Critical thinking and Clinical thinking

[Diane]

I found a new blog today (well, new to me anyway) by following links from Science-Based Medicine blog (http://www.sciencebasedmedicine.org/). It is denialism blog (http://scienceblogs.com/denialism/), and I thought perhaps this post from yesterday might help get our new forum rolling along a bit.

The post is Galileo, Semmelweis and you (http://scienceblogs.com/denialism/2008/08/galileo_semmelweis_and_you.php#more). In it, the author, an MD who once hosted White Coat Underground blog (http://whitecoatunderground.com/), talks about how he keeps a piece of paper to track his diabetics' care. He summarizes what he thinks goes into "good" clinical science thinking: Relevance: an idea should bear directly on a real clinical problem

Testability: it should be possible to test the idea to see if it has merit (this includes Popperian falsifiability).

Plausibility: the idea should have some basis in reality and should not have been birthed de novo from between someone's buttocks. It should not require a "suspension of disbelief" or "open-mindedness".

Abandonability: the poser of the question should be willing to abandon the idea if it is proved false. Moving the goal posts, invoking a conspiracy, or any other deus ex machina is never necessary for a good idea.

Modifiability: an idea can be rationally modified and retested if it may still contain a kernel of truth despite failing one or another tests. Any idea that is held so tightly that reality must be modified to fit the idea should be highly suspect.

This made me think of something Jon asked awhile back about what difference there might be between a science-based clinician and a clinical scientist. (Or something to that effect.)

Another site linked to Science-Based Medicine is Notes from Dr. RW. I found his post What is a troll? (http://doctorrw.blogspot.com/2008/08/what-is-troll.html) quite interesting. I was reminded of my own experience at one or two other forums (certainly not this one): Years later I became convinced that even though I was the sole dissenting voice I was, in a very real sense, trolled. Thoroughly, relentlessly, mercilessly trolled. Why? The group had an impassioned agenda and couldn't seem to countenance tough questions and challenges to their views... Over the next several years many appeals to evidence went unacknowledged and personal attacks trumped collegial debate. Although the group’s raison d’etre was about professionalism much of the on line behavior exhibited there was anything but professional.

It sounds like he was never banned from the site he wrote in, as I was (from one of them at least), but the flavor of what he describes tastes familiar. Maybe others have had a taste of being "mercilessly trolled" by other members on a site...

So why do these two posts appeal to me enough to want to include them both in one post? It seems to me that if the thrust of an idea someone is trying to express contains the elements of the first post, the behaviour of peers in response to it shouldn't include a reenactment of behaviour as described in the second. That it did, merely confirmed what I had already suspected, that the profession has a long way to grow. (Anyway, there's a very nice picture of a troll disguised as nature in RW's post, if anyone wants to check. :angel:)

Here's another RW post that caught my eye, Separating clinicians from automatons: the long tail (http://doctorrw.blogspot.com/2008/08/separating-clinicians-from-automatons.html).
The long tail refers to the horizontal tail of a power law graph. This is a polynomial function which has garnered great interest because of its applicability to a large number of phenomena in commerce and nature. When applied to differential diagnosis the horizontal axis can be visualized as an array of diseases of increasing rarity the farther away from the origin. The vertical axis represents the probability of the given disease explaining the patient’s presentation. A small number of common diseases are clustered toward the origin (to the left). Toward the right (in the long tail) are uncommon diseases, becoming increasingly rare as the graph approaches the horizontal axis as an asymptote.


It seems to me that the ortho crowd, still using their training wheels (needing a high degree of "certainty" as per Robert Burton's book (http://www.amazon.com/Being-Certain-Believing-Right-Youre/dp/0312359209/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1218387827&sr=8-1)) like to hover near the left side of the graph, and those of us who enjoy a bit of real intrigue meander further over to the right and treat people who don't easily fit into predictable categories. Persistent pain is over to the right, somewhere along the tail - maybe it's the whole tail, in PT...

Threads can pick up on any point they might like, go anywhere they want, although I think I'd like this thread, at least, to remain within the confines of the ideas in the first post quoted (RW's little list is very succinct) - this is, after all, a new subforum for skepticism and critical thinking.

Other threads in this forum might want to explore other topics and chase other rabbits.

[Mary C]

Suppose I try some clinical thinking, and ask you all to chime in with the critical part.

Observation: Lymph drainage (LDT) to the arms relieves pain in the hands.
Pts 1 (RA) & 2(OA) had swollen IP joints. No visible decrease in swelling, but significant decrease in joint tenderness. So I teach them how to do it for them selves.
Pt 3 is a very active carpenter, with no visible swelling. Pain was mainly in the dorsum of the hands, as well as the fingers. Just one treatment so far, and I will not know for 2 weeks how long the relief lasted.

The Question: How do I explain the mechanism to other physios? I'm supposed to give a workshop in Sep to demonstrate the techniques, but my neurology is still way too sparse and I cannot, in good conscience, claim it is entirely due to LDT.

[Jon Newman]

This made me think of something Jon asked awhile back about what difference there might be between a science-based clinician and a clinical scientist. (Or something to that effect.)--Diane

Hi Diane,

Just for clarity and to give appropriate credit, it was Eric not I. I think many clinicians are all but forced to be productivity based clinicians.

[Diane]

Thanks for the clarification Jon. Sorry about that Eric.

Mary, Suppose I try some clinical thinking, and ask you all to chime in with the critical part.

Observation: Lymph drainage (LDT) to the arms relieves pain in the hands.
Pts 1 (RA) & 2(OA) had swollen IP joints. No visible decrease in swelling, but significant decrease in joint tenderness. So I teach them how to do it for them selves.
Pt 3 is a very active carpenter, with no visible swelling. Pain was mainly in the dorsum of the hands, as well as the fingers. Just one treatment so far, and I will not know for 2 weeks how long the relief lasted.

The Question: How do I explain the mechanism to other physios? I'm supposed to give a workshop in Sep to demonstrate the techniques, but my neurology is still way too sparse and I cannot, in good conscience, claim it is entirely due to LDT
Here is a link to a paper about static mechanical allodynia (http://www.somasimple.com/forums/showthread.php?t=5957). I know it has nothing to do with lymph... or does it?
Cutaneous nerves maintain all the skin autonomic function. If you are treating for lymph and find pain reduced, I don't see how there would be any difference really...

I like that paper. It talks about tender points, for one thing, something I've keyed on and treated for decades...
Now, about explaining the mechanism... there might not be just one - there might be several, all nervous system, all happening simultaneously, central and peripheral. Here is a link to an answer I provided on my blog (https://www.blogger.com/comment.g?blogID=3190056069771978380&postID=7432678975118599880) - perhaps it will be of some use to you. Not that I "know" if it's right, it's what I think might be in the ballpark of "right"...

[Mary C]

Thanks, Diane

The paper is currently in the stack to be read, and the blog bit will be put with it.
And I have the beginning of a bibliography :D

[BB]

Hi Mary,

There are some old threads here on LDT (http://www.somasimple.com/forums/showthread.php?t=3079&highlight=manual+lymphatic+drainage)that you might find helpful for your presentation.

I cannot, in good conscience, claim it is entirely due to LDT.

You shouldn't have to as long as that mechanism hasn't been confirmed and apparently it hasn't. It's plausibility as a mechanism is definitely questionable. Some of your observations of pain relief in absence of change in edema measurements would seem to exemplify this.

[Jon Newman]

Mary, it might help for you to expand on what sort of connections you're making between arthritis, lymph drainage, swelling and pain.

Beyond discussing whether lymph drainage techniques actually drain lymph (especially in these particular cases), something worth considering is whether measurement of pain is a reasonable marker for a change in this (apparently very small degree) of lymph congestion.

[Mary C]

Thanks, Cory

I read the thread. Bernard insists we do not have the mechanoreceptors to palpate lymph flow. I'm going to ask the OT dept if I can borrow the fibres they use for sensory tests, to see how fine my sensation is.

As for Diane's take of "perceptual fantasies," I hope to sit down with her some day and have a good discussion. If I mentioned some of the stuff my hands can pick up, she'd probably want to behead me and get a replacement brain.

I really like the idea of combining the surface sensory nerves and the lymphatics in the same diagrams. The diagrams in the DNM manual would be a terrific place to start.

[Diane]

Mary, I don't doubt your hands are brilliant, or that they have receptor capacity that would rival the largest radar dish. I do however, have to consider the fact that as humans all of us are prone to entertaining beliefs as though they were something real, and that manual therapists have sold packages to other manual therapists since forever that are based on nothing but their own perceptual fantasies, but have sold them hard, as if they were treatment concepts carved in stone.

The whole point of this thread, the whole board for that matter, is to dig deeper and understand this, use understanding of human perceptual bias as a basis for further discussion toward digging ourselves out of deep pits of misunderstanding about

1. the nervous system of the humans we treat
2. our own therapy perceptions and treatment constructs about the humans we treat
3. seeing that many of them are inconsistent with what is now known about the human nervous system
4. seeing that they do not have to remain welded together through eternity, that sensory perception is one thing and that it can (and should) be de-conflated from erroneous concepts and perhaps linked to new and hopefully better ones.

[BB]

In keeping with the theme of Diane's thread, perhaps we can apply critical thinking to the clinical reasoning of LDT: assessment of lymph flow and application of treatment based upon these findings.

