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F.O.M. (Fear of Movement) and Changing Context.

Do your patients suffer from F.O.M.? (Fear of Movement)… ? Is motion of the painful body part approached as if a heated game of Jenga is coming to closure? Maybe this is anxiety induced because of iatrogenic “nocebo” from their MD (i.e. “your spine is crumbling” or “you slipped a disc”) or maybe their pain levels are cautioning them to go slow. Either way, movement is a necessity for tissue health, and getting it can require a bit of tact.  

In longer lasting pain, pain circuits can become linked to specific movements. Louis Gifford (if not aware, strongly recommend his “Aches and Pains” series) has a saying “Circuits that fire apart, wire-apart.” Post injury, nerves are already mechanically sensitized, thus even simple movements can be approached forebodingly. Especially in the context of a therapy session: the therapist watching them, the patient hyper focused on every little sensation from their body, ready for fight or flight. This scenario doesn’t help the already sensitized tissue, and often seems a set up for failure. Often the target area that most needs to be reached, and introduced to simple movement to reduce tissue hypoxia, desensitize tissue, and give the patient hope, is heavily tapped off in caution tape.

This is where a therapist can be creative, in setting a context as well as an explanation of symptoms that allow the patient to see things through different lenses, and perhaps change the way they process their movement. Education on the effects of immobilization may come into play (Butler et al (2000) studied 21 normal immobilized wrists and found increased mechanical sensitivity, stiffness, abnormal sweating, often pain, and this was just 4 weeks…) and other studies note immobilized joints lead to a chemical change, tissue breakdown, and arthritic like environment. So maybe its best to keep moving!

Attempts should be made to reduce anxiety fear, and to promote relaxation during simple movement. One way Louis Gifford like to “wire-apart” pain circuits associated with neck movements was with what he called “window shopping.” He describes a patient walking, fixing their gaze on an object while keeping their torso forward and continuing to walk slowly forward, thus getting indirect cervical rotation. You may get a lot more movement here then in the context of them sitting in the chair while you hover over them, guiding them with sweaty hands. It changes the context a bit, and your patient may realize they just rotated a lot further than they had before, as the focus had shifted, and thus the body’s response also shifted. This can be an exercise!

In the above example, a patient may work on left cervical rotation in a novel way. 

In the above example, a patient may work on left cervical rotation in a novel way. 

In the above example, a patient may work on left lumbar rotation in a novel way. 

In the above example, a patient may work on left lumbar rotation in a novel way. 

One way to utilize the Motion Guidance visual feedback in clinic in this sense is to promote desired mobility in a different context. For example, a cervical patient can center the laser in target, and try to keep it there while slowly rotating their torso left or right. Lumbar mobility may be achieved in push-up position at the wall, and rotating from bottom up (rotating from pelvis) while tracking the laser to visualize the movement excursion. This may mix things up with the way your patient processes movement, and may open a window for increased ROM in a new context. 

-Tal Blair, DPT

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