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Published Articles: Chronic Spinal Pain and Dysfunction
Trager Psychophysical Integration
Phil Witt is an assistant professor in the University of North Carolina's Division of Physical Therapy, a Trager Practitioner and a practicing therapist with Piedmont Rehabilitation Services-Division of Physical Therapy.
This article presents an overview of one physical therapist's successful experience in combining the techniques of Trager Psychophysical Integration with traditional physical therapy intervention for the treatment of chronic spinal pain and dysfunction. Some of the problems surrounding the current treatment of persons suffering from chronic back pain are discussed. Trager Psychopysical Integration is defined and the procedures and processes of the technique are described.
The benefits to the patient and therapist are reviewed prior to the description of a case study report of one patient's experience with this treatment intervention.
Just ten years ago few physical therapists were interested in concentrating their practice on the treatment of chronic pain. Our success rate was not high and we too easily labeled people in long-term pain as “chronic pain patients”. That label conjured up the image of malingerer, the quack, the workman's compensation case, the lawsuit, and the psychological cause of the pain. All these scenarios do exist, but the physical therapy profession is finally accepting the fact that most chronic pain has a physical origin that needs to be addressed with physical intervention. These patients may also have a psychological problem that is aggravating their condition or that predisposes them to injury, that also needs to be addressed successfulIy. Trager Psychophysical Integration combines a primarily physical approach and accomplishes psychological changes as well.
Treatment of people with chronic back pain is a complex and difficult task. The paucity of sound clinical research on the efficacy of various approaches combined with the difficulty in accurate diagnosis have led to a myriad of treatment approaches proffessed by a number of health professionals and non professional “healers”. The result has been both good and bad.
Patients have tried many unfounded treatments in hope of relief from their pain at times to their detriment. At the same time, physical therapists have expanded their scope of traditional training to learn some worthwhile techniques. Over the last ten years, to treat spinal pain they have accepted numerous techniques as being useful such as mobilization, manipulation, deep tissue massage, muscle energy, craniosacral techniques and Feldenkrais awareness through movement and functional integration.
All of these techniques have added to our ability to help the patient with back pain and have led physical therapists to become much more interested in treating this population. Our treatments have become more successfull as indicated in the article, “Physical Therapists Score High in National Survey on Back Pain Relief” (Progress Report 1986).
One technique I have found to be of tremendous benefit is Trager Psychophysical lntegration, a unique and gentle technique for improving movement dysfunctions. It assumes that the therapist merely provides the learning tools and gives the appropriate physical and verbal movement cues for the patient to change movement patterns for the better. It utilizes gentle, passive movements that emphasize rotation and traction and a system of active movement termed “Mentastics® “.
The most unique component of the Trager work is the attitude and Ievel of concentration of the Practitioner. The work requires the therapist to be able to clear his/her mind of everything except the patient. Effort, force and trying hard are counterproductive. The therapist works within the patient's pain free range and provides a sense of how it feels to be able to move freely and painlessly. The Mentastics are designed to augment and eventually replace the need for the passive tablework.
There is a real difference between doing the movements that make up the Trager work and “Tragering” someone. This concept sinks in about the 90th treatment. It takes time to learn that the less one tries to help the patient get better, the more progress is made.
In the following case study be aware that it is very difficult to describe a series of movements that adapt constantly to the reaction of the patient. This work, like other similar work, is learned by doing under the supervision of a trained Instructor who can relay not only the technique but also the sensory experience of the therapist that goes along with the work.
Mentastics is best described as gentle free flowing dance-like movements whose main goal is to increase the patient's self awareness and provide the patient tools to increase his/her ability to move and control the pain. A variety of Mentastics can be used and combined with awareness through movement lessons to enhance the outcome.
The unique feature of Mentastics (and the passive tablework) is that instead of requiring the patient to control the movements as in regular exercises the patient is encouraged to “let go”. In practice this means that the patient is instructed to initiate a movement and then to let go of the muscle tension and allow the weight of the body part to carry the motion to completion. The better the patient becomes at this the larger, the freer, and more effective the movement becomes.
