Barrett L. Dorko, P.T.
There is a certainty common to many of those who focus on manual means for pain relief: we are certain that the body naturally and perpetually moves in a way that promotes health and optimal function (called inherent movement). This motion is often easily observed, but at times is only palpable. We are certain that our methods of manipulation should take this movement into account, and thus we typically employ our hands, not in an effort to create shapes or impose forces, but as instruments of perception and communication. First and foremost, we look for and ultimately trust the movement that is our inheritance, and we encourage its greater expression.
This brief article is intended to examine the nature of that movement and its manifestation in the clinic. Though inherent movement has long been described in the osteopathic literature, this author feels that its origins and purpose may differ significantly from that previously proposed.
We live close to the lighthouse by the sea and view the water of the Pacific day by day; and even when we do not see the sea we feel its presence. ~ William Garner Sutherland, 1951
Perhaps the most compelling example of the study of inherent movement in the Osteopathic tradition is seen in the voluminous work of William Garner Sutherland, the originator of Osteopathy in the Cranial Field, whose career extended from 1900 until his passing in 1954. A collection of his writings compiled in Contributions of Thought,1 produced under the auspices of The Sutherland Cranial Teaching Foundation, reveals an adherence to the central notions of cranial bone mobility and fluctuations in cerebral spinal fluid pressure. Sutherland felt that this movement was primal, rhythmic and that its restriction was palpable, valid and reliable. His life’s work was centered on its interpretation and gentle manipulation. Many subsequent studies have concluded that his observations were in error,2,3,4,5 though none go so far as to say that his method of management had no effect upon his patient population.
In this article, an alternative concept will be put forward that explains this movement. Further, a theory of correction compatible with the clinical observations of many who listen to their patients with their hands will be presented.
Ideomotor movement (Ideomotion)
Ideomotion can be described as actions, or muscular movements, which are automatic expressions of dominant ideas, rather than being the result of distinct volitional efforts. Examples include the act of expressing the thoughts in speech, or in writing, while the mind is occupied in the composition of the sentence. Though it is rarely spoken of in discussions about human movement, descriptions of ideomotor activity are present in the medical literature beginning in 1852 when a lecture by William Carpenter was reprinted in The Proceedings of the Royal Institution. Carpenter identified ideomotion as a third category of nonconscious, instinctive behavior, which also included excitomotor (breathing and swallowing) and sensorimotor (startle reactions) activity. Ideomotor movement is secondary to thought, and it begins in the cerebrum. The discovery of its presence, and descriptions of intricate studies demonstrating its manifestation conducted in the 19th and 20th centuries, can be found in Hermann Spitz’s text, Nonconscious Movements: From Mystical Messages to Facilitated Communication.6
In short, ideomotor action is well documented and the reality of its presence has never been refuted. Instead, it seems simply to have been forgotten. As renowned psychologist Ray Hyman states, “Although the effects of ideomotor action have been understood for at least one hundred fifty years, the phenomenon remains surprisingly unknown, even to scientists.” It would appear that Sutherland was one of the scientists distinctly unaware of ideomotor activity despite the fact that it was written of in some detail by William James, a contemporary and highly regarded psychologist and neuroscientist. He wrote in his classic text, Principles of Psychology:7
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. (Authors emphasis)
I can only presume that Sutherland’s inattention to ideomotor phenomena was the consequence of his fervent belief in cerebral spinal fluid fluctuation and his insistence that the secrets of normal and abnormal functioning lie in careful study of anatomy. As he said many times, “Anatomy, properly understood, invites intelligent application.” I can see no evidence that Sutherland was a fan of psychology.
Another potential example of ideomotor activity being observed, but incorrectly labeled, is the movement palpated during so-called ‘fascial unwinding’ techniques. During these techniques, the practitioner initially induces motion in the body with their hands and then ‘listens’ for the subsequent, inherent motion of the body. This movement is not directed, but rather is followed as the body is said to ‘unwind’. After a period of time, the movement ceases and the unwinding is said to have completed. Various theories have been put forward to explain this phenomena, including the concept that the fascia has a memory of stored potential energy that is released during a fascial unwinding session. Ideomotor activity may be the best physiological explanation for this palpated, non-volitional movement.
Robert Ward makes mention of inherent tissue motion in the text Foundations for Osteopathic Medicine8 in his chapter on neuromusculoskeletal and myofascial release. He states:
“Inherent tissue motions are palpably evident, asymmetrically patterned, neuroreflexive activities in the soft tissues. They constantly move, often at variable rates. Palpation that focusses on these motions should readily identify patterns of shifting asymmetric tightness and looseness.”
Ideomotion as therapy
In order to demonstrate how ideomotion may be incorporated in to the clinic, it is necessary to describe some common experiences. Imagine being desperate to speak but fearful of doing so. A common consequence of this situation will be an isometric contraction of the muscles that drive speech. Humans are capable of suppressing the isotonic contraction of these muscles for prolonged periods, perhaps indefinitely, and will do so if fearful that their speech is in some way unsafe, unacceptable or harmful to others. Some people speak anyway. In many cultures the permission to speak freely and to verbally express ourselves in an authentic manner is recognized as an essential aspect of mental health. We encourage it, make laws to protect it and, if necessary, train professionals to recognize and elicit it from those who need to do this in order to resolve psychological issues. From a physical perspective, the chronic isometric contraction of the throat and jaw is probably the easiest way to identify someone who needs to speak, yet we discourage their verbal expression at their peril.
