Is neuroscience really necessary anyway?

[mikesangster]

I am currently supervising a student PT from my alma mater for a musculoskeletal placement. She is the first of the new program - a new and improved program designed to develop stronger clinical reasoning skills and better equiped clinicians who are more prepared for the demands of direct access to physiotherapy services. It became very clear to me early in her clinical rotation that she hadn't a clue about even the most basic neuroscience... in fact, she informed me that with the 'modular' format of the new and improved program that neuroanatomy and neurophysiology were taught next semester - just before the neurology module and after the musculoskeletal module is long over... presumably one only needs to know about anything neuro if one intends to work only with people who have had strokes. She is quite prepared to 'show' me how to do 'mobs' for just about any joint in the body and can talk the biomechanics... in fact, she admitted that she can only really 'show' me what the 'mobs' are supposed to look like but that she has never really felt any kind of joint play (I tried to resist crushing her spirit here, honestly I did, but I couldn't, so we looked at the evidence and she kind of went pale and then seemed relieved) ...but just in case any of you were worried, she assured me that her class had one lecture on pain in the beginning - something about a bio-psycho-something-or-other model (that she admitted most of her class slept through) ...so when she asked me if I wanted to see her course manual I said no and told her it wasn't going to change what I was planning on teaching her anyway... it's now week 4 and we haven't done a 'mob' yet. In fact, Barrett if you are reading, she is doing some pretty nice Simple Contact with a patient of mine.

Okay, so I know this is a bit of a rant - but how is it that those academics who shoved evidenced-based practice down my throat have conveniently left out neuroscience from the musculoskeletal curriculum? Feeling a little lonely in my round earth world...

[Diane]

presumably one only needs to know about anything neuro if one intends to work only with people who have had strokes. I KNOW! The orthos took over PT somehow when none of us were watching. PT got dumbed down. It's time we took it back and breathed life back into the profession again, teach PT students how to handle whole human organisms. Way to go on that Mike.

[Barrett Dorko]

Mike,

You've a lucky student there. Your question of the academics is perfectly appropriate. Of course NONE of them ever visit this forum or, as far as I can tell, leave the echo chambers they've created elsewhere.

I know I never see them at my workshops.

[EricM]

Mike, I commend you for taking on this teaching role, the sad reality is that after graduation these students have to take, and pass, a comprehensive written and practical examination before they can practice independently. This musculoskeletal (even the name is inadequate) portion of the exam is historically biased towards the biomechanical model. Do you worry about confusing your student? Will they be adequately prepared to pass this exam following your instruction? These are thoughts that worry me when I think about accepting a student placement.

[nari]

Mike, good luck with the student/s. Catch them while they are fresh, like fish.

I would not worry too much about the clash between neuroscience and orthopaedic rituals; it depends on the student. At least plant the seeds, so when they are through, they will remember to nurture them.....
That is what my students told me; that they would do the requisite stuff and incorporate the new approaches later.

It is quite true that neuroscience is downregulated as appropriate for the injured brain only; but there are strong signs of change, particularly in the land of Butler: South Australia.

nari

[Bas]

Diane, I am a bit more cynical than you with regards to the heavy "ortho-slant" our profession has been subject to for a few decades now. I think their "take-over" was unintentional: they were the first group to really start looking at the dearth of evidence for most modalities, developed a workable (not saying correct) model for manual therapy, and organized into a indentifyable group. And all this while the other PTs (with a a few exceptions) were puttering along, ignorant of anything scientific, ignorant of self-examination, ignorant of the importance of neurosciences, and yes - even ignorant of the idea of "evidence". This was very fertile ground for the ortho-group to fall into. In the land of the blind.....

I echo the lament of Mike: despite the strong public and written commitment to "evidence based practice", our universities are NOT doing as good a job as they could. Too many profs are mired in the publish-or-perish marshes, have taught so long in a certain manner, or are simply stuck in their own little slice of PT to really challenge the capabilities of the students to disseminate research and to problem solve based on that. This is still happening. As Mike experiences.....