Typically patients feel a little foolish at first; however once they begin to feel some relief from the pain and stiffness that has been plaguing them for years, they start to loosen up and enjoy doing the exercises. At this stage the therapist no longer has to encourage patients to comply with the active movement component of the treatment program. Ordinarily, it initially takes about two weeks for them to really get the idea of what they are supposed to do. Once this has happened they learn new movements very quickly and begin inventing their own.
Patients should not be given a quota on how often or how many movements to perform. In the early stages the movements should be done three times per day for about ten to fifteen minutes each session. They should be told from the start that if they do these movements gently, freely, and painlessly, they can do as many as they would like to and that the more they do, the better their progress will be.
The tablework consists of a series of gentle painless movements that resemble general mobilization techniques. On one level that is how this approach works. There are quite a few grade 2-4 rational movements and a fair amount of manual, cervical and lumbar traction incorporated in the patterns. On another level, the work acts as a relaxation technique. The gentleness and the extensive body rocking that takes place, allow the patient slowly to give up muscular and mental control and sink into a very deep state of relaxation not unlike that experienced in hypnosis. On the third level the Trager work acts as a movement re-education tool much as does the Feldenkrais work. The technique is different but the purpose is the same.
When these means of change--mobilization, relaxation, and movement re-education -- are combined the entire neuro-physiological makeup of the patient changes. Not only do they experience relief of pain but they experience a re-integration of their body parts and a re-introduction of their mind to their body. For years these patients have had a running feud between the pain their body was producing and the mind that was trying to suppress the awareness of this pain. It is a fairly emotional and wonderful experience for the patient to realize that his/her mind and body can function together to affect positive movement change. In these patients it is not uncommon to experience significant improvement in their psychological well-being.
Trager Psychophysical Integration is easy to do and is fun for both the therapist and patient. It is almost too easy to perform, like putting together an erector set (“so easy that only a child can do it”). The work is very basic. It does require that the therapist be in a state of relaxation. It requires that the therapist give up the notion that it is he/she who is doing the work, who will cure the patient. People today are very much in tune with all that is bigger, better, and faster. It is sometimes difficult to let go of that pace and just feel the weight of your patient's head and the subtle changes in muscular force and react to these subtle changes without frustration and without thinking “Oh would you just relax, please.”
A 50-year-oId professional male came to me with a complaint of chronic low back pain. He had seen an orthopedic surgeon in the past who told him that he had a lumbar disc problem. He had been seeing a chiropractor once a week for several years for an adjustment that made him feel better for a few hours. He had had this problem for about five years.
It was significant enough that the patient was unable to do the things he liked and was angry about the limitation, but he could function at his job, which was intellectual and required little physical effort. My evaluation indicated that this person exhibited spinal and pelvic movement dysfunction and that any attempt to correct an underlying cause to the pain would be futile without first re-establishing this person's ability to move his spine and pelvis in a free and integrated fashion.
A series of Mentastics was instituted which included such movements as:
There are many other Mentastics for all spinal levels.
The tablework consisted of gentle rotational movements with traction performed first on the neck then the legs, abdomen, chest, back, and shoulders. The entire body was worked on because this person had adapted his entire movement pattern to accommodate the years of pain. The first session lasted approximately an hour and a half. Subsequent sessions lasted an hour or less. Because of our schedule, our treatment sessions were not regularly timed. However over the next month, I saw this man six times. Each time the tablework was performed, and the number of active movements that the patient was to perform at home was increased. This patient was amazed that after all of this time someone had something to offer that he could do for himself. After one month of work the patient was free of pain, his ability to move had increased dramatically, and his anger level had reduced significantly.
The patient continued to exercise and remained pain free. Over time the patient slowly stopped exercising and maintained a pain free status. Approximately one year later, the patient had a weight lifting accident and reinjured his back. He reinstated the movement program and successfully took care of his back by himself.
This is one brief case study demonstrating a patient in which Trager Psychophysical Integration was an effective basis for treatment. The reason that physical therapists should be familiar with this approach is that understanding of the Trager work will improve the use of all of the other techniques used. The therapist may find out that they work in a Trager-like fashion now no matter what treatment they are using. Knowing the Trager system, physical therapists will increase their sensitivity to musculoskeletal changes in the patient's condition, which will lead to a different approach to patient care in general.
This article has been reprinted with permission of Whirlpool, a physical therapy journal. It appeared in their Summer, 1986 issue.
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