Relevance: an idea should bear directly on a real clinical problem

As lymphedema and pain are very relevant clinical problems there are definite clinical presentations of relevance. The relevance of lymph drainage or lack thereof to pain is questionable though. Do all people with inadequate lymph drainage have pain? Do all people with pain have inadequate lymph drainage? There is no doubt that some cases demonstrate both edema and pain, but are they corelative or causitive?

Testability: it should be possible to test the idea to see if it has merit (this includes Popperian falsifiability).

It would seem that the ability to affect lymph flow manually, the ability to feel lymph flow manually, the effect of lymph drainage on paifnul presentations could all be tested and likely has been already. I believe much of this was posted in the thread I linked to earlier.


Plausibility: the idea should have some basis in reality and should not have been birthed de novo from between someone's buttocks. It should not require a "suspension of disbelief" or "open-mindedness".

While it is plausible to affect lymph flow, assessing its flow manually is suspect and is I believe not supported. If I remember from the other thread, Karie mentioned at one point that SHE could feel it, even if those in the studies could not. I believe that this would fall under suspension of disbelief.

Abandonability: the poser of the question should be willing to abandon the idea if it is proved false. Moving the goal posts, invoking a conspiracy, or any other deus ex machina is never necessary for a good idea.

It is abundantly clear that those that teach these techniques, such as the Upledger Institue, are failing at this stage enourmously (to no one's surprise).

Modifiability: an idea can be rationally modified and retested if it may still contain a kernel of truth despite failing one or another tests. Any idea that is held so tightly that reality must be modified to fit the idea should be highly suspect.

It would seem that the "I can feel it" argument would fall into this category of changing reality vs. the idea. Is it more likely that the studies are wrong (based upon the quality of the study) or that perceptual fantasy conflates our experience? As some of the cases that respond to this technique (per your observations) do so without a change in edema measurements, modification of the idea that lymph flow was the operative change, at least in these cases, seems warrented.

Thanks for submitting this as a case for scrutiny.

[Mary C]

Cory, you've given me some opportunities here to clear up the way I say things.

The relevance of lymph drainage or lack thereof to pain is questionable

I agree. That's why I was so surprised at the effect on the pain. And that's why I'm looking for a more adequate explanation. Diane's work has given me lots to chew on.

Do all people with inadequate lymph drainage have pain? Do all people with pain have inadequate lymph drainage?

No to both.

some cases demonstrate both edema and pain

These are usually the post-trauma (including surgery) cases. The change in swelling is easy to measure with them. I believe a pressure donut has been developed to measure joint sensitivity, as well.

While it is plausible to affect lymph flow, assessing its flow manually is suspect and is I believe not supported.

Okay, research to date has not been adequate for that. Unfortunately, that is not something I can rectify. I can only check on my own consistency. I only found one study (by Chikly) in the thread on LDT.


If I remember from the other thread, Karie mentioned at on point that SHE could feel it, even if those in the studies could not. I believe that this would fall under suspension of disbelief.
Not when the inter-rater reliability demonstrates a certain consistency. Again, we lack adequate testing. One study does not a convincing proof make. Karie could feel it, I can feel it, most of my class could feel it. Now it needs proper testing. I admit it.

I'd like to work with Diane to see how light her touch is. She can feel a "softening". Can she identify what it is that "softens?" Can that type of palpation be taught? Has it ever been submitted to inter-rater testing? Can surface electrodes pick up a change in muscle activity? Could we inject a dye to follow the lymph drainage?

modification of the idea that lymph flow was the operative change, at least in these cases, seems warrented.

In the case of chronic pain, that's what I'm in the process of doing.

Thanks for the help.

[Mary C]

Another light touch technique that I would like to learn more about is bindegewebsmassage. I once saw a patient who could not tolerate more than a few minutes. This was at least 20 years ago and his reaction has always puzzled me.

Does anyone here practice the technique?

[Diane]

bindegewebsmassage
Have never heard of this. How could it be much different from what you apparently successfully do already?

[BB]

Hi Mary,

I would definitely recommend looking through Diane's material. She's already done a lot of the weeding you're probably looking for.

research to date has not been adequate for that.

How so? Admittedly I've not combed the research on LDT.

Not when the inter-rater reliability demonstrates a certain consistency. Again, we lack adequate testing. One study does not a convincing proof make. Karie could feel it, I can feel it, most of my class could feel it.

This is not an example of inter-rater reliability unless Karie, yourself, and your whole class all assessed the same person or group of people and consistently came to the same conclusions/findings. Lot's of people, indeed whole classes, can "feel" pelvic obliquity and spinal motion palpation as well. Of course, it's been shown to be unreliable and invalid. Of course that hasn't stopped the multitudes of courses based upon it nor the belief amongst the devoted that THEY can feel it.

Unfortunately, this is not isolated to the poorly monitored CEU courses out there.

I had a conversation from a student this year who had lots of questions for me about application of the various evidence that is in vogue right now. As she began disagreeing with me based upon what her professors with their expertise had taught her, it turns out, they had taught her to administer the lumbar manipulation CPR but had added to it motion palpation so that you could "feel the level needing to be manipulated." Also, she was having a hard time with the neuromatrix theory vs. the gate control theory. As we got further into it we started talking about phantom limb. These same professors had told her that congenital phantom limbs don't exist which validates looking for peripheral sources of pain. Damn, we've got a long ways to go!

[estherderu]

dear Contributors,

As I have already mailed to Mary C, I know a bit more about BGM ( official German Abbrev) having been near the sourch, using it for more than 30 yrs. and having revised it. I have only been using the superficial technique for the last 10 yrs.
By trying to research the reasons behind it working (in this case I mean ....researching as in is finding all the literature, in as many languages as possible, enthicing those who teach it to get into contact etc etc... and doing my little bit by trying to film the whole process) I and hoping to fascilitate further research if necessary.

The very interesting thing is, that it ( the superficial technique) could possibly be more of a a skin technique, than a fascia technique.

Very shortly after the stroke the skin reacts either with a vasodilatation, a vasoconstriction or a variation of both. I am currently filming the various reactions and hope to use them later on.

Mary : "the light touch", the patient you observed could not stand...
for me that means only 2 things.. the therapist made a mistake and didn´t do the technique properly or she misread the patients reactions.

It is a very interesting technique and after having read Diane´s Manual ( thank you so much for sharing this with us all) I am sure it is not the same technique.

I hope to use all your knowlegde in my "search for the evidence" of a technique I "know" works so well.

Esther

[nari]

Mary,

A lot of folk can't tolerate light touch and they haven't any neurological condition. I wonder if your patient was similar, or did you mean he could not tolerate the pain?

I haven't see many patients with lymphodoema; those with pain were all post-op and I suspect the pain was linked to the destructive surgery techniques more than anything else. However the weight of the limb could certainly provoke pain for some. Once Complex bandaging was applied, after distal--> proximal massage, the pain and swelling improved significantly. So it was never possible to tell whether massage+bandaging worked, or just massage or bandaging.
(Complex bandaging with sheets of padding is used in Australia, I don't know about elsewhere).

Nari

[Diane]

Hi Esther,
The very interesting thing is, that it ( the superficial technique) could possibly be more of a a skin technique, than a fascia technique. Certainly the skin neurons will be reading your hand like mad, and sending the info in, all levels of the nervous system will be responding to the exteroxeption, examining it for possible threat, the locus ceruleus (the sympathetic innervation to the rest of the brain) will be activating it, the sympathtic nervous system of the body will be activating, shunting blood out of the skin and into the underlying muscle.

I think fascia has probably got nothing to do with anything actually.
I think a response by the nervous system, reasonably predictable and carefully engaged, has much more to do with the fluidic feelings in the skin/cutis/subcutis layer (which remember is a good quarter to half inch thick) instead.

Very shortly after the stroke the skin reacts either with a vasodilatation, a vasoconstriction or a variation of both. I am currently filming the various reactions and hope to use them later on.

There is a description of axon reflex here, in one of the many threads on autonomic nervous system and skin. You probably want to investigate that before you submit anything. It's wonderful that you are filming your work. :)

It is a very interesting technique and after having read Diane´s Manual ( thank you so much for sharing this with us all) I am sure it is not the same technique.

It might not be precisely the same in application, or done for identical reasons, or keyed onto the same patient complaint or presentation, but I would argue that what you call lymph drainage (of whatever flavor or named practitioner) is a form of dermoneuromodulation anyway, because dermoneuromodulation means accessing the nervous system through the skin in order to help it effect a change, a change of anything.

Dermoneuromodulation is not a rigid thing, that I "invented" and therefore lay claim to and want to sell as "my" specific treatment construct - instead, it is a large stretchy conceptual totebag (I hope) which can easily encompass and carry and provide construct for any sort of non-ortho treatment you could care to deconstruct.
I expect there is only one "right" way to do "Vodder" or whatever.... but there are thousands of ways to do "dermoneuromodulation." In fact, you can do it any way you might like. Including the "Vodder" way, perhaps... :)

[Mary C]

Diane--BGM is quite different from LDT. One of the very few things I remember is that BGM targeted the autonomic system.

Esther--I have not had any contact with anyone trained in BGM for over 20 years. What I remember might be considered pure DNM. The stroke technique was really superficial and seemed to activate the autonomic system. I wanted to learn more but could not find any courses or any literature in English. I can read French, but not the academic sort.

Can you share some references?

[Diane]

Diane--BGM is quite different from LDT. One of the very few things I remember is that BGM targeted the autonomic system.

