Rumination - Part II

Barrett L. Dorko P.T.


The body learns to recognize its own
When foreign touch invades familiar space,
And weight of stillness echoes down the bone.

When fathoming what subtleties of tone,
Hands eloquent with caring rest in place,
The weight of stillness echoes down the bone.

from "The Weight of Stillness" by Joan Altick


I wrote in Part I of this essay about causal modeling for fibromyalgia and how it predicts and explains the emergence of this condition following an accumulation of concurrent events and processes. The usefulness of this model for physical therapists lies in its offering several factors that might be altered with the help of our expertise.

A causal model appears much like a ladder, the topmost rung (in this case, "traumatic events") contributing to the presence of the next and so on. It is possible for some of the higher rungs to enhance the presence of several lower ones, or for lower ones to perpetuate the presence of those above.

In the model for fibromyalgia, inactivity and deconditioning occupy the lower rungs, and it is here that the majority of our current care is concentrated, and reasonably so.

But as someone who mainly employs manual care for painful conditions, I need another level for intervention, and I think it is higher on the ladder. This is why I'm drawn so strongly to the factor of rumination.

Consider this. If I were playing high-stakes poker in the company of experienced opponents, I would soon become aware of the fact that my thoughts about my cards were somehow visible to them. I would have to struggle to hide my physical inclinations, and I would probably be unsuccessful.

Thoughts carry with them some physical correlate, some manifestation of how they might be expressed. And I am certain that within the depths of rumination lie some movements that can relieve pain.

I say this because it makes sense that a living body would carry with it always some capacity for self-correction, and that this would be largely unconscious and effortless. Such activity would account for the spontaneous relief of pain secondary to mechanical deformation that most people experience. Doctors know it's there. That's why they tell people to wait a couple of weeks before they consider going for therapy.

To me, rumination implies a physical stillness that is distinct from obsessive compulsion, and I'm glad the causal model chose this word. If given full rein, rumination might lead toward a creative thought, a thought that lends new light to a particular situation, changes the way we feel about it and react to it.

If our rumination is not honored as possibly productive, if it is dismissed in favor of routine activity, it will only provide us with the mental treadmill known to depress us and confine our movements.

But if our thoughts carry with them some subtle movement, or, at least, an isometric contraction, it might be possible for a therapist to sense that. If this is not interpreted as inappropriate, but rather as the beginning of correction, manual technique could be designed to allow its growth. I call this "simple contact." If parasympathetic tone grows along with it, we are assured that this movement is what the patient needs, even if it is not entirely painless.

This movement is a creative act, and thus very easy to extinguish with judgment or external direction. I'm convinced that this is why most therapists never see it. They see the inactivity as part of the problem. But every word begins in silence, every dancer with an empty stage, every writer with a blank page.

I'd suggest you look for and enter the stillness that your patient's rumination must be producing, even if for a moment. Encourage it to grow in its own unique way toward a movement that is as surprising as a comment from their heart.

When I don't interrupt my own ruminating with routine and dutiful preparation, it grows into a creative and, for me, therapeutic movement of my hand. This essay is simply an example of that.

Enter the causal model for fibromyalgia at a higher level, and with manual technique that reveals self-correction. You might find that your patients arrive not only with the problem, but with the solution as well.