; stress generally holds the diaphragm in expiration limiting the expansion of the thoracic cage. Other good indicators of the stress level are the stomach and duodenum as well as the upper back and neck muscles (trapezius, levator scapulae, SCM, scalenes...). The way I would explain it, is that when the diaphragm is held in expiration, the thoracic spine is forced in a kyphotic posture. This kyphotic posture induces the posterior muscle chain (thoracic erector spinae, trapezius...)to contract constantly in order to maintain a relative balance. The lack of diaphragmatic expansion forces the accessory muscles of the respiration to increase their tonus. These muscles are the SCM and the scalenes. Their contraction allows the breathing to take place in the upper chest by raising the upper ribs. Another interesting effect of the kyphotic posture is that the shoulders rolls inward thus compromising their biomechanic.

In short the main complains of a stressed person are upper back pain, neck pain, headache, shoulder pain and thoracic outlet syndroms. Stress increases stomach and duodenum acidity thus resulting in gastritis or ulceration. The fact that these organs suffer can make the patient adopt the above posture. I can't say if these organ are always the direct/indirect cause of this adaptative posture.
We lost the track here ... where were we ? yes, we were talking about the psycho-somatic memory. So, is there a memory in there ?

Of course there is ! when the patient is clearly stressed because of his job, his symptoms don't go away as soon as he leaves his office. After a whole life of perpetual stress, the patient can become really rigid and his muscles really fibrotic.

Another example could be if you were involved in a car accident. I can promess that the first time you will get back into a car you will realise that your whole body is more tense than usual.

In fact this psycho-somatic memory can be more specific. if you had suffered from a relatively serious injury or trauma, months after the incident you will over protect the affected area. This over protection is accomplished by facilitating the contraction of protective muscles. The muscular tone is increased from a constant neurological firing. After years of over-stimulation the muscles become fibrotic.

This is how powerful is this psycho-somatic memory/reflex.

The somato-somatic memory :

Can a tissue have a memory by itself without involving the brain ?
Some may disagree but I will say : " Yes, of course !"

The memory will not be the same type of memory stored within the brain, but the memory will be a structural/mechanical memory on a cellular level.

After a whiplash, a repetitive trauma, an injury the structure of a tissue will be affected and that is a form of memory. If you suffered from a broken radius in your childhood, 40 years later an Xray will reveal an extra calcification; this is a structural memory of a trauma. If you suffer from a complete tear of a ligament, the memory is there, the ligament is gone.

Infact mechanical/chemical changes will take place around an injury which in the long run may affect the local vascularisation, the tone of the muscles and ligaments. Generally a sensation of density can be felt by the practitioner over an old injury. Dr John Upledger calls it : "kyst of residual energy".

This is where the concept of tensegrity take its place.(i'll come back later to this point in another post)

So far we have seen that :
1. to a physical trauma is attached to an emotion and a memory of this trauma
2. a "memory" of a mental trauma or stress can affect the physical body
3. a "memory" of a previous trauma can make us overprotective of the injured area
4. a physical trauma will affect the structure and therefore the function of the affected area, this is a structural/functional "memory" of an injury.

From these we can deduct that each traumatised or injuried area will be unique because of the unique psychological/structural/functional "memory" associated with it.

As each traumatised or injured area is unique we can understand that they will behave and react differently to the same external stimulus. Two different injured/traumatised areas will react differently to the same type of technique (same stimulus). Each "osteopathic lesion" has its own psychology.

If you have been brave enough to read until this point, you deserve a tea break...


Different bodytype, different psychology


The notion of different body types is a concept. I will discuss the bodytypes described by Sheldon. Sheldon distinguished three main bodytypes coming fom the three types of embryological tissues known as endoblast, mesoblast and ectoblast. Each one of these groups is associated with specific physical and psychological attributes.

-the ectomorph : is roughly a predominance of the element of restraint, inhibition, and of desire of concealment. Cerebrotonic people shrink away from sociability as from too strong a light. They "repress" somatic and visceral expression, are hyperattentional, and sedulously avoid attracting attention to themselves. Their behaviour seems dominated by the inhibitory and attentional functions of the cerebrum, and their motivational hierarchy appears to define an antithesis to both the other extremes.

In fact the ectomorph is not a physically strong individual. To "survive" in the world he cannot rely on his physical body but on his intellect. The ectomorph type has a tendency to intellectual over-stimulation and introspection.

The ectomorph is tall, long, thin, introverted, inhibited, quiet, serious...

-the mesomorph : is roughly a predominance of muscular activity and of vigorous bodily assertiveness. The motivational organisation seems dominated by the soma. These people have vigour and push. The executive department of their internal economy is strongly invested in their somatic muscular system. Action and power define life's primary purpose.