Mary, any kind of touch will affect the autonomic nervous system, the point I was trying to make in the previous post.

In your opinion, what distinguishes the two sorts of "treatments" ?

[Mary C]

The 2 target different structures. However, the target is not always attained. Even though the desired results are. That's what makes the discussions so worth while. Clarifying the treatment situation will hopefully result in better treatment choices.

BGM was the only technique I had ever heard of back then that targeted the autonomics for pain relief.

[Diane]

Hi Mary,
Please bear with me while I dissect this a bit more:The 2 target different structures. How do we know they can do this? Can physically target two different structures?
1. Is it the instructor's/originator's "idea" or treatment construct only?
2. Or has it been shown somehow that it's possible to differentiate structure target, affect one but ot another?

If number two is the choice, I'd love to know where to find the evidence.

However, the target is not always attained.

OK, same with most "techniques"...

Even though the desired results are. That's what makes the discussions so worth while. So... the results are obtainable, even though the "target" is not reached? This leaves me a bit confused.


Clarifying the treatment situation will hopefully result in better treatment choices.

Can you explain a bit more what you mean by "treatment situation"?

BGM was the only technique I had ever heard of back then that targeted the autonomics for pain relief.

Again, I'd like to know what makes this some kind of stand-alone treatment for autonomics, especially when it comes to handling of skin. :)

[Mary C]

by target, I meant what the technique was supposed to affect.
BGM--> autonomics system
LDT--> lymphatic system

so how do we approach the patient? What criteria influence our choice of treatment technique? I've gone too long on intuition. Time to start thinking, too. Ask better questions before I start to make the results--or lack of them--easier to identify.

"Back then" and "now" are 2 different time zones.
BT no internet Now--incredible riches
BT curiosity but no resources Now--I'm meeting people with experience and taking advantage of it.

[Diane]

by target, I meant what the technique was supposed to affect.
BGM--> autonomics system
LDT--> lymphatic system
OK, so then it's "treatment construct", not the physical handling itself or details therein. Agree?

so how do we approach the patient?
As carefully as ever, probably..
What criteria influence our choice of treatment technique? I guess I just stopped worrying about this ages ago, the names at least, they sort of all blurred together.
How one handles what is in front of one would be determined by the fedback one is getting from that system in the moment.

I've gone too long on intuition.
Don't throw that away - it's a good thing to keep.
Better (I think) to throw away all the conceptual clutter instead. :)

[Mary C]

Diane, there have been far too few concepts rattling around in my head. It was largely a case of--hmmm, what will this do? I've always lacked reasoning. So don't discourage me from starting to build some.:p

When something works, especially the way some things have been working lately, I look to develop better technique, but my biggest question is why did a technique that aimed at X produce such good results for problem Y? ie Just what did I do back there?

Along came SS and I started learning some modern neuro. Along with a whole new dialect I call "researchese." It's hard reading papers in a "foreign" dialect. Webster's is not much help with this jargon. If anyone knows of a good dictionary/thesaurus for this jargon, I could sorely use it.

latest example: treatment construct

I've seen a few articles on examining research and evaluating the quality. What I read seems to go in one eye and out the other. Very little sticks. this is gonna take some time, that's all.

Nothing like being an old :bat: he he

[Diane]

Mary, I would not want you to feel discouraged. :eek: Absolutely not. Not by me!

"Treatment construct" or "treatment concept" is a term I learned, not too many years back, from Luke. Anything researchese that you want to have defined, ask Luke. He's most likely to know, having graduated osteopath school just a few years ago, and already with two papers (good ones), one published, the other one close.

I think it means this: whatever idea the practitioner had in mind when he or she concocted the technique. E.g., Upledger's "treatment construct" about moving skin lightly about the skull is that he is affecting sutures and cerebral spinal fluid and something about manipulating its rhythm.

Most of them are pretty terrible, in my opinion, including that particular one. They are based on such "implausible" (see my first post, re: plausibility) ideas as to be ludicrous. (Yet they stick for some reason..)
Plausibility: the idea should have some basis in reality and should not have been birthed de novo from between someone's buttocks. It should not require a "suspension of disbelief" or "open-mindedness".

We have a whole thread here somewhere about a study done in New Zealand, where 13 rabbits were sacrificed in order to prove once and for all that cranial sutures cannot be moved with the forces equivalent to those generated by fingers on the scalp. They actually tractioned the sutures apart, and it took pounds and pounds and pounds of force (can't remember how much, but definitely way more than the weight of a nickel) to just move them slightly.

So, that's an example of a terrible treatment construct.

What's even more terrible about them is that research has to be done by others, later, to disprove them. Rabbits have to die, etc.
And still, Upledger goes on teaching those workshops and he has hundreds of minions believing/teaching his constructs..
What we try to do here is raise a storm of protest about things like this.
This thread is about the general shape of this.

[Jon Newman]

Mary,

See here (http://www.somasimple.com/forums/showthread.php?p=12750#post12750) for more.

[Mary C]

But, Diane, that just raise more questions! What is actually happening??? This is right personal with me so I keep looking for explanations. Here's an example: a so-called sphenoid lift unblocks my throat. OK, it's just temporary, but since I use a CPAP for sleep apnea, I would love to know about any other way to keep my throat from shutting down while I'm asleep. Blanket dismissal of CST seems to me like throwing out the baby with the bath water. Yes, bash the lousy constructs, but I'd also like to see some ideas to replace them--even mesodermal ones.

[Diane]

Mary, read that link Jon put in, in post 26. You'll get what the terms mean.

Seriously, just pull the skin up (just as gently and carefully) in the same location/hand placement as the "sphenoid lift" and see what happens. Any of the "results" can be duplicated, and with using a simpler, more nervous system based construct.
No point replacing one mesodermal construct with another.

Here's an old thread named, A set of fingers comes to rest lightly on my head (http://www.somasimple.com/forums/showthread.php?t=3237).

[Diane]

The link Jon placed is to a thread called "Validity (http://www.somasimple.com/forums/showthread.php?p=12750#post12750)." In it two main ideas were discussed; "validity" and "reliability."

Luke posted three links to explanatory pages in his post #8 (http://www.somasimple.com/forums/showpost.php?p=12750&postcount=8).

They are certainly worth reposting here:

1. A Comparative Discussion of the Notion of 'Validity' in Qualitative and Quantitative Research (http://www.nova.edu/ssss/QR/QR4-3/winter.html), by Glyn Winter, 2000, compares qualitative to quantitative research.

2. Validity (http://www2.chass.ncsu.edu/garson/pa765/validity.htm): Excerpt:A construct is a way of defining something, and to the extent that a researcher's proposed construct is at odds with the existing literature on related hypothesized relationships using other measures, its construct validity is suspect.

3. Reliability, Validity, Causality, and Experiments (http://edf5481-01.fa01.fsu.edu/Guide3.html)

<<<<<<<<<<>>>>>>>



Validity

In post #14 (http://www.somasimple.com/forums/showpost.php?p=12787&postcount=14), Luke said, The most important starting place for any manual therapy is construct validity (is it plausible?) and content/face validity (does it work in the way it purports to?). This is why the basic science of a technique is important.
Makes sense right? Before testing a construct it makes sense to base it on what is already "known" or else it becomes tooth fairy science, or the measuring of the virtues of putting teeth into baggies as opposed to face tissues, instead of finding out whether or not the tooth fairy is "real" in the first place.
Luke again: For example: Construct validity would ask of JB, “Is memory stored in fascia?” Face validity would ask, “Was the reduction in pain the result of a traumatic memory being removed from the fascia?”

In craniosacral therapy, construct validity might ask, “Does CSF fluctuation cause palpable cranial pulses of 8-12 bpm?” Face validity would ask, “Is the reduction in symptoms a result of altered CSF fluctuation?”

Need we really say more about that? :angel:
Maybe yes...

It makes more sense that a reduction in symptoms would be a result of something more externally triggered, like exteroception and the nervous system's attempt to respond through ideomotor movement, which may include changes in blood flow in the skin as a result of sympathetic response to handling. Barrett would call this simple contact. I would add to that and say that to stretch the skin a little more, brings in something else (plausible, with good face and construct validity) called neurodynamics, occurring through cutaneous fascicles of peripheral nerves.



Reliability
Luke again: The realiability of measures is an essential part of determining validity. If a therapy says that it addresses a particular dysfunction, then that dysfunction must be reliably and consistently detected. This may be done with an instrument or by a clinician, depending on the nature of the proposed dysfunction. If a clinician is to detect and then treat a dysfunction/impairment – a myofascial restriction for example - then that lesion must be defined in terms of a palpable entity and two or more examiners must be able to detect it consistently (inter-examiner reliability). It is also important that the same examiner can detect the same lesion on two or more separate occasions (intra-examiner reliability). Craniosacral is a good example of poor reliability – no study has shown an inter or intra-examiner reliability above zero. Specific spinal manipulation is in a similar boat.

Simple Contact has a distinct advantage in this regard.

1. Firstly, one does not attempt to detect a dysfunction, so reliability is not an issue.

2. Secondly, the construct is both simple and plausible – in essence it only says that (in the absence of frank pathology) movement of some kind is necessary for pain relief (no one can argue with that) and that such movement can come instinctively from the patient.

