Rumination - Part I

Barrett L. Dorko P.T.

ruminate; to ponder repetitively, to chew over and over

I often sit quietly and mull over an idea for a column. Sometimes I waken with something nearly formed in my head and this remains constant as long as I lie quietly. Moving too quickly into my morning routine will disrupt it, and perhaps make it disappear.

I read a remarkable article recently that suggests excessive rumination may be an important contributing factor leading to the syndrome known as fibromyalgia.

Let me explain.

In "Causal Modeling and Alternative Medicine" (Alternative Therapies March 1997, Vol.3 No. 2), Schuck, Chappell and Kindness write of the problems that biomedicine has with multifaceted, chronic conditions, and how alternative medicines might play a useful role here through their emphasis on disease prevention and quality of life.

They detail the fundamental notions of causal modeling, and its ability to help us understand the origins of certain syndromes. Very simply put, the statistical relation among the various conditions or events thought to contribute to a syndrome are carefully considered, and then those that are found to be essential for production of the syndrome are included. Typically, one or more factors lead toward others, which in turn lead to more until the condition can be said to exist.

The authors use fibromyalgia as an example of a diagnosis that lends itself to causal modeling, citing the relevant research indicating that it is a multifactoral and chronic syndrome for which there is no known specific cause and for which treatment is commonly ineffective. It is clear that they view this less as an entity possessed by the sufferer, and more as a state of being. I agree.

The factor in their model that drew my attention was that of rumination. They point out that this repetitive thought process following "traumatic events" can lead to depression, sleep disturbance and inactivity, three other essential elements in their model of fibromyalgia. Since women are more likely to ruminate, while men tend to distract themselves with physical activity (this is backed by psychiatric research), the condition develops far more commonly in females.

My personal experience as a clinician seeing patients with this diagnosis has been that simple naming of the condition in this way provides few clues about how to approach care. This is largely due to the fact that fibromyalgia is a nominal, and not essential diagnosis.*

Looking at this model, I found myself fascinated by the identification of rumination as an important and early element in the sequence of factors leading to the syndrome.

It stands to reason that any physical therapist could help such a patient with an appropriate regime of exercise to offset their inactivity and deconditioning. That's easy. Unfortunately, it doesn't relieve pain as much as we would hope.

The model made me realize that I could describe manual care that intervened at the point of rumination. By this I mean that the stillness of this potentially creative process might be encouraged to become a movement toward correction, toward a reduction in the mechanical deformation responsible for the pain.

Such a movement would contain the qualities of effortlessness, spontaneity and parasympathetic increase that are not common to most choreographed regimes of exercise. Maybe that's why these regimes often fail to relieve pain.

I have for years sought to manually gain access to the moment of stillness that can be palpated in virtually all patients if our approach is gentle and accepting. Now I understand this technique as a method of intervening in the causal model at a high level.

There will be more about all of this in my next column: Rumination - Part II.

*See "Incantation" by Barrett L. Dorko Copies available from the author