Looking for the adequate “dose” 1

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Looking for the adequate “dose”

sending an electric impulse to the patient’s body in electrotherapy1

Daigoro Ebita (Niigata Seiryo University)

&

Shinichiro Sakai (Kyoritsu Women’s University)

August-7th-2013 / 9:00-10:30

@ Wilfrid Laurier University ROOM202

2013 IIEMCA Conference

PRACTICAL INQUIRY MEDICAL SETTING

abstract

Only loosely associated with the martial art of the same name, judo therapy is an

established medical discipline in Japan that focuses primarily on treating fractures,

bone dislocation, sprains, and soft tissue injuries. This study examines the work an

electrotherapy treatment session at a judo therapy clinic. The central focus of this

presentation is to analyze sense-making practices that organize pain as the resource the

therapist must use to determine the adequate dose of electricity. While electrotherapy

can effectively reduce pain and speed the healing of soft tissue damage, it also causes

some short-term pain during the treatment due to the application of electrical impulses.

To maximize the benefit of the treatment, the therapist needs to increase the voltage

until it reaches a level that is just slightly lower than the level the patient can no longer

tolerate. In order to achieve this, electrotherapy requires the active involvement of the

patient: the expression of unpleasant feelings. Using audiovisual data, this study

explores how therapists and assistants classify particular expression, verbal and

non-verbal, as a patient’s response to pain from electrical energy. We thereby contribute

to empirical understanding of the ways participants coordinate and collaborate their

actions in giving/receiving electrotherapy treatment.

1 Information and data in this presentation has been derived from Daigoro Ebita’s

unpublished doctoral dissertation research (written in Japanese), “Interaction between

Judo Therapists and Patients”, chapter 8. Any comments, suggestions, questions are

welcome. Email: ebita@n-seiryo.ac.jp / ssakai@kyoritsu-wu.ac.jp

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1. Introduction

In addition to the professional application of technology and technique to solve

the patient’s problem, there is also the “social” side of medical care. In order to

accomplish a medical activity there needs to be, and there certainly is, a successful

collaboration in the clinic being carried out. This study consists essentially of three

questions concerned with “What to do next?” (Garfinkel, 1967:12; Button and Sharrock,

2000:47, et al.):

(1) What makes the pain intelligible as an accountable, “public” matter? : How can

the therapist (and the assistant and we) understand that the patient is in pain?

(2) How can the therapist & patient determine the adequate dose of electricity?

(3) What makes it possible for the therapist and the assistant to collaborate on a

work routinely?

Just to give some examples, there is patient’s participation with the practitioner, as in

doctor-patient consultation; there is cooperative teamwork, as within a surgical team.

This presentation focuses on the methods of collaboration between the therapist and the

patient in electrotherapy session, and how they come to organize mutual understanding

of pain that plays a crucial resource in bringing electrotherapy to effect. We thereby

contribute to the growing stream of research of embodied interaction in which modern

medical practices2 has become a perspicuous setting in describing the local production

of their organizational or institutional phenomenon (e.g., Goodwin, 1995; Mondada,

2007).

2. Background

Judotherapists are regulated under the Judo Therapists Law 19 of 1970. By Article 3,

in order to become qualified as a judotherapist, a candidate must pass the national

judotherapist examination and obtain a license from the Minister of Health and

Welfare. Under Article 12, candidates must be eligible to enter a university according

2 According to ten Have (1995), medical ethnomethodology is grouped together into two

major study types, ethnomethodologically study based on ethnography (for example,

Garfinkel (1967), Sudnow (1967), Ikeya & Okada (2007), Slack, et al.(2007) and so on),

or doctor-patient interaction study (for example, Heath (1986), Maynard (2002),

Heritage & Maynard eds. (2006), Stivers (2007) and so on). Presumably, this

presentation may belong in the same equation as the latter studies. But it is one of our

major argument that the accountability on interaction enables the therapist and

assistant to collaborate on a work routinely which is argued by the former studies.