The mesomorph relies on his physical body and he is a man of action. He tends to be competitive, dominating and power seeking. They enjoy physical team sport.

The mesomorph type is muscular with large bones and strong ligaments. He is assertive, risk taking, adventurous.

-the endomorph : in its extreme manifestation is characterised by a general relaxation, love of comfort, sociability, conviviability, gluttony for food, for people and for affection. the viscerotonic extreme are for people who 'suck hard at the breast of mother earth' and love physical proximity with others. The motivational organisation is dominated by the gut and by the function of anabolism. The personality seems to centre qround the viscera. The digestive tract is king and its welfare appears to define the primary purpose of life.

The endomorph relies more on his digestive system. Life is not only about hunting and thinking but is also about eating and enjoying it ! The endo is a "bon vivant" as we will say in french.

The endomorph type is a social, loving, friendly, lively person and has a tendency to put weight on.

Osteopathic approach of the bodytypes

The following idea is easier to expose with the ectomorph and mesomorph type. Tom Dummer was using the functional/structural terms: Structural for mesoblastic constitution and functional for ectoblastic and endoblastic constitution.

In Osteopathy structural type of techniques are really effective on mesomorph patients while ectomorphs tend to react better to the functional techniques. Of course sometimes a functional approach is better to be used with a restriction of a mesoblastic patient and vice-versa.

It means that HVT/LVT ("cracking") techniques, GAT (general articulation techniques), deep soft tissue work, General Oteopathic treatment are the techniques of choice with the mesomorph patients.Whereas ectomorph patients have a good response with indirect functional techniques, Balance ligament tension techniques, gentle innhibition, fascial techniques, cranio-sacral treatment...

It also means that ectomorphs react a bit too much to structural techniques while the mesos are wondering what you are trying to achieve by touching their head lightly!

We said in the previous chapter that different bodytypes had different psychological profiles; let's make a comparison between the techniques used and the psychological profiles of these two groups.

Mesomorph :

gross psychological profile: vigorous, aggressive, competitive, dominating

type of technique: GAT, HVT, LVT, deep STW.

Ectomorph :

gross psychological profile: (hyper)sensitive, intellectual, introspection, inhibited

type of technique: gentle inhibition, functional techniques, BLT, cranial, fascial unwinding...

I don't know if we read the same thing but it appears to me that there is a disturbing correlation between the psychological profile and the technique used. I would even say that the technique used for each profile is the best psychological way to communicate manually with the tissue of the patient. Structural approach imposes a certain state to the tissue whilst the functional one listens and discusses with the body of the patient.

Now let's take a typical mesomorph patient : a rugby player or a marine soldier. How would you convince them about something ? How will you convince them to win a game or to fullfill their mission ? Will you use a diplomatic or an authoritative speech ? that's right an authoritative one : you will give orders, you will shout at them and you will have to be more dominating than they are. The structural techniques are authoritative, strong, "aggressive", dominating...

What about a typical ectomorph patient : a chess player or a computer "geek". How would you convince them ? How will you convince them that they should change their tactiques or their programs ? Will you use an authoritative or a diplomatic speech ? Of course a diplomatic speech will be the best approach in order to convince them step by step of the need to change their point of view ! The functional techniques listens to the tissues, follows their logic and gently influences them.

We saw in a previous chapter that tissues had a "memory" and a "psychology". Wouldn't it be logical that our osteopathic techniques were psychological manual techniques ? In this case each technique will be a specific psychological manual tool to communicate with the traumatised tissue of the patient. It would mean that one technique would be more suitable than another according to the psychological profile of the injured tissue...

In the next chapter we will try to give a psychological definition to the most common osteopathic techniques.

Psychological explanation of osteopathic techniques (Chapter in construction)

This part is HIGHLY subjective and I invite anyone to comment on it

In Osteopathy we treat the hypomobilities, the restrictions. We said that a traumatised tissue (a somatic dysfunction) had a certain psychology. In fact a traumatised tissue is "stuck" in a certain behaviour pattern (a way of thinking) because of a previous stimulus (trauma).

For a easier understanding we will say that the tissue thinks "A" when it is traumatised (traumatised=osteopathic lesions). The aim of a successful treatment is to bring this traumatised tissue which thinks "A" to a balance relaxed and open state of mind where it will think "B".