3. Thirdly, the content – that ideomotion is responsible for the movement observed – is very easy to determine simply by asking the patient about the nature of their movements during treatment. To measure outcomes in Simple Contact one does not need to show that a dysfunction has been resolved (eg change in myofascial structures, improved external rotation of the temporal bone, change in z-joint position). All you need to do is give a patient rated pain scale and measure ROM (if you like).

Internal and external validity (and others) come later when conducting outcome studies (eg RCTs). As Eric has pointed out above (see post #5 (http://www.somasimple.com/forums/showpost.php?p=12729&postcount=5)), internal validity essentially looks at bias. Bias comes in many forms: selection of population, blinding, attention (amount of time spent with each patient), instrumentation, appropriateness of statistical tests, drop-out analysis, etc. External validity is simply the generalisability of the outcomes based on the study population.

[Diane]

Mary, I found an old Nociception? newsletter that contains a piece written by me on that New Zealand rabbit study that disproved the craniosacral treatment construct. See attached:

[Mary C]

Thanks Diane, But I read all Nociceptions from stem to stern. Including that one.

CST may not affect the alleged target, but something does happen some times. I was wondering about mesodermal-style fascial shifting of the line of pull from one structure to another. Seems I need to do more head and neck anatomy as well. Studying the back of the throat has paid dividends so far. Just "...miles to go before I sleep..."

[msaracen]

Hi Karie,

I am a MLD/CDT Vodder trained therapist. I am sorry to say I don’t think you can feel/palpate the direction of lymph flow. I learned the superficial lymph flow is bi-directional, but the general pathways follow the same venous pathways as in Netter’s Atlas. I don’t think you can palpate something you can’t see. The only visible lymph channel on the human body in the long thoracic duct. I think Diane’s case post was very interesting since I often wondered how the visual input of a swollen limb changes body scheme. I have found only one such study. In addition, I have wondered during the compression/wrapping phase of MLD/CDT what input this on the SA mechanoreceptors.


Mike

[Mary C]

Hi Mike

I only have 8 days training in LDT with (shhhh) Upledger. Lymph nodes are visible structures, are they not? They have some smooth muscle fibres? Which contract rhythmically? Can we not palpate these?

[msaracen]

This post should have been posted in reply to critical thinking. Opps.

[Diane]

Don't worry - I will move it there msaracen.
Done.

[BB]

Something else to consider in critical and clinical thinking is how confident are you? (http://www.theness.com/neurologicablog/?p=354#more-354)

[Mary C]

In CDSMP, a 7/10 is considered sufficient to predict probable follow through on the planned action.
10/10 means no challenge at all. consequently no change in behaviour will result.
5/10 means the challenge is a bit too steep. Better to modify it so that the confidence level increases to seven.

Now what levels of confidence are considered reasonable in critical and clinical thinking?
What are the characteristics of these levels.

[Diane]

I want to copy a post over to this thread, post 25 (http://www.somasimple.com/forums/showpost.php?p=57050&postcount=25) of the "Why is it so hard to let the nervous system take the credit for pain relief?" thread (http://www.somasimple.com/forums/showthread.php?t=5971). It contains some personal thoughts on why we might be better off long term when we support critical thinking and clinical thinking going hand in hand instead of continuing to pretend they exist on separate planets. Hi estherduru,
Quote:
The reason I love the BGM (bindegewebsmassage) so much, and the reason why some-many colleagues didn´t dare use it.... was/is that you have to depend on what the patients´ body reactions weretelling you and treat accordingly or even worse ( not treat... or treat for 3 minutes only). It was most unscientific of course, imagine, trusting your patients reaction! ( we are talking the 70tees)...

That sounds like good handling to me - if the emphasis is on nervous systems' reactions more than the the provocations. How did it end up with that particular name? (Rhetorical question only)...

In fact, while we're talking about names, how did our handling end up splintered into a million different names, all named after a person, and almost all containing a type of mesoderm as well, and what we think we "do" to it?

My point is, named "techniques" pile up and litter the landscape like giant landfills - big conceptual weeds and underbrush grow wild. Ragged plastic bags blow through the ravines and get caught on twigs. The smell is not pleasant. Scavengers are attracted to exploit all this as surely as microglia are attracted to synapses in the dorsal horn. It requires the equivalent of Occam's Chainsaw, Occam's Bulldozer, Occam's Backhoe and Occam's Dump Truck to get rid of all this overgrown mesodermality, deconstruct it, get the view back.

You're right - the point is, build trust/handle somebody/build more trust/watch reactions. Help the nervous system do it's thing, help it do it better. Get yourself out of the way and let the system you've attached to self correct. While remaining all the while in contact with it. Don't have much in the way of objective. Be in the moment. Keep cutaneous nerves in mind if you need something physical to key on.. but as much as possible keep the nervous system itself in mind, with all its liveliness and motion and physiological expression and correction of pathways and first one subsystem coming to the surface, then another, then the patient's awareness coming into the picture, then another subsystem, and so on. Like watching a fascinating movie, but slightly interactive.

In the end, all you have done is catalyze something in their system that needed a bit of help to get going, but you exit leaving nothing of yourself behind, like a good catalyst should, and any improved ROM or pain reduction or better alignment or what have you was not because you were pushing away at them trying to move mesoderm (even the liquid lymphy kind), rather it is an outcome of you having handled them in a way that helped their nervous system figure out how to fix its own output. Including decrease in pain production. Including better drainage (after all the nervous system is in charge of volume control too).

So, back to the question on the thread, why is it so hard to just do this, call it PT, or simple contact, or dermoneuromodulation (DNM could be considered the "training wheels" or de-mesodermalized weaning process on the way to simple contact maybe.. thinking about how to help cutaneous nerves could be considered the equivalent of a mental pacifier for recovering mesodermalists..) and be done with it? It's less about the "name" and more about the handling, for sure.

And surely studying it or researching it would be easier, not harder.

[BB]

Hi Mary,

Perhaps the Prior Probability (http://www.sciencebasedmedicine.org/?p=55)holds some answers?

clinical research is inductive and Bayes’ Theorem (simply proved, by the way) is the way to figure out how new data alter the probability of a hypothesis being true

[Diane]

Here is Deric Bownd's post (http://mindblog.dericbownds.net/2008/11/behavioral-revolution-in-economics.html) on an NYT article about the misperception of the economic systems. It is informative and parallel to this discussion because it is almost exactly like clinical thinking. David Brooks writes, Roughly speaking, there are four steps to every decision. First, you perceive a situation. Then you think of possible courses of action. Then you calculate which course is in your best interest. Then you take the action.

What most of us need to work on most is perception. It's that crucial first step. That is what this thread has been about.

PT s a very creative act. We barely realize that our training from day one dupes us, gives us treatment constructs that conveniently turn us into treatment robots. Although these constructs give us a sense of security, and a feeling of being certain (http://www.sciencebasedmedicine.org/?p=103) which we probably need when we take on awesome responsibilities of adulthood and being licensed to touch people as well as the means by which we can make a decent living... they insult our intelligence (without us realizing it!) until later (maybe a bit, maybe a lot) after our brains have grown in a bit more fully.

Brooks agrees: Perhaps this will be the moment when we shift our focus from step three, rational calculation, to step one, perception.

Brooks continues: Perceiving a situation seems, at first glimpse, like a remarkably simple operation. You just look and see what’s around. But the operation that seems most simple is actually the most complex, it’s just that most of the action takes place below the level of awareness. Looking at and perceiving the world is an active process of meaning-making that shapes and biases the rest of the decision-making chain.

Also: (Taleb)touch(es) on many of the perceptual biases that distort our thinking: our tendency to see data that confirm our prejudices more vividly than data that contradict them; our tendency to overvalue recent events when anticipating future possibilities; our tendency to spin concurring facts into a single causal narrative; our tendency to applaud our own supposed skill in circumstances when we’ve actually benefited from dumb luck.

To me, this sums up everything about PT and manual therapy that this board exists to deconstruct. :clap2:

The article continues: ...it is easy to see dozens of errors of perception. Traders misperceived the possibility of rare events. They got caught in social contagions and reinforced each other’s risk assessments. They failed to perceive how tightly linked global networks can transform small events into big disasters.

This is PT without knowledge of how the nervous system operates, why it's there, how it came about, what it can do. PT ends up focusing on the wrong thing , tissue instead of the person inhabiting the spectrum from skin synapse to social construction of self, misses the whole point of therapy, and, despite years of post grad training at the finest university institutions and all sorts of societal support and acceptance, no need to battle, still manages to have turned itself into a pseudoscience. To be fair, most of this happened prior to the neurobiologic revolution (NBR), but nowdays, there is no excuse for not going in and overhauling the engine that drives our profession. None.

The article continues: If you start thinking about our faulty perceptions, the first thing you realize is that markets are not perfectly efficient, people are not always good guardians of their own self-interest and there might be limited circumstances when government could usefully slant the decision-making architecture (see “Nudge” by Thaler and Cass Sunstein for proposals). But the second thing you realize is that government officials are probably going to be even worse perceivers of reality than private business types. Their information feedback mechanism is more limited, and, being deeply politicized, they’re even more likely to filter inconvenient facts.

Again, perfect parallel to us. Practice habits became entrenched, passed down, took on the equivalence of "turf" which had to be hotly "defended"for the good and perpetuation of the "troop."

It’s a big, whopping reminder that the human mind is continually trying to perceive things that aren’t true, and not perceiving them takes enormous effort.