Looking for the adequate “dose” 3

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to Article 563 of the School Education Law 26 of 1974; have studied more than three

years at a school recognized by the Minister of Education, Science, and Culture or at

a training institution recognized by the Minister of Health and Welfare; and have

obtained the knowledge and technical skill necessary to be a judotherapist, including

knowledge of anatomy, physiology, pathology, and hygiene.

(World Health Organization 2001:158)

Only loosely associated with the martial art of the same name, judo therapy is

an established complementary medical discipline in Japan that focuses primarily on

treating fractures, bone dislocations, sprains, and soft tissue injuries. It is unique in two

ways. One is non-invasive treatment: Judo therapists do not perform open surgery.

Another is non-prescribed medication: Judo therapists do not dispense medications.

Judo therapy is partially similar to Osteopathy, Bonesetter, or Chiropractic. Judo

therapy is utilized with medical practices that bring energy to the body’s natural

healing ability. They include, but not limited to, hands-on techniques of manual therapy,

conservative treatment, and electrical therapy, the treatment of our interest.

Electrotherapy is the application of electrical energy in the body as a medical treatment.

The purpose of electrotherapy is to increase blood circulation and relieve joint pain. An

electrotherapy is commonly found in any judo therapy clinic in Japan and also widely

used in complementary and alternative medicine worldwide.

The material for this paper was derived from ethnographic observations of

therapeutic work performed at two judo therapy clinics in Japan over a period of half

year. Daigoro has observed, interviewed, and conducted audio-visual recordings of

employees’ work. During the fieldwork, he recorded 171 clips of video (equivalent to 23

DVD discs). In this presentation, we discuss an episode from therapeutic work in which

the therapist and the patient interact on the adequate “dose” of electric impulses to

maximize the benefit of the treatment4.

A “pain talk” (Heath, 1989), the expression of unpleasant sensations, is a

significant analytical concern in our research. Chrisitian Heath’s analytical interest

overlaps with that of ours: “the way in which the revelation and expression of pain is

sensitive to the accomplishment of certain medical activities” (p.114). Heath

demonstrates that under physical examination the patient is required to have an

“active” participation. For example, in order to locate the source of the symptom the

3 This is an error. The right article number is 90. 4 But there is insufficient evidence for its benefits and it has not been found to be

effective in increasing bone healing.

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therapist elicits the pain, a response cry from the patient is treated as the resource to

identify the source and locale of pain. Moral obligation as we would ordinarily expect

(say, an apology) has been suspended. The doctor is “licensed to inflict pain” (p.116),

thereby doing and being an analyst. While settings vary, pain talk emerges in electro

therapy too. However, the inflicting pain in electrotherapy is due to the application of

electrical impulses, whereas in diagnosis the inflicting pain is due to the doctor’s

maneuver over the affected area. Crudely put, for patient in diagnosis, it hurts because

the doctor is touching, moving, pulling, stretching etc. the affected area, the very reason

the patient comes to ask for medical consultation. In electro therapy, on the other hand,

it hurts because of electric shock, though physically unharmed. Electro therapy

therefore involves two kinds of pain: pain from the affected area, and pain from electric

shock. How these two different kinds of pain are being distinguished is of course a

practical matter for participants.

3. Pain as a crucial resource in electrotherapy

This video excerpt was recorded at one of two judo therapy clinics Daigoro has

been observing in February 2010. The patient (P), a porter, was around 60 years old and

had pain in his lower back, specifically fifth lumbar vertebra compressed fracture (see

figure 1). For the last two months he had been visiting this judo therapy clinic quite

frequently. Before this excerpt the patient had gone through diagnosis and palpation,

and then it was time for electrotherapy, as routinized. The patient laid down on the bed

with equipment strapped around his waist. The therapist (J) has an assistant (A) who

stood nearby with a blanket in which she puts at the end of the adjustment so that the

patient would not feel prickly pain intolerable (see figure 2). It takes about 10~15

minutes to come to an end of electrotherapy.

