General exercise vs. motor control vs. SMT

[Luke Rickards]

This just in.

Pain
Volume 131, Issues 1-2, September 2007, Pages 31-37
Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial

Manuela L. Ferreiraa, Paulo H. Ferreirab, Jane Latimerc, Robert D. Herbertc, Paul W. Hodgesd, Matthew D. Jenningse, Christopher G. Maherc

Abstract

Practice guidelines recommend various types of exercise and manipulative therapy for chronic back pain but there have been few head-to-head comparisons of these interventions. We conducted a randomized controlled trial to compare effects of general exercise, motor control exercise and manipulative therapy on function and perceived effect of intervention in patients with chronic back pain. Two hundred and forty adults with non-specific low back pain greater-or-equal, slanted3 months were allocated to groups that received 8 weeks of general exercise, motor control exercise or spinal manipulative therapy. General exercise included strengthening, stretching and aerobic exercises. Motor control exercise involved retraining specific trunk muscles using ultrasound feedback. Spinal manipulative therapy included joint mobilization and manipulation. Primary outcomes were patient-specific function (PSFS, 3–30) and global perceived effect (GPE, −5 to 5) at 8 weeks. These outcomes were also measured at 6 and 12 months. Follow-up was 93% at 8 weeks and 88% at 6 and 12 months. The motor control exercise group had slightly better outcomes than the general exercise group at 8 weeks (between-group difference: PSFS 2.9, 95% CI: 0.9–4.8; GPE 1.7, 95% CI: 0.9–2.4), as did the spinal manipulative therapy group (PSFS 2.3, 95% CI: 0.4–4.2; GPE 1.2, 95% CI: 0.4–2.0). The groups had similar outcomes at 6 and 12 months. Motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain.

[Diane]

It watered down over time, like so much else.

[Karie]

Makes me feel even better about my decision to not go down the manipulation road many years ago!

[Luke Rickards]

Karie, I'm sure there will be plenty of people out there who will say, "Makes me glad I didn't spend all that money buying US equipment and time training patient's TAs.":)

[Diane]

Here's the whole thing (http://www.somasimple.com/forums/showthread.php?p=36183#post36183).

[Randy Dixon]

Karie,

I don't understand your comment given that SMT had the best short term results. All three methods improved patient scores and the improvements seemed to have held reasonably well. They did not return to baseline but stayed at their improved function, so why is this taken as a criticism of SMT or motor control exercise? Do you have evidence of a better intervention?


I have to agree with Luke though, it does put the use of US in motor control training under some suspicion.

[Diane]

Randy, there is this line: Motor control exercise and spinal manipulative therapy produce slightly better short-term function and perceptions of effect than general exercise, but not better medium or long-term effects, in patients with chronic non-specific back pain.
Same with less?

[Luke Rickards]

I often see a tendency in these studies to overlook the short term outcomes as unimportant in light of the eventual long term result (the big "but" as used above). I feel this is a mistake. What patient wouldn't choose to feel better quicker if the eventual result is going to be the same?

[Karie]

In my opinion Randy and 25+ years of experience I didn't find manipulation to be optimum. I do know how to do it, just didn't choose to do grade 5's, but I was taught by a variety of people before the $1000 dollar price tags that are now out there. I'm glad I didn't have to become "certified" in ability with that price tag. I have fallen away from most of it because I find light touch and ideomotor techniques, as well as, DNM (Diane's) to be much more effective and patient control centered. My patients are getting significant relief in 1-3 sessions and I deal with the chronic pain group generally. I see them after all these other treatments have been done by others and what's more discouraging it appears, is to get short term relief but not lasting change. As one patient told me one time, it would have been better for me not to have known (reexperienced) what good feels like, it's even more depressing now that I can't do a..b..c. The techniques I now use provide that but more important give the control over to the patient in handling their health. We need to give them that back if they are to be long term successful in my opinion.

With respect,
Karie

[Diane]

Karie, I couldn't agree more.
What's missing in the study is any form of "soft" or nervous system sensitive manual therapy having been included as a fourth arm. So Luke, I agree with you too.

[Jason Silvernail]

Something else to ponder....I haven't read the study (how's that for a lead-in?) but I wonder if they evaluated people with subgrouping? If they just threw them all together in one "chronic low back pain" pot, then the subgroup which might improve with manipulation (for example) would probably be equally distributed in all groups, calling results into question.
The time since onset of pain is just one indicator for successful manipulative treatment, there are 4 others. When I see a study like this, I have to wonder if it would have turned out differently had they done subgrouping appropriately.

To me, it's no surprise that in an undifferentiated group, these treatments are roughly equal. Though I was surprised to see the motor control group improve more rapidly short term than the general exercise group.

The new JOSPT is full of Ultrasound stuff, I'll be interested if there's anything in there that makes me think more highly of US biofeedback, as I remain overall underwhelmed thus far.

[Diane]

Here's a nice article re: physio perception of/beliefs about CLBP (http://www.somasimple.com/forums/showthread.php?p=36250#post36250).

[Randy Dixon]

Karie,

I understand why you feel the way you do, what I asked is what about the article supports your belief? You claim DNM and light touch to be more effective, I asked about what evidence you have to support this claim. So I don't think your answer addressed my questions. Not that you have any obligation to.

Jason,

I did slightly better than you and only read it briefly, but it does discuss the possibility of differing results using subgrouping and it mentions the Childs study. Also, the two exercise programs were done in conjunction with a CBT approach and home exercise program while the SMT was done independently. They mention this may have underestimated SMT's effects.

[Karie]

Randy,

With respect, Diane is working on research presently for support of her DNM methods.

Soft tissue methods such as I and others use are not well researched because by there nature they are difficult to do double blind control studies. I believe Barrett doesn't have specific research on the method of simple contact either. It's the research regarding why the light touch works based on neurophysiology etc. which this site is devoted to, that is presently available that I utilize in description of it's effect.

Karie

[Diane]

Soft tissue methods such as I and others use are not well researched because by there nature they are difficult to do double blind control studies. I think in addition, there is an historical factor at work. In manual therapy for decades and decades and decades soft tissue work was always the "default", and accepted ipso facto, no reason to have to "study" it. The onus was instead on the rougher kinds of interventions to "prove" themselves, particularly with regard to safety. Somehow along the line, perception of the foreground/background of manual therapy changed, and now everyone is seeing the reverse of what they once saw.

A number of factors have contributed to this situation, one of which has been the association of soft tissue work with poor treatment constructs and even laughable anti-scientific treatment constructs due to the historical emphasis on mesoderm; one other is the big headlong rush of PT practitioners toward the bones&joints (the harder mesoderm), for whatever reason (I call this situation "clinging to the dock" of manual therapy instead of learning how to really swim, or "praying at the altar of Mesoderm").

In the first case, the vast amount of information that has been generated in the last 20 years should more than suffice as backdrop to regain ground for gentle MT, even though there needs to be the (annoying, really) grind of putting out some actual studies too. I'm determined that soft tissue work retain its place, not be dropped out of sight because no work has been done to demonstrate its effectiveness. I'm determined that it regain its value as a non-invasive process-oriented intervention that works via the nervous system, so that the entire profession doesn't sink into complete and terminal mesodermal madness. The ortho people, unless they find a way to let go of that dock, may be forever beyond help. :rolleyes:

[Randy Dixon]

I guess I haven't done a very good job of making myself understood. I understand why Diane and Karie practice the way they do, after the amount of time I have visited this forum I should either understand or not expect too, the question I have asked is "What about the article supports your belief, or what about it provokes the response that "you are glad you didn't go down the manipulation road""?

I have so far only skimmed the article but it appears to mildly support all three interventions used, and of the three it seems to favor SMT slightly more. If Diane's study, or any other technique recommended, came back with similar results and a poster submitted "That study makes me glad I don't bother with THAT stuff", they would be challenged immediately on this forum.

Why am I questioning what was probably meant as a throw-away statement? Because, as is often discussed here, evidence should form our opinions, we should not let opinions form the evidence we use. I think your statement, and the subsequent posts, show that the evidence was being evaluated as to whether it supported an opinion, not on its own merits. This is something that is easy to do and hard not to do, especially in a group of like-minded individuals (isn't that the complaint about mesodermalists?). You can't expect others to look at your reasoning objectively and without bias if you don't act in the same manner. So my intention is to just "keep us honest".

[bernard]

Randy,

I agree but I may bring this questioning:

In terms of patient acceptance, what is the best method between the presented ones?

In term of energy cost for the PT, what is the one that use the least?

In term of Power (work) what is the one that use the least?

What is the one that looks like much more Nature means?

[Diane]

Which one works best for persistent pain?
Which one is least likely to pepetuate persistent pain?

[Jason Silvernail]

Well, I don't think we have the data to judge either of Diane's questions either way. This study did approach LBP > 3 mos duration, however, and that's pretty "persistent" to most people.