I.e., trying to find patterns of behaviour in tissues that have no actual control behaviour to speak of, all the while ignoring the system which does have control and which, even though it cannot move itself, uses the moving parts like a puppeteer embedded within his/her own puppet strings.

[Barrett Dorko]

Diane,

In a long line of very important posts from you this is the most importantest, so to speak.

I'm going to try to put this work and your take on its relation to manual care today into a short and concise series of slides for my power point in Florida next month.

I'll be back with some examples asking for help.

[Diane]

"most importantest"?
OK ... my editor within wonders about this lapse in your usually careful grammared writing style, but I'm glad you see the parallels too. :)
They sort of just flew out at me when I read that article. Maybe I've read your posts for so long I'm starting to see things the same way, i.e., how everything relates to manual therapy.

[Adiemusfree]

Some of the issues you're discussing in this thread, while you've directly related it to manual therapy, certainly applies across the board in any clinical intervention - and I'm passionate about being critical about any/all interventions. I do define myself as a scientist-practitioner (or clinical scientist), based on the so-called 'Boulder' model used in clinical psychology.
I completed two postgraduate papers in theory development and scientific method, both of which used all of these wonderful 'researchese' terms... all of them polysyllabic and technical! but unpacking what the terms mean and being pedantic and precise really helps my critical thinking.
So: some of the things I'd love to bring into this discussion I've blogged about today - what about the known cognitive distortions or biases we have as humans, how do we (or do we at all) account for them in our clinical reasoning? Quite apart from the need to detect effects from random variability within a population, and quite apart from the need to also parse out 'meaning response' or placebo/nocebo effects...
Some of the distortions we know about are:
- the order in which material is presented - what is presented first is remembered more easily
- the tendency to seek confirmation of our opinions
- the 'power' or hierarchy effect - what is shared by someone who is seen as 'important' is more likely to be remembered
- we tend to discuss already-known or shared information rather than new or contradictory information
- we often make 'connections' between what we've recently read, on similarities between the person we're seeing and someone else we have treated/known - and this influences our judgement
- and today I posted on the fact that as we explain the reason for our decisions, we tend to strengthen our conviction or confidence
- the models we hold about cause or relationships beween variables will inevitably shape the patterns we then detect. It's really difficult to be completely objective and value-free...

These are things we can already draw upon from cognitive and social psychology. And they apply to any and every health profession - and it's right and proper to question any and all health professionals! Which is why I stick my neck out so often (and feel the effects of doing that!), because to do the best by our patients, we must constantly question our practice.
**end of rant, stepping off soapbox, running back into corner**

[Jon Newman]

Adiemusfree,

This is news we can use. Thanks for the contribution.

**end of rant, stepping off soapbox, running back into corner**

Why? You've posted nothing that participants here will have a problem with. I don't think so anyway.

[Diane]

the models we hold about cause or relationships between variables will inevitably shape the patterns we then detect. It's really difficult to be completely objective and value-free...
I couldn't agree more. All we can do is adopt/approximate the model that accounts for the most variables.
What I see in PT is a deliberate choice of Models that deliberately screen out most variables, and are therefore unnecessarily tenuous instead of as robust as it is possible to be. Screening out consideration of the nervous system is where most PT (mesodermal) models start. This has to be continually pointed at and commented on, if this profession (the whole profession) is to ever move beyond "operator" (physical) and become more "interactor" (therapist/therapy).

[Diane]

Here is a link to Nick's thread, No More Research ... on Some Things (http://www.somasimple.com/forums/showthread.php?t=6304), and a thumbs - up to Cory's post 9 (http://www.somasimple.com/forums/showpost.php?p=61777&postcount=9) on it:I'd like to address some of you specific statements:

Quote:
Reiki and other energy practitioners have many such stories
That's their problem. Whenever it's come down to providing anything other than a story, nothing is ever provided. Records become lost, etc. There is not a single credible demonstration on record, not one, that lends credence to energy medecine instead of a placebo response.

Quote:
so it should be possible to produce a small sample for serious study.
You'd think so, but somehow it never happens or if it does it is so corrupted as to provide no real information, or it is negative. It is like bigfoot sightings in that way.

Quote:
There must be reasonably simple testing procedures for this, even if the form of "energy" involved can not be directly detected or verified.
Simple indeed. So simple that maybe the best research done to disprove therapuetic touch was done by a child (http://en.wikipedia.org/wiki/Emily_Rosa). The youngest author in the history of JAMA.

Quote:
Western medicine as we know it is excellent at dealing with many health problems, but it has also earned public distrust. Iatrogenic complications, skyrocketing prices, questionable activities on the parts of Big Pharma, many MDs, HMOs, and insurance companies... and the USA health care system has a low ranking (not even in the top 30!!) relative to other industrialized nations.
This is what is known as a Tu Quoque (http://en.wikipedia.org/wiki/Tu_quoque) argument, or as the SBM bloggers like to call it the "Oh yeah, well you're fat" argument. I know it is true that these reasons are oft cited for why a person may choose CAM providers over medicine. However, all of medicine and the health care systems' problems don't make the impossibilities of CAM go away.

Quote:
When people find relief, they refer more people
This relates more to satisfaction than it does outcome most likely...

Quote:
and methods and practitioners become accepted over time.
...and here you've articulated one reason for the popularity of CAM. Satisfaction is mistaken for outcome which is mistaken for justification and acceptance is the result.

Quote:
Despite a lack of supporting scientific evidence, hospitals are finding the inclusion of CAM treatments to be a cost-effective means of improving patient outcomes.
Not outcomes...satisfaction. See above.

Quote:
The business administration of a hospital is much less concerned with science than with improving profitability.
Well said.

Quote:
but negative outcomes would rapidly lead to the closing of such programs.
Not according to your last statement, which I thought nailed it.

Quote:
Why do patients and their families express satisfaction with CAM treatments?
This is the key question in my opinion. I think it would be great for you to grab the Last Well Person by Nortin Hadler, Jason, and jump in on that discussion (http://www.somasimple.com/forums/showthread.php?t=6303) with us.

People with be satisfied with treatment that is consistent with their own belief system. When you have a treatment that is consistent with your belief system you will use all of the fallabilities of human perception (http://www.somasimple.com/forums/showpost.php?p=61761&postcount=40) at your disposal, including confirmation bias. This is, I feel, the power of CAM. It is rooted in subjectivity and therefore human nature. As I recently heard Barrett say, that doesn't make someone a bad person, it just makes them human.

The scientific method is cold and unfamiliar for exactly this reason. It is the tool we've created for ourselves to combat our own subjectivity. It is contrary to human nature by design. And human nature is so well encoded within us that we still find ways to corrupt science with our subjectivity.

Also, it becomes clear that much with pain is non-pathological. We spend a great amount of time discussing here the nature of this problem and how communication is involved in its resolution.

Quote:
Why do so many of my massage clients tell me "I've had more success with your massage than I had with my doctors and PTs"???
There could be a lot of reasons for this. You may be skilled at establishing a therapeutic environment.....you may have a manner of communication that meets the expectations of your patients......you likely listen to your patients better than most physician's....etc., etc. Of course, none of these things nor the outcomes you have with your patients is a credible support for the proposed mechanisms of any CAM treatment.

Quote:
If the NCCAM also definitively proves that some methods aren't effective, that will help me too.
In my opinion, one of the more legitimate arguments against the NCCAM is that is never disproves anything. Despite all its funding and research the NCCAM is yet to count anything out. A negative study simply yeilds a result of "more research needs to be done." Why? If its been disproven, why would more research need to be done? I don't necessarily think this is all the NCCAM's fault by the way. In fact, I'll go ahead and blaspheme and say that evidence based medicine is more to blame.

Evidence based medicine is built on a hierarchy of evidence. All one needs to become "evidence based" is to have a place within that hierarchy. If you've got an RCT for homeopathy to your credit even of dubious methodology, EBM places you higher up on the hierarchy than my measly case study for massage. So, what ends up happening is that studies are funded ad infinitum with the hope that one will finally show an effect and place it within the blessed hierarchy. The problem is that plausibility is lost in the ranking. An RCT showing a positive effect for therapeutic touch should be put on its ear right off the bat because it is not plausible. It violates known physics, biology, etc. Incorporating plausibility into evidence based medicine is what the "science based medicine" people are advocating and I'm all for it.

Quote:
I am succeeding even though the means by which my methods work are not well understood.
I would argue that there is plenty of understanding by which to explain what you do and why it works when it does. What is most lacking are studies demonstrating how well and on what populations specific treatments act and what specific effect is at play with each method and population. It is becoming more and more clear (http://www.somasimple.com/forums/showthread.php?t=6342) the role that expectation plays.

In other words, there is absolutely no need to resort to the magical thinking inherent in CAM.

[Kharma44]

Diane, all you explained about our own subjectivity and the need for a method fitting our beliefs is so true. It's also the reason why there is a lot of alternative oriented technics/approch/way of thinking in physiotherapy world.

Even If i would get some of my very educated collegues to read most of the post on this subject, they would still feel what they do is working for some reason that we still aren't able to explain with current EBM or SBM (other than placebo)

It is our own beliefs as therapist that guide us into the approach we choose... So if a hightly respected and very educated PT believes in ghosts and past lives (believe me, when it comes to that, i'm sure many do) they surely can find energy medecine plausible and for them, it doesn't requires any suspension of disbelief !