Let's try to understand and analyse the most common type of techniques :

The Structural techniques:

HVT: these are the "cracking techniques". Manual description of the technique :With this type of techniques we impose a quick and "violent" stretch against the restriction of the somatic dysfunction in order to gap the joint. A "crack" sound is usually synonyme of a successful maneuver. Within a few minutes the joint has gain a significant gain in its range of movement. Psychological description of the technique : we give an order to the joint by imposing a point of view exactly opposite to his. You think "A" and I order you to think "B"and I impose you "B", no discussion.

GAT (general articulation technique): Manual description : there is a notion of repetition with this techniqne. The aim is to mobilise a restriction by going against it. generally the grip is relatively firm in order to focus a "six degree of liberty"type of movement on the specific area and you . The technique is progressive, a slight pain/discomfort can be felt. It allows to smoothen up the restriction thus improving the mobility of the joint, especially fibrotic joints. Psychological description : there is a notion of repetition and progression in this technique while being in safe hands (the firm grip). It looks to me as if there was a coach encouraging, stimulating, brain-washing and overcoming a negative thought "A" to bring it to a point of achievement "B".

The Recoil (from the Mechanical Link, Paul Chauffour) : this is quite interesting one . Manual description : after 300 to 400 tests the practitioner finds THE primary lesion of the body and exert a recoil (a kind of precise flick) against the barrier of the restriction, and and you quickly remove your fingers from any contact with the body. Psychological description : the effect of a recoil could be like, questioning in a few words the patient about a deep rooted psychological conflict that he is victim of, bringing this thought from the unconscious to the conscious. eg: "did you accept the death of your father ? " the fact that your hands are not in contact anymore means that you don't want to listen to the reply, letting the patient to deal on his own with this issue. if the tissue thinks "A" the recoil could tell it : What about "B" ?

The functional techniques :

Indirect cranial/fascial and Balance ligament techniques : Manual description : the aim and philosophy of these techniques is to move toward the lesion in order to arrive at the still point. The still point is a point of relative calm (the eye of the tornado) where tensions are balanced. It induces a lack of proprioception coming from this area, the body react by changing the muscle tone or tensions in order to regain some afferent informations. The aim is to move from still point to still point until a balanced fluidic movement is felt. Psychological description: In these type of techniques the aim is certainly not to go against the will of the thought but to encourage it. The tissue thinks "A" ok, show me the idea, the concept, why are you like this ? why do you think "A"? why ? why again ? I don' judge you, i am not against you, I want you to show me why you think "A", what does it involve. Sometimes we don't really believe in it but we follow an idea (A) just to be in confrontations with others. The fact that others try to confrontate us on this idea make us react even more. this is the exemple of the donkey at the beginning of the post, the Donkey doesn't mind to get into the box, it doesn't want to be forced into ! or we could give another example : you need to leave and ask your child to come but he refuses to let go of his toy. Either you force him to let go of his toy and to come (big tantrum) otherwise you can say ok you want to stay here ? stay here but me, I am leaving. By leaving the child to what he thinks he wants, you avoid the confrontation, the child realises that he was looking for a confrontation not really being alone. As he sees you leaving, he quickly realises that he needs to follow you.

Another way to see it : if some one has a short sighted point of view on a particular subject, "A". Instead of contradicting it, you ask the reason why. Try to get to the bottom of his "A" point of view. There is a moment where the root of the idea "A" has no logical value. As soon as you will get to this unlogical root of the problem, the patient will logically analyse that it is unlogical. This realisation will start unwinding the whole misconception about this "A" idea leading the tissue toward a more balance "B" way of thinking.

Functional technique: Manual description : Our starting position is "in" the restriction and the aim of a well executed technique is to arrive to the opposite position of the joint without avoiding any conflict with the restriction of the lesion : "follow the ease, avoid the bind". Psychological description : the tissue thinks "A" and by using a step by step agreement we bring the point of view of the tissue to "B".

MET (isometric): manual description : we find the motion barrier of a muscle or a joint and ask the patient to push against our resistance with 30 % of his force. After maintaining the isometric resistance for 5-7 secondes, we ask the patient to relax. After 2-3 seconds we stretch the muscle/joint until the next motion barrier. This process is generally effectuated 3-4 times. Psychological description : This technique feels like you ask the traumatised tissue to express its "A" thought while you remain still. After the "A" thought is expressed then you conter-attack with a gentle opposite "B" view (stretch). The fact that your resistance remains still may express that you don't accept the "A" argumentation given by the tissue.

The concentric MET could express encouragement to the tissue we want to strengthen. The Eccentric MET could challenge the tissue we want to work on.