I think Randy is right to wonder why one arm of the trial should be dismissed as "glad I don't do that" when it might produce slightly better short term outcomes and was essentially equal to the other interventions in the long term. It might be good to bring up that Diane (and maybe Karie) don't do any of the 3 things mentioned, either. So really they could just have easily dismissed the other 2 methods as well.

I think my primary concern is subgrouping regarding the manipulation issue - it probably underreported the benefit of SMT in the short term, though I doubt (based on the published studies and my own experience) that subgrouping would change the long term outcomes much.

[JaneS]

Hi All,

Forgive me if I am being stupid, but I agree that this is not a case of choosing one approach over another. In the case of the study reported, it seems to indicate a treatment programme consisting of, say, a few months of concentrated motor control Xs and manips. Some non-specific general exercise may or may not be appropriate - such as in ADLs, walking etc. After the short term interventions have had their major effect, these could be dropped off in favour of increasing time or intensity of general exercise.
I have not mentioned the DNMs and other treatments. I just wanted to make the point that a treatment programme could be structured to take advantage of interventions if and when they are found to be most effective.

Maybe I'm being a bit simplistic - but the KISS principle is a valid one!

Jane

[Randy Dixon]

Bernard,

I can give you my opinion and answer your questions, but the study doesn't talk about the questions you are asking. They are a separate topic. I'm not saying that there aren't reasonable explanations and philosophical ones to practice without using one, or all, of the interventions tested, I'm only saying that the article gives no reason to reject them.


I agree but I may bring this questioning:

In terms of patient acceptance, what is the best method between the presented ones?

Randy: From what I have seen, SMT.

In term of energy cost for the PT, what is the one that use the least?

Randy: I don't know. I'm not sure that should be a major issue. Many SMT techniques are simple and easy, I've seen some that are arduous. Then you have to consider a higher intensity lower duration cost of SMT versus the lower intensity higher duration cost of the other two. I think motor control is the costliest in the energy of the PT.

In term of Power (work) what is the one that use the least?

Randy: Again, I'm not sure that should be an issue unless it gets to the point that the techniques become unmanageable or overly taxing. I have seen some mobilization techniques that fit this description, it does not mean that all mobilization techniques do. On the part of the patient, SMT definitely requires the least amount of work and probably has the least total combined work.

What is the one that looks like much more Nature means?


Randy: I'm not sure what that means or its relevance.

[bernard]

I'm not sure what that means or its relevance.
I just mean that Nature finds principles that costs the least in term of energy and but works the best.
SMT couldn't be natural.

[Karie]

Hi Randy,

Yes, I totally did not get your question. I thought you were asking for research to justify light touch treatment.
I stated my answer based on the fact that over a longer period of time, the manipulations positive affects did not maintain at the level that they did initially. I prefer to spend my time with techniques that provide short and continue into long term relief because that is what the patient population I see is looking for. They have already done the yo yo patterns, of moving forward and then back which includes having manipulations done by PT's, chiropracters, osteopaths, etc. On the aside, functional exercise and ideomotor activity is part of my home programs. I do not negate or not use them as someone earlier suggested.
Of course, you can argue that I don't see the patients that manipulation has helped because they don't need my help. So maybe I am providing treatment to a specific type of nervous system that responds to what I have to offer the best. When people ask me if cortisone injections and other types of injections can work, I respond with the same answer. If you go by my patient population and experience, the answer is no. But, then again the people for whom they may have worked, don't need my assistance and they won't be walking through my door for treatment.

I hope this satisfactorily responds to your question. If not we'll try again.
:)

Karie

[bernard]

Randy,

We aren't on the same line of thought, here.
The problem is common with language differences.

1/ I'm not against SMT but do not use it because I think there is better solutions.

The patient acceptance is high because, often, they were told that is a quick fix for their problems.
It is low in term of patient brain comprehension since it is a practice that is not really embedded in our motion inheritance.

The energy cost is very high => You are using a huge force to move the spine. Of course it is a low work because its duration isn't long.
It doesn't change the problem at all.
I prefer to be shot by a ball that comes at 1 km/h than one that runs at 1 km/s, even if this one is 1000 times smaller.

[Luke Rickards]

Of course it is a low work because its duration isn't long.
It doesn't change the problem at all.Bernard, This may be true for some patient populations, but I'm not sure it can be justified as a general statement.

[bernard]

Luke,

I just brought an equation from Physics.

W = (1/2)*mv²*duration
and P = W/dt

These equations are universal.

[bernard]

Perhaps I may use this metaphor:

SMT is like a slap and it works but I prefer a caress.
The two means use touch but aren't perceived as same.
The necessary power for a slap is much higher than the one needed for a caress.

And because the slap has a short duration, even the two means need the same work (physics), the second wins in term of energy cost.

[Jason Silvernail]

Perhaps you're right bernard but given the existing evidence and usefulness of manipulation in some cases, I'm not sure such relatively small energy differences matter that much.
I'm a minimalist, too, but who could argue over energy expenditure differences of a few kcal?
:)

[Luke Rickards]

Bernard,
I'm not sure I understand why the duration of application is related to the outcome. You can potentially spend 2 hours touching someone and get nowhere, or spend a few minutes priming for a strong placebo and get a cure.

I also don't understand how you can say SMT "doesn't change the problem at all". There is little evidence that we can determine what the problem is in the first place, so when someone benefits from SMT we cannot be sure it has addressed the 'problem', but we also cannot be sure it hasn't.

[bernard]

You can potentially spend 2 hours touching someone and get nowhere, or spend a few minutes priming for a strong placebo and get a cure.

Luke,

You're cheating! Nobody told you the second mean had no result.
BTW, I was not thinking about a 2 hours duration.
We are comparing two means with same results but different duration. ;)

I also don't understand how you can say SMT "doesn't change the problem at all".
I said "it" instead of SMT. THat's make a big difference since the "it" was a general statement (about energy). :confused:

I'm a minimalist, too, but who could argue over energy expenditure differences of a few kcal?The difference is like a Master and his student: The second has to learn how to lose these few kJ. :D

[Diane]

The argument here has gone off a technical deep end.
Let's bring it back up on the rails.
Let's say, for argument's sake, that we are talking about how best to elicit a placebo effect. Let's pretend that the problem we are treating is persistent pain, and nothing but. Let's define "persistent" as pain that the patient cannot seem to downregulate on their own, which is why they are in your office. Let's use the Wall definition of placebo, which states that the best placebo is the one elicited, not given. It's up to the patient's brain to produce it, and it will be precise in its formulation, components, specificity, target, and will be of extremely long duration.

Now, go back to arguing over which sort of handling works best to accomplish this.

[Luke Rickards]

the best placebo is the one elicitedDiane, the only placebo is one that is elicited.

which sort of handling works best to accomplish this.No one handling approach has any inherent advantage in terms of placebo than any other. If you read the chapter in the Textbook of Pain, Wall explains that the 'appropriate response' / consummatory act is not simply biological, but psychological / cultural etc. As far as a particular patient's brain is concerned, SMT may be every bit as powerful in eliciting placebo that any other approach. How could it not be?

Of course, that has little to do with how a practitioner should decide whether it is appropriate.

[Luke Rickards]

We are comparing two means with same results but different duration.OK Bernard. But how are we sure that the two are effecting the same mechanism, ie they are exactly the same means.

[nari]

Back to the SMT thingy - the question has often arisen as to why pain relief can be instant, within seconds, with SMT. Like pouring water on a smouldering fire.
This has to be placebo (fast response) and the practitioners of SMT probably know it, or suspect it, and would never admit it.
The speed of a HVLA, however, usually means the effect is short-lived, unless other measures are taken as well, to enhance a long/er term response. On occasions, however, it would seem that one thrust has lasting effects, though only on a certain category of folk.

The same result can be achieved with education alone, but again we have limitations, usually due to emotional/meme factors on behalf of the patient and the therapist.

Ceteris paribus, everything we do, quickly or slowly, elicits a response which is either a placebo or nocebo. Which way the penny drops probably depends on what the therapist had for breakfast or whether the patient had a fight with a spouse before attending. Or vice versa.

Which is why, to me, instinctive movement seems to win out. It at least excludes one set of variables - the therapist's.

Nari

[Luke Rickards]

I agree Nari.

[Diane]

why pain relief can be instant, within seconds, with SMT
Pain relief can be instant with soft tissue handling too. What does SMT do that something less effortful or assaultive can't? SMT, IMO is still much ado about nothing much, more a show for the therapist's benefit than the patients'.

[nari]

Diane, I agree that pain relief can be instant with soft tissue handling. I should have added that DNM most likely desensitises long term because the method 'talks' to the nervous system. SMT probably doesn't because of rapidity. Wham bam etc.
But the time factor involved, the quick fix in under 2 minutes is what appeals to therapist and patient. If patients are offered nothing much else, they take it as being the only 'real' option, and are keen for more.

I also agree it is over-rated, but it does remain an effective method of pain relief; it is rather vaudevillesque and carries the magical solo performance of a castanet or two. According to the practitioners, it is easy to learn and requires no deep-model learning. It will always be around. But no-one is ever obliged to practise SMT if they choose not to.
In Oz many physios learn SMT but not many care to practise it, due to the risks. (And that topic of risk is closed) :thumbs_up

This is an interesting thread with skeins of dissonance through it.

