What is an "ectodermal approach" versus a "mesodermal approach"?

[Diane]

Since it is all my fault these terms have come into our PT world, I feel I should explain what I mean by them.


How these terms came to be

A few years ago I laid out the embryologic unfoldment of the human body in a series of threads which now reside in a folder called "In the Beginning". I deliberately pointed out, highlighted, drew attention to the differences that exist between mesodermal derivatives and ectodermal derivatives.

1. Ectoderm makes everything, including germ cells, mesenchyme and fetal endoderm:

germ cells are the first cell line to be differentiated; they split off and hang around in the egg yolk for awhile - once the gonads are built, they are drawn into the body and find their home inside them.
mesenchyme later diffentiates into about 5 "family" groups, turns itself into all the structural elements and much of the blood system
fetal endoderm turns into linings for tubes and ducts in the fetus (extraembryonic endoderm comes from the original egg and becomes amniotic sac, membranes etc.)


2. Ectoderm saves itself for building structures which will be heavily signalling in function. As such, ectodermal derivatives do not take up as much room. They do, however, consume a much larger share of available energy/oxygen.

3. Bear in mind this division of labor is all orchestrated by cells that are originally in the ectoderm layer. The outside builds the inside.

4. Ectoderm then becomes spinal cord, brain, neural crest cells and the outer skin layer. Neural crest cells turn into peripheral neurons, and various kinds of "sensitive" structural elements (which is different functionally than ordinary mesoderm in that it is more sensitive, more signalling): e.g. teeth, some bits in the throat, adrenal gland medullas, chromaffin tissue.

5. Mesoderm becomes 98% of the body but uses only 80% of available oxygen. Ectoderm becomes only 2% of the body but uses 20% of the available oxygen. You can see here that ectodermal derivatives are expensive, which is why there is less of them on a weigh scale.

6. The ectodermal derivatives are 100% responsible for function in the body, including faulty or magnificent movement, coordination, etc. They are also 100% responsible for pain generation and perception. Children born without pain perception bite their tongues and lips off, gouge out their eyes, break their legs and burn their skin, because they do not feel the warnings of nociception, and usually die young from all the trauma they've never learned to avoid.

7. One can view the ectodermal derivatives as a sensory net that reaches all mesodermal tissue derivatives, and provides motor output to some of them.

8. Neuronal cells have a very high surface area per unit volume compared to mesodermal cells, which are more spherical in shape. Jack Nolte, a neuroanatomist, has been quoted as saying (Encyclopedia of the Brain) that if a soma of a neuron were enlarged to the size of a tennis ball, its axon would extend a half mile and would be the size of a garden hose - its dendrites would fill a small room. Their shape means that there need only be three cells spanning the distance between, say, the big toe and the S1M1 map of the toe in the brain.
By contrast, mesodermal cells do not have long projections or very much surface area at all. They cling together with bits of molecular glue called integrins, which keep them from pulling apart. They do not signal much or very far away from themselves. Instead, movement excites mechanoreceptors (ectoderm, not mesoderm) which are buried all over into the mesoderm like little roots.


So, why bother differentiating derivatives?

When dealing with persistent pain problems, it is useful to a practitioner as a thought exercise to separate the two kinds of derivatives. It doesn't matter that this persistent pain is felt in one region over another, or that you put your hands on body parts and push here and pull there. Understanding where the "pain" perception is being generated is what is important. Persistent pain is generated by the nervous system in one "place" and projected to the nervous system in another "place". These places include actual physical body zones, and the representational "maps" in the brain - you can treat both at once. It's useful for patients to understand this as well, so they don't go around blaming parts of their body for their pain or thinking that they need to get bits of themselves amputated.

Of all the various depths of body parts/layers, the representational map for the skin layer is one we are the most familiar with, i.e. the Penfield homuncular map over the top of the brain, also known as S1M1. It is the most easily accessed in manual therapy. Making a change in skin by handling skin and its innervation appropriately will provide the brain with novel input which could assist it in re-edging its other maps, and produce new output, including less pain production or different pain perception.

Generally an outside-layer/S1M1 ectodermal consideration is eclipsed entirely by concern about/over mesodermal "structure". "Mesodermal" approaches to manual therapy ignore this "ectodermal" consideration (skin sensitivity/excitability) because of history and treatment construct, and therefore find it difficult to see any point or relevance in studying it. Ignoring this easily accessed mechanism via the skin, considering only that which lies beneath (fascia, bones, joints, muscles), is what I call "mesodermal" approach or mentality. Meanwhile, practitioners are "treating" the skin/ectoderm by default whether they realize they are or not, because of its location between their hands and the mesodermal target they think they should be after, with associated mechanoreceptors which many by now, to their credit, recognize as inseparable.

In any other "science", this oversight would be recognized as a "confounding factor". And it is, to treatment constructs. Ways should be devised to correct the problem. Because it is impossible to remove the confounding factor by removing skin, then seeing if "pushing" on the joint/bone/fascia or muscle still elicited the same treatment effect, the next best way to solve the problem is to devise ways by which only the skin (ectoderm) is considered, skin deep ways of treating, avoiding deeper mechanoreceptors, to see if desired results can still be obtained.

My own opinion is:

we could make treatment life a lot easier for both ourselves and our patients, and understand pain science a lot easier, by learning the distinction between mesodermal and ectodermal derivatives and not letting them remain blurred together in a mental mishmash;
we could explain a lot of CAM approaches better, from a more robust and much less pseudoscientific frame, if ectodermal considerations, brain science and pain science were examined first;
manual treatment could be made a lot lighter and a lot more comfortable for patients if this distinction were better understood.

[TexasOrtho]

6. The ectodermal derivatives are 100% responsible for function in the body, including faulty or magnificent movement, coordination, etc.

When you say ectodermal derivatives, do you mean the mesoderm? If you don't mean the mesoderm, why does the mesoderm exist? If the ectoderm is 100% responsible for function, the mesoderm is the appendix of embryology?


They are also 100% responsible for pain generation and perception. Children born without pain perception bite their tongues and lips off, gouge out their eyes, break their legs and burn their skin, because they do not feel the warnings of nociception, and usually die young from all the trauma they've never learned to avoid.


Interesting phenomenon. I have never heard of before, what is the name of this condition?


Instead, movement excites mechanoreceptors (ectoderm, not mesoderm) which are buried all over into the mesoderm like little roots.



So it would be safe to say they are interdependent? What would the function of mechanoreceptors be without mesoderm to embed?

Of all the various depths of body parts/layers, the representational map for the skin layer is one we are the most familiar with, i.e. the Penfield homuncular map over the top of the brain, also known as S1M1. It is the most easily accessed in manual therapy. Making a change in skin by handling skin and its innervation appropriately will provide the brain with novel input which could assist it in re-edging its other maps, and produce new output, including less pain production or different pain perception.

What kind of physiologic change occurs in the skin? How do you know when the skin is changed? Also what parameters define handling it's innervation appropriately or inappropriately?

Generally an outside-layer/S1M1 ectodermal consideration is eclipsed entirely by concern about/over mesodermal "structure". "Mesodermal" approaches to manual therapy ignore this "ectodermal" consideration (skin sensitivity/excitability) because of history and treatment construct, and therefore find it difficult to see any point or relevance in studying it.

I couldn't agree more with you here. I think it is important to learn more about their relationships vs diving directly into the mechanical components.

My own opinion is:

we could make treatment life a lot easier for both ourselves and our patients, and understand pain science a lot easier, by learning the distinction between mesodermal and ectodermal derivatives and not letting them remain blurred together in a mental mishmash

This is where I couldn't disagree more Diane. What benefit is there in distiguishing the two phenomenon when they are inextricably tied together? The potential pitfall to your approach is no different than the pitfall of a purely mechanical approach.



we could explain a lot of CAM approaches better, from a more robust and much less pseudoscientific frame, if ectodermal considerations, brain science and pain science were examined first;
manual treatment could be made a lot lighter and a lot more comfortable for patients if this distinction were better understood.Right. I think you made a good point here: the distinctions are not well understood at this point. As such, it makes no reasonable sense to devote our efforts purely to one specific approach over the other. The mental mishmash is going to have to be cleared up before we can confidently use terms like "100%", "always", and "never".

I go back to what I mentioned in an earlier thread. I think there are some great things to take away from on this and other forums. I think we gain little by taking an absolutist approach however. The debate and dialog can continue along a productive line if the silly labeling and back-handed name calling died down.

[Barrett Dorko]

Mesoderm is a designation for a specific tissue, not a derogatory name.

There's NOTHING silly in Diane's description and if you don't yet understand that mesoderm responds to coercion and ectoderm to communication you may soon enough. The impact of this on manual care is huge.

[Diane]

When you say ectodermal derivatives, do you mean the mesoderm?
No. Once a mesenchymal layer is (essentially) "sloughed off" by the primitive ectodermal layer in an embryo, they cease to have very much to do with each other. When I say ectodermal derivatives, I mean the things that ectoderm itself becomes. If you don't mean the mesoderm, why does the mesoderm exist? I think it exists to becomes tool like structures, provide leverage, greater mechanical advantage, that sort of thing, at less cost to the overall organism. If the ectoderm is 100% responsible for function, the mesoderm is the appendix of embryology?
No. The derivatives of mesoderm are more like the stuffing in a pillow or the insulation in a wall or the framework of a house. Their job is structural as opposed to signalling. Interesting phenomenon. I have never heard of before, what is the name of this condition? I will look it up. There was a 20/20 program about it a few nights ago. Someone at EIM started a thread about it on the pain forum there. So it would be safe to say they are interdependent? I guess you mean ectoderm derivatives and mesoderm derivatives. Sure, why not? But ectoderm can live without mesoderm much easier than mesoderm can live without ectoderm, functionally speaking. What would the function of mechanoreceptors be without mesoderm to embed? They wouldn't need to exist, except perhaps in the outer membrane of the "animal", which would likely then be able to exist only at a much smaller scale, like earthworm size maybe. What kind of physiologic change occurs in the skin? Mechanoreceptors are deformed and fire, exteroceptive (large myelinated) and interoceptive fibres are excited, reflexive blood flow mechanisms are stimulated, (small) neural tunnels are excited, the brain goes into alert mode, the S1M1 map starts to light up. How do you know when the skin is changed? Same way you would know if a "joint" has changed, likely.. you surmise the amount and quality based on new motor output, like relaxation, increased range, less pain, those sorts of things we are always looking for. Also what parameters define handling it's innervation appropriately or inappropriately? Comfortableness to the patient. Instructing them to tell you if they experience any discomfort from the handling. Impressing upon them that the intention is to give the brain no further discomfort to have to deal with, but rather to help it devise new options which may include less pain output. This is where I couldn't disagree more Diane. What benefit is there in distiguishing the two phenomenon when they are inextricably tied together? Because learning to distinguish the two, even as a thought exercise, would help prevent PT practitioners

from falling in pseudoscientific quicksand, mind traps like the MFR one JFB got going, and the many that SMT is slowly being extracted out of;
from falling permanently into either of the two main camps in PT, ortho and neuro.