In transcribing the conversations, we adopted Jeffersonian transcription

conventions (Jefferson, 2004). J stands for the judo therapist, P stands for the patient,

and A stands for the assistant. We first transcribed their conversation in Japanese and

made our analysis.

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Figure 1. fifth lumbar vertebra

Figure 2. Assistant puts a blanket on patient.

J A

P

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< excerpt 1>

001 J dewa switch hairima::su. Hh

*turns on the switch

I’m turning on the switch now

002 (6.0)

*Therapist turns up the intensity

003 *Patient winces

004 J tsuyoi?

is it high?

005 *Patient nods

006 J itai?

does it hurt?

007 P ºeehº

yeah

008 (2.0)

009 J itai?

does it hurt?

010 P (5.0)*Patient moves his hip tremulously

011 P iya daibu

no it’s much

012 (1.6) *Assistant leans forward with a sheet of blanket and remains still

013 J ochitsuitekimashita?

soother now?

014 P hai

yes

015 J hai

yes

016 *Assistant puts a sheet of blanket over patient’s body*

#figure 2

017 J hai

yes

018 *Therapist closes the curtain and leaves

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3-1. Understanding that the patient is in pain

While electrotherapy can effectively reduce pain and speed the healing of soft

tissue damage, it also causes some short-term pain during the treatment due to the

application of electrical impulses. The sequence of conversation between the therapist

and the patient in lines 4-7 apparently demonstrates that there is a causal relation

between electric impulse and pain caused by sending an electric impulse. To maximize

the benefit of the treatment, the therapist needs to increase the voltage until it reaches

a level that is just slightly lower than the level the patient can no longer tolerate. So the

very premise of electrotherapy is that the therapist understands the pain of the other:

the patient. The therapist cannot feel the same pain the patient feels, it goes without

saying. The therapist however can certainly understand that the patient is in pain.

Despite the fact that there lies an asymmetry between the two in feeling the pain, the

electrotherapy is nonetheless accomplished without hassle. We also note that we, the

researchers, are entitled to describe that the patient we are looking at is in pain. Our

first analytical interest would be, then, what makes the pain intelligible as an

accountable, “public” matter? Here we are taking a Wittgensteinian view (e.g., Coulter,

1979; Lynch, 1993; Francis, 2005) that the description of pain is about the language use

and the language we share, rather than a subjective experience.

The therapist turns on the switch of the electrotherapy equipment as he

announces (line 1). For the next six seconds, the therapist keeps turning up the

intensity. The therapist, though not visible from this angle, keeps his hand on the knob

of that allowed the sensitivity of electronic impulse to be adjusted. The therapist told us

that he never lets his fingers off the knob because this adjusting work requires careful

attention. While keeping his fingers on the knob, he is looking down at the patient. Just

after the patient winces (line 3), the therapist asks “tsuyoi? (is it high?)” (line 4) and

“itai? (does it hurt?)” (line6), demonstrating his sensitivity to the patient’s facial

expression. A grimace of the patient, then, is a criterion that the therapist uses to see

the patient is in pain, and to react accordingly to the routine of electrotherapy

treatment: the voltage of electrical impulse should be lowered. As David Francis (2005)

argues, the relationship between pain and pain behavior is a normative one that “Given

the pain behavior, one is entitled to say that the other is in pain, just as one is entitled

or required to react in the appropriate way, e.g. by giving help” (p.267, emphasis

original). A grimace is a resource that the therapist uses to determine when to stop

turning up the voltage, and when to start fine-tuning. For this reason the expression of

unpleasant feelings becomes a crucial resource to accomplish the work of electrotherapy.