Nari

[Randy Dixon]

I disagree with there being no skeins of dissonance behind it. You make the claim that the relief felt by SMT "must be placebo". Why? It is certainly neurological, but why must it be placebo? There is a resistance to the very idea of manipulation here that seems to be based on philosophy and an emotional attachment to a position that goes beyond a review of the science or of reasoning.

I believe that there is a response to manipulation, whether by self, positional or applied by another. I believe that there is a different physiological response to "popping" than other techniques. The science is unclear about this, there are many theories about what is being affected neurologically, but as far as I know, none are definitive. I have entertained the idea that "popping" may be a natural and maybe even necessary part of maintaining joint health. Why? Because I have spent a lot of time, partly because of this site paying attention to what my body does. If I am paying attention there is a subtle "popping" of joints almost anytime I feel musculosketal discomfort, followed usually with relief. This is not the contorted forcing that is usually associated with self-manipulation, but just normal movement. Standing after sitting too long, stretching, yawning, lifting a jar. Normal, everyday movement. I don't know if this happens to everybody, I don't appear to be abnormal. Maybe people can spend a week paying attention and looking for just this in their own actions and see if they observe the same.

Additionally, I often get a small pain in different joints. I will use the elbow as an example as it is currently the most common. There is a pain and a feeling that I can't fully extend my arm, but if I fairly quickly flex it and then extend it, it "pops" and the pain is gone and my motion returns to normal. I know I am not alone in this since I see many people perform similar actions and I hear them as well. This is not something I learned, it comes naturally. I've even seen my dog do it.

Thirdly, and the one that is most like the manipuation that some find so unjustifiable here, I will give an example that happened last week. I rode an hour long ride on a bike that wasn't mine and didn't fit me well, ran for 3 miles and finished by doing some fast resisted knee raises (on our neat Vertimax trainer). That night my back ached so that I couldn't sleep, this is very rare for me, no movement, or breathing or anything else I tried gave me relief. I could palpate my back and find the point of pain at L2-L3 and I could feel it "out". I managed self-manipulate with a good "pop" and the pain was gone and it didn't come back. It was a miracle, I got GREAT RESULTS!! (Ok, I'm just waving the red flag). I know the arguments, but the one that seems most likely to me is that I moved the joints, which had a neurological effect, one which I was unable to create any other way. Of course, this is quite different than someone else being able to recognize that this would resolve the problem. I have had back pain that gave me no desire to manipulate my back and I doubt that it would have been helpful.

My point, I think there is too much there to dismiss manipulation as a parlor trick, it may be oversold but all I see here is an attempt to dismiss it, not explain it. I don't think there is any doubt the effect is caused neurologically rather than mechanically, and I understand the philosophy behind not wishing to use it, what I don't understand is why it doesn't stimulate any curiousity about how it works.

[nari]

Randy, I actually said:

This is an interesting thread with skeins of dissonance through it.
Of course there is dissonance with SMT. From my point of view, I have said that SMT does work. Your anecdotes about 'popping' your various joints are legendary ways that people use around the world. I've used them on myself.
An anticipation that some method will work, and work well, is half the battle won. That is a placebo. Placebo is neurological in nature.

You described what some chiros call a subluxation at L2-L3 after your bike ride. That's fine, changes in and around vertebral bony surfaces are palpable.
According to the 'experts', these changes are not evident on XR; so we do not know what they are. Maitland called them 'thickenings'.

As to how it works, there have been discussions about this on RE and NOI. Nobody actually knows of a valid explanation that I know of. I'm curious, but previous discussions have rather led to a cul-de-sac.

Nari

[Jason Silvernail]

Explanations may have gone in circles on the manipulation issue, but I think it's premature to declare that the results of manipulation must be due to placebo alone.

I'm unaware of an inactive treatment which elicits placebo that can have the effect size demonstrated in the CPR studies for manipulation. Maybe I'm just uninformed?

I know I'm on a lonely boat here regarding manipulation, but surely there's enough dissonance in the published evidence to have a group of scientists say more than, in effect, "it has to be placebo and deep down they know it."

While sometimes pain relief is instant with SMT, sometimes there are no acute changes but later changes withing 24-48 hrs, sometimes it doesn't help, and other times only temporarily worsens the problem. These effects may be ascribed to the treatment itself or a placebo or nocebo response on a continuum, I suppose.

[Diane]

I think it's premature to declare that the results of manipulation must be due to placebo alone.

I would venture to say that all pain relief from physical treatment is from placebo. (Right Luke?)


While sometimes pain relief is instant with SMT, sometimes there are no acute changes but later changes withing 24-48 hrs, sometimes it doesn't help, and other times only temporarily worsens the problem. These effects may be ascribed to the treatment itself or a placebo or nocebo response on a continuum, I suppose. So, I thought this maybe-it-will-work-, maybe-it-won't issue had been solved by that great manip study awhile back.

What would be an example of an "inactive" treatment, Jason?

[Randy Dixon]

Nari,

Oops. Sorry.

[nari]

Randy,

That's cool.

Nari

[Luke Rickards]

I would venture to say that all pain relief from physical treatment is from placebo. (Right Luke?)Diane, I feel that statement may be a little too strong. Placebo is a central processing mechanism. While all physical treatments will involve some degree of this I still think many approaches do affect nociception at the transduction level.

[BB]

I agree with Luke. I've thought on this for a bit, and I actually think that Wall's assertion on Placebo might be a bit too strong as well.

Placebo is meeting of expectation by an inactive agent. Nocebo is meeting a negative expectation by an inactive agent.

The commonality is expectation. Expectation can also be met by an active agent such as reduced mechanical deformation.

So, I think that a more accurate statement would be "all pain relief from physical treatments is from meeting expectation." The manner in which that expectation is met is where they differ.

[Diane]

Placebo is a central processing mechanism Is everyone absolutely certain about this, that it is confined strictly to central processing?

[nari]

Maybe it would be fair to say that placebo and nocebo are part of the response to all treatments, regardless of the type of Rxs.
Some ideas from the Butler course:
Iatroplacebogenesis was coined by Shapiro in 1997, and it can be conscious or nonconscious. He did not like the association people make iwth placebo being regarded as a nuisance. It certainly confuses the researchers.
Butler stated it (placebo)is at the heart of (any) clinical reasoning process
But then he was coming from Wall's work.....

Nari

[BB]

Randy,

I wrote this on another forum about why I feel manipulation "works."

Let's consider the manipulation CPR. The subgroup of people is determined through physical testing in addition to subjective history.
Pain not extending below the knee: if pain were below the knee do you think a person may suspect something more sinister than non-pathologic back pain? A possible explanation made popular through our culture with such a finding would be a disc herniation....tissue damage. Do you think someone operating under an explanatory model of "i have tissue damage" will likely expect a manipulation to be effective?
FABQ score: A lower score indicates a higher likelihood of success. Those with higher scores percieve that activity might harm them, keep them from returning to work, etc. These people believe that avoiding stimulation is a good thing.
Duration of symptoms: Would it seem likely to a patient that the longer symptoms are present the more likely something must be wrong and more likely to be something sinister or pathologic?
Now the more interesting ones....positive prone P/A mobility testing for hypomobility:
In this scenario you are performing a physical test. You are very obviously examining the patients lumbar spine. You are very obviously checking the joints. You are very obviously checking the joints for movement. Maybe less obviously to the patient you are finding a decrease in movement. Do you think it possible that the mere fact that you have shown these things to the patient might impact their perception of what it going on? "This respected therapist is checking my lumbar spine joints. Feels as though they might have found something. Something must be going on with my joints which needs addressed." Do you think this might impact expectation?
Hip rotation finding:
Again the above scenario for mobility testing makes sense. The physical test you are providing is impacting their perception. Now it seems likely to be in the opposite direction. Someone with LBP whose hips are lacking significant rotation may have a tendency to think, "whoa, this is involving more than just my back." versus someone whose hips move normally may confirm that it is a problem in the back joints as confirmed by the last test this person just did.

I feel meets an expectation that can be established by the manner of testing, social norms, past experience of relief, etc.

[Luke Rickards]

Diane, as I understand it - Yes.

Cory,
Expectation is one aspect of placebo. The other is conditioning. Conditioning can develop from exposure to an 'active agent' (as you have put it) in the absence of initial expectation - though expectation can strengthen the effect of the initial exposure. I think Wall is still safe.

For more on the interactions between manual therapy and placebo check out Nic Lucas' editorial To what should we attribute the effects of OMT? (http://www.somasimple.com/forums/showpost.php?p=10327&postcount=1)

[Diane]

Diane, as I understand it - Yes.

I'm not so sure anymore. After reading lately about how efferent afferents really are, and how mechanoreceptive, I'm wondering about local effects and how "placeboic" they might feel - to the brain. Yes, I still think the brain does the placebo thing for the longterm improvements. But it needs time to construct the necessary biochemical soup for that. I think. I'm pretty sure.