Now imagine being desperate to move some part of your body other than your mouth, but being discouraged from doing so due to cultural restrictions that are imbedded in the educational systems and social customs of your society. How easy would it be to overcome such obstacles? My thought is this: if pain arises from sufficient mechanical deformation of various tissues and/or a lack of adequate blood and lymphatic flow through these tissues (a reasonable assumption), and if the movement required to reduce that deformation is not permitted because of cultural norms to the contrary, wouldn’t the body respond with an array of isometric muscular activity? This is the “antagonistic representation present simultaneously to the mind” spoken of by William James.
According to the fairy tale, the emperor paraded naked before his subjects until at last a small boy proclaimed loudly that he had no clothes. What might we have seen or palpated in the throats of those assembled prior to the boy’s announcement? I presume a small boy said this because he was less likely to be restricted in his expression by the surrounding culture. Given time, he too would have remained silent. Similarly, someone desperate to move a body part in an effort to resolve some mechanical deformation is traditionally encouraged to move only within the parameters choreographed by another and additionally admonished to adopt an attitude of erect stillness whenever possible. Such instruction suppresses the spontaneous, unique and effortless qualities always seen in ideomotor activity. The very instinct designed to resolve mechanical deformation is thus held at bay and the consequent increase in isometric muscular activity is epidemic: heavy exercise and manual manipulation have a negligible effect on the overall situation.
Perhaps clinicians like Sutherland gained a sense of ideomotor activity by simply using their hands in an especially non-provocative manner. It has long been my experience that such an approach to palpation is absent from the teaching of manual skills in physical therapy, primarily due to an ignorance of ideomotor activity and its purpose. I am suggesting that this motion is not merely designed to express us in an artistic sense or to telegraph our intention to move consciously, but that it is also the primary means through which we acquire comfort via a reduction in tissue deformation. The shifting we do when we stay in any prolonged position is a simple example of this. For example, when sitting, it is common to slightly shift the weight from one buttock to the other; or in standing, from one foot to the other. These are both customarily movements without volition and represent ideomotor activity. There is no reason for this movement to be especially rhythmic or predictable and, in fact, its surprising and chaotic nature is probably the very thing that makes the surrounding culture uncomfortable with its expression. Small children pursue it quite fully until admonished to “sit still and sit up straight,” often by someone they wish to please. Thus begins our lifelong distrust of instinctive, corrective movement. For thirty years I’ve watched the therapy community collude with the culture in this matter, and I feel that our notoriously poor record at reducing chronic pain is a reflection of that.
Manual techniques designed to elicit the expression of ideomotor activity are not, in my experience, difficult to master. The touch itself is gentle and non-coercive. The goal of the clinician is simply to make the patient aware of internal motor activity and then get out of the way of that movement. They do so by offering that activity the slightest bit of resistance, not enough to retard its expression, but enough to give it something to oppose and thus be reflected; for example, the beating of the patient’s heart might be opposed with your hand placed gently on their chest wall. The attitude of the practitioner toward the consequent movement, and it might be quite a large and powerful one, should be quiet acceptance and interest, not unlike the attitude adopted by a counselor once they’ve created an environment conducive to authentic verbal expression. If helpful, it is likely that the one counseled will be surprised by what they say, and so it is with ideomotion. After all, both come from the unconscious mind and only the patient knows what they will be. One the culture encourages, the other it regards with distrust and disapproval. As I’ve said to countless patients, “When they say, ‘It’s a free country,’ they mean you can move your mouth-they don’t mean you can move your body.” Invariably they nod with understanding and realization.
Finally, I would like to emphasize that ideomotion is characterized by four easily recognized attributes:
• muscular softening, and
The muscular softening I attribute to the customary response of any muscle to full expression (think of the softness of the throat once you’ve spoken your mind), and the warmth to an increase of blood flow. To my knowledge nothing else would account for this and the only motion likely to produce such a thing is one that reduces painful mechanical deformation of tissues. The effortless and surprising qualities of this motion are both characteristic of instinctive and unconsciously motivated movement; and this is the definition of ideomotor action.
Ideomotor activity may provide an explanation for clinical phenomena seen and documented for many years, phenomena that may very well have been misinterpreted. The therapy community has typically assumed that the ablation of inherent muscular activity would lead to rest and recovery. Conversely, manual care that encourages its full expression with permission and understanding is reasonable and potentially harmless. Clearly, it adheres to the traditions of osteopathic care in its original form.
1. Sutherland WG. Contributions of thought: the collected writings of William Garner Sutherland, DO: pertaining to the art and science of osteopathy including the cranial concept in osteopathy covering the years 1914-1954. 2nd edn. Portland, OR; Rudra Press: 1998
2. Hartman S, Norton J. Interexaminer Reliability and Cranial Osteopathy. The Scientific Review of Alternative Medicine. 2002; 6(1): 23-34.
3. Rogers J, Witt P, Gross M, Hacke J, Genova P. Simultaneous Palpation of the Craniosacral Rate at the Head and Feet: Intrarater and Interrater Reliability and Rate Comparisons. Physical Therapy.1998; 78 (11): 1175-1185.
4. Moran RW, Gibbons P. Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum. Journal of Manipulative and Physiological Therapeutics. 2001; 24(3):183-90.
5. Schleip, R, Neurobiologic aspects of the cranial rhythmic impulse http://www.somatics.de/cranial.htm . Accessed September 2003.
6. Spitz H. Nonconscious Movements: From Mystical Messages to Facilitated Communication. Manwah, NJ: Lawrence Erlbaum: 1997.
7. James W. Principles of Psychology. New York; Holt: 1890.
8. Ward RC. Neuromusculoskeletal and myofascial release. In. Ward RC. (ed) Foundations for Osteopathic Medicine, 2nd edn. Philadelphia; Lippincott, Williams & Wilkins: 2003: 934.