The potential pitfall to your approach is no different than the pitfall of a purely mechanical approach. There likely are pitfalls, but none so large as the pitfall of obtuse and deliberate ignorance of the bigger picture of the human organism and how it works. The mental mishmash is going to have to be cleared up before we can confidently use terms like "100%", "always", and "never". OK, ok, I take your point. I go back to what I mentioned in an earlier thread. I think there are some great things to take away from on this and other forums. I think we gain little by taking an absolutist approach however. The debate and dialog can continue along a productive line if the silly labeling and back-handed name calling died down. I agree completely. Further to this point, when people proclaim SMT and other bits and dabs from the orthodigm as the be-all and end-all of manual treatment, or that only the ortho (i.e., meso)-digm deserves to use the name physical therapy, I get a bit allergic myself.

[nari]

Diane, this is an excellent summary of the ecto/mesodermal relationship.

Rod, there are no true absolutes in science when it comes to managing patients. A mesodermalist primarily thinks in terms of mesodermal structures in general ortho-based approaches. I did say primarily; it doesn't mean he/she ignores ectoderm totally, but the vital role of the ectoderm is usually misunderstood or not known.

I carry the title of neuronut evangelist in my userCP; I was given this title. Part of the reason I am happy with it is the fact that more PTs need to know they can't affect mesoderm without affecting the skin.
It can never be cancelled out of the equation; therefore it must be seriously considered in every clinical approach. Skin "talks" to the brain; mesoderm, as far as we know, does not.

Nari

[Diane]

Here is a paper on congenital insensitivity to pain that refers to a family of disorders, Congenital Analgesia (http://serendip.brynmawr.edu/bb/neuro/neuro06/web1/aschmid.html). I think there are various names within the family. "Hereditary Sensory Autonomic Neuropathy Type IV" mentioned on EIM suggests there are likely types I, II, and III, if not V or VI or higher..
Back in with this (http://www.pediatriconcall.com/fordoctor/CaseReports/hsan.asp). Looks to be five types documented.

[TexasOrtho]

Mesoderm is a designation for a specific tissue, not a derogatory name.

There's NOTHING silly in Diane's description and if you don't yet understand that mesoderm responds to coercion and ectoderm to communication you may soon enough. The impact of this on manual care is huge.

Right. Mesoderm is not a degrogatory name, but in the context of how it is often used on this board (ie mesodermalist using orthodigms) it contributes little to the conversation and simply serves to inflame.

Also...I hope you are not referring to me. I never referred to anything Diane said as "silly". The language you choose to use in describing phenomenon is very political. You use words like "coersion" to describe the effect of mechanical therapy and "communication" for your proposed methods. These are not political idologies, although some treat them as such.

I feel like I need to shout this again for the cheap seats: Neither you nor I know enough about various conditions to bring them to an immediate and effective resolution. I think a taste of humility in this sense might be good for all involved in the study of human movement science.

If you have all the answers, publish the data linking a specific treatment to a sailient and measuralble change in the pathology and I will be all ears. Until then, your methods are just another piece of the puzzle - just like ours.

[Diane]

Neither you nor I know enough about various conditions to bring them to an immediate and effective resolution. I would beg to differ. We are starting to know an awful lot more about the manufacture and behaviour of pain patterns and how they interact with movement patterns than we used to, because of neuroscience, not because of orthoscience. It provides a better trail to follow, for practitoners who want to help their patients overcome pain felt in the body.

Really Rod, you are starting to sound a bit peeved. You knew what you'd be coming into before you came here, so if you can't take the heat, there's no reason for you to stay in the kitchen let alone keep your hand in contact with the big red burner in the lower right hand corner of the stove top.

[TexasOrtho]

There likely are pitfalls, but none so large as the pitfall of obtuse and deliberate ignorance of the bigger picture of the human organism and how it works. OK, ok, I take your point. I agree completely. Further to this point, when people proclaim SMT and other bits and dabs from the orthodigm as the be-all and end-all of manual treatment, or that only the ortho (i.e., meso)-digm deserves to use the name physical therapy, I get a bit allergic myself.

Our conversations are certainly leading me to review my physiology. Pain and now embryology. Always good mental exercise for me.

Again, no one is talking about "obtuse and deliberate ignorance of the human organism". When did that come across in any of my posts? By the way, at what point does the mechanical approach become obtuse? Obtuse as you've defined it? Again, you seem to speak as if you are an authority or arbiter of this issue. I have a very hard time with this. There are no authorities and no proofs. Only experts and support. Present your case with reason and all the other superfluous ad hom's become...well superfluous.

If you could distill your message in a way that is less alienating, I think some of the really fascinating filtrate would make it into mainstream practice.

[TexasOrtho]

Really Rod, you are starting to sound a bit peeved. You knew what you'd be coming into before you came here, so if you can't take the heat, there's no reason for you to stay in the kitchen let alone keep your hand in contact with the big red burner in the lower right hand corner of the stove top.

Again I think you are having a difficult time addressing the fact that you may not be 100% correct. And yes, if someone takes my posts out of context, I will certainly be happy to correct them. I have avoided the use of ad hom and misrepresentations of other posts. At no point have I said anyone was "silly" or described anyone's viewpoint as "obtuse".

If the debate cannot adhere to facts and continues to drift into misrepresentation and exaggeration, then you are right. I will have difficulty carrying on a meaningful debate. It is not a level of discourse that benefits anyone. You have salient points. I have salient points. I think we can articulate them without the "If you don't like it...get out" attitude.

[Diane]

Again, no one is talking about "obtuse and deliberate ignorance of the human organism". When did that come across in any of my posts?I did NOT mean you Rob, I meant the general (low) level of knowledge and understanding in our profession of the materials we are dealing with, and apparent cluelessness of directions taken in attempts (however genuine) to understand things better. Pain science is the trail of neon, lit-up bread crumbs we need to help us get out of the woods. This whole forum functions as a showcase for this (third) way (http://www.barrettdorko.com/articles/third_way.htm) of painscience-supported thinking about treatment, neither "ortho" nor "pseudo". Please do not feel personally affronted by anything you read here. Please do not feel personally affronted by anything Barrett says. It's not about you - we get that you are here with some curiosity and no desire to overturn our board. It's about the general mentality of practitoners, lazy thinking habits, no real demonstration of intelligence, no apparent curiosity or drive to understand, just cult adherence and boring outdated or pseudoscientific constructs that aren't worth the intellectual powder to shoot a rat. (Just a saying - I've got nothing against rats.)

[Barrett Dorko]

If you have all the answers, publish the data

Do yourself a favor and don't imply that anyone here has suggested such a thing - you'll be asked to back it up.

[TexasOrtho]

.. if you don't yet understand that mesoderm responds to coercion and ectoderm to communication you may soon enough

I am fully prepared to back it up. You say the above as if I have to accept it as a proof. Yes. I have an appreciation that the relationship between the ectoderm and mesoderm exists, but I don't presume to know the intricate details of this relationship. I don't think there is enough evidence out there to support your proclamation.

Be patient with those of us who still have something to learn.:angel:

[Diane]

I have an appreciation that the relationship between the ectoderm and mesoderm exists, but I don't presume to know the details of this relationship. I don't think there is enough evidence out there to support your proclamation. There is if you know where to look. (Hint - it won't be in ordinary PT literature probably - look to pain science or neuroscience, and then look for PT literature that has examined these, like Butler, Moseley, Gifford..)

Be patient with those of us who still have something to learn. :angel:
If you really want to learn, we are the soul of patience around here - it's why we're here. :angel:

[TexasOrtho]

Don't worry Diane. I'll keep my eyes and mind open for any plausable explanations out there. Again, this forum has been a great source of information in the short time I've been around. Like I said, just be patient with me as I'm not easily led and often need to independently verify things before embracing a particular idea.

[Diane]

I'm not easily led What a relief - really. :shade::thumbs_up
None of the regulars among us are either.

[EricM]

I’m posting the following as an exercise helping me organize my thoughts on the matter. Hope it helps anyone else reading along who may still be a little confused about the significance of the mesodermal/ectodermal issue.

I have been chasing this 'ectodermal' rabbit daily for the past 5 years now. It's a journey that has been fraught with episodes of both rewarding and surprising discovery as well as periods of soul-searching cognitive dissonance. The thoughts that characterize this forum are the fruit of that pursuit; and in case there is any doubt, they do change with different seasons as new information comes in.

Just as it is incumbent on all of us to provide evidence for the efficacy of our methods, we believe it is equally incumbent on all of us to provide our patients with the most valid explanation of their pain complaints and our efforts to effect its resolution – regardless of what technique we may use. As has been written during the current MFR discussions, evidence of efficacy is not the same as support for a theory. We think this logic should apply equally to the traditional orthopaedic paradigm, and any other paradigm that falls within the boundaries of our profession(s).

Another way of looking at it is this, and remember we are talking about pain here; any intervention that has an effect on pain can justifiably said to have been neuromodulating in its nature. I have not read or heard anything that would refute this viewpoint. If there is, I’d love to know about it. It is simply incorrect to state we don’t know enough yet to make this claim. Sure the quantity of information is vast and daunting, but this site makes it liberally accessible to anyone unlike anywhere else on the net. Sadly it is not taught in our schools and thus does not form the backbone (pun) of our collective mindset towards pain which is heavily geared toward orthopaedic theory, which occupies only a portion of the spectrum of potential neuromodulating agents.

It shouldn’t take much stretch of the imagination (another pun) to realize we have at our disposal a wide array of neuromodulating agents that run the spectrum from so-called energy medicines to orthopaedic approaches, electrotherapy, thermal therapy…, to the less tangible things like treatment environment, and tone of our voice and everything in between. They are all neuromodulating agents. Sure, different neuromodulating agents may have effects on different tissues, however this becomes far less interesting or relevant when what we require to treat pain is neuromodulation which by definition involves the nervous system, an ectodermal derivative.

The terms ectodermal and mesodermal are convenient labels to help organize one’s mental clutter, as Diane would put it. I only wish I had encountered them earlier, it might have saved me a few years effort. I feel our profession will be far better served into the future when viewed from this perspective and who knows, one day we might even have enough data to say which form of neuromodulation works best for which pains. Until then however, we at least now have solid footing to move forward on.

[BB]

I'm not easily led and often need to independently verify things before embracing a particular idea.