[Luke Rickards]

How, then, does naloxone-an opioid receptor blocker-reverse placebo analgesia? There are no opioid receptors in mechanoreceptors.

[Diane]

I'm talking about skin afferents, way out from where the spine is located. The concept would be, stimulate the mechanoreceptors, change the substance P and CGRP etc. out in the peripheral part of the periphery, let the chemoreceptors take it from there, to the CNS. They let the opioid thingy happen all it wants to. Takes time though.

[Luke Rickards]

External stimulation of mechanoreceptors and the resulting chain of peripheral events describes something very different to the neural substrates of expectation and response conditioning. I'm not saying that what you have described doesn't occur, I just don't think it can be called placebo.

Where is the idea that a placebo response takes time from? Can't it happen immediately?

[Diane]

Yes, I think so, and then the tide can really come in. I think that for it to be permanent improvement, a process of some sort must occur over the course of a few minutes. Like 2.

[nari]

I would think that, with persistent pain, there has to be a second process, whatever that may be, to confirm resolution. With acute pain, I'm not so sure.

When persistent (3 yrs plus) pain can disappear just with education, even during education, that's evidence of some sort that placebo is elicited, without contact of any kind or movement. That is, no mechanoreceptors are stimulated.
To resolve pain perception, some kind of follow-up is essential. At this point it would seem ideomotion and/or DNM.

Nari

[Randy Dixon]

Cory,

As I understand your post you are simply saying that SMT works because of placebo and suggestion. That is why I posted three personal examples as references for discussion. the first and second are not explained by your explanation. The third, my self mobilization, can be partly explained by your explanation, that I got what I expected. The questions that remains for that are, why don't other techniques give that same effect and why doesn't manipulation always give that effect?

I understand why there is resistance to the clinical use of manipulation (and I include clinical manipulation, self-manipulation and spontaneous manipulaton in this), but I think there is a resistance to examine it intellectually, instead there is a wish to find a way to dismiss it because it doesn't match up philosophically with the way most here wish to practice. It is as if there is a wish that it never was effective, that we never experienced pain relief as a result of a manipulation or a "pop" ourselves even though many of us have. There will be pages long discussions about how the weight of long hair can impact the vagus or trigeminal nerve, and other esoteric occurences, yet a common, interesting, occurence of a neurological nature is dismissed and ignored because people don't like its use clinically or don't like the people who use it clinically. I'm suggesting that we separate the technique from the phenomenon.

[Jason Silvernail]

I think we may be giving placebo too much credit clinically as well. I think that to achieve a measure of pain relief, many treatments actually reduce the nociceptive drive by reducing the mechanical deformation of nerve tissue or engaging descending inhibition.

I've helped many people with manipulation or with simple contact who were quite clearly suspicious of the process and unsure of whether it would help. They consented, but had a negative general expectation.

Re: placebo - of course in physical medicine it's hard to create these, research-wise, but I would consider an inactive treatment to be one that was designed to be unable to reduce mechanical deformation of nervous tissue and unable to produce descending inhibition through a physical means. Of course - good luck finding that.
If we are going to attribute SMTs effects to placebo only (which is what I'm reading) then I would think we could point to loads of research showing such a large effect size as in the CPR studies with just about any treatment - all that would be needed is expectation and an appropriate group predisposed to the treatment. And yet we don't see that.
I'm not suggesting this is an airtight case, but I think there is definitely a physical effect for manipulation, and ascribing it to placebo only is I believe not warranted.

[nari]

For the record, I have never stated that SMT is due to placebo only. If that has been interpreted as such, that is not right. Anticipation of pain relief is in most patients' minds if they see a clinician, and that means a placebo response. Other things that are done complement the response.

We have to remember those who are in pain before, after and during a procedure (NOT just SMT) but if the PT or Chiro turns out to be a caring and thoughtful practitioner, they will not mind, and probably return.

Nari

[Jon Newman]

This longest entry in Wiki that I have seen happens to be on placebo (http://en.wikipedia.org/wiki/Placebo_(origins_of_technical_term)).

[Diane]

I think that to achieve a measure of pain relief, many treatments actually reduce the nociceptive drive by reducing the mechanical deformation of nerve tissue or engaging descending inhibition.

Let's say, for discussion sake, I concur.
1. How would any treatment, including the polar opposites of SMT, i.e., SC and DNM, not do the same?
2. Also, what is the difference between "engaging descending inhibition" and facilitating placebo (the Wall kind)?
3. Why do people persist in giving SMT some sort of "special" meaning? E.g., "why don't other techniques give that same effect and why doesn't manipulation always give that effect?"

I swear there's a corny love affair going on with SMT, not good deconstructive sense. And I've never fallen under its swoon.

[Luke Rickards]

Diane,
I'm a little surprised. If you truly believe that all manual treatment is placebo and you are skeptical of the idea that "many treatments actually reduce the nociceptive drive by reducing the mechanical deformation of nerve tissue", why have you made so much effort in DNM to develop such specific methods of mechanically unloading nerve tissue and 'reoxygenating' sensory nerves etc, etc?

[Jason Silvernail]

Yeah, what Luke said.

Plus-
Let's say, for discussion sake, I concur.
Does this mean that you feel that most treatments are placebo alone - but for this discussion? I mean, given the origins of pain as demonstrated and discussed in the Five Questions (http://www.somasimple.com/forums/showthread.php?t=2404) thread, this is what I'm gathering if you'll only provisionally admit that treatments reduce the mechanical deformation in the relevant tissue.

How would any treatment, including the polar opposites of SMT, i.e., SC and DNM, not do the same?
Are you asking how any physical treatment "wouldn't do those things?" Isn't this angle, the primary argument, that many here (including me) have used against the concept of stretching and strengthening for pain? The basic point being that they don't target the right tissue with an aim to reducing it's mechanical deformation?

On the difference between engaging descending inhibition and the placebo response - I believe this is a difficult question but in papers on proposed mechanisms of manipulation (http://www.somasimple.com/forums/showthread.php?p=21846#post21846) descending inhibition comes up, one type of which might be the placebo response.

Why do people persist in giving SMT some sort of "special" meaning?
Why do you persist in denying it's limited usefulness and refuse to discuss it from a neurophys point of view? I would say that since successful treatments have mechanisms in common (http://www.somasimple.com/forums/showthread.php?t=2823), it behooves us to discuss what those might be, and include manipulation in that equation. I don't see any special meaning being conferred here, just an attempt to get at why it sometimes works - let's talk about it like we talk about any other treatment, right?

[Diane]

I'm a little surprised. If you truly believe that all manual treatment is placebo and you are skeptical of the idea that "many treatments actually reduce the nociceptive drive by reducing the mechanical deformation of nerve tissue", why have you made so much effort in DNM to develop such specific methods of mechanically unloading nerve tissue and 'reoxygenating' sensory nerves etc, etc?

Because, if all we amount to as manual therapists is placebo-eliciters (and I'm not saying that's a bad thing - obviously it's a good thing to be able to elicit another nervous system to produce what it needs to overcome its own pain output, or we wouldn't all do it) ... if that's all we do, then I want to do that with the least amount of input, the most refined approach, the least amount of potential effort expended (by me) that I can, and get the longest lasting results possible. That's why. And because I have the time and inclination.

Does this mean that you feel that most treatments are placebo alone - but for this discussion? I mean, given the origins of pain as demonstrated and discussed in the Five Questions thread, this is what I'm gathering if you'll only provisionally admit that treatments reduce the mechanical deformation in the relevant tissue. I don't see any problem with equating reduction of mechanical deformation of neural tissue with induction of placebo response, which to me is fairly inseperable from descending inhibition. What I smile about is the excruciating lengths that lovers of SMT go to to work out what is "special" about their favorite technique. Why not just ignore the spine, which is mostly bone and other mesodermal housing, which doesn't deserve all the pounding it takes from everyone, and elicit effects from further away/more superficially, let the person's own nervous system decide when and if to "relax" the spine itself?

I guess an analogy would be, instead of having to hold one's breath and dive for every fish one needs to catch, it's easier to just sit on the bank and dangle a line in the water. The fish(brain) will be enticed to come up and nibble the bait, since that is in it's nature anyway (come to the cutaneous surface).

[Luke Rickards]

That's why. And because I have the time and inclination. Diane, that doesn't really answer the question. Specific unloading of nervous tissue would be completely irrelevant in the stance you have taken. Why bother?

don't see any problem with equating reduction of mechanical deformation of neural tissue with induction of placebo response, which to me is fairly inseperable from descending inhibition.A placebo response can occur in the absence of any reduction in mechanical deformation, and reduced transduction of mechanical input will give pain relief without the need for descending inhibition.

[Diane]

Specific unloading of nervous tissue would be completely irrelevant in the stance you have taken. Why bother? Sometimes I wonder why too. Let's see: create a new non-mesodermalist approach, that gets more people fishing off the banks instead of diving, doesn't disurb the fish as much (let's them choose their own action), and doesn't churn up the water as much. Yup, I guess that's why.

