On mammalian play, training for the unexpected and its application in physical therapy.
In my teachings, I’ve been advocating play and playfulness as a therapeutic tool for many years now. Recently I found two articles on mammalian play that have increased my confidence in using play for people with pain/injury. Both articles focus on play in mammals, non-human mammals that is, but do not talk about the relevance for the clinic. That will be the goal of this article: another plea for using more play in your therapy…
The two articles are:
Spinka et al (2001) Mammalian Play: Training for the Unexpected. Quarterly Review of Biology
Petru et al (2009) Revisiting play elements and self-handicapping in play: A comparative ethogram of five Old World monkey species. Journal of Comparative Psychology
But first, let me point to some problems I see in physical therapy and rehabilitation:
Humans, although all are homo sapiens, are not the same.
We don’t really know what consists ‘ideal movement’.
What we know about ‘ideal movement’ appears to be difficult to test.
If we want to change movement patterns, we are stuck with the problem of skill transfer: there is minimal skill transfer between the exercise done and real life.
Therapists typically underestimate the complexity of the real world, of the complexity of movement tasks, and of the complexity of the human organism.
Patients more often than not dislike exercises.
Let us see how these articles can help us address these problems…
Biologists agree that play may indeed appear purposeless (Bekoff: “Play is all motor activity that appears purposeless”), but ultimately serves a increased Darwinian fitness. Its adaptive value is proposed to be the preparation of the animal for real life, the learning of skills that are necessary to survive and reproduce:
“One striking feature of animal play behaviour is that it contains elements closely resembling behavioural patterns used in non-play behaviour during prey capture, food acquisition, predator avoidance, aggression, escape and/or sexual behaviour.”
This is the more or less well-known function of play: Play is learning! And learning should involve play! This may seem so logical, even obvious, one wonders why it is almost totally absent in the rehabilitation world. If we want our patients to learn something, it should involve at least some playfulness!
So, play can involve doing ‘normal things’ to learn to do ‘normal things’. But play also involve ‘abnormal’ behaviour, that does not resemble normal (adult) behaviour. This includes things like self-handicapping:
“Actively seeking and creating unexpected events, deliberately relaxing control over movements or actively putting themselves into disadvantageous positions and situations.”
The authors of the articles suggest that this is to train for the unexpected.
“We propose that play:
Results in increased versatility of movements used to recover from sudden ‘gravitational’, ‘kinematic’, or ‘positional’ shocks such as losing ground underfoot, falling over, being knocked over, being pinned down, or being shaken vigorously; and
Enhances the ability of animals to cope emotionally with unexpected situations. These may include both locomotor shocks and psychological shocks.”
Animals know better: the world out there is complex, the things you do are complex and your organism is complex too, so there’ll be a lot of unexpected things happening in real life, and they train for it, through play! They play and use self-handicapping to further increase their capacity to live in the real world! Kids know this too. Adults and therapists treating human animals seem to have forgotten this truly ancient, ancestral and original wisdom…
I admit, play can be a bit strange and out of the comfort zone, both for therapists and patients. That’s why it is interesting to look at something that often is considered a part of play, but by the authors here is suggested being a bit different, although closely related, to play: exploration.
“Exploration can be viewed as a serious counterpart to play. During an initial encounter with a novel environmental feature, animals first investigate it through ‘serious’ exploration, examining whether it is dangerous and whether it has any resource value to them. If they find the novel feature to be relatively non-threatening, play may follow.”
“Though exploration is often associated with play, it differs from play in three aspects:
Exploration may be to learn how to avoid getting into trouble by gathering information
There is no deliberate self-handicapping in exploration
Exploration is more closely associated with fear and perceived danger (compared to the more relaxed and secure state of play).”
Now, from a clinical point of view, that’s very interesting. We want our patients to learn how to avoid getting into trouble. People with pain (especially long lasting pains) are known to associate movements with fear and perceive them as dangerous.
This makes movement exploration a very useful clinical tool! This kind of exploration I would suggest using makes use of the following (in random order):
careful, gentle movements,
probably rather slow,
full attention to the task at hand,
a safe environment,
a safe movement task,
not pushing too hard in the perceived danger zone,
varied movement (exploration is not just taking one look at something!)
I think exploration occurs in the zone where fear and curiosity meet.
If you explore, you will find things that are dangerous, but because of the way exploration occurs, the negative consequences will be minor, the lessons learned interesting. If a patient explores movement, he/she will almost certainly find out some things that are (perceived) ‘dangerous’, but because of the relatively safe context and the improbability that losing control will have serious consequences, the fear is kept low, injury is unlikely to occur, and the lessons learned will be interesting.
“If they find the novel feature [the thing/movement explored] to be relatively non-threatening, play may follow”.
After the explorative phase, comes play. Why again? Because you really, deeply learn something through play. And self-handicapping actions even enhance the training for the unexpected. Can therapists learn something from self-handicapping non-human animals?
Let’s take a better look at self-handicapping play elements, categorised in one of the studies like this:
Effort restriction (e.g. when a stronger animal restricts its strength or skill)
Selecting a superior partner
Disadvantaged position towards a partner (e.g. when an animal play-fights starting on its back)
Physically demanding movement and postures (e.g. play fighting on your knees, for quadrupedal animals: on two legs)
Selecting a demanding substrate (e.g. a slope, a wobbly branch, a slippery surface)
Carrying an extra object (that is not the focus of play, therefore occupying a hand/mouth)
Restriction or deteriorating sensory perception (e.g. eyes closed, head rotations and spinning)
I think the social self-handicapping is mostly appropriate in play like rough-and-tumble games, with (a) partner(s). I do use these in my therapy, but the self-handicapping is mostly done by the therapist, or the ‘healthy’ partner.