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3-2. Determining the adequate “dose” of electricity

As we noted earlier, electrotherapy causes some short-term pain due to the

application of electrical impulses, a mild tingling sensation. It is an adjustable pain, and

is distinguished from the chronic pain in the course of application. An adjustable pain is

in reflexive relationship to adjustable voltage of electric impulse in the sense that pain

is produced through sending electric impulse, and at the same time, pain expression, be

it verbal or nonverbal, is used as a resource to assemble an adequate intensity. Chronic

pain is, on the other hand, is non-adjustable. The therapist may be able to heal the

chronic pain in the long term, however the therapist has no control over it in this room.

This distinction, a part of an (un)remarkable routine in judo therapy clinic, is

organized in several ways. First, it is announced. Prior to the treatment, it is mandatory

for the therapist to tell the patient that electrotherapy causes some pain. Second, it is

routinized. The patient in our data today has been here for the last two months and has

been undergoing electrotherapy, so he knows that he would experience pain from the

application of electrical impulses, which is distinguished from the chronic pain in the

lower back, the very reason he has come to see the therapist.

Furthermore, it is locally intelligible. The therapist does not explicitly state the

object of what is “high” (line 4) or what “hurts” (line 6) however they suffice as questions

that the therapist asks. While the question-answer sequence ensues, the therapist has

been turning the knob up and down slightly. The therapist therefore uses patient’s

answer as a resource in looking for the threshold the patient can tolerate. So the

patient’s reply to the therapist’s question determines the direction of the intensity knob.

When the patient replies “yeah” (line 7) to the question “does it hurt?” (line 6), the

therapist lowers the intensity. When the patient replies to “no it’s not much” (line 11),

the therapist stops lowering. Furthermore, because the electrotherapy device delivers

low and medium frequency currents that oscillate rhythmically, the two may take

additional time to agree with the final determination of the intensity – the pain comes

in waves, lasting for few seconds and subsiding respectively. So the work of adjusting

the adequate “dose” between the two comes to an end in lines 13-14 when the patient

replies “hai” (yes) to the therapist’s question “ochitsuitekimashita?” (soother now?) 5,

demonstrating that the patient can tolerate the pain through the “waves.” The therapist

lets go of the switch, thereby ending the adjustment work.

As called low-frequency wave or mid-frequency wave, the electric stimulus for

5 And now, what is ‘soother now?’. It is obvious that the subject is not strength of

electric stimulus. How much electric impulse is sent can be controlled by the therapist,

not the patient. On this situation, what is ‘soother now’ may be not the strength of the

electric impulse but the patient’s body sensitivity on the electric impulse.

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electrotherapy is described as rhetoric of ‘wave’. The electric impulse is not sent at a

certain amount but at high amount and low amount alternately. In sum, high and low

amount of electric impulse consists of the first ‘wave’, the second ‘wave’, the third

‘wave’…, and these ‘waves’ can be naturalized and tolerated for the patient. We consider

that these concepts of ‘naturalized and tolerated’ tie the question “ochitsuitekimashita?

(soother now?)”(line 13).

The therapist may as well send an electric impulse to the patient’s body as

possible as high voltage if the therapist thinks about electrotherapy effects, but the

therapist must accommodate amount of electric impulse to the extend for the patient to

tolerate the pain of electric impulse. On these activities, the concepts of ‘naturalized and

tolerated’ seem important. If amount of electric impulse is overflown for the patient, but

as long as the sense of the patient’s perception is naturalized and tolerated, then it’s the

patient’s experience of electric impulse that seems adequate line of amount of electric

impulse. Then, in fact, activity in adjustment of amount of electric impulse is closing at

this point.