A placebo response can occur in the absence of any reduction in mechanical deformation, and reduced transduction of mechanical input will give pain relief without the need for descending inhibition. I never said it couldn't. Did I?

[Barrett Dorko]

Interesting.

I'm with Jason and Luke here but would also agree that treating from the periphery makes sense and I've watched that sort of handling result in precisely the effect desired.

When the system changes as we desire despite the absence of any overt outside force I don't think "placebo" but rather "unseeable (but often palpable) ideomotion." This would account for the reduction in mechanical deformation responsible for the pain's origin.

I would use the analogy of twisting and untwisting a finger. Untwisting may happen automatically (ideomotion), passively (SMT, massage, "soft tissue work," Rolfing and others) or active-consciously (exercise). For the last two to work too much luck is involved, I think. I'll take the first in response to Simple Contact, and I'm not certain that placebo is the primary factor in its success.

[Diane]

It is as if there is a wish that it never was effective, that we never experienced pain relief as a result of a manipulation or a "pop" ourselves even though many of us have. I see pops as secondary to relief, and pretty much inconsequential in the wide angle view of things. Peoples' bodies/spines/joints pop all by themselves. In fact spines sometimes pop on my treatment table, the people who own them just lying there, and me working on some bit way distant from the spine.

The real agenda I have is to refocus our view of the body away from joints (mesoderm) and pops (joint behaviour, entirely passive) and toward the nervous system. In SMT the two things, the act of SMT and the supposed mechanism of pain relief, are so historically and hysterically conflated, pounded into each other like the layers of steel in a Samurai sword, that I'm more inclined to pitch the whole mess of deconstruction of ALL of it. Into the compost bin. To me, SMT and Z-thingy have much in common, i.e., a fascination with joints. In one case, moving them passively, in another, actively. Still joint mentality, mesodermal thinking, focusing only on parts that bend rather than on the whole thing.

By the way, if (the poorly named) muscle energy technique counts as a form of popless spinal "manipulation", then I'm guilty of using SMT on occasion.

[Diane]

Untwisting may happen automatically (ideomotion), passively (SMT, massage, "soft tissue work," Rolfing and others) or active-consciously (exercise). By this definition of untwisting, untwisting happens "automatically" via ideomotion with DNM.

[EricM]

Is it safe to say that not all mechanical deformation leads to pain? Do we know when performing SMT or DNM, or SC that nervous tissue has been undeformed sufficiently to reduce transduction? All we really know is that the patients perception of pain has changed. Diane has certainly been making the case that is it highly probably that a change in mechanical deformation could occur with her treatment, and with some specificity. This is something that I'm not sure SMT can claim yet. But I don't think we can know to what degree mechanical deformation is changed. I think maybe this is a great unknown I was referring to in another thread. What all treatments have in common is an undeniable influence on the processing within the neuromatrix and it's subsequent output. To me this is where the placebo or nocebo is created.

[Diane]

Is it safe to say that not all mechanical deformation leads to pain?
I think that would be safe to say. If it happens at a rate the brain can manage to downregulate successfully, and while it's not dealing with external threats, or internal threats from some other sort of allostatic or homeostatic load, why wouldn't it? It can learn at every level, accommodate to lots of things until those things feel "normal" to it. Even to pain itself, in many cases. Not that that is a "good" thing, but I think it's a "normal" thing, i.e. biological. The brain is a threat reducer/interoception minimizer/ and pain producer when pain producing is seen as a better means toward survival.

All we really know is that the patients perception of pain has changed.
Yes. And everything else hinges on that. (Especially for the patient.) Including treatment constructs. Including old and obsolete ones.

[Barrett Dorko]

Diane says: "...untwisting happens "automatically" via ideomotion with DNM."

I've always felt that this was the case.

Eric,

Mechanical deformation simply means "movement from natural shape" and it is absolutely essential and inherent to life. The key issue is its relation to tolerance which is, to me, much the same as autonomic state and can change sufficiently with remarkable speed, even if it needs to do so profoundly. DNM and Simple Contact work specifically with this phenomenon by virtue of their non-threatening nature. I add education regarding breathing and hip position as well. I imagine Diane does too.

This is something a SMTer or acupuncturist or personal trainer or Rolfer or massage therapist has quite commonly to overcome with great difficulty. For DNM and Simple Contact (which, by the way, doesn't necessarily require touching) non-threat is inherent to the method itself.

[Jason Silvernail]

Well, while I enjoy one of Diane's "manipulation is outdated and useless banging on a spine" speeches as much as the next guy, she really isn't addressing the question of why the neurophys explanation for the results seen isn't worth addressing or discussing. All fishing analogies aside.

I agree with what Barrett is saying in that in the periphery, the focus is to remove mechanical deformation via movement - ideomotor, manipulative, or exercise. I also agree that there is a certain amount (ok, a large amount) of luck involved in the second two. However, many people respond in a predictively positive way to manipulation and we can predict with some accuracy who those people might be.
Many times the speed of relief is such that I think there's been SOMETHING done in the periphery to account for that. I'm not certain what it is. Given our current understanding of the origins of pain, I'd say some degree of mechanical unloading or descending inhibitory action is at least partly responsible - I don't think it's all placebo.

[Jason Silvernail]

Luke: Specific unloading of nervous tissue would be completely irrelevant in the stance you have taken. Why bother?
Diane:
Sometimes I wonder why too. Let's see: create a new non-mesodermalist approach, that gets more people fishing off the banks instead of diving, doesn't disurb the fish as much (let's them choose their own action), and doesn't churn up the water as much. Yup, I guess that's why.

From this exchange, Diane are you saying that you feel no specific deformation is being resolved peripherally with your approach and that you designed it just so it was a less (in your opinion) invasive way to elicit a placebo response?
Please tell me i'm misunderstanding.

[Jon Newman]

During the APS meeting last May Julie Fritz addressed mechanism a little bit and made a case against expectation playing an important role. Her bulleted points about neurophysiology stated


Effects of manipulation are non-specific
Therapeutic mechanism underlying manipulation likely more related to neurophysiology than biomechanics


She cited Dishman, et.al (2002) and highlighted


Motor evoked potential facilitated to 60 sec post manipulation
Manipulation produced central motor facilitation


She also cited Herzog, et. al (Spine, 1999) and other bulleted points included


Manipulation triggers the release of endorphins
Stimulation of large afferents impedes the passage of nociceptive information at the level of the spinal cord


On the topic of patient expectations she had a graphic depicting the four week trend of "patients who believed manipulation would help". See attachment. I'm curious about the population characteristics of those negative on the CPR, especially in the -cpr/manip group. Anyone know?

Hi Randy,

I think over the years there have been attempts to explain it and those attempts lead some to think it's placebo by and large. To that I say "so what?" Not "who cares?" but more along the lines of "so what are the implications of that?"

Part of what has been frustrating for me is that much of the recent research on manipulation has simply been to show that it works with little regard for why it works. Because of this, I'm far less frustrated with anyone who concludes it is placebo than with those directing manipulation research. On the other hand, I do understand the need to demonstrate that it works and I'm not pooh-poohing those efforts.

[anoopbal]

Neurophysiological effects of spinal manipulation.Pickar JG.
Palmer Center for Chiropractic Research, 1000 Brady Street, Davenport, IA 52803, USA. pickar_j@palmer.edu

BACKGROUND CONTEXT: Despite clinical evidence for the benefits of spinal manipulation and the apparent wide usage of it, the biological mechanisms underlying the effects of spinal manipulation are not known. Although this does not negate the clinical effects of spinal manipulation, it hinders acceptance by the wider scientific and health-care communities and hinders rational strategies for improving the delivery of spinal manipulation. PURPOSE: The purpose of this review article is to examine the neurophysiological basis for the effects of spinal manipulation. STUDY DESIGN: A review article discussing primarily basic science literature and clinically oriented basic science studies. METHODS: This review article draws primarily from the peer-reviewed literature available on Medline. Several textbook publications and reports are referenced. A theoretical model is presented describing the relationships between spinal manipulation, segmental biomechanics, the nervous system and end-organ physiology. Experimental data for these relationships are presented. RESULTS: Biomechanical changes caused by spinal manipulation are thought to have physiological consequences by means of their effects on the inflow of sensory information to the central nervous system. Muscle spindle afferents and Golgi tendon organ afferents are stimulated by spinal manipulation. Smaller-diameter sensory nerve fibers are likely activated, although this has not been demonstrated directly. Mechanical and chemical changes in the intervertebral foramen caused by a herniated intervertebral disc can affect the dorsal roots and dorsal root ganglia, but it is not known if spinal manipulation directly affects these changes. Individuals with herniated lumbar discs have shown clinical improvement in response to spinal manipulation. The phenomenon of central facilitation is known to increase the receptive field of central neurons, enabling either subthreshold or innocuous stimuli access to central pain pathways. Numerous studies show that spinal manipulation increases pain tolerance or its threshold. One mechanism underlying the effects of spinal manipulation may, therefore, be the manipulation's ability to alter central sensory processing by removing subthreshold mechanical or chemical stimuli from paraspinal tissues. Spinal manipulation is also thought to affect reflex neural outputs to both muscle and visceral organs. Substantial evidence demonstrates that spinal manipulation evokes paraspinal muscle reflexes and alters motoneuron excitability. The effects of spinal manipulation on these somatosomatic reflexes may be quite complex, producing excitatory and inhibitory effects. Whereas substantial information also shows that sensory input, especially noxious input, from paraspinal tissues can reflexively elicit sympathetic nerve activity, knowledge about spinal manipulation's effects on these reflexes and on end-organ function is more limited.