[Bas]

" first group to really start looking at the dearth of evidence for most modalities,"

I have put that poorly - the ortho-group was NOT motivated by the lack of evidence - they had a tool that they could find better evidence for.

[Diane]

Bas, maybe this makes you a bit less cynical then rather than a bit more..

[Barrett Dorko]

Has anybody noticed how closely related this thread is the the Alien Abduction (http://www.somasimple.com/forums/showthread.php?t=3885) thread?

Mike,

It appears that you've stopped this young lady somewhere along the ramp leading to the Mothership. She may never know how close she came to being kidnapped, but you have saved her and should be proud of yourself.

[nari]

Four weeks without a 'mob'; are there many clinics in the world which could say that?

Mike, you are definitely setting a trend to save PTs from the treadmill of protocols, hyperextended thumbs and patients saying 'ouch!'.

Nari

[anoopbal]

Just out of curiosity, are there conditions or situations whhich require an approach devoted to the musculoskeletal sytem more than the nervous system or it is always the nervous sytem that dominates? Or it is just hard to pin it down

Thanks
Anoop

[nari]

Anoop,

Whatever we do with patients involves the nervous system first and foremost; if we focus on what seems to be a musculoskeletal problem (say, a fracture without frank nerve injury or a torn muscle/ligament) with the usual techniques, we are still impacting on the nerves albeit in a roundabout way, and sometimes quite profoundly.

So I would say that there is no such thing as musculoskeletal treatment per se. It is a misnomer. :)

Nari

[ptguy]

Interesting thread, it is a great experience taking students and I have always found I learn as much as they do.

I attended a conference with all the university profs from Canada earlier this year to help develop a university core curriculum document and two of the biggest surprises for me was that everyone agreed that the term is neuromusculoskeletal and someone immediately spoke up to the importance of including the skin in the curriculum. Diane, Im sure that will bring a smile to your face.:teeth:

Steve

[Diane]

Steve, I can die a happy woman now. :teeth: :thumbs_up

(I wonder if it was the same prof who is my research partner?)

[nari]

Diane, that is something. :thumbs_up

I did a search today, ambling through various sources available to general readers, (hoping the PC would behave) and in most references, the phrases 'pain pathways', 'pain receptors' and 'pain stimuli' are still being used. So the general public would still think that pain is an input. That's a big problem when it comes to understanding the role of the skin.....but you know that, anyway.

An anecdote: yesterday I was with a young guy who is doing work experience in a bookshop; he twanged his index finger rather intensely while lifting a very heavy box which slipped from his hold. A few moments of DNM and the pain melted away. He was very impressed, but his career will be with books - not patients. :)

Nari

[Jon Newman]

Every student that comes into contact with me (whether they're my student or not) gets offered a copy of Explain Pain, Science of Suffering, Topics in Pain and Clinical Neurodynamics (actually that one went missing and I have to replace it.)

[Barrett Dorko]

Jon,

Every student who comes into contact with me gets a lecture about Kindergarten Cop, Titanic, Cast Away, The Sopranos, Poker Dome, The Beverly Hillbillies and Dr. Phil.

Oh yes, and all that other stuff you mentioned.

[Randy Dixon]

Just out of curiosity, are there conditions or situations whhich require an approach devoted to the musculoskeletal sytem more than the nervous system or it is always the nervous sytem that dominates? Or it is just hard to pin it down-Anoop

I would disagree slightly with Nari, the nervous systmem is not always first and foremost and neither is the mechanics of the musculoskeletal system always first and foremost. The problem to me comes when you try to separate the two. On a conscious patient there is no practical separation between the two. In fact, there is no reason to confine it simply these two categories. There are other systems that are also being affected simultaneously, vascular, endocrine, etc.