A very logical approach, Rod.

I'm curious if the term "orthodigm" is clear. What I've found to be helpful for myself was to define orthopaedics as involving the tissue strain aspects of pathology. Orthopaedics to me is the study and work involving the pathology of the tissues in the neuromusculoskeletal system. Tissue damage, so to speak. I don't think that is too much of a stretch for anybody.

Orthodigm and mesodermalism as we speak of them here represent the practice of treating mechanical pain from an orthopaedic perspective. It's an assumption that pain and tissue pathology must happen together.

Maybe this was already obvious to everyone, but I thought spelling it out might serve to help make it clear that concepts not people are being discussed.

Excellent post, Eric!

[EricM]

Orthopaedics to me is the study and work involving the pathology of the tissues in the neuromusculoskeletal system. Tissue damage, so to speak.

Precisely Cory. It worries me that many assume we ignore this aspect of a patients presentation in our focus on pain. Nothing could be further from the truth.

[John W]

There are many examples in medicine where the use of so-called "coercion" is used with successful outcomes. In orthopedics, of course, the setting of bones and reductions of dislocations are the obvious coersive procedures performed by the practitioner that if left to the devices of the ectodermally derived tissues, the patient would likely end up lame.

A very controversial procedure traditionally performed on patients with depression, but now being used more and more on chronic pain sufferers is electroconvulsive therapy (ECT). I was interested to find some intriguing references to ECT in a Medline search. Changes in cerebral blood flow in particular areas of the brain responsible for the pain output have been shown with sophisticated PET scanning techniques in patients with CRPS and fibromyalgia after ECT. Certainly, ECT would be considered a coercive intervention.

In physical therapy, high velocity, low amplitude joint manipulation is the most obvious example of coercive technique. So far, outcomes using this technique in patients with acute LBP show high levels of evidence with positive outcomes, particularly when combined with exercise. When used judiciously, it is very safe.

So my question for the members of this forum, given what we know about the relative safety and efficacy of manipulative therapy in certain patient populations: "Is coercion such a bad thing?"

BTW, Diane, thank you for the summary, it was very useful and elucidating for me. Although, I do wish we would avoid referring to connective tissue as "mesoderm" as it rankles my desire for words to represent things that they actually are. Mesoderm-and ectoderm- have very particular physiological properties distinct from the adult organism and only exist in a germinating organism during fetal development.

[Diane]

John, the examples you give of medical "coercion" are given under anesthetic. Well, maybe not the second. Lightly sedated perhaps. No one argues with them.

Your third example, HVLA, is done on conscious people. It's interesting to me that there is such a heavy effort by the orthodigm to preserve it, presumably for pain relief. I don't dispute that it has an effect. I don't think anyone does.. however, it seems awfully (perhaps overly) violent. And effective/safe for just a little group of people.
So my question for the members of this forum, given what we know about the relative safety and efficacy of manipulative therapy in certain patient populations: "Is coercion such a bad thing?"
To treat persistent pain problems? probably, yes.

I do wish we would avoid referring to connective tissue as "mesoderm" as it rankles my desire for words to represent things that they actually are. Mesoderm-and ectoderm- have very particular physiological properties distinct from the adult organism and only exist in a germinating organism during fetal development.
I do try to use the term "mesodermal derivative" or "ectodermal derivative." Sometimes I do forget to do that. So thanks for the tip.

[Barrett Dorko]

Coercion is what it is. It simply implies that something is moved passively and not necessarily with permission. This is precisely what is needed in some casesl.

When proceeding with manual care it seems to me that we must balance this sort of understanding with an appreciation for what the nervous system will respond to more readily, and coercion isn't it.

Given Diane's insight, the term "soft tissue," which inevitably combines these two elements as if they would respond as one is misleading at best. I'm for identifying this and abandoning the term when discussing dysfunction and/or treatment.

[Jon Newman]

Medical coercion is a bad thing when the coercive tactic is not a necessary condition for the ends sought. And even then it might be a bad thing but maybe not as bad as not achieving the desired end for which it is a necessary condition.

[Diane]

One of the tendencies I see in the orthodigm is a real urge to conflate itself with "medicine", specifically orthopaedic surgery, everything from adopting the tests and terminology and differential diagnoses that were designed to determine "pathology" - i.e. "broken" or "torn" mesodermal derivatives, to the desire such PTs have to adopt the prefix "Dr."

Cory has explained it: Orthodigm and mesodermalism as we speak of them here represent the practice of treating mechanical pain from an orthopaedic perspective. It's an assumption that pain and tissue pathology must happen together.

If we are honest, we will admit that what we mostly treat in outpatient clinics is mostly persistent pain. Persistent pain without recent (or even any) injury requires a new framework. Eric has spoken to this: Another way of looking at it is this, and remember we are talking about pain here; any intervention that has an effect on pain can justifiably said to have been neuromodulating in its nature.

Barrett has broken it down to, are we dealing with chemical pain (as in, from a pathology or systemic illness) or mechanical pain ( from just sitting around, on the one hand or else overdoing some action on the other)?

There is a thread here containing a lament (http://www.somasimple.com/forums/showthread.php?t=3831) by an orthopedic physiatrist who feels there is not sufficient manual care taken with patients. I feel much as he does, but about PTs. PTs who handle people gently? they develop all sorts of weird ideas about it! Weird ideas develop when a vacuum exists instead of a knowledge base, like of embryology for example.

Further to this point, I have never (there's that word again Rod) learned anything about how the nervous system works from within my own profession - certainly not from the orthodigm - I have had to go outside it to learn the importance of embryology, nervous system, evolution of it, what's happening in the field. Pain science is another story - that is definitely something many PT researchers including former orthodigmers like Butler and Gifford have delved/are delving deep into.

I'm working to improve the profession in my own somewhat buttheaded way. Yes, I do think I know a better way, and I think I have the right to say so.

P.S.: Here is where the word "silly" cropped up - it was in post #2, and yes, you did use it Rod, in reference to the effort that is being made to highlight the differentiation of mesodermal derivatives from ectodermal derivatives, to describe their very basic functional distinctions, and to set apart the orthodigm from this third way in terms of our profession. The debate and dialog can continue along a productive line if the silly labeling and back-handed name calling died down. What exactly did you mean by that Rod, if you don't mind?

In order to conceive of and define the third way, it is necessary to describe the shortcomings of the existing ways honestly, as they are perceived. This is not ad hom toward any individual embracing the orthodigm in lieu of anything better, just as when we protest energy medicine being taught at a university level, to PT students, it's not about Carol Davis personally, it's about the ideas she holds and propagates.

[bernard]

So it would be safe to say they are interdependent? What would the function of mechanoreceptors be without mesoderm to embed?

Take a car and a driver.

It would be safe to say they are interdependent and it would be safe to say the driver is driving the car and not the inverse.

[bernard]

Is coercion such a bad thing?
I would reply with another question:
Is it so difficult to care givers to say please and explain the meaning of their acts?

That is only a different way to understand: Communication.

[Bas]

An intermediate phase in my growing understanding of the importance of all things of ectodermal derivation, brought me to a profound change in my explanation to patients. This alone was a revolution for my treatments and led to different handling. I am very much a product of the late 70's, and of the 80's with a full immersion in the Canadian Ortho education. My focus has shifted from a structure/tissue oriented approach to persistent pain and acute, non-pathological pain (e.g. idiopathic acute torticollis), to a much more neuro approach. With a lot of emphasis on the brain. For that, I have to thank many here: Diane, Barrett, nari, Jon, Luke, Cory, Chris, Nick, Jason, Bernard etc etc

I am not using "mesodermists" or "ectodermists" as terms or labels, because I have begun to see a shift in even the most ortho-oriented colleagues - including those who teach for Canadian Ortho group - to a more "everything involves the nervous system" approach.
At this time, they straddle the divide between ecto- and mesoderm.

[TexasOrtho]

P.S.: Here is where the word "silly" cropped up - it was in post #2, and yes, you did use it Rod, in reference to the effort that is being made to highlight the differentiation of mesodermal derivatives from ectodermal derivatives, to describe their very basic functional distinctions, and to set apart the orthodigm from this third way in terms of our profession. What exactly did you mean by that Rod, if you don't mind?



Again, taken completely out of context...the phrase "silly name calling" was in reference language frequently used on this forum that belittles an approach or those who use it. In this case I'm talking about the "obtuse and deliberate ignorance of the human organism" approaches that mesodermailsts employ. I find the use of these words unfounded, unnecessary, and...well silly.

If you will look closely at post #2 Diane, this should have been plainly evident. I will not use this kind of language in reference to a salient point in an argument. I will use it in reference to tactics taken to distract from facts and logic.

[John W]

I would reply with another question:
Is it so difficult to care givers to say please and explain the meaning of their acts?

That is only a different way to understand: Communication.

Bernard,
Are you implying that those of us from an ortho perspective are not communicating as effectively as those who use a more neurophysiological-based approach?

Before I perform any high velocity technique on a patient, I ALWAYS explain what I am about to do and why it may help reduce their pain. I am emphatic about dispelling any myths about "alignment" or "subluxation" correction. I tell them that the effect is likely on a neurophysiological level.

And, BTW, this is what I was taught in my AAOMPT credentialed residency training as well. Except in rare circumstances (loose body, true adhesive capsulitis, meniscoid inclusion in lumbar facet joint) I was never taught that we were somehow unsticking a stuck joint. We talked about the neurophysiological response to manipulation via the different joint mechanoreceptors. So, my training in that regard was neurophysiologically-based. And that was about 10 years ago.

The questions here that I am looking for answers to are these: Is there a more effective, safte, gentle way to achieve pain relief without the risk and physical effort of more coercive techniques? Is the interaction at the level of skin sufficient to achieve results that are significant and lasting? Which patients are most likely to benefit from a skin-deep approach? Are there certain circumstances where stimulation of the capsular mechanoreceptors is necessary and/or more effective/efficient in resolving the pain problem?

My days of thinking I am altering connective tissue architecture with joint mobs are long gone.

[Barrett Dorko]

Communication includes what you do as well as what you say, but I'm sure you know that and don't mean to imply anything else.

Yes, there is a gentler way, and this, I think, is best employed when an abnormal neurodynamic is present. I call it Simple Contact and work here and elsewhere to explain what that is. I really try to do this well enough to keep people from having to attend a workshop but have found that difficult.

[John W]

Yes, Barrett, what you said about communication.

[bernard]

Bernard,
Are you implying that those of us from an ortho perspective are not communicating as effectively as those who use a more neurophysiological-based approach?
Did I?
I often take the car and driver metaphor;
You can coerce a wheel and try to move it but it is simpler to ask the driver to act on it: he is seated at the best place.

[EricM]

Is there a more effective, safte, gentle way to achieve pain relief without the risk and physical effort of more coercive techniques?

I'll assume your referring to coercive techniques in general vs HVT alone? Yes to safe and gentle. The relative efficacy between these methods and other techniques is yet to be established. Not even HVT can claim superiority over gentler techniques until it is trialed head to head.
Is the interaction at the level of skin sufficient to achieve results that are significant and lasting?
My experience tells me yes. Once again however, as you well know, efficacy is yet to be established though efforts are underway and results should be forthcoming.
Which patients are most likely to benefit from a skin-deep approach?
Alive ones. Ones who will let you touch them. Mechanical neurogenic pain predominately although occasionally peripheral neuropathic problems benefit too.
Are there certain circumstances where stimulation of the capsular mechanoreceptors is necessary and/or more effective/efficient in resolving the pain problem?
Yet to be determined.

[Diane]

Rod,
Ah yes, I see the offensive line way down in post 5, long after you already had used the word "silly." So using the word "silly" could not have been in reference to this, unless you are prescient.
The potential pitfall to your approach is no different than the pitfall of a purely mechanical approach.
There likely are pitfalls, but none so large as the pitfall of obtuse and deliberate ignorance of the bigger picture of the human organism and how it works.

But listen, far be it from me to quibble over this... silliness.

I let my statement in post 5 stand as quoted. It does not refer to any person in particular, but it does refer in general to both the orthodigm and to the JFB-MFR proponents. Not you Rod, and not you John, because both of you seem willing to learn a bit more than what you already "know works."

Here's an example of what I mean:
I'm not exactly unfamiliar with ortho workshops. I graduated in 1971, and have worked in private practice/manual therapy since 1983. The last workshop I took was in 2005, from Shacklock. But the last specifically "ortho" class was in 2002, a Mulligan technique class. In it the instructor emphasized "no pain", but taught everything using biomechanics (a language that always seemed a bit like sanskrit to me, strange and redundant in that I already spoke kinesthese fluently). No mention was ever made of the nervous system, or that nerves themselves can be "sensitive".

Meanwhile Butler had started to talk nerves back in the late 80's early 90's. I had his first book, but until I took his workshop in 1998 I really didn't get what he was on about. It was an absolute revelation, the first time I had ever heard that "nerves" could "hurt." He taught how to slide deep nerves through limbs by bending hands & elbows, feet & knees in novel ways. I was quite happy using skin techniques I'd learned from a DO near Seattle, called collectively MFR, not the Barnes version... more authentic without all the pseudoscience, so I adapted Butler theory to what I was doing clinically, focused on pain science instead, because it made so much more sense than worrying about fascia. But something was still missing.

From the DO I had learned embryology, but nothing of the cutaneous nerve system, which has many unexamined properties in addition to an unexamined morphology. In fact, nowhere, in any manual therapy system (except Barral who manages to mash in some Oschman, therefore I shall ignore him), is any information about this part of the system examined/taught, despite the fact that it is fully connected to the brain and is probably the most "sensitive" in terms of a live conscious person being able to "feel" it directly, of any portion of the n. system (the brain can be directly operated on without anesthetic, for example, because it contains no "sensory" fibres to itself). Does no one but me consider this a major gap? And a scandal? For manual therapy of all kinds to ignore the nervous system in general and the cutaneous one in particular?

Knowledge of the cutaneous layer of the PNS (structure) and how it interacts with the CNS (function) is:

completely missing from the osteopathic manual therapy picture (the DO I studied with anyway)
mostly missing from the neurodynamic picture (it seems only deep nerves are important in that system)
ignored completely by the orthodigm in general, and finally,
completely replaced by the JFB-MFR system in favor of some nonsense about a "second nervous system", that fascia can "transmit" of its own accord, that it handles "photons" or something...


I mean.. seriously, I don't know where the systemic ignorance began or with which branch of the human primate social grooming family, but a knowledge void appeared at some point, and now would appear to be getting filled up with rubbish and nonsense. I want to beat back the nonsense and establish that the nervous system, in all its physicality and function, instead of being bypassed by all, deserves center stage instead.

Before you scoff at the cutaneous nervous system, think about this:

there are estimated to be 45 miles/72.5 km of nerves in the PNS
given the morphology of a peripheral neuron, and oxygenation necessities, some pretty fancy microanatomy has to be in place for these structures to be fed or to self-feed through movement
skin and its attached subcutaneous layer accounts for just under a third (third!) of body "volume" (not necessarily weight) and is highly innervated. To me, this suggests that at least a third of the PNS is cutaneous only, meaning combined sensory and autonomic motor. There are way more numerous cutaneous branches with their own names than what we ever are taught.
the organism will protect itself, meaning the nervous system inside the organism will defend itself, more predictably than it will defend its mesodermal derivatives. It is hardwired into skin.
the coating around individual nerves is also from the ectodermal layer (neural crest), not the mesodermal layer.


I think I've managed to get in everything I wanted to say. Time to get ready for work.

[BB]

John,

"Is coercion such a bad thing?"

I don't think it is necessarily, depending on what you mean by bad. Effective? Certainly can be. Damaging, as in causing more pain or even a pathologic event? Certainly can be too.

Perhaps another question that just skips all around the arguments we would have on the above is: "Is coercion necessary?"

Also, not that Bernard needs me to speak for him, but I don't think he was saying you don't communicate with your patients. It seems to me he was saying that you DO communicate with your patients as an example and imply that a non-coercive approach to manual communication is of the same sort, as Barrett also said.

There is a difference between coming to a decision yourself or someone forcing a decision upon you. This is intuitive, but neurally there is a difference as well. Even if the act or decision is the same in both cases.

[EricM]

I don't think we should forget the health care consumer in all of this either. Some patients will prefer a gentle approach, while others will choose the more coercive option. Though in my experience many more people dislike forceful manipulative techniques compared to gentle handling and express surprise and gratitude upon discovering it was even an option.

[TexasOrtho]

I think we all can agree our view points have been shared to the fullest degree possible on this issue of meso/ecto approaches. I think the differences lie in the degree of devotion one puts into a specfic approach vs on some continuum between the two.

Diane you seem to have a great bit of basic science and empirical support for your approach. Once you are able to tie this in with peer-reviewed support, I think I will be more likely to see things your way. Right now, your evidence lies in citing basic science facts about oxygen consumption and linear footage of the PNS. This does not extrapolate to clinical data.

When your approach begins to connect the dots to peer reviewed and measurable clinical outcomes, I will lend it the credibility it deserves. This is the burden of evidence demanded by all credible health professions and should be the standard. I'm looking forward to seeing what you bring to the arena of ideas in this regard. I think I a have said my piece on this discussion.

[John W]

Eric,
Thank you for the succinct answers to my questions.

I'll be sure to let my non-living patients know that I can be of no help to them with skin deep techniques.:D

Diane,
You've made a very convincing argument for the important role of the cutaneous division of the PNS in the pain phenomenon. I hope this can be fleshed out with more concrete definitions, reliability and validity studies with measurable variables and finally head to head outcomes studies with other techniques-coercive and even MFR (particularly looking forward to that!)- to show it's potential superiority.

Cory,
With Bernard, my question about communication wasn't a "yes" or "no" issue, it was more about relative effectiveness of communication utilizing neurophysiological vs. orthopedic paradigms.

If our health care system ever becomes driven by actual results rather than by the more you do the more you get reimbursed, tehn the question of "necessity" will become more a question of effectiveness. We may discover that in certain patients or conditions non-coercive techniques provide "better bang for the buck" whereas with others, coercive techniques are more effective. Part of the problem I think that Diane has pointed to with the gaps in application of our knowledge has to do with the lack of results driving care- at least in the US system.

One of the main reasons people like Barnes thrive is because the current system rewards providers for learning more techniques to justify "doing stuff" to patients, even if the stuff you're doing doesn't make sense or follow any kind of rational basis in science. Do you think insurance company executive care that Barnes uses quantum theory to explain MFR?

[BB]

Which patients are most likely to benefit from a skin-deep approach?

Well, no sub-grouping studies exist so we are left to attempt to answer this question with what makes sense based on what we know and on clinical experience.

Barrett's dichotomy of chemical and mechanical pain is a good start. Does their pain change with movement indicating mechanical involvement? If so, they are a candidate so far. See the Five Questions thread (http://www.somasimple.com/forums/showthread.php?t=2404) for much more.

Next, is their pain indicative of anything more sinister? If so, refer on. If not, they remain a candidate.

Is there any reason that you should remain hands off with this person? If not, they remain a candidate.

Now, it may be that they are a candidate after all of this, but there are indications that a belief system is in place that would make success less likely. These are the bone is out of placers and the like. You don't have to abandon ship here, you just address the belief. Mostly you do this with your manual care as an example that their belief is incorrect. After all, how could moving skin put a bone back in place?

Another way to look at this is that it seems the more coercive a technique the more narrow the population that it can effectively be employed with. The inverse would also make sense. The less coercive the technique the broader the appropriate population.

[Diane]

Rod, thanks for hanging in, but please take this thread in before you completely leave the discussion: The Goodley Dr. Goodley (http://www.somasimple.com/forums/showthread.php?t=3831).

[Diane]

it seems the more coercive a technique the more narrow the population that it can effectively be employed with. The inverse would also make sense. The less coercive the technique the broader the appropriate population.Maybe we could provisionally call this "Corey's Inversed Coercion Law of Manual Therapy." :D

[Jon Newman]

A very controversial procedure traditionally performed on patients with depression, but now being used more and more on chronic pain sufferers is electroconvulsive therapy (ECT). I was interested to find some intriguing references to ECT in a Medline search. Changes in cerebral blood flow in particular areas of the brain responsible for the pain output have been shown with sophisticated PET scanning techniques in patients with CRPS and fibromyalgia after ECT. Certainly, ECT would be considered a coercive intervention.--John Ware

Between the above, my recent thread on cults, and EIM's recent bemoaning of people trying to get better by themselves, this accidental find was too irresistable not to post.

Authors Adachi T (http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=LGEIFPFIMKDDMDBFNCILNAMJPOPPAA00&Search+Link=%22Adachi+T%22.au.). Masumura T (http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=LGEIFPFIMKDDMDBFNCILNAMJPOPPAA00&Search+Link=%22Masumura+T%22.au.). Arai M (http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=LGEIFPFIMKDDMDBFNCILNAMJPOPPAA00&Search+Link=%22Arai+M%22.au.). Adachi N (http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=LGEIFPFIMKDDMDBFNCILNAMJPOPPAA00&Search+Link=%22Adachi+N%22.au.). Akazawa S (http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=LGEIFPFIMKDDMDBFNCILNAMJPOPPAA00&Search+Link=%22Akazawa+S%22.au.). Arai H (http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=LGEIFPFIMKDDMDBFNCILNAMJPOPPAA00&Search+Link=%22Arai+H%22.au.).

Authors Full Name Adachi, Takuya. Masumura, Toshiaki. Arai, Minoru. Adachi, Naoto. Akazawa, Shigeru. Arai, Heii.

Institution Department of Psychiatry, Juntendo University Hospital, Tokyo, Japan. adachi_iin@hotmail.com

Title Self-administered electroconvulsive treatment with a homemade device.

Source Journal of ECT. 22(3):226-7, 2006 Sep.

Abstract

Two patients with personality disorder and depression attempted to self-administer electroconvulsive therapy with a homemade device. The patients showed no proper psychopathological improvement after these attempts. Both of the patients' temples were seriously burned, and one of them required skin grafting. Both patients rejected to have reasonable psychosocial support, and followed a cult mental health manual in attempting to self-administer electroconvulsive therapy. To our knowledge, this is only the second report of its kind. The intractable psychopathology, poor interpersonal skills, and misleading information seemed to lead to the self-harm behaviors of our 2 patients.
Publication TypeCase Reports. Journal Article.

[Diane]

Hmm. Reminds me a bit of self-trepanation (http://www.somasimple.com/forums/showthread.php?t=4997).

[EricM]

Shocking!

[bernard]

Right now, your evidence lies in citing basic science facts about oxygen consumption and linear footage of the PNS. This does not extrapolate to clinical data.

You're kiddin?
I could give some thousands...

[bernard]

With Bernard, my question about communication wasn't a "yes" or "no" issue, it was more about relative effectiveness of communication utilizing neurophysiological vs. orthopedic paradigms.


I often take the car and driver metaphor;
You can coerce a wheel and try to move it but it is simpler to ask the driver to act on it: he is seated at the best place.

In my view, an ortho PT is talking to car parts and a neuronut tries to talk to the driver. I know, I'm not kind... :o
Of course, it is an awful generalization that helps to understand we are focused on different points of human beings.

Intelligence of joints are given by neurons, so are muscles and bones. :angel:

[bobmfrptx]

In my view, an ortho PT is talking to car parts and a neuronut tries to talk to the driver. I know, I'm not kind... :o
Of course, it is an awful generalization that helps to understand we are focused on different points of human beings.

:angel:
And an JFB MFR PT is talking to both and perhaps something even bigger! :D
Couldn't resist.
BOB

[kongen]

Bob,

The car parts have no ears so they don't listen very well.. :)

[TexasOrtho]

Bob,

The car parts have no ears so they don't listen very well.. :)

Nor are car parts capable of inflammation and healing...the analogy was dead before it got off the ground.
;)

[bernard]

the analogy was dead before it got off the ground.
It is a special car and there are many embedded sensors. The driver is thus seconded/helped by a computer.

The metaphor is certainly weak but cars are more well understood than body for patients.

[TexasOrtho]

It is a special car and there are many embedded sensors. The driver is thus seconded/helped by a computer.

The metaphor is certainly weak but cars are more well understood than body for patients.

So...it's a fictional car? :p

[bernard]

Did I say the contrary?
A simple model is helpful for neurokids. ;)

[nari]

A car is nothing without a driver, but the engine, once activated, can idle by itself.
A driver can't operate the car if its mechanical status is run down.
So fix the mechanism with tools and the driver can now drive the car with skill and precision.

Is this what you are saying, Rod?

[TexasOrtho]

A car is nothing without a driver, but the engine, once activated, can idle by itself.
A driver can't operate the car if its mechanical status is run down.
So fix the mechanism with tools and the driver can now drive the car with skill and precision.

Is this what you are saying, Rod?

No I was basically just being a jackass...I tend to fall back on my gifts and that certanly is one of them.

[bernard]

I said there was a computer that helps the driver.
It is also well known and accepted that a driver may drive the car without deep knowledge about its internal functioning. That's great because you can drive quite immediately but it becomes a misery when you do not understand the failures that happen and have no clues in their repairing.
Many car repairers know that electric faults are often a nightmare; The system is then unable to transmit important information or may create artifacts that are misunderstood.
Another big problem comes with the driver himself: Some are good pilots, most of them are neophytes.
Neophytes may destroy a Ferarri within seconds and unfortunately (???) there is no driver's licenses.

[TexasOrtho]

I think there needs to be a license to make analogies on an internet forum.

[bernard]

I think there needs to be a license to make analogies on an internet forum.
I think you need to explain why! :angel:

[TexasOrtho]

Thank you for taking that in the way it was intended. :) All in good fun.

[Diane]

I think you need to explain why! :angel:

And feel free to use an analogy if it will help. :cool:
Oh, I see you were joking. We posted at the same time.

[bernard]

No problem. I'm not serious even if I say some serious statements.

[Diane]

It would seem to me those trained in the orthodigm, which teaches only the innervation to/from subchondral bones, muscles, etc, become practitioners who end up "believing" that only the mesodermal innervation, therefore, matters, probably.

As Eric alluded to in his post (http://www.somasimple.com/forums/showpost.php?p=48350&postcount=18), on the other "ectodermal evidence" thread (http://www.somasimple.com/forums/showthread.php?t=5189), they look at the body as if it were inside out, with their oh-so-important-to-them-because-of-how-they've-had-their-brains-shaped
mesodermal derivatives on the outside, instead of the way the organism actually is, mesodermal derivatives sandwiched, surrounded by a heavily-innervated ectodermally derived layer with fast large fibre highways to the brain, just three nerve cells (fast ones) between any point on it and the S1M1 map in the brain.

It looks to me very few can achieve the depth of focus Jason can(see his post 89 (http://www.somasimple.com/forums/showpost.php?p=48483&postcount=89)), by daring to pick up and look through ectodermal derivative goggles at the

entire human organism, mesodermal derivatives and all,
at studies,
at treatment.


He's right, it's a perspective, nothing more, a conceptual perspective that effectively contains all manual, educational, movement interventions, and turns one into a professional who can look at a new patient and see connections that DO exist in them, at multiple levels no less, instead of extrapolating some story about "pain" from bits, bits that hardly count when a persisting pain construct is the actual wily foe.

[TexasOrtho]

I played "I believe I can fly" by R. Kelly while reading your last post and it really hit home Diane. I am sorry for doubting you.

[bernard]

Since TexasOrtho do not like analogy or metaphor, I'll tell:

The troubling story of Upper Limb
The misadventures of Lower Limb's brother


Once upon a time two brothers, Upper and Lower, lived quietly and had no troubles. Lower was working hard and unfortunately one day he began to complain:
- Hey... My right foot hurts!
His brother said:
- But you're working hard and walking all along the day.
Lower replied;
- That's true but pain isn't a pleasurable thing. I'll go to the Doctor.
The next day, Lower went to town and the Doctor found an explanation that was surprising;
- It comes from the back!
Doubtful, Lower asked:
- But it hurts in my foot???
-Yes, but neurology explains this fact. It is called a sciatica.
Back to home, he explained the thing to Upper, his brother;
- That's a bit strange but all the problems come from the back.
And the life continued quietly in the Limb's house until the fatal and terrible February 5th.
Upper started to complain, too, but it was in a different area:
- Hmm, my wrist is sore and I feel some pins and needles this morning.
Lower has a good advice;
- I had pins and needles too when I got this damned sciatica but it is now an old story. You may consult our good Doctor.
Upper went to town and asked the Doctor:
- Have I a sciatica, Doctor?
- No Upper, that is a carpal tunnel syndrome. That is a strange thing but surgery will relieve the problem.
- Is there something that is going wrong in the wrist, Doc?
- Not really but the ligament compresses the nerve and it must be removed.
Surgery was done but Upper condition was never completely cleared. Pins and needles were felt in the arm and shoulder for long.
But the good Doctor warned Upper:
- It may take some time and it doesn't kill anyway! Medicine doesn't make miracles.
- Thanks Doctor Ortho.

Morality: If your first name is Upper then you may have a different point of view from the good doctor Ortho.

[Diane]

Skin really is the fork in the road, conceptually, for manual therapists, folks.
The simple point/stumbling block/confounding factor that the orthodigmers persistently ignore, to their ultimate detriment if they want to eventually be considered scientific rather than merely "tooth fairy", is that skin (both one's own and that of the patient) will always be between oneself and one's supposed "target tissue".

If one accepts this simple fact, one can then accept that putting one's hand on some part of a conscious patient's skin in a therapeutic context automatically lights up the brain, and all the pathways that are expectant about relieving a little something something called "pain". There are a few fMRIs around that demonstrate this. Butler says, "..just as you sample someone else's nervous system, theirs is sampling yours." My main argument is, since you can't avoid any of this, so why not learn about it, accept and work with it?

Add to the brain lighting up, the issue of being able to stimulate and recruit many of its autonomic and other nonconscious movement or efferent functions by which it supplies itself with O2. Furthermore, not just the brain "lights up" - much or all (eventually) of the peripheral tree part of the ns does too. It takes a bit of time for a therapeutic contact to become sorted out and routed appropriately - longer than a few paltry minutes spent with a patient while juggling 4 or 5 others at the same time in ortho insurance mills that pass for treatment centers.

To me the orthodigm is a distillate of manual therapy, a superstimulus, a not very well balanced diet - sort of like insisting everyone stick to a diet of only protein tablets (conceptually speaking) instead of learning to enjoy the array of the full salad bar of knowledge about what makes people (and all their protein expressions) tick, hurt, not hurt, and get better. The dopamine reward for eating this very boring protein tablet diet and convincing oneself it tastes good, is that those who decide to do therapy this way are convinced they'll make more $, that it's more efficient, that they'll "help more people", get more referrals ... all dubious.

[TexasOrtho]

Since TexasOrtho do not like analogy or metaphor, I'll tell: ...

Bernard. I tried to post an orthopedic limerick in response but this forum must have some sort of obscenity filter on...:D

Diane as odd as this sounds given the tenor of our recent discussions, I agree with the last paragraph of the above post. It just seems you think if your name isn't Diane, Jason, Barrett, and Luke et al, you must be blithering idiots worshipping "Orthos": God of Thunder and Muscle.

Now I'm not saying I'm not an idiot who worships the tooth fairy (it's close really- I'm Catholic), but I would like some peer reviewed evidence supporting it! :D

[Diane]

Rod, Now I'm not saying I'm not an idiot who worships the tooth fairy (it's close really- I'm Catholic), but I would like some peer reviewed evidence supporting it!
1. No one ever said you were
2. Do you want evidence for kleenex or for baggies?

[Luke Rickards]

It just seems you think if your name isn't Diane, Jason, Barrett, and Luke et al, you must be blithering idiots worshipping "Orthos": God of Thunder and Muscle.Rod,
I sincerely hope I have not written anything in our discussions that has implied I think you are an idiot.

[TexasOrtho]

Rod,
1. No one ever said you were
2. Do you want evidence for kleenex or for baggies?

We call them Huggies...either would be fine.

Rod,
I sincerely hope I have not written anything in our discussions that has implied I think you are an idiot.

Luke you certainly haven't implied any such thing. I just find it a little distastful when someone claims to have found the holy grail of therapeutic approaches when there is much, much more to learn. I think it's an issue of humility that seems to be lacking on this forum.

[Diane]

Rod, I don't know if you'd be interested or not, but there is a blog I'm involved in with Cory and with Matthias in Germany, where we speak "ectoderm" fluently and dream up studies we'd like to see take place some day, discuss ones that have taken place. It's called Neurotonics, and can be accessed from my signature line. Here is a recent post (http://neurotonics.blogspot.com/2008/02/getting-past-fear.html) that connects to a bunch of topics, including good evidence for moving into the direction and use of illusion in PT, i.e., mirror therapy and maybe use of videos to connect a perceptual construct of a virtual body to help down regulate a physical one.

Check out Neurotopian, Matthias' own blog (linked on the righthand menu). He is out of his orthodigm days, which he refers to as "structuralist" in favor of a neurodigm, which he refers to as "functionalist." He does thought experiments, dreams up ideas like, what would happen if we put paraplegics in front of a screen where they could see the top half of their bodies in a mirror and a movie of the bottom half of them (or somebody) walking? Would that reduce perceived pain? Apparently Moseley took that idea on and showed it did reduce pain scores.

I did my own thought experiment as you'll see linked in the link. These ideas are for the future (although with adequate equipment there'd be no reason not to do them now). Of course, the manual therapists of the world would have to face the possibility of potential obsolescence... :embarasse

Not to say the world still wouldn't need physical therapy and therapists... just less physicaltherapy. Working smarter, not harder.

[Diane]

I just find it a little distastful when someone claims to have found the holy grail of therapeutic approaches when there is much, much more to learn. I think it's an issue of humility that seems to be lacking on this forum.

And we are trying to learn it. What are your reasons for not trying to catch up?

[Luke Rickards]

Rod, I don't recall making such a claim. I am not convinced that a single treatment method will ever be equally effective for everyone. I am convinced that improved understanding of how we (humans) work can lead to more effective interventions and less wasted time.

[Barrett Dorko]

I just find it a little distasteful when someone claims to have found the holy grail of therapeutic approaches when there is much, much more to learn.

Rod,

You're not going to get anywhere accusing ANYONE here of such a thing. I'd suggest you quote such a claim or reconsider what you've said.

[TexasOrtho]

Rod, I don't know if you'd be interested or not, but there is a blog I'm involved in with Cory and with Matthias in Germany, where we speak "ectoderm" fluently and dream up studies we'd like to see take place some day, discuss ones that have taken place. It's called Neurotonics, and can be accessed from my signature line. Here is a recent post (http://neurotonics.blogspot.com/2008/02/getting-past-fear.html) that connects to a bunch of topics, including good evidence for moving into the direction and use of illusion in PT, i.e., mirror therapy and maybe use of videos to connect a perceptual construct of a virtual body to help down regulate a physical one.

Check out Neurotopian, Matthias' own blog (linked on the righthand menu). He is out of his orthodigm days, which he refers to as "structuralist" in favor of a neurodigm, which he refers to as "functionalist." He does thought experiments, dreams up ideas like, what would happen if we put paraplegics in front of a screen where they could see the top half of their bodies in a mirror and a movie of the bottom half of them (or somebody) walking? Would that reduce perceived pain? Apparently Moseley took that idea on and showed it did reduce pain scores.


I'll definitely check it out. Sounds interesting.

And we are trying to learn it. What are your reasons for not trying to catch up?

This is what I'm talking about Barrett. My treatments are based on clinical intuition, evidence, and a fusion of what those on this forum have chosen to separate into "meso" and "ecto" approaches. I get very good patient-centered functional outcomes in this setting, yet I would never claim you (or anyone else for that matter) needs to "catch up" with me. This kind of statement is elitist and has no place in an otherwise interesting discussion. All it does is distract from some otherwise sound observations.

Rod, I don't recall making such a claim. I am not convinced that a single treatment method will ever be equally effective for everyone. I am convinced that improved understanding of how we (humans) work can lead to more effective interventions and less wasted time.

Luke my statement was not directed at you and have never said anything to disagree with you (yet). ;)

Rod,

You're not going to get anywhere accusing ANYONE here of such a thing. I'd suggest you quote such a claim or reconsider what you've said.

Barrett, please refer to my diatribe on Diane's comments above...I will continue listening and learning about the ideas on this forum. It would just be nice to read about them with out sifting through all the West Side Story rhetoric about why our gang of ectos could beat up your gang of mesos.

[Barrett Dorko]

Rod, you've seen quite a drama where none exists, and, as far as I'm concerned, you're now telling others how to behave.

I have never done well in the presence of such a thing, and I doubt that will change.

[TexasOrtho]

Rod, you've seen quite a drama where none exists, and, as far as I'm concerned, you're now telling others how to behave.

As far as you are concerned? It's the internet mate. I'm not telling anyone how to behave, and if I were, they'd be morons to listen if they didn't agree with me. We're all adults here and I doubt anyone on this forum who disagrees with me on a regular basis would start by paying attention to my recommendations on behavior.

Also, West Side Story was more of a musical than a drama...we can debate that at another time. ;)

I simply don't appreciate high-mindedness. Your response can simply be: So what Rod? I can be high-minded if I want to be. You know what B?...that would be something I would have to swallow and take like a man.


I have never done well in the presence of such a thing, and I doubt that will change.

Here, let me help you out with handling a dispute: I couldn't care less that you "don't do well in the presence of such a thing", and I doubt that will change either. My opinions are my opinions regardless of how you may feel about them.

Feel better? Now we both can agree to disagree with each other, knowing that the Gore's internet is a place where two grown men can disagree and still be respectable to each other.

By the way, I was wondering if I could get your autograph someday...:D

[Jason Silvernail]

Rod-
I gather what you mean when you say "high-mindedness" is that it's demonstrating a more complete understanding of the mechanisms of relief of therapy care, the relevant basic science and supporting case existing for treatments, and the predominant scientific explanatory theories.

Aren't you just saying you don't appreciate it when people display the knowledge that comes with study and effort?

Perhaps this is also something you'll have to - for lack of a better phrase - take like a man?

[Barrett Dorko]

Jason's right. I don't assume that you use the phrase "high-minded" as a compliment. I also note that right after you said you weren't telling anyone how to behave you said that reasonable people wouldn't listen to what you've already said about that. Which is it?

Rewriting my responses in a form you find less "high-minded" isn't going to get you anywhere either.

This forum is quite commonly full of intellectually challenging material and certainly isn't for for everyone. That won't change.

We need to move on from this.

Oh yes, in West Side Story several people die tragically. I will admit that there's a lot of singing and dancing going on at the same time, but it's no comedy.

[Diane]

Rod,
1. no one ever said you were an idiot on this forum. We like that you are here. It's more fun to have one ortho here than it is to have 20 MFRers with their energy medicine, at least I think so.
2. if you think we're sounding highminded that's just your own perception - truth is there's a lot of ground to cover to catch this profession up to the level of something else ecto and clinical, like, for example, psychology - Melzack, the "father" of pain research, is a psychologist. How is it, I wonder, that a psychologist ended up cracking the code (well, he had many others working alongside him) on physical pain? Shame on us. "We" were too busy enjoying nice busy lives pushing bones about, I suppose.
3. None of this is about you personally - really. Really, it's about the orthodigm, which I guess you feel a tad sensitive about, so you feel obliged to both defend yet perpetrate it, whereas I think you can now see how the mesodermal and ectodermal derivatives are completely interwoven with ectodermal taking precedence at all times.
4. I can't speak for others, but when I insist that people see things this way, it's not about me - really - it's about seeing the human organism like it really is. Alive, conscious, in pain usually, with a layer of "brain" wrapped all around the outside, bi-directional neurons heading into a processor screwed up at many levels, functionally not structurally.

Hope you stick around. Ain't cognitive dissonance fun?

[TexasOrtho]

Rod-

Aren't you just saying you don't appreciate it when people display the knowledge that comes with study and effort?

No but that's ok.

Perhaps this is also something you'll have to - for lack of a better phrase - take like a man?
You are right on here my friend. It's a form of communication I just have to get used to around here. Again, it's the internet and that's ok.
Jason's right. I don't assume that you use the phrase "high-minded" as a compliment. I also note that right after you said you weren't telling anyone how to behave you said that reasonable people wouldn't listen to what you've already said about that. Which is it?

Ah...correct. Not a compliment. Also telling people how to behave and the observation that they aren't listening aren't the same thing. I am innocent of the former and guilty as charged on the latter.

Rewriting my responses in a form you find less "high-minded" isn't going to get you anywhere either.

No but it might help you out.

This forum is quite commonly full of intellectually challenging material and certainly isn't for for everyone. That won't change.

We need to move on from this.

I agree on both points.

Oh yes, in West Side Story several people die tragically. I will admit that there's a lot of singing and dancing going on at the same time, but it's no comedy.
Fair enough...;)
Rod,
Hope you stick around. Ain't cognitive dissonance fun?

Thank you Diane and I would like to stick around. I've always been a bit of a punk who challenged authoritative sources of information. It's my version of cognitive dissonace. It drives me nuts from time to time as I am always asking..."Why am I doing this with the patient?". However I think it's a necessary exercise to move beyond from what we think we know toward what is truly the case.

[Barrett Dorko]

A fine response on all counts Rod.

I grew up in a home where my older sisters were in charge of the stereo. I know every word to every song in every musical from the 50s and 60s, including Pajama Game and Flower Drum Song. West Side Story was perhaps in the top three and the words and music have been in my head all morning. It's all I can do to keep from leaping around.

I'm not sure if I should thank you for that or not.

[TexasOrtho]

I have my dad (a family practice physician) to thank for my knowledge of muscial theater. He really likes it and I have the emotional scars to show for it in the form on knowing a lot of silly factoids about them.

It's kinda wierd, we are both jocks who like football, baseball, sports, orthodigms (;)) etc...but theres this musical theater thing that just showed up. It kinda freaks me out from time-to-time.

[Diane]

I want to put a link here to a post (211) (http://www.somasimple.com/forums/showpost.php?p=49123&postcount=211) I made on the Ectodermal evidence (http://www.somasimple.com/forums/showthread.php?t=5189) thread, about a study that depicts visualization of activation of pathways of the sensorimotor cortex stimulated by deformation of a mouse whisker. The study is linked there. I had originally intended to place the post on this thread, but it ended up on that one instead, because of my own mistake. But it's ok, it should be on both threads anyway.

[oldecanalpt]

Stephen Myles Davidson, DO CPOMM has been teaching a cutaneous approach to manual medicine for 20 years. He was so far ahead of the curve that most practitioners couldn't fathom what he was teaching them. www.healthabounds2.com (http://www.healthabounds2.com)

[Diane]

I want to examine Eric's (#17 (http://www.somasimple.com/forums/showpost.php?p=48169&postcount=17)) post a bit. I think it is one of the best posts ever.

Eric says,
1. As has been written during the current MFR discussions, evidence of efficacy is not the same as support for a theory. We think this logic should apply equally to the traditional orthopaedic paradigm, and any other paradigm that falls within the boundaries of our profession(s).

I couldn't agree more. Many in our profession are guilty of ignoring any curiosity they may have, however brief and fleeting, about how something they are doing to someone else might be efficacious. We have little to no theory developed by our profession. This leaves our PT profession (not to mention the broader group of HPSGs) with a serious intellectual abyss: like a real (geographical) ravine, it usually isn't visible from ground level, but for those who know where to look and from what angle, it appears. If ignored consistently (as it has been..) it ends up a conceptual dumpsite; mental equivalents of tires, bedsprings poking out of soiled mattresses, discarded plastic bags snagged on twigs, waving in the breeze, broken glass, bad smell.

This neglect has all been fueled and reinforced by the momentum of an orthodigm/chirodigm/mesodigm that has barreled on, not caring about such things, only interested in knowing "what works" and "how do I do that?" and "teach me how"...

... never "teach me how come."

2. any intervention that has an effect on pain can justifiably said to have been neuromodulating in its nature. I have not read or heard anything that would refute this viewpoint. Ditto that.

3. It is simply incorrect to state we don’t know enough yet to make this claim. Sure the quantity of information is vast and daunting, but this site makes it liberally accessible to anyone unlike anywhere else on the net. Exactly. This site is here to build the case for a third way (http://www.barrettdorko.com/articles/third_way.htm), neither ignoring the ravine (as the orthodigm has) nor allowing it to remain a garbage dump for the crazy ideas that currently inhabit it (courtesy of the chiro/and other mesodigms). We're here to clean out the bad ideas from the conceptual abyss/ravine, and either restore it to its natural function, salmon stream perhaps, turn it into a place where people can come for good input and not be put off.

4. Sure the quantity of information is vast and daunting, but this site makes it liberally accessible to anyone unlike anywhere else on the net. Sadly it is not taught in our schools and thus does not form the backbone (pun) of our collective mindset towards pain which is heavily geared toward orthopaedic theory, which occupies only a portion of the spectrum of potential neuromodulating agents. Here will be found tools and resources for the Big Cleanup. There is plenty here for everyone. Many hands will make light work.
Those who define themselves by never doing any "dirty work" are not welcome. :thumbs_do
Those who would add rather than subtract from the conceptual debris are not welcome. :thumbs_do
Those who would argue that none of this effort is necessary are not welcome. :thumbs_do


Those who are keen to help, interested in seeing/measuring progress or just curious about what the fuss is about, are always welcome. :thumbs_up

[Diane]

Hello oldecanalpt, welcome to SS. Would you like to introduce yourself in the welcome forum (http://www.somasimple.com/forums/forumdisplay.php?f=126)?

I checked out the link you provided, and it looks like more mesodigm training to me. Not that learning how to contact patients' skin is a bad thing - looks like this guy has learned and is teaching people to do that in a sensitive way, but his thinking is very mesoderm-in/out as opposed to ectoderm-in/out.

[oldecanalpt]

Diane,
We have studied many times together with Dr. Rex learning all about embryology. Dr. Davidson is all about neural tissue and the fluid dynamics of the nervous system. It would be akin to Simple Contact only more sophisticated.

[Diane]

In that case oldecanalpt, I'd love to get reacquainted. I've sent you a pm. (you aren't JC are you? If so, it's great to see that you've learned to release your caps-only key. :D)

[Nick]

Diane,
We have studied many times together with Dr. Rex learning all about embryology. Dr. Davidson is all about neural tissue and the fluid dynamics of the nervous system. It would be akin to Simple Contact only more sophisticated.

What makes it "more sophisticated"?

[Barrett Dorko]

Nick,

You beat me to it. I am dying to know just exactly how Simple Contact lacks the sophistication inherent to Rex's method. Do tell.

[John W]

I don't know Diane this sounds, smells, looks to me like something you would find dumped in the ravine:

Some scoliotic curves are the person’s adaptation to a generalized tissue toxicity from chemical pollutant exposure. A chemical exposure has imprinted a weakness in the general fascial system. No chemical may remain in the tissues, but its physiological effect continues. In the same way, many patients will say, "Ever since I had this infection, I’ve felt such and such..." Obviously, the infection state has long passed, but the infection created an effect that is maintained in the system, running like a computer software program.-- from Dr. Davidson's website

There's also references to "releasing" old mental and emotional "trauma" with his neurofascial release technique.

Sounds like JFB with a neuro-twist to me. Stinky...P.U.:eek:

[Diane]

jwware, yes. Sounds like you're already on the job, on the clean-up crew.
Barrett, I think the reference to "greater" sophistication was something Davidson-esque, not Rex-esque. That's how I read it, anyway.

[Diane]

Here's a link to Michael O'Hearn's article on PT theory (http://findarticles.com/p/articles/mi_qa3969/is_200201/ai_n9027300/print). It was googleable, so I don't think there are any copyright issues. Here are some excerpts. Conceptualization of a grand theory is not merely an exercise in semantics but a part of understanding the essential identity of physical therapy and what distinguishes it from other professions. It forms the overarching framework for our research and outlines the knowledge that belongs to physical therapy. It helps define who we are and what is our purpose.

There is an interesting discussion in the paper about postmoderism, and best of all, it discusses physiotherapy "theory."

Hislop Theory: The most well-known grand theory in physical therapy is pathokinesiology as proposed by Hislop, who postulated that pathokinesiology is the "distinguishing clinical science of physical therapy."1(p1071) She proposed that there is an interactive hierarchy from cells to tissues to organs all the way up to person and family and that each level of the hierarchy correlates with a different science (eg, tissue is studied by histology, systems are studied by physiology, and so on). At each level, some form of motion is required (eg, tissues require blood flow, people require locomotion). Disease and injury can occur at any level and affect others.

Cott Theory: Building on Hislop's pathokinesiology theory is the MCT as proposed by Cott et al.3 It was described with the purpose of being unique and central to physical therapy, as well as being broad and applicable to research and education while "subsuming" current middle-range theories. It is similar to pathokinesiology, being established on the principle that movement is essential for human life, taking place on a continuum from a cellular level to an individual's interaction with society. Physical therapy intervention can take place at one or several places along the interdependent continuum similar to Hislop's.1

Within the continuum, each individual has a maximum achievable movement potential (MAMP), which varies over an individual's lifetime and can be influenced by the MAMPs at other levels. There are also a preferred movement capability (PMC) and a current movement capability (CMC). The Figure outlines the various levels of the MCT. Biological, psychological, or social problems or developmental limitations have the potential to change the MAMP and to create a differential between the PMC and the CMC. Physical therapy intervention, regardless of the pathology, diagnosis, or other limitations, seeks to assist patients to either achieve their MAMP or reduce the difference between the PMC and the CMC. Intervention by the therapist may be at one or more places on the continuum. For example, an individual who is recovering from a total knee arthroplasty may not be able to bend his or her knee past 70 degrees due to stiffness (CMC) but may want to bend it sufficiently to be able to get out of a chair easily (PMC). Assuming 95 degrees of knee flexion is needed to achieve this, we see the differential between the CMC and the PMC as something that can be addressed by physical therapy.

In order to achieve the PMC, we may have to intervene at different levels of the continuum. Consideration would be given to the use of therapeutic modalities at the cellular level, manual stretching of the knee joint (body part), and encouragement to stay socially active (person in society). With continuing recovery, the same patient may want to be able to do deep squats, but the prosthesis does not allow flexion beyond 120 degrees (MAMP). Thus, the knowledge of the physical therapist about MAMPs enables to the patient to set appropriate goals. The MCT considers intrinsic and extrinsic influences to movement potential. In the example of the patient with a total knee arthroplasty, factors such as age, cardiovascular health, obesity, and the condition of other joints, as well as the daily environment of the individual, would be considered.

The reason I'm putting this on the ectodermal approach thread is that in humans (which we mostly treat) or mammals in general, motor output is an ectodermal issue - nervous system output, not a mesodermal output.

A leg (or any other body part) with no neural input/throughput/output is pretty much dead weight. Ask anyone still alive who lived through having polio. Nature does its best to lighten the limb by atrophying the mesoderm, which can't do anything on its own, but the limb will still be dead weight.

My main point is that if we are to be congruent with the meager offerings our profession does have to offer as theoretical underpinnings, we have to get familiar with an ectodermal approach, and start building ourselves a good "neuro"-digm, which will also come in very handy for those of us treating pain and or dysfunction in conscious patients at their conscious and various non-conscious levels. It will align us with the better understanding of pain that has developed, and free us from any irrelevant or misleading pathoanatomical thinking. I like the movement continuum idea, because it's consistent with neuronal life itself, including Buzsáki's oscillations.

[TexasOrtho]

The reason I'm putting this on the ectodermal approach thread is that in humans (which we mostly treat) or mammals in general, motor output is an ectodermal issue - nervous system output, not a mesodermal output.

Sorry Diane, but I have to be a persistent thorn in this argument. It seems that excluding "mesoderm" or muscle, articular, and periarticular structures in the role of regulating movement really provides an incomplete picture. I may be misunderstanding what your definition of mesodermal vs ectodermal output is, but it seems that unless both are functioning at optimal levels, maladaptive movement patterns are more likely.

I'm sure there are holes in this argument (there always are), but I'll take a stab here. There is a significant body of evidence suggesting that the loss of cruciate ligament and/or meniscal pathology (both mesodermal structures as I might define them) accelerates the development of osteoarthritis. The theory behind this of course is that these structures play a key role in maintaining normal kinematics of knee loading.

In this situation, I believe there is a strong likelihood that the neuroregulatory function of the cruciates, meniscus, and other periarticular structures contribute to this process. This would make this, in my estimation, both a mechanical and neuroregulatory issue. Ignoring one while only addressing the other would seem to provide quite an incomplete picture of the problem. I still don't see how separating movement disorders into "neuro" and "ortho" problems that have either "neuro" or "ortho" solutions accomplishes much.

I do think it would be important to determine what degree either system contributes to the movement pathology in question. This should be under intense investigation. But to simply state it's either one or the other, just seems to leave too much room to miss something important.

A leg (or any other body part) with no neural input/throughput/output is pretty much dead weight. Ask anyone still alive who lived through having polio. Nature does its best to lighten the limb by atrophying the mesoderm, which can't do anything on its own, but the limb will still be dead weight.

How about asking someone with a ruptured quadriceps tendon to walk down a flight of stairs? Again I think just about any movement dysfunction can have greater or lesser degrees of orthopedic or neurologic etioloties, and obsessing over the distinction could be treacherous.

[Bas]

I also can not wait to see the explanation of the "more sophisticated"-line.
Especially when the espoused Dr. Davidson is promoting homeopathy as well; he suggests the neurofascial technique is "standing on the shoulders" of Sutherland (CST) and Jones (counterstrain). I would call that very shakey grounds....


(sorry to interrupt a very interesting thread)

[Diane]

Hi Rod,
No one said loss of "meat" didn't figure in - such a thing as you have described would fall under and be treated at the level of "current movement capability (CMC)". Meat does not a total PT theory make. :)

[TexasOrtho]

Hi Rod,
No one said loss of "meat" didn't figure in - such a thing as you have described would fall under and be treated at the level of "current movement capability (CMC)". Meat does not a total PT theory make. :)

Well we know loss of both "meat" and "wire" are both important. Again, you are missing my point boss. I never said "meat" makes the total PT theory. In fact, that was the exact opposite meaning of my post.

What say you?

[Diane]

Again, you are missing my point boss. I never said "meat" makes the total PT theory. In fact, that was the exact opposite meaning of my post. I am not the boss of you. I need further clarification from you on what you actually did mean in your post, Rod.

I want to bring Barrett's post 22 (http://www.somasimple.com/forums/showpost.php?p=48176&postcount=22) here, onto this page. ...the term "soft tissue," which inevitably combines these two elements as if they would respond as one is misleading at best. I'm for identifying this and abandoning the term when discussing dysfunction and/or treatment.
I just want to say, for the record, that I agree. If we are going to sort out an ectodermal approach from a mesodermal approach, then it's necessary to get out Occam's micro scalpel and do all the necessary differentiation.

[TexasOrtho]

I am not the boss of you. I need further clarification from you on what you actually did mean in your post, Rod.

I want to bring Barrett's post 22 (http://www.somasimple.com/forums/showpost.php?p=48176&postcount=22) here, onto this page.
I just want to say, for the record, that I agree. If we are going to sort out an ectodermal approach from a mesodermal approach, then it's necessary to get out Occam's micro scalpel and do all the necessary differentiation.

The term boss isn't derogatory incidently. Quite the contrary. just something I say to just about everyone in a conversation that didn't translate well into forum-speak.

It looks like we probably agree on some important issues but the language we choose to describe it is pretty different. It seems that you take great effort to separate two very integrated systems and approaches. There are probably those in the orthopedic community who do the same. Fortunately, I think most people fall somewhere in the middle and are trying to find the answers somewhere between the extremes.

[Jon Newman]

...but it seems that unless both are functioning at optimal levels, maladaptive movement patterns are more likely.--Rod

Rod, could you expand on what you mean by optimal? I expect that you mean some range of a value (similar to "lab values" such as Hgb).

It also seems that context is quite important. My optimal meat values for watching TV aren't the same as my optimal meat values for setting a world record for dead lifting.

And it could be argued that if my meat values are optimal for setting a world record for dead lifting that perhaps my wire values are necessarily suboptimal (<--value laden judgment joke, but I'm serious about the clarification and context part).


.

[Diane]

This introduction of the theory (such as it is) perhaps should go into a new thread. What I was thinking about was:

1. the theory/ies were built prior to the advent of all the brain/neuro/pain science, so they do not incorporate it.
2. if they incorporate only movement analysis for PT, patho or not, relational or not, they leave PT wide open for "rubbish in the ravine" to continue to accumulate.

Therefore, I think an updated theory should be devised that is based on all the (ectodermal) science base that has built up since the 70's or whenever these PT theories were elucidated. Does anyone know how or even if there's been any progress to date?

[bernard]

There is a significant body of evidence suggesting that the loss of cruciate ligament and/or meniscal pathology (both mesodermal structures as I might define them) accelerates the development of osteoarthritis.

Rod,

I'm sorry but I'll bring, again, the car's analogy: If you get a problem in a cardan you'll get unfortunately problems in sequence. Once the rubber joint is broken the wear will appear because the driver isn't able to replace it.

Osteoarthritis is the best response the car's computer found in this pathological situation.

[John W]

I know we've discussed/debated about this condition before over at EIM, but I would like to see what Rod might add to the discussion on tendinopathy. I think this is a good example of a painful and debilitationing condition where both "meso" and "ecto" tissue are literally intertwined to create the dysfunction.

We know that in addition to histological changes on the ultra-strucure level of the collagen that there is also a process of neo-vascularization that implies also neo-neuralization as blood vessels require innervation. Interventions directed toward destroying the neovascular/neural tissue have shown effective in recent studies (here's a link to one: http://www.ncbi.nlm.nih.gov/pubmed/12055110?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlu sDrugs1).
Also, interventions directed toward mechanically "over-loading" the tendon with eccentric training have shown promise (http://www.ncbi.nlm.nih.gov/pubmed/15060761?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlu sDrugs1).

Therefore, it seems that this particular, persistently painful condition responds well to interventions that address the totality of the problem on both a "meso" and "ecto" level. This seems to be a good example of what I think Rod is talking about, which is that we may miss the opportunity to provide optimal care if we try to tease out these aspects into distinctly separate entities when they are in fact so obviously integrated.

I'll add to this that in my opinion, by the time we see patients with persistent pain problems, I think the likelihood of histological changes occuring on the "mesodermal" level is likely the rule, not the exception, and that these tissue changes will eventually require addressing if the patient wants to shift upward from the "meat on the couch" towards a higher level of PMC.

[Diane]

by the time we see patients with persistent pain problems, I think the likelihood of histological changes occuring on the "mesodermal" level is likely the rule, not the exception, and that these tissue changes will eventually require addressing You mean through exercise?
It's not so hard to think ectodermally about tendons. Here's a Butler blog on IT band "syndrome" (http://www.noineurodynamics.blogspot.com/).

[TexasOrtho]

Rod, could you expand on what you mean by optimal? I expect that you mean some range of a value (similar to "lab values" such as Hgb).


Sure. I think it would be important to define optimal. I'm sure others are capable of defining it more precisely, but I define it as safe and efficient performance of a patient-specific motor task during daily activity, vocation, or avocation. Of course if you are Kobe Bryant, "optimal" has a completely different connotation than Granny Gumbumpers.

I think whether you are Kobe or Granny, both orthopedic and neurologic functioning must be adequate to achieve "optimal" output in their environments. As one system begins to falter, a sequence of events is more likely to produce dysfunction in the other system. I'm sure it exists in some capacity, but I have yet to see a purely neurological or orthopedic condition. Thus, I see little reason to classify interventions as such.

[Diane]

I have yet to see a purely neurological or orthopedic condition. Thus, I see little reason to classify interventions as such.Yet ortho classification is all you ever seem to do, Texasortho..

[TexasOrtho]

Yet ortho classification is all you ever seem to do, Texasortho..

I have no idea what this even means Diane. Anyway you could clarify? I thought I've been implicating both neuro and orthopedic processes this whole time, but somehow you always seem to extract something different from my posts.

Also the moniker (TexasOrtho) is from by board-certification and the fact I live in Texas. It doesn't refer to the name of the temple I worship. ;) That's actually St. Phillip the Apostle.

[Diane]

I was advised to go check out Steven Davidson's site, which I did. I saw nothing on there to convince me that his perspective on the human organism, treating the body of said organism, or explaining how to treat said body of said organism, is anything more than the same old osteopathic mesodigm, with the prefix "neuro" plunked inappropriately in front of all of it. Here's what I found:

1. Cranial credentials: Life member of the cranial academy (http://www.healthabounds2.com/pages/meet-dr.-davidson/about-dr.-davidson.php), has a certificate of competency from it.

2. Homeopathic credentials:
A member of the Arizona board of medical examiners for homeopathy.. he's an MD(h), meaning homeopathic physician. He belongs to 4 other homeopathic organizations.

3. Neuro(sic)fascial Release: Neurofascial release is just myofascial release (http://www.healthabounds2.com/pages/neurofascial-release/brief.php) by another name it would seem. He isn't talking about nerves or innervation at all. I think he is trying to imply that the fascia itself is sensitive, rather than embedded by mechanoreceptors which can become sensitized (a neurological process - see Clifford Woolf (http://www.somasimple.com/forums/showthread.php?t=3677&highlight=clifford+wolfe), "father of central sensitization"). It would be like the orthodigm trying to call what they do "neuroarticulomanipulation". You can't make either the mesodigm or treatment constructs based on it, more presentable by putting "neuro" in front of it/them. It's still like driving with only a rear view mirror to guide you.

4. No mention at all of the actual nervous system: In his "scholarly paper (http://www.healthabounds2.com/pages/neurofascial-release/scholarly-paper.php)", he does the usual osteopathic thing, keeping the nervous system completely invisible conceptually and perceptually while defining everything about his system in terms of perception/perceptual fantasy of the practitioner. This is the usual conflation that practitioners and manual therapy teachers persist in perpetuating when they mix up what they feel or sense (subjective) with what's going on in the nervous system of the human organism (objective) to produce responses. The only time he even hints that the body may have a brain attached is when he's talking about homeopathy (http://www.healthabounds2.com/pages/homeopathy/scholary-paper-on-homeopathy.php), saying it works on "mental, emotional and physical realms" - but he doesn't define "realms"..

5. Commercial: He also sells air cleaners, massagers, backnobbers and big purple plates (http://www.healthabounds2.com/pages/items-for-healthful-living/electromagnetic-pollution-protection.php) to shield one from electromagnetic pollution, in addition to his training DVDs etc. Is it the special purple color that works, or the aluminum it's made from?

6. Testimonials only: He has lists of testimonials but no list of papers published.

As a website that promotes a manual therapy teacher and his method, it's nicely laid out and organized, etc, but nothing there makes me want to take a class from him. I don't think I'd learn anything I don't already know. I think I'll trust my hands to do what they already know how to do, and will get my information about how the system works from more reliable sources.

The cranial academy membership, the homeopathy, and especially the purple electrical pollution deflector thing are all red flags.