CONCLUSIONS: A theoretical framework exists from which hypotheses about the neurophysiological effects of spinal manipulation can be developed. An experimental body of evidence exists indicating that spinal manipulation impacts primary afferent neurons from paraspinal tissues, the motor control system and pain processing. Experimental work in this area is warranted and should be encouraged to help better understand mechanisms underlying the therapeutic scope of spinal manipulation.

Anoop

[Diane]

Jason,
From this exchange, Diane are you saying that you feel no specific deformation is being resolved peripherally with your approach and that you designed it just so it was a less (in your opinion) invasive way to elicit a placebo response?
It's definitely a less invasive way to elicit a placebo response. Eliciting a placebo response (one that sustains permanently, or at least very long term) is the goal.

I.e., pain relief is the goal.

DNM is the strategy.

The tactics involve skin stretch and unloading whatever nerves feel stressed - ones that are literally palpable, because they lie parallel to and below the C/subC, and ones that aren't, because they lie too deep (for DNM), but are undergoing tensioning via observation of movement, position of hips, whatever whatever. The tactics can change according to conditions if need be, as long as the strategy is working.

The nervous system being the nervous system, and willing to first check for threat value, then accommodate itself to all input of an exteroceptive sort, I think it probably doesn't matter too much where I end up, because all the nervous system runs out to skin somewhere. I therefore don't have to be anal-complusive about where I put hands, or what skin I stretch, I just do something and wait to feel what the nervous system response is. Then I alter a bit if necessary. Grip, direction, position.
I can assume that the nervous system will read the input and downregulate normally, to greater normality. If I happen to be directly over a nerve, and it's close enough to target, and I can feel its surrounds soften in response to something I'm doing, then that's a bonus. Something I might teach to others even. Otherwise, I can just sit there and let the patient report on how things are proceeding - "I can feel my shoulder", "the right elbow feels like it's got water running through it, but you're working on my left wrist - how is that possible?" etc etc.

Please tell me i'm misunderstanding. Yes and no.

Now I have a question for you: How can you perform SMT without moving skin or signaling the brain through it? Please tell me you don't take it off people before you treat them.

[luca m]

Diane,

If a study was set up where one group received SMT and the other a "fake" SMT (involving the same contact with the skin) would you expect the same results for the two groups?

Luca

[nari]

Diane does make a good argument that skin cannot be excluded from any kind of physical contact with a patient. SMT distorts the C and subC, so is it reducing mechanical deformation in its nonspecific way? And if not, why not?

Barrett, I agree that eliciting ideomotion cannot be placebo alone. If a patient consents to SC for the first time (and not necessarily touch) he/she cannot have any perception of what to expect. What is excluded is the fear of the PT 'doing' things to them which involve physical contact. If we conclude that anticipation of pain relief is an inherent part of consent, that's fine. However,the patient who is fearful that anything done will make the pain worse, can still respond favourably.

As stated, this includes SMT. However someone can instinctively resist SMT to the point where the practitioner has to coax and cajole relaxation so the technique can be carried out safely. To me, this is not a preferred method for that reason alone. It's OK for those who do not resist.

Luca - how would one perform a 'fake' manip?

Nari

[luca m]

There have been several studies that use a sham manipulation as the control group where the sham is perceived by the patient as the real thing. There was even a study that tried to validate the sham procedure.

What I took Diane's comment to mean is that if we're applying a force to the skin during a SMT how does one know whether it is the SMT that has the physiological effect or simply the skin contact. The Sham group should address this. In many of these studies the sham groups did not respond as the SMT groups did.

Luca

[nari]

Luca, I understood the reason for your post.
What intrigues me is the concept of a fake manip, and wouldn't a person participating in a trial recognise it as 'fake'??

Nari

[Jon Newman]

If post manipulation analgesia has a large mechanical effect (i.e. relief of mechanical deformation) one would think that this could be confirmed by performing a manipulation known to be effective on a group known to respond to it while the subjects are under anesthesia.

Subjects would be completely blinded to which group they are in. The manipulation itself could be performed by someone otherwise not involved in the study thus allowing for blinding of data collectors/therapists also.

If results between groups were equivocal we could begin to think about ruling out important mechanical effects at both the spine and skin levels leaving the interaction between conscious people essential to the observed effects (i.e. active neurophysiological processes).

[Barrett Dorko]

Some good ideas there Jon.

I remember that Stan Paris would often speculate about the effects of manipulation under anesthesia, but, as far as I know, never did this. Occasionally we'd talk about how we knew that normal range was present while our patients were anesthetized but would return to their "joint stiffness" upon awakening.

Gee, why do you suppose that was?

Paris went on to focus on the neuroanatomy of the facet and never the neuroscience of pain. This explains a whole lot.

[BB]

That is a great idea Jon. None of the studies listed in pubmed for "spinal manipulation under anesthesia" are blinded.

Also of interest is that naloxone (an opoid antagonist) administration did not take away the positive effects of manipulation nor mulligan MWM in studies.

I'll take a look at Daniel Wegner's studies on expectation/perception. Simply asking a person if they think it would be of benefit may be oversimplified. That would address the conscious, long-term survival part of the brain, but not necessarily the immediate survival parts that are non-conscious. I think this still addresses the other 2 examples you gave Randy, but let me get back to you after I remind myself of how Wegner studied this.

Jason,
I'd think that all need happen in the periphery is a novel input, which could easily be from SMT. The perceived threat would account for positive or negative outcome and that would be tied to expectation. Non-threatening context. It would make sense that a reduction in mechanical deformation is ONE of the ways that this could happen. I do see dilemma in how high velocity movement could create a reduction directly unless you buy into a "bone out of place" theory, and we all know that is bunk. It would have to be through descending inhibition as a result of the initial increase in deformation of the intervention. So a decrease in mechanical deformation need not be present to trigger a positive response. In fact, an increased deformation can trigger it. It all depends on how it is perceived. And perception depends upon expectation.

Perhaps an interesting way to look at the Placebo issue is that, since all change of the sort we discuss happens from within, but is triggered from outside (whether through touch, communication, etc.) all our treatments are placebo (inactive agents) but trigger an active response. I think this is what Barrett said too?

[Barrett Dorko]

Cory,

Yes, that's what I was trying to convey.

The less force from the therapist the better, which matches the admonitions of Weber-Fechner, which leads to enhanced self-awareness, which is where placebo originates.

Sometimes I felt as if I were opening a package when treating patients. I wonder if anyone else here has had that feeling.

Placebo emerged, accompanied by parasympathetic increase and ideomotion. Mainly, I just served as a witness.

Reading all the posts here has helped me understand this more each day.

[Luke Rickards]

Now I have a question for you: How can you perform SMT without moving skin or signaling the brain through it? Please tell me you don't take it off people before you treat them.Rhetorical question??

If you make the argument that all of the therapeutic effects of SMT are easily explained by non-specific deformation of the skin and the brains interpretation of that, then there are some very interesting implications for DNM. There is no doubt that SMT can lead to rapid and lasting pain relief for some patients. Yet it involves a three second input on the skin and, to differing degrees depending on the patient and therapist, a more threatening context. I wonder Diane, could you ever see an immediate result by simply touching someone rapidly on the iliac crest and anterior shoulder for three seconds? Since this explains the results of the CPR study, for example, and you are looking for minimum effort, why not treat LBP with this 3 second method?

There is lots of talk about perceived threat here. However, a differentiation needs to by made between perceived threat of the pain experience and perceived threat of the intervention. I think that perceived threat of the pain experience is by far the dominant factor in recovery and the literature certainly supports that.

[BB]

Hi Luke

a differentiation needs to by made between perceived threat of the pain experience and perceived threat of the intervention. I think that perceived threat of the pain experience is by far the dominant factor in recovery and the literature certainly supports that.

Wouldn't you say that they have a relationship to each other? Perceived threat of an intervention influences perceived threat of pain experience which determines recovery? If I'm confused maybe you could expand on your thoughts of the importance of this dichotomy.

[Luke Rickards]

Wouldn't you say that they have a relationship to each other?Perhaps, but only during treatment itself. Those with low enough perceived threat of pain won't even seek care, even though the pain may be severe. Conversely, many people seek care that they absolutely hate simply because it sufficiently alters their pain experience.