So our argument will work mostly amongst ourselves (critical thinkers) and not so much in «believers» (open minded to unexplain phenomenon or something)

Well, that's what I have noticed so far.

Frédéric

[Mary C]

The way I see it Frederic, is that there's a big difference between intelligence and wisdom. The former is a capacity to ingest and retain information, the latter is making good choices with what we have.

I really did like Diane's reference to the concentrations of myosin in this post. http://www.somasimple.com/forums/showthread.php?t=5659

[Jon Newman]

So our argument will work mostly amongst ourselves (critical thinkers) and not so much in «believers» (open minded to unexplain phenomenon or something)

Frederic I'd like to point out that critical thinkers are open minded about unexplained phenomena. That is, they seek to explain such phenomena.

[Adiemusfree]

To start with a single model shapes data collection - which is why I reject starting from anything other than a biopsychosocial model, because at least this starts with the premise that people are more than their physical body parts, they have psychological aspects as well as social interactions that influence their presentation.

The most effective way to collect data without pre-supposing a specific model is to use a semi-structured assessment approach, based on the evidence-based domains that are commonly found to influence the condition. Then systematically collect information within each domain without prematurely deciding on a specific hypothesis/explanation of what is going on.

It's only after all the information is collected from all the domains that we can sift through and look for patterns that may, just may, be part of the explanation for why this person is presenting this way at this time.

And this will usually mean there will be several competing hypotheses that we need to systematically test to establish whether they hold up to scrutiny.
In doing the testing, we often start doing treatment - and if the treatment produces the expected/predicted results, then we usually think we're right in our hypothesis. BUT if the treatment doesn't produce the expected/predicted results, then we often think the person failed, or the treatment wasn't carried out correctly rather than considering whether we had the wrong hypothesis in the first instance. That's a typical cognitive error!

So, one thing we can do to correct this error is test our hypothesis through more than one method. This might mean asking the person to do a behavioural experiment that could confirm or disconfirm the hypothesis, or carry out an 'N of 1' case design where we treat, withdraw treatment or replace it with another, then treat - and carefully record results.
I have to fly - I'm at work, but I'll be back (as Arnie says!!)

[Kharma44]

Myself Quote:
So our argument will work mostly amongst ourselves (critical thinkers) and not so much in «believers» (open minded to unexplain phenomenon or something)
Jon
Frederic I'd like to point out that critical thinkers are open minded about unexplained phenomena. That is, they seek to explain such phenomena.



Oubviously, my choice of words where bad!!!! I mostly wanted to relate to believers of therapies that can't be explained by a sound logical basis, one that would be plausible under the laws of physics has we currently understand them.

[Adiemusfree]

I couldn't agree more. All we can do is adopt/approximate the model that accounts for the most variables.
What I see in PT is a deliberate choice of Models that deliberately screen out most variables, and are therefore unnecessarily tenuous instead of as robust as it is possible to be. Screening out consideration of the nervous system is where most PT (mesodermal) models start. This has to be continually pointed at and commented on, if this profession (the whole profession) is to ever move beyond "operator" (physical) and become more "interactor" (therapist/therapy).

The problem is that we often don't identify the models we are using (they're implicit not explicit), and because of our cognitive biases, we are often not aware of our errors - and we don't systematically test our models against the evidence in this particular individual.

There are several ways to evaluate whether a model 'fits' or not - Thagard (http://cogsci.uwaterloo.ca/Biographies/pault.html) is a science philosopher who talks about ways to evaluate whether a model or theory should be adopted.
I'm going to snip from a paper by Brian Haig (DOI: 10.1002/jclp.20506) about the Abductive Theory of Scientific Method - despite the difficulty of the language, if you take it slowly it really does make sense.
'The abductive theory of scientific method (ATOM) takes the systematic evaluation of
mature theories to be an abductive undertaking known as inference to the best
explanation, whereby a theory is accepted when it is judged to provide a better
explanation of the evidence than its rivals.

ATOM takes 'inference to the best explanation' to be centrally concerned with establishing explanatory coherence (Thagard, 1992). The theory of explanatory coherence maintains that the propositions of a theory hold together because of their explanatory relations.

Relations of explanatory coherence are established through the operation of seven
principles: symmetry, explanation, analogy, data priority, contradiction, competition, and acceptability. The determination of the explanatory coherence of a theoryis made in terms of three criteria: explanatory breadth, simplicity, and analogy.

Each criterion is embedded in one or more of the principles. The criterion of explanatory
breadth, which is the most important for choosing the best explanation, captures the idea that a theory is more explanatorily coherent than its rivals if it explains a greater range of facts or phenomena. The notion of simplicity deemed most appropriate for theory choice is captured by the idea that preference should be given to theories that make fewer special assumptions. Finally, explanations are judged more coherent if they are supported by analogy to theories that scientists already find credible.

OK, so what that means is that one of the best ways to judge an explanation (which is essentially what a theory or model is) is whether it explains more, has the least number of assumptions, and it is analogous to something that already has evidence to support it.

Given that we're inclined not to look beyond what we think supports our beliefs, it's hard to evaluate competing explanations.
So I suppose in a way I'm saying that it's a wonder we manage to arrive at any model that looks anything like what actually happens! Firstly we don't look at things that don't fit with our usually implicit assumptions, then we selectively look for things that confirm our first impression, and once we've decided on something, we find it incredibly hard to consider anything else!

Occupational therapists apparently use a biopsychosocial model in practice - this means they 'should' be able to choose models that include factors that are relevant...but they don't. I'm ashamed of my original profession, because it often doesn't use critical thinking in any shape or form - hence my embarrassment at the 'Culture or cult?' paper on occupational therapy. Unfortunately, it's not JUST occupational therapy that has these blind spots. So do many professions.

Is maturity in a profession reached when the majority of the practitioners are able to honestly critique themselves and acknowledge their own deficits - and then work to remedy them?

Kelly, G., McFarlane, H. (2007). Culture or cult? The mythological nature of occupational therapy. Occupational Therapy International 14 (4), pp188-202.

[Jon Newman]

Bronnie,

Great contribution. You may enjoy this essay (http://www.barrettdorko.com/articles/discovery_and_abduction.htm) by Barrett Dorko.

I find it both humorous and annoying that I'm fully aware that I possess these biases but not always (or, "often not") able to know when they're keeping me from understanding.

[Diane]

I'm putting a link in here to the Operator/Interactor thread (http://www.somasimple.com/forums/showthread.php?t=6254).

[Diane]

This video featuring Michael Shermer's TED talk on attentional/perceptual blindness belongs, I think, on this thread.

[Diane]

The abductive theory of scientific method (ATOM) takes the systematic evaluation of mature theories to be an abductive undertaking known as inference to the best explanation, whereby a theory is accepted when it is judged to provide a better explanation of the evidence than its rivals.

Cott in Canada published (13 years ago) something called the Movement Continuum Theory of PT, as a "grand theory" for the profession. In it she discussed movement as fundamental to life on a continuum from single cells to us. She planted PT firmly into place as movement therapy. I think she intended PT to be a verb itself, and to concern itself with verbs, not be a noun, concerning itself with nouns. Our motto in Canada just about ever since (or maybe even before) is "Physiotherapy - it'll move you."

To me, this still makes the best sense of any/all approaches we've examined here on SS. As a "grand theory" it reigns as verb, not noun, congruent with most if not all of reality, capable of soaking through our cluttery and misleading English language to give the profession traction and lubrication both at the same time, help it move forward. It circumvents problems of syntax and highlights movement as being our prime target in therapy, as therapists.

It reminds me of something Lorne Rex said (in many a workshop I attended): "Motion is life, stillness is death. The stiller you are the deader you are."

[Adiemusfree]

Diane I think that theory sounds great! What are the predictions it makes? I wonder whether it could be thought of more properly as a value? Similar to the occupational therapy fundamental belief/value that 'doing' is good.

Abductive theory of method is a really useful theory for describing how we as clinicians often 'detect phenomena' from having seen a number of patients presenting with similarities. What we do is move from identifying a robust pattern (phenomenon) to propose an underlying construct beneath that. Then we articulate the construct into testable hypotheses in order to extract ways to access the empirical support for the construct (which means one assumption of this model is that patterns can be detected, and hypotheses can be measured somehow in the real world - scientific realism), then after this has been done in different ways with different populations in different forms, the explanatory breadth of this construct can be compared against competing constructs/theories/models.

What I find happening in therapy literature is that few robust phenomena are detected and described (exploratory research is never well-supported by funding!). People leap to a 'model' to test without ever being introduced to thinking about how they arrived at that model. Most science teaching starts with the H-D method rather than thinking that this is down the road somewhere from where the first 'aha' moment in a researcher's eye!

Let me describe this briefly with my research.
I'm looking at resilience. People who cope well with their chronic pain without seeking treatment. This group are a really large group, but we know very little about them, because almost all our research is about people who do seek treatment. So here is a phenomenon that has been detected: some people seek treatment, some people don't. But it hasn't been fully described yet - while we know a good deal about treatment seekers (they're usually distressed, often have people around them who encourage them to look for help, often disabled by their problem, can be depressed, have usually seen a lot of treatment providers about most of their health problems, often don't have coping strategies that support activity etc), we don't know about people who don't seek treatment, so we don't know much about distress, social supports, disability levels, mood, why they don't seek treatment, and for my research, we don't know what coping strategies they actually do use.