Sensory self-handicapping is something I think all therapists do, at least some form of it: closing the eyes and moving the head in balance training. Maybe it is also something to do in other skill training? Animals often use spinning in play, as do children: swinging, rotation, sliding, and lots of things you find at playgrounds. I’ve not really used this in therapy, maybe I should explore this in the future…
Kinematic self handicapping is the form I tend to use the most. I’ll give some examples, applied to a movement assignment I use quite often: getting up from the floor (either some lying or sitting position):
Imagine a part of the body is injured and thus cannot take support (or at least only minimal) in getting up from the floor: don’t use that leg/hand/knee/elbow, don’t use both hands, only use one arm and one leg, ipsi- or contralateral, …
Catching a ball (or something else) thrown at the patient who’s lying or sitting: the same getting up movements, but more reactive and quick (adjustments possible, e.g. no bounce, 1 bounce, just as quick as possible). So catching from a disadvantageous position.
For the above movements, I often suggest making use of different surfaces: tiles, wooden floor, carpet, yoga-mat grass, bed, pillows, … If they have access to a slope, I stimulate them to incorporate it: getting up uphill, downhill, perpendicular, diagonally. If we move through space, I’ll put things on the floor not to touch, or only allowed to touch: e.g. catch the ball, but the floor is lava, or don’t touch those balls on the floor (or other things deliberately put there).
Carrying an extra object (any kind really, not only weighty ones), in all possible ways, is also frequently used: in one hand, two hands, on the shoulder, carried like a baby, on the back, overhead, …
Of course combinations of the above are useful…
And just to give an example of another dimension to the same task (getting up from the floor), you could add some heckling, you push or pull the person who’s trying to get up in various ways. This little game can even evolve into a nice little wrestling game…
This is just one movement task, diversified by self-handicapping. If you’re interested, you can learn more examples in my course, this blog is already getting too long.
There was another aspect of play that we didn’t address yet: the emotional part. Remember:
“Play enhances the ability of animals to cope emotionally with unexpected situations.”
Again, really important in real life. In rehab, how you react emotionally in certain situations is related to the prognosis. The authors predicted, and validate with studies from animals, that:
“the amount of play experience obtained affects the ability to physically and emotionally handle unexpected events and temporary handicaps.”
I’ll repeat that last quote for you: “the amount of play experience obtained affects the ability to physically and emotionally handle unexpected events and temporary handicaps.” Now that would be interesting (but difficult) to test on humans! Could the amount of play you had, be a predictor of chronic pain? This could be of utmost importance for the development of our children, for all working in prevention, and it sure seems another important reason to use play, playfulness and exploration in your therapy!
But, there’s a problem:
“Severe or prolonged negative emotions, such as fear, pain, anger, hunger, frustration, or malaise, suppress play behavior.”
This is what we see in the clinic. And it makes biological sense: when stressed; there’s no energy to waste, and play is very costly energetically (mind you, not the esoteric kind). Even if it makes biological sense, it is not a good situation to be in for a longer time. This is an important vicious circle to break.
I said exploration occurs where fear and curiosity meet, but for people with pain, especially chronic pain, there’s no interest in the new (no neophilia), only in the known (only neophobia), even if these known behaviours are not improving their well-being. Thus, somehow, we need to make our patients curious and interested in new things. We need to carefully change the state of “nothing ventured, nothing lost” into a state of “nothing ventured, nothing gained.”
This is where careful education (avoidance of nocebo!), communication skills and empathy is important. Important, but not enough, in my experience. Education, as in information for the brain, often appears not to reach the parts of the brain where it is needed. My very simplistic neurological knowledge thinks that the cognitive, frontal parts of the brain do not influence the deeper, older, more primitive parts of the brain, where fear and emotion reside, at least not enough to bring change. Those parts need experience, bodily information, not only verbal information. Actions speak louder than words. “Knowledge is only a rumour until it is in the muscle,” says my favourite Papua-New-Guinean proverb!
And of course, this is what exploration could do!
Ok, this article is getting much too long. Let me just add two extra quotes and some remarks.
“Individuals may, through play, find and develop their own personal methods for coping with different kinds of unexpected misfortunes.”
This could be a solution for the problem that every individual human is different! Maybe more on this in another blog.
“Play is emotionally exciting and rewarding, maybe even pleasurable, while at the same time being relaxed.”
Quite obvious, play is most often fun, especially compared to standard exercise, so play and playfulness surely could increase compliance!
To finish, let us see if play and exploration could help overcome the problems mentioned in the beginning.
Does play take in account that all humans are different and need different, personal movement strategies? Check!
Does play tackle the problem of ‘ideal movement’? Check! (let the organism find the optimal way, bottom up, although I didn’t really address this problem in this blog)
Does play address the problem of skill transfer? Check!
Does play take in account the complexity of the world, the task and the organism? Check!
Does play make therapy more fun? Check! (by the way, for both patient and therapist)
I would strongly encourage you to explore and play with this in your therapy! 😉