[Diane]

I wonder Diane, could you ever see an immediate result by simply touching someone rapidly on the iliac crest and anterior shoulder for three seconds????
Why on earth would touching someone rapidly for three seconds help? It might, but I doubt it. Maybe if you got some ideomotor movement going..

SMT involves a number of things, mechanically, all of which get hopelessly buried under wondering what the pop is "doing" to the nervous system. I say, the almighty pop is mere artifact, and has been used for decades by snake oil salesmen to sell this BS to both students and patients.

Lets look at some of the other factors;
1. A strong skin stretch over a rotated trunk. Has to be an interesting input for all cutaneous nerves of the trunk.
2. A major differential between skin and mesoderm, i.e., the mesoderm that makes up the outer layer of the back. You know, lats and traps. Those mesodermal bits innervated by cervical nerves, but with the dorsal cutaneous and lateral cutaneous nerves from all the other segments sending back their afferent info.. and lots of info from themselves, feeling quite possibly about to become uprooted.
3. Another layer under that, held to the first, through which all the dorsal cutaneous and muscle branches of them are laced/embedded. Such fun for them. Other layers of segmented muscles below those..
4. Not much of this registers in conscious awareness, in S 1, because there's not much homuncular space there for the trunk, in case anyone ever noticed.
5. So, conscious awareness of patient doesn't take much notice.
6. Heave ho and a bottle of pop.
7. Whatever the aftermath might be. Loosened up pretty good at first. Probably descending dose of opioids from the basal ganglia, who are no doubt very concerned for the cord and all the rootlets that have just been yanked.
8. Conscious awareness of patient sort of likes the kick from that.
9. Potential for addiction to process. Likely as not, patient will develop persistent back pain that they believe can be "relieved" with a pop, and siphon in any or all the other meme crap doled out to them by those who would prey on such gratitude, in the effort to build a "practice membership", caseload, whatever you want to call it, to pay off all those student loans... but I digress.

I think SMT is much hooey about nothing, and not worth the powder to shoot a rat. Or any intellectual effort to try to come up with anything that would possibly justify it. It's a cult, and PTs are falling into thick, fast, sideways, head over heels. They are becoming indistinguishable from chiros gooning over this moronic set of assault tactics on the spine and the poor brain tail living inside it. Have I made myself clear? Any more questions? :)

[Diane]

The less force from the therapist the better, which matches the admonitions of Weber-Fechner, which leads to enhanced self-awareness, which is where placebo originates.

Sometimes I felt as if I were opening a package when treating patients. I wonder if anyone else here has had that feeling.

Placebo emerged, accompanied by parasympathetic increase and ideomotion. Mainly, I just served as a witness. I'm completely in agreement here with Barrett, all except for the word "parasympathetic". Everything to the soma is sympathetic, except a couple parasympathatic fibres to the vasculature of lips and forhead. In humans, at any rate.

[Diane]

If a study was set up where one group received SMT and the other a "fake" SMT (involving the same contact with the skin) would you expect the same results for the two groups? Luca, I'd expect better results from the "fake" group, ... with no pop. :)
Especially if the fake manip was done incredibly slowly.

[Luke Rickards]

Why on earth would touching someone rapidly for three seconds help?I asked that because of your suggestion that this explains the effects of SMT. Now you seem to have added a whole host of possible mechanical effects to the mix, which takes us right back to the initial suggestion that physical treatments, including SMT, can directly effect mechanical deformation responsible for pain.

Just a trivial aside regarding your concern that nerve trunks and roots are going to become uprooted, I see people moving through far greater ROM during exercise or SC than I ever need to take them through to perform manipulation.

[Luke Rickards]

In many of these studies the sham groups did not respond as the SMT groups did.

[Diane]

I asked that because of your suggestion that this explains the effects of SMT. OK, I'd like to see where I said that.
I never realized you were such a SMT apologist Luke.. ;)

[Luke Rickards]

How can you perform SMT without moving skin or signaling the brain through it? ] [ I'm talking about skin afferents, way out from where the spine is located. The concept would be, stimulate the mechanoreceptors, change the substance P and CGRP etc. out in the peripheral part of the periphery, let the chemoreceptors take it from there, to the CNS.

I never realized you were such a SMT apologist Luke.
I'm not Diane. I have simply found it very useful for certain presentations (or often when more indirect methods have failed), and I don't think that blowing off rational discussion of why this is so because of personal preference is very productive.

[Diane]

Thanks for providing that reference (http://www.somasimple.com/forums/showpost.php?p=36878&postcount=94) Luke. I still wonder how skin-put could be eliminated as a confounding factor. Jon's idea is interesting.

So, supposed usefulness is at least part of the big attraction.
Please everyone and Luke, feel free to carry on rationally discussing it then, but I'm will departing this thread (not that I'll be missed on it), because I always feel crabby about SMT for some reason. Descent into Joint-olandia. Bye. :)

[Jason Silvernail]

Picking up your marbles and going home then?
Things are just getting interesting.

So, supposed usefulness is at least part of the big attraction.
Well, demonstrated usefulness is, at least for me. It's what makes it so interesting to me to discuss.

Diane, I have to share some of Luke's questions, specifically:
-if you think eliciting placebo is all we're doing, why go to all the trouble to treat specific peripheral nerves and talk about re-oxygenating them through DNM? If it's just random novel input and placebo response, then just put your hands anywhere and do the same thing - why bother addressing specific nerves?

-i understand your point about stripping off the skin in explaining manipulation (for the record, I don't do that), but if you're using skin input as an explanation for manipulation, then the 3 second skin stretch that is the positioning for these techniques ought to be all that's required - if it really is the skin stretch that's doing it.

-i get that you hate manipulation - roger, understood. But can't we talk about it like clinical scientists?

Studies with sham manipulation:

Sham 1 (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=10519559&ordinalpos=42&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum)
Sham 2 (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15750369&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlu s)
Sham 3 (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11890430&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlu s)

These studies are all pretty small, but some interesting discussion in the abstracts. Luca, do you have a study that showed a significant difference between sham and regular manipulation?

[kongen]

Great discussion and interesting thread.

I think a consideration of the cuboid syndrome might be relevant to this discussion. Can the instant pain relief of the cuboid manipulation be explained by placebo alone? I doubt it. Restoring proper motor control of the joint that in turn reduce the mechanical deformation of sensitive nervous tissue? I like to believe so :)

As a side note, I often use the analogy of a sprained ankle to educate my acute low back patients. Most of them get it, and it's great to reduce fear.

[Barrett Dorko]

You're right Diane. I should have said, "A reduction of sympathetic activity."

Remarkably rapid decrease in pain, even chronic discomfort, can be seen with the proper movement if, as Jason says, the grass isn't too parched. Since there's no linear relationship between the amount of mechanical deformation introduced or the size of the nerve irritated and the pain felt (other factors, especially threat, confound this) a small motion can be dramatically helpful in a moment. The reverse is true as well.

Diane,

Your penchant for rising up in opposition to SMT doesn't bother me much. I liken it to the seemingly irrational dislike many have for certain things. Often these strong feelings and the behaviors they evoke seem irrational even to those who hold them. See this essay (http://www.barrettdorko.com/articles/with_death_comes_food.htm) for more on this.

Don't go away. I need a straight man.

[Diane]

I need a straight man OK Barrett, even though I can't lay claim to being either, I'll stick around one for more post. Thanks for pointing out I have Aspberger's on this issue. I probably do. I've always loathed SMT - in fact any professional curiosity I've ever had about it, either learning it or getting it done to me, has invariably been quickly extinguished by this loathing.

To me, it makes about as much sense as the people who think they can do something moving head bones. They can't, and, even if they could, why would they want to?

Because it is possible to override sensible threat protection in the backbone, this whole miserable cult has emerged where people do it because they can. Or at least think they can. Sure, go ahead and provoke the CNS all you want. It can take lots of assault, mechanical, physical, but please stop calling it "therapeutic". I seriously doubt this kind of handling is anything but major provocation, that the NS deals with as best it can. SM - it is well named indeed. I don't mind a cult existing that is up front about what they are about, but calling this spinal manipulation stuff "therapy" drives me binkybonky. If you want to explore the effects of more pain on existing pain, check out the authentic SM people sometime. They will be glad to tell you more about pain than you ever knew existed, and how to get high from it - from their perspective, which is one I don't happen to share.

SM does absolutely nothing to help a nervous system learn to downregulate itself. Neither does this version of SM. Last word, I promise.

[Luke Rickards]

Comparing practitioners who use manipulation to sadists and patients who benefit from it to masochists is ridiculous.

[Diane]

I don't think so. It's about domination and submission - the domination of one person's nervous system motor output over another's sensory input. I think it's a rather apt analogy. It takes a certain sort of person to really like either one role or the other. I think a great many people don't see it this way, and I think that is because this, like many other things in life, are sublimated/symbolic.

[Luke Rickards]

So by your definition then, except for psychotherapy and Simple Contact, every form of healthcare, including some aspects of DNM, can be seen as sadomasochism.