Fascial unwinding : Manual description : the practitioner contacts the tissue to unwind. It can be a fascia, a muscle, a joint, a limb or even the whole body ! The aim is give a positive feedback to the proprioception to the tissue to unwind allowing it to express itself. The patient may have the sensation that the practitioner is moving his arm (for eg) while in fact the practitioner just follow the movement that the arm of the patient wants to express. The fascial unwinding may look like a "Neurologic Symphony" as the movement described are very smooth and intriguing. You can adapt this technique to the whole body and relive a certain traumatic event such as a fall in the stairs, a repetitive fascial trauma (repetitive hammering for eg) or even re-live your birth! Psychological description : it is a sort of encouragement to the expression of a trauma by "mirroring" the information received.

The explanations that I give are purely coming from my own interpretation. If you disagree or have another "psychological explanation", I'll be happy if you could comment on this post.

Conclusion

As two different osteopathic lesions have a different cause and a different memory, the chance that they react the same to the same technique is inexistent. This can explain why a mesomorph may react better with a functionnal technique on certain of his somatic dysfunctions and visa versa with an ectomorph.

It is possible that there is more than a single psychological blockage with a traumatized tissue. This could be the reason why sometimes you need to use different techniques to relax a tension, eg : deep STW, functional inhibition and HVT.

It could explain why such studies to check if spinal manipulations are effective in acute lowback pain are failing. Maybe that some of the acute facet lock shouldn't be manipulated because it is not the "psychological" way to convince them to relax ! (Of course other reasons may certainly interact with the study : please report to the post "lower back pain, an osteopathic perspective")

It could also explain the example that I give at the beginning of the post. This patient reacted so much with a fascial unwinding technique because it was the technique needed to express this tension.

It is, I think, very hard to know which exact technique to use on which patient, and this comes from a practitioners experience, skill and an open mind; this is the art of Osteopathy. If the somatic dysfunction doesn't release with a technique , I urge you not to persist but maybe to communicate with it in a different way.

From my belief a very good Osteopath should succeed to detect and understand the causes of the patient's complaint and at the same time he should know which technique needs to be used to get the best release from this particular restriction.

6 comments:

Anonymous said...

HI Pierre

I just found your blog - great! I work at the British School of Osteopathy in London and you may liek to know that your blog comes at the top of the list in technorati!
Amanda

Pierre de Lasteyrie du Saillant said...

Thank you Amanda,
I am pleasantly surprised about that.
Thanks for our interest in this blog.
I still have to finish this post. I hope you will like it.
Take care,

Anonymous said...

Salut pierre,
Je vais écrire en francais car je ne métrise pas du tout l'anglais et en plus rien de telle que sa langue maternelle!
Je viens de prendre le temps pour lire l'article sur la psychologie des tissues, et je l'ai trouvé tres intéressant. Je pense que pour un ostéopathe il sera très difficile de traiter une dysfonction de type psycho-somatique car a mon avis la clée du traitement réside dans le patient (comme toujours, mais encore plus profondément cette fois), c'est a lui de trouver le traumatisme psychologique qui a pu présenté se bloquage. L'ostéopathe pourra peu être remttre le patient en face de se qui a pu provoqué le bloquage somatique, mais est ce que ca ne serait pas brusquer le patient? Est ce que cela respectera son rythme? Ceci est peu etre du domaine de la psychothérapie?

Merci pour ton blog, j'essayerais de lire tous les articles. Bon courage pour le reste monsieur supo.

Tonio de saint étienne

Fanciful Effusions said...

Hi Piere,

I found your post on "psychology of the tissue" really interesting as I enjoy working under that sort of philosophy. I'm a final year osteo student in NZ and I'm writing up a case study of a patient with Fibromyalgia. I used a GOT-type approach in an attempt to bring her body to a level of harmony. To my great surprise she experienced considerable relief after one or two treatments. My problem is, is that I need to back up why I did what I did! I was wondering if you know of any journal articles which deal with such an approach, as well as what you are talking about in your post. Unfortunately good osteopathic journals are few and far between and seem to be reluctant to publish on these more "airy fairy" topics.

I look forward to reading more of your blog!

Hayley.

Ronan said...

Hi Pierre

I enjoyed reading your article and look forward to more. I'm speaking at the Advancing Osteopathy 08 conference in February on the topic of using Internet technologies to further osteopathic education and foster collaboration. Your blog is a great example of this.

Keep up the good work.

Ronan
http://www.sacralmusings.com

Pierre de Lasteyrie du Saillant said...

Hi Hayley,
Just giving the name of a good book in which you may find some useful informations :
Osteopathy, Models for diagnosis, Treatment, and Practice.

from Jon Parsons, and Nicholas Marcer, Churchill Livingston Elsevier 2005
ISBN :0443073953
Good luck for your exams,

Pierre