People like to classify things and it is helpful in learning and thinking about things but the body has no compunction to stay within the neat little lines we like to draw. I believe it is as big a mistake to focus solely on the ectodermal as the mesodermal or any other single system, even if we take it as a fact that the ectodermal is the "controller", the complexity of it is too far beyond our understanding to think that we know exactly what we are influencing. Think of circles instead of lines, multiple feedback loops, the effect of inserting something new depends on where in the circle you happen to insert it as much as what you are inserting.

[Diane]

Still Randy, the NS is the "Ministry Responsible for Everything" no matter how you slice it. Everything has to go through it for approval or nothing changes.

[Chancellor Mobley]

Could some one please tell me who wrote Topics in Pain?

Chance

[Diane]

Hi Chance,
It's the Topical Issues in Pain (http://www.achesandpainsonline.com/tip1.php?Group=Books&Subgroup=Tip1) series, PT books from the UK, edited by Louis Gifford. Every PT needs a set in their personal library, on their bookshelf and one issue or another on the bed stand for when you wake up at night and can't sleep. Learn instead.

[nari]

Randy,

On a conscious patient there is no practical separation between the two.

Precisely.
Which is why we are looking at the most effective and efficient way to manage dysfunction and/or pain. We don't ignore the mesoderm, we know it is affected by an ectodermal approach, along with most or maybe all of the other systems. We know that because the patient has improved function and pain tends to resolve.
We also know that traditional physiotherapy with the usual stretch/strengthen/exercise regimes work in some instances, but not so in the case of chronic pain, where the nervous system tends to become feudal and rather loopy.

That's the problem many of us are trying to address.

Nari

[Jon Newman]

Just out of curiosity, are there conditions or situations whhich require an approach devoted to the musculoskeletal sytem more than the nervous system or it is always the nervous sytem that dominates?--Anoop

I'll give this question a shot. I think the key words here are more than even more so than devoted to.

Acute treatment for a broken leg will require little knowledge of the nervous system. Treatment for the pain associated with a broken leg would likely be improved with knowledge of the nervous system. There are many iterations of this theme, perhaps people will add their own.

[Randy Dixon]

Diane,

I think you missed the point. The nervous system is both controller and controlled, and sometimes only incidental to. It depends on where in the feedback loops you are considering the start and in which feedback loop you are concerned with. I think Jon and Nari's posts both point this out. If you are concerned with pain primarily then your primary concern may be the nervous system, but the body being treated is not making that distinction.

Following up on Jon's post I think I've read Barrett making the distinction between rehabilitation, which can very well have a "musculoskeletal" emphasis and the type of therapy and patient those here are more concerned with. I place musculoskeletal in quotes because I find it difficult to even conceptually separate the "neuro" out of the "musculoskeletal". I see some of the distinctions that is made more as "mechanical" and non-mechanical, with some of the mechanical neurological approach, such as Shacklocks, closer to a mesodermalist approach than some approaches which are identified here as mesodermalist. such as Richardson and Hull.

[Diane]

A nervous system that is not embedded in the mesoderm it made in the first place (when it was stil ectoderm) quickly collapses into a heap and dies. Mesoderm without nerves going into it is just dead meat and bone. So I get what you are saying, they need each other. But I will treat ectoderm only. It's the only conceptual system that has skin in it.

[nari]

Randy

Neurodynamics is mechanical, but I am not sure about the 'more mesodermal' description. Certainly the other tissues are affected, but the movements are specific to the nerves. One can do aerobic-style movements and stretches which may actually be nociceptive; the movements he and Butler suggest are designed with the nervous system in mind. Most stretchy/ballistic/sustained stuff is not.
However, either way, the skin is intimately involved.....

Richardson and Hull, to me, are more mesodermalistically inclined than Shacklock et al. In the end, they are trying to show one muscle group's activity and integrity is more important than that of several others.

Nari

[Jason Silvernail]

I will agree with what I perceive to be Randy's general statement that the care of people with neuromusculoskeletal problems involves knowledge of and consideration of both muscular/articular and nervous tissue.
I've said before that these can overlap in many patient presentations, and I agree with that.

It may be that the patients Diane sees only need their ectoderm treated - but I see acute injuries and problems all the time and I (and most other PTs) need good orthopedic diagnosis and treatment skills as well.

[nari]

Jason, that's a fair enough comment.

I think it rather depends on the context of the clinic; I had avoided rather successfully (over the last three years of working life) most acute conditions by choosing work areas where they rarely occur. So I am speaking from my recent experiences with nonpathological chronic pain, which exists in some form or the other in 80% of folk....according to estimations from those who are supposed to know these things.

However, if I had come across acute "ortho"conditions and had been familiar at the time with DNM and ideomotion, it would have been a very different approach: for these two approaches add a dimension that cannot be ignored. I can say that, coming from an acute neuroscience background including ICU for 11 years. Probably many of those people would have benefited significantly from such input; no miracles but a simple effort to decrease morbidity.
That is being realistic; clearly a TBI or a stroke patient with no perceived pain and trying to knock my block off will not benefit from manual therapy.
But that would be quite obvious anyway. Most other acute patients would have required a minimum of ortho work and a focus on neuroscience.

That's my 2.5 cents...

Nari

[Barrett Dorko]

I think you're all making excellent and defendable points. And how often do you hear that from me?

The emphasis of our care and how we imagine our instruction is being perceived and used constantly shifts and, like Nari and Diane, I manipulated my practice to such a degree that the abnormal neurodynamic was really the only thing I needed to attend to though that wasn't necessarily the only thing I should have noticed.

It's interesting to contemplate the difference between self-healing, self-correcting and self-rehabilitating. We possess them all to some degree but all are influenced powerfully by the culture surrounding us. What therapists need to understand first is how much they can influence that culture both within their professional community and individually in the presence of their patient.

[EricM]

On the distinction between mesodermal and ectodermal problems in practice, I work in a setting where I'd estimate 90-95% of my patients have ectodermal origins for their complaints. This is a private practice with an emphasis on sports, work and traffic related injuries. The rare time I do encounter a disruption to the mesoderm, it is always easy to detect and may or may not be associated with a sensitized ectoderm. I'm often surprised at how someone can have a significant mesodermal injury and yet report little pain. These injuries are easy, requiring very little input from me in order to improve, or heal, in a predictable way. Often the most useful input I can have is by treating whatever sensitization has occurred in the surrounding ectoderm.

[Jon Newman]

Perhaps the book Ian recently referenced (http://www.somasimple.com/forums/showthread.php?p=34098#post34098) would help answer the question.

[Sarah]

Hi Mike,

I can completely relate to your post about having students in the clinic. I recently instructed a second-year student on an eight week rotation who admitted to being very intimidated to practice in outpatient orthopedics (my practice area) due to the weight placed on the musculoskeletal techniques learned in her very OMPT-based program. I hope I was able to teach her something about treating the whole person including the nervous system and about pain science. I think the biggest learning experience for her was observing my "evaluation" of a patient with a long history of chronic pain complaints who was very frustrated with the medicalized treatment she had received to date. The patient and I talked for 45 minutes and she felt more relief than she had in years because someone actually listened to her story and seemed to care about what she was saying. By my asking a few relevant questions, she was able to comprehend herself and her symptoms in a different way and began to heal. We've had three sessions since (mostly education, gentle movements and light touch techniques) and she is doing very well. My student said she would've had no idea how to approach this patient, which is not the student's fault, as they are not taught how to treat chronic pain patients. It's no wonder that other PT's had failed to help this patient in the past if not made her worse.
I am currently working on a research project that addresses therapists' attitudes, beliefs and knowledge of chronic pain, to shed light on the lack of information taught in this area, and to help illustrate the need for a change in curricular content. The way I see it, I can continue to teach one student at a time, or try to improve upon professional program content to reach many students at once.

Sarah

[Diane]

Sarah,
Way to go! - this is exactly the kind of research the profession as a whole (everywhere) should support and pay attention to.

[BB]

That was one lucky student, Mike. Nice work.