We haven't fully described the phenomenon we see - that some people seek treatment, some people don't. Because of this, we don't have a comprehensive model of treatment seeking in chronic pain. Which means although we can test some hypotheses about treatment seekers (eg are treatment seekers highly distressed?) we can't test the converse (eg are non-treatment seekers accepting of their condition?) because we haven't really articulated the underlying constructs. I mean, what would happen if we did test levels of distress amongst nontreatment-seekers and found that they were just as highly distressed as treatment-seekers? That would blow the model of treatment-seeking out of the water...and our assumption that by reducing distress, people with chronic pain will reduce treatment-seeking (and therefore become similar to nontreatment-seekers) would be challenged.

So abductive reasoning fills in some of the gaps - and means that exploratory, descriptive research as an extraordinary role in detecting patterns that can be used to more fully describe our world. And it's something that all clinicians can do simply by recording clinical observations and using EDA to understand that data. Yum! I just love the idea that the 100's of patients I've seen over the years can provide such rich data that might help us explain our world more fully and hopefully help develop interventions to enhance life.

**now do you see what I mean about ranting, soapboxes and waaay too much typing?**

[Mary C]

That would blow the model of treatment-seeking out of the water...and our assumption that by reducing distress, people with chronic pain will reduce treatment-seeking (and therefore become similar to nontreatment-seekers) would be challenged.

As a volunteer for The Arthritis society, I meet many "nontreatment seekers." At least, they are not seeking treatment in physiotherapy at our hospital.

Those who do are often in pitiful shape by the time they do get to us. IMO some of the people "treating" them have blocked access to physio because we are perceived as ineffective.

Maybe The Arthritis Society would be interested in funding this type of research.

[Diane]

Here is a link to a discussion around Cott and her theory (http://www.somasimple.com/forums/showthread.php?t=5239) (and others) that I tried to start ages ago. It will provide more background. Check out the Michael O'Hearn article (http://findarticles.com/p/articles/mi_qa3969/is_200201/ai_n9027300/print). He is someone who has tried to rustle the theoretical bushes too. Rustling bushes does no good if the critters hiding in them are conceptually deaf and blind to all of it.

Bronnie, I for one am glad you're here and so energetic around discussing conceptualization of our collective "human primate social grooming" work.

[Adiemusfree]

thanks Diane!!
Mary - the NZ Arthritis organisation is sponsoring my project and has been invaluable for helping me find recruits! There are so many healthy people with pain who don't seek treatment, but as you say there are some out there who seem bent on preventing access to therapists who can help. I don't know why! I think it could be around the biomedical *need* to be able to fix, and fix quickly, the problems - and lack of updated knowledge on what nonmedical health providers can do. And there are those nonscience-based providers who would really just like people to carry on buying magnets, and copper bangles, and woolly 'therapeutic' wrist splints, and smelly preparations to wear next to your skin, and woowoo aura repairers, not to mention crystals and certain colours....I must stop. Not good for my blood pressure.

[Luke Rickards]

Bronnie,

I'm very interested in your research. Have you done a lit search yet - what little do we actually know about this.

Are you doing interviews or designing a questionaire? And are you considering only arthritis sufferers or neuropathic/spinal pain etc as well. I ask because I am aware that there are some differences in psychological aspects of neck pain and LBP sufferers, for example. Perhaps some people with WAD would be useful.

[Adiemusfree]

Hi Luke
I don't want to hijack the thread, so I'll start another one to discuss resilience more generally - I think there's a heap we can learn about it, and you're right there is not much in the literature at all, about four epidemiological studies of chronic pain in the general public, and one or two directly trying to identify resilient people.

[BB]

To expand on some thoughts and quotes I've provided recently on belief as well as some of those that have been raised in other threads I'd like to talk a bit about explanatory model.

There is a difference between belief and explanatory models. Belief arises as a narrative based upon our explanatory model and is likely an emergent phenomenon. So, in order to impact a belief system we need only inform the explanatory model upon which it is based. I don't feel we have any business nor expertice in attempting to intervene at the level of belief. I do, however, feel that we can and should and indeed cannot help but to impact the explanatory model.

The more accurate the explanatory model, the better equipped we are to interact with our environment and build a narrative in a way that is consistent with reality.

[Adiemusfree]

I think therapists do influence belief constantly. We may not do this intentionally, but we certainly do it (and therefore should be very aware of the factors that do influence belief).
what do I mean?
Well, we put people into situations where they will think things 'I'm not doing that, it hurts!'. We ask them to experience something different and reflect on that.
We provide information - but more than that, we provide opportunity for people to use that information and verify its place in their lives.

Information alone simply does not change behaviour one jot. If you don't believe me, think about the years of information the general population has had about the evils of tobacco smoking, the need to eat healthily (more veges), and exercise more. New smokers take up the habit every day, obesity is increasing, and exercise for children especially has reduced (how many kids now cycle or walk to school? and how many sit in front of TV, computer or reading rather than getting into dance, swimming, making huts and running around)

Health behaviour change theories suggest that it is only once the information has personal relevance, and the balance of ambivalence has moved from remaining static to making a change that it has any influence on what a person will actually do.

Even accurate explanations alone do not change an individual's belief - how many people with chronic pain still want a further MRI, another surgery, another CT simply to confirm or disconfirm their belief that they 'still have something wrong' - and even with the best explanation in the world, they remain unconvinced 'because it still hurts'. The explanation can come from really good people, be really thorough, be accurate, but mean absolutely nothing to the person's behaviour.

I think a cognitive behavioural approach to managing chronic pain especially has to be adopted by the entire team, used consistently, and the person has to experience something different before they can make changes that remain. This means physiotherapists, occupational therapists, and other health professionals involved in helping people recover do need to do more than provide information - we need to actively help people process the information, understand its relevance, then experience the consequences of incorporating information into their behaviour. Usually this involves some degree of challenging unhelpful beliefs, reinforcing 'well' behaviour, helping people focus on sensation/experience, and recording progress. These are typically thought of as 'psychological' interventions - but happen every day in physiotherapy, occupational therapy and other health encounters.

[Jon Newman]

There is a difference between belief and explanatory models. Belief arises as a narrative based upon our explanatory model and is likely an emergent phenomenon. So, in order to impact a belief system we need only inform the explanatory model upon which it is based. I don't feel we have any business nor expertice in attempting to intervene at the level of belief. I do, however, feel that we can and should and indeed cannot help but to impact the explanatory model.I can't tell yet whether I agree with you and I'm hoping that if we explore an example that it will help. If we have a patient fill in the Fear Avoidance Beliefs Questionnaire or the Pass-20 (http://www.somasimple.com/forums/showthread.php?t=6202&highlight=pass+20) (which asks questions like "when pain comes on strong I think I might become paralyzed or more disabled") is it not our responsibility to help change those beliefs?


edit: apparently I was writing while bronnie posting

[Adiemusfree]

I can't tell yet whether I agree with you and I'm hoping that if we explore an example that it will help. If we have a patient fill in the Fear Avoidance Beliefs Questionnaire or the Pass-20 (http://www.somasimple.com/forums/showthread.php?t=6202&highlight=pass+20) (which asks questions like "when pain comes on strong I think I might become paralyzed or more disabled") is it not our responsibility to help change those beliefs?


edit: apparently I was writing while bronnie posting

Jon
I think you and I are on a very similar wave-length. We can and do change beliefs all day every day as we work.
For example, a person sprains their ankle when out walking. The first thing we do is give an explanation of what has likely happened. Then if you're doing basic self-help, you talk about the need to rest for a short while then start moving it. Many people will go right along with that recommendation, and start using the ankle. A few won't. These few might come back saying 'but my ankle's still sore, I don't think I'm ready to use it' - this is a good indication of an underlying belief which could be something like 'I'm still damaging something if I walk on it - and if I'm damaging it then I shouldn't use it'.
One tack we might take is to give the person more information about inflammation and the healing process etc etc. Another tack might be to let the person remain off the foot a bit longer, hoping it will settle down a bit and the person might be more comfortable using it.
Neither of the above approaches will 'make' the person use the ankle unless he or she changes beliefs! And one possible belief is, as I said, fear of ongoing damage. In the case of chronic pain-related anxiety and avoidance, it can lead to loads of interference with daily activity and quite a lot of distress.
So, it can be really helpful to ask the person 'what do you think might happen if you walk on it?'
or 'how will you tell if it's ready to be used?'
What these two responses do is ask the person to actively process the underlying beliefs about their statement 'I don't want to do this'.
Once we've uncovered the underlying belief (often a catastrophic thought based on fear), we can then set up a behavioural experiment to help them overcome their concern and do things differently.

So, we might find out they think they'll fall over if they walk on it, or they won't be able to 'bear' the pain, or they might 'wreck' the ankle 'forever'. We might find out they have no way to work out when it is safe to use it, and they are hoping for either a scan, X-ray or the pain to go before they start to use it.

Whatever we find out, we can work with - yes information about ways you truly can 'wreck' an ankle (whcih is not what you're asking them to do), and reassuring them that they can 'bear' the pain (it just makes you feel crap, it doesn't kill you, and it does settle down especially if you can help them with some breathing or coping statements). If they are waiting for X-ray or imaging - tell them what can and cannot be imaged with X-ray, give them an indication that pain will continue... and then get them experiencing that movement is helpful.