3-3. Accomplishing the division of work

There is yet another participant in this office: the assistant. Throughout the

conversation between the therapist and the patient in 3-1 and 3-2, the assistant holds a

sheet of blanket in her hand. The expected nature of her task is to put a sheet of blanket

over the patient in order to keep the patient’s body temperature once the adjusting is

done. It is part of routine work of electrotherapy in this judo therapy clinic; it is part of

her assigned work. The practical concern for the assistant, then, is to understand when

the two have come to agree with the adequate amount of electric impulses. Just after

the therapist confirms that he has reached a level that is slightly lower than the patient

can no longer tolerate (lines 13-15), the assistant puts a sheet of blanket over the

patient’s pair of legs (line 16). The assistant thereby demonstrates her understanding to

the closing of interaction. The assistant once leaned forward with this sheet of blanket

(line12), however she remained still until the conversation between the therapist and

the patient comes to a close, with a sequence closing third (Schegloff 2007:120-123) in

line 15. The assistant is sensitive to the ongoing interaction of pain talk, being sensitive

to where it ends and how the patient is feeling.

After the assistant covers a sheet of blanket over the patient, the therapist

closes the curtain and they both leave the spot. The therapist apparently takes the

assistant’s action for granted and finds it unremarkable, which demonstrates, in terms

of organizational routine, that the assistant has found the right timing as expected. The

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two has therefore accomplished coordination of the division of work whereby one

completes his work and passes it to the other. The technology of electrotherapy and the

“technique” of adjusting electrotherapy in and through pain talk are “organizational

hubs” (Hindmarsh & Heath, 2000) whereby its establishment underpins the efficacy

that coordinates distributed work. Pain talk is therefore a crucial resource in making

collaboration work.

4. Conclusion

We have considered what consists of accountability of interactions among the

therapist, patient and assistant in electrotherapy setting and how interactions are

relevant to organizing work of judo therapy. In this study, there are three sub-questions

oriented by the participants: the therapist, patient and assistant. (1) What makes the

pain intelligible as an accountable, “public” matter? : How can the therapist (and the

assistant and we) understand that the patient is in pain? (2) How can the therapist &

patient determine the adequate dose of electricity? (3) What makes it possible for the

therapist and the assistant to collaborate on a work routinely? Our consideration is, in a

word, answering these three questions.

In this data, in interactions between the therapist and patient, the therapist is

sensitive to the patient’s facial expression and he can understand that the patient is in

pain. In sum, a grimace of the patient is a resource and criterion that the therapist uses

to determine when to stop turning up the voltage and start fine-tuning. These

discussions would be based on the discriminablity of pains, in this data, two kinds of

pain: pain from the affected area and pain from electric shock. Because pain from the

affected area can’t be tuned but pain from electric shock can be adjustable.

Of course, the question, “How can the therapist & patient determine the

adequate dose of electricity?”, is relation to this understanding that the patient is in

pain and this discriminablity of pains. This understanding of the therapist is emerged

as the beginning of fine-tuning. This discriminablity of pains influences the very nature

of activity in adjustment of amount of electric impulse. By means of analysis on

interactions among the patient, therapist and assistant, the closing point of activity in

adjustment is accountable.

The question, “What makes it possible for the therapist and the assistant to

collaborate on a work routinely?”, is relation to this accountability of the interactions

between the patient and therapist. In this situation, the assistant must make a

judgmental decision which is demonstrated by putting a blanket on the patient. It ought

to be an assumption here that closing point of interactions between the patients and

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therapists is accountable. If not, the therapist can’t instruct the assistant to put blanket

on the patient promptly after the completion of adjustment of an electric impulse to the

patient’s body. In sum, accountability of interactions between the patient and therapist

makes it possible to collaborate on a work routinely.

At the end (and saying unnecessary things), we have one simple suggestion.

When the researchers think about intervention by ‘Technologies and Techniques” on

practical inquiry in medical setting, accountabilities for interactions among the

participants of medical activities may remain important. Interventions in human body

have a tendency to evoke negative feelings of anxiety, discomfort, disgust, distrust, fear

and so on. Then for both the medical practitioners and patients, accountabilities for

interactions may have a direct and huge effect on making medical decisions. This is the

“social” side of medical care.

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