[nari]

Um, Diane, it does sound as though you have had some bad experience/s with SMT.
I am willing to bet that there are many practitioners who are brutal in their application of SMT, but there are also many who practise with care and aforethought, and whose patients return because of the pain relief they receive. Done in isolation, it creates dependency and the unlikelihood that anything positive other than short term relief is achieved.

It would seem that SMT performed in isolation is done less and less these days, except in some dodgy practices where 40 patients a day can be seen for 5 mins each at $50 a pop (excuse the pun). I know these places exist, in Oz anyway.

A benign and non-invasive approach is preferable, and probably essential with long term chronic pain people, as studies have shown. But SMT does have its place. It's knowing where and what that place is. And who with...

Nari

[Diane]

Um, Diane, it does sound as though you have had some bad experience/s with SMT. Not so much personally, just have observed several human train wrecks in pain who have been through it for years, since being children, becoming convinced over time, that repeatedly applied, it's addictive and harmful, plus the total bluffery of it, and its endless perpetuation because people of all sorts think it's so cool. I've just always been repelled by it. And I'm repelled by the apparent tsunami of PTs who think it's the cat's A$$, that without it the PT profession would be useless. Get a grip, I say.

So by your definition then, except for psychotherapy and Simple Contact, every form of healthcare, including some aspects of DNM, can be seen as sadomasochism. No.

[Jason Silvernail]

Wow.

[Diane]

Please pardon my interruption, Jason, Luke, and all, and go back to discussing the most over-discussed, overrated and underwhelming hands-on so-called therapy in the history of humankind, and whatever neural underpinnings it may have. I really am done here now. Promise. Bye.

[bernard]

Another prove our moderators haven't allways the same practice and thought about everything. :angel:

They have, as individual, their own opinions and they are free to express them. :thumbs_up


Back to the subject:
I think that "general exercice" is a bit fuzzy as description and the motor control thing remains in the same tune.
What are their contents ?

[bernard]

Forget! I found it :embarasse
Comparison of general exercise, motor control exercise and spinal (http://www.somasimple.com/forums/showthread.php?t=4117)

The SMT group is not really a pure manipulative one since it allows mobilizations ala Maitland.

The exercice group has 1 hour of practice (1 hour :eek:).
But I'll find the real content.

[nari]

Bernard wrote:
Another prove our moderators haven't allways the same thought and practice about everything.
They have, as individual, their own opinions and they are free to express them.

Reminds me of a book I'm reading by Robert Park, Professor of Physics at the Univrsity of Maryland - Voodoo Science.

He explores various OAM practices in the book, all interesting. He attends a conference of alternative practitioners run by the NIH.
He describes how each pracitioner describes personally preferred therapy from acupuncture and magnet therapy to Vitamin O.
But there was no sense of conflict or rivalry. As each spoke, the others nodded in agreement. The purpose of the (press conference), I began to realise, was to demonstrate that these disparate therapies all work. It was my first glimpse into what holds alternative medicine together: there is no internal dissent in a community that feels itself besieged from the outside. It is the same bond that holds the cold fusion community together.... (Chapter 3: Placebos Have Side Effects)
My bold.
So if there is no dissonance amongst us, that is not a good thing.

Nari

[Jason Silvernail]

No dissonance is indeed bad.
I would also argue that an over-emotional refusal to discuss a major form of therapy in one's profession is also bad.
But surely no one should have to participate in the discussion if they'd rather not.

[nari]

But surely no one should have to participate in the discussion if they'd rather not.

True. I drop out of a lot of discussions; not because of any emotional factor but out of sheer boredom with circular arguments struggling to climb Mt Improbable. But that's me. We all use our own drum.

(Acknowledgement to Richard Dawkin's text on....Mt Improbable)

Nari

[BB]

Luke,

Perhaps, but only during treatment itself. Those with low enough perceived threat of pain won't even seek care, even though the pain may be severe. Conversely, many people seek care that they absolutely hate simply because it sufficiently alters their pain experience.

Sorry to keep beating a dead horse here, but if they seek it because it alters their pain experience, wouldn't that still represent an expectation of resolution, regardless of whether or not they hate it?

I do think I see what you are saying though. The intervention may be threatening on some level, yet still bring resolution. I think in such a case the question would be what is threatening? Is it other nocebos, such as effort required, going to a clinic, etc and does that over-ride the expectation of resolution?

[Luke Rickards]

Sorry to keep beating a dead horse here, but if they seek it because it alters their pain experience, wouldn't that still represent an expectation of resolution, regardless of whether or not they hate it?Cory, the answer was in relation to your question on the interrelatedness of perceived threat of pain vs treatment, not a question on placebo.

What I was getting at is that patients don't avoid bending forward because they are afraid of what the osteopath is going to do with them on their next treatment in 5 days time. They avoid bending because they are afraid of their pain and its meaning. Overcoming this threat cognition is a far more important factor in recovery than the absence of threat during treatment itself.

[EricM]

If getting the story right is important, as has been suggested here in the past, what message/type of education should a therapist opting to manipulate being telling their patient about what they are going to do and why it might help? I am presuming explanations along the lines of freeing up misaligned or stuck joints are considered inadequate. What neurophys education is or should be provided? Thanks.

[Nick]

In my experience it doesn't matter what you tell them, manipulation convinces them that something is out of place and someone needs to put it back in. I think that is the biggest problem with it.

Having said that, I still encounter many who will not listen to extensive pain education. And many who, in spite of my best efforts, insist that corrective movement arises from my 'magic hands.'

It is not just therapists who want magic...

Nick

[Luke Rickards]

In my experience it doesn't matter what you tell them, manipulation convinces them that something is out of place and someone needs to put it back in. That has not been my experience.

[Nick]

Do tell.

[Jon Newman]

I'm interested too Luke. I ask everyone who happnes to mention "manipulation" or "chiropractor" to me how they understand what it is that is happening. Without exception some version of alignment or bone out of place is the answer.

That doesn't mean the public can't come to understand a new story but what a difficult narrative to dislodge. Boop and alignment don't just have hooks; they're apparently barbed.

[Jason Silvernail]

I find if I make an effort to deliberately create a different explanation, then people seem to do pretty well with it.
I tell them that they have mechanical pain, and that their active movement is the real solution for their pain. If they have difficulty with the movement, then sometimes other things are used to help reduce their pain and help them get started on the movement they need - and that's what manipulation can be used for. I tell them "it's a temporary jump start - not a cure". I then reinforce to them the importance of active movement and tell them everything else - medications, massage, manipulation, heat, cold, etc - is just "talk" and not the real solution. Usually if I move my hand like a small puppet when doing the "talk" thing it helps sell the point better. :)

I do sometimes have problems with people who arrive with this meme already firmly entrenched, but I teach it out of them just as I teach out the importance of the popping sound. Either people learn that "bone out of place" isn't happening, or they know I don't believe it and they stop talking about it around me. No way to know either way.

[Luke Rickards]

Jon, Nick,
I follow a similar approach to Jason. I make sure that they know I am not talking to hear myself but because it's important they understand that their current idea of manipulation will hinder their perception of treatment and possibly their recovery. I simply can't agree that no matter what you tell patients their idea of manipulation won't change.

Jon,
It is generally true that if you ask a patient who has only ever had manipulation from a chiro what is happening they will tell you bones are going into place. Ask the same of patients who have only seen an osteopath and the answer will be different (though there's always a few who get lazy with their patient education).

[Jon Newman]

Hi Luke,

Maybe that's part of the problem. I've never heard someone say the word osteopath less a few professionals. Perhaps someday someone will mention the word manipulation and after I quiz them (as is my habit) they'll tell me a story steeped in neurophysiology. My surprised follow-up will be to ask where they learned that. I'm looking forward to it.

I simply can't agree that no matter what you tell patients their idea of manipulation won't change.

I count on the ability of my patients to change based on what I communicate to them too.

[EricM]

How about,

The (mesodermal) dysfunction that you sense, and that I can palpate (stiffness), is a product of a neurodynamic that is also involved in creating your pain. We are going to try to override that neurodynamic by doing this technique that we call a manipulation. I’ll try to apply it as close to the site of stiffness as I can. This will provide an input into your nervous system that might allow the neurodynamic to change.


Metaphor of the day: This is kind of like using a defibrillator to jump start someone’s hear after it’s gone into atrial fibrillation. The goal is to change the way the nervous system functions.

[nari]

Umm Eric, may I correct your metaphor? Atrial fibrillation can be resolved by cardioversion if necessary as a last resort, rather than what you suggest. Ventricular fibrillation may need jumpstarting to prevent death.

Nari

[Jon Newman]

Hi Eric,

I like your idea. Maybe we could start a manipulation metaphor thread. I'd start but I don't have any good ones.

[EricM]

Thanks for the correction Nari, that' the best I could come up with at this time of day! I'm not particularly convinced its a great analogy, but things start to make sense for me only by working through them like this.

[Jason Silvernail]

The discussion continues...

http://www.somasimple.com/forums/showthread.php?t=4170