[Diane]

I think I know where Cory is coming from with: There is a difference between belief and explanatory models. Correct me if I'm wrong Cory, but I think, using Bronnie and Jon's example,
1. the patient's "belief" based on the unfamiliarity and suddenness of onset of huge pain levels (which are entirely normal in a fresh sprain) is that he or she might have really really hurt him/herself.
2. The pain (an entirely appropriate and healthy nervous system response) stops that person from walking on his or her foot. They feel impaired by it. Their "action" is to seek meaning, and perhaps as a consequence, reassurance of some sort.
3. Enter the friendly neighbourhood HPSG.
4. We examine, explain, treat, and in that process (and in that order), reassure.
5. The explanatory model IS important... we can choose from many, depending on our OWN belief systems/constructs. Is it a sprained "ligament" or is it a good yank on a sural /superficial peroneal/ fibular nerve? Well, we don't really know, so we can treat from the least disruptive to the most.

Most of the time nothing is broken, the nerves are mighty upset and yes, there is some bruising so some vasculature has been disrupted, but simple gentle treatment with pain education woven throughout suffices and by the end of a single session swelling is down and weightbearing is improved. Most of the time. The only time we need to look further or think further or test further (IMO) is if and when this scenario does NOT unfold as described.

It's not so much that we are changing beliefs, as it is that we are preventing false ones from forming in the patient and in ourselves in the first place. This is so much easier than fighting entrenched beliefs. Altho I do all the time, because I get the ankles usually a year later after all the "false" beliefs have taken root.

The deconstruction begins.

I usually start out by saying that correlation does not equal causation (in language that they understand), that lots of people with terrible xrays don't have pain, and lots of people with pain have good looking xrays, and that the two often have nothing to do with each other.

Then I show them a picture of the nervous system and explain its care and feeding. Then tell them how I'm going to show them how to look after it so that it can breathe easier. People humor me.. I have no idea if they adopt this set of ideas (an explanatory model) as their new "belief" or not, but they usually play along and we get things done and they improve. At least they say they do. I try to connect with them through objective measures as well as subjective ones, but I do make it clear that I expect them to set boundaries, tell me if they are experiencing any discomfort with any contact I'm making, challenge them to feel stuff fully, ask they how they feel their body and/or body part after, if it feels like they can occupy it better, if it's easier for them it be "in" it, if it feels like it has more space inside, feels stronger or lighter or stretchier or more elastic, if it feels like it has better shock absorbers, all the sorts of feelings of ease that the body can supply (once the body maps are improved) that have nothing to do with pain or its absence.

[BB]

When I say explanatory model, I am not speaking of the act of an explanation. I speaking in terms of the system of rules the person is using, both consciously and non-consciously, with which to build the narrative under which they operate.

I do think we influence belief constantly, but indirectly and through the explanatory model.

For example, we identify a person who has an unrealistic fear (it is not consistent with the reality of their situation) involved in their pain. It is obvious that this fear is impeding their return to well being. The intervention on our part involves making the fear, which is currently rational to them based on the information they are using, irrational by changing the rules with which they are basing their current state. Bonnie, you gave several examples of how we accomplish this, through motivational interviewing, presentation of information which may very well be new to them, etc. It isn't the information that brings about the change, it is the incorporation of the information into the explanatory model of the person.

I think it similar to how we don't change structure with manual therapy but can influence the manner with which it is used.

I think we are in agreement, but we are using the same term to describe different things. Maybe not though. Are we still in disagreement?

[Adiemusfree]

I think we agree....!
Explanatory model is used in technospeak within the clinical psych case formulation tradition. It's typically used to describe the series of explanations, or hypotheses, that both the clinician and the person use to describe what is happening and why - which is, I think, the meaning you were thinking of.
Explanation can influence an individual's explanatory model, but we can also influence an explanatory model by being quite open and honest with the person that we really do not know what is happening, but we have a series of potential explanations or hypotheses that we want to work with them to test. By testing these hypotheses out, we can work out which ones hold and which ones don't. By including the patient in the process, we ensure their buy-in, we remain honest and ethical, and we allow for mistakes (or hypotheses that are not supported) to remain useful as learning experiences.

[Jon Newman]

This thread is great reading and Cory I agree with you. Having a shared definition of belief (http://en.wikipedia.org/wiki/Belief) will be useful as the conversation unfolds.

[Adiemusfree]

from wikipedia, citing Stanford Encyclopedia of Philosophy (http://en.wikipedia.org/wiki/Stanford_Encyclopedia_of_Philosophy) by Eric Schwitzgebel
Belief is the psychological state in which an individual holds a proposition (http://en.wikipedia.org/wiki/Proposition) or premise (http://en.wikipedia.org/wiki/Premise) to be true.
If you want to read through polysyllabic philosophical guff on belief/epistemology, this is a good site: Epistemology
(http://plato.stanford.edu/entries/epistemology/)

Stanford Encyclopaedia of Philosophy
I can't find a plain language version of it, but am happy to try and decipher, but not sure how long it will take!

[Diane]

I am going to add this link to a thread Eric started a long time ago, on Barry Beyerstein's work (http://www.somasimple.com/forums/showthread.php?t=5121).

The direct link to his excellent paper, Distinguishing science from pseudoscience, no longer works, so here is a fresh link. It is a 50 page pdf (http://www.sld.cu/galerias/pdf/sitios/revsalud/beyerstein_cience_vs_pseudoscience.pdf).
The pdf itself is attached.
I think this paper is perfect for this thread, and many others too probably.

But I do not want to derail the topic that is current re: explanatory models/beliefs, so carry on please.

[gilbert thomson]

Diane-
Great paper! Thanks for posting it again, as I had not read it the first time.

[Diane]

Back to critical thinking and clinical thinking, specifically with regard to pain, lately I've picked up on some descriptors used by medical thinkers as they think and sort through their diagnoses. They use words like "dimensional," applied to things that go in and out of being dangerous, like blood pressure. They use "categorical" to describe pathology such as leukemia. Lately I read the term "valence (http://www.google.ca/search?hl=en&q=define%3A+valence&btnG=Search&meta=)" and checked it out. In the psychological sense it means the goodness or badness (http://en.wikipedia.org/wiki/Valence_(psychology)) of an emotion (and I'm thinking, pain too probably, since pain is primarily affective, subjective, an aporia, all that stuff...)

'Valence', as used in psychology, especially in discussing emotions, means the intrinsic attractiveness (positive valence) or aversiveness (negative valence) of an event, object, or situation.[1] However, the term is also used to characterize and categorize specific emotions. For example, the emotions popularly referred to as "negative", such as anger and fear, have "negative valence". Joy has "positive valence". Positively valenced emotions are evoked by positively valenced events, objects, or situations.

Valence might be one of those mobile qualities of pain, the same way centroversion (http://www.somasimple.com/forums/showpost.php?p=20758&postcount=4) is a mobile quality of ... what? affinity? Anyway, the important thing is that it can move a thought construct like "pain" from one state to another, maybe. Be the verb moving a noun around. It helps a "self" get a grip or find a bearing or look from an angle. Whatever happens in one's neuromatrix, it's important that a construct of self (whatever that is or wherever it comes from) learn to move around a problem (like pain) and view it from as many different sides as it can.

I think that's what we do - we accompany people (kinesthetically usually) as they explore their pain, which is why we HAVE to not directly create any more of it for them to deal with, with our handling... We're trying to help them change their valence on their pain, we're trying to move it from something that seems overwhelmingly categorical in meaning to them, their subjective meaning, and instead help them see it as dimensional (that it can come and go), help them feel "good" pain instead of "bad" pain then feel other sensations which are "good" as opposed to "bad" then finally no pain at all because they brain has moved off whatever square it had become stuck on and was freaking out about.

This whole train of thought needs more work, I realize..

[Mary C]

I first saw the term valence in chemistry in high school in the 60's.
It described ions as negatively charged or positively charged, with + or - signs indicating the number of electrons available or sought.
Then there were the variable substances that could have different values for valence. They were "polyvalent."

When the Quebec government decided to rename their secondary schools they chose the term "polyvalent" as opposed to ecole secondaire or high school.

Pain is usually polyvalent--very changeable. That's a concept we can use with patients. Pain changes, can be changed, and controlling factors can be identified and utilised.

[Jon Newman]

Diane, check out this entry (http://www.somasimple.com/forums/showpost.php?p=34891&postcount=1) as it pertains to how the author uses the term valence. Would this be along the same line you are considering?

[Diane]

Yes I think it would be very much along these lines Jon.

And as for the precise chemical definition of valence, Mary, that's where I first heard it too. Looks like others have turned it into a metaphor for subjective valuation before we stumbled upon it here. I like it, and I think I'll keep it. :)
Along with "dimension" and "category."

Maybe we'll even be able to come up with a new pain measure someday, measuring the bothersomeness of pain according to how much of a "noun" (stuck quality) it is/has, or if it's more of a "verb" (feels like it can "move" or "be moved" by considering it from different kinesthetic sides). :)

The "goal" would be to get it to "move" somehow, recede, shrink, break up, change shape, soften, become more translucent, then transparent (become invisible kinesthetically), which would all be indicators of perception itself of the pain or the perception that "is" the pain, changing.

[nari]

The term could be used in the patient's notes after initial subjective/objective entries and could become a focal point for someone reading the case history....hmmm.

Nari

[Diane]

Yes. I think we might have to colonize the visual cortex in order to do something like this. Teach people how to move their pain around/move around their pain. "See" ways of dealing with it. "Watch" it creatively.

Learn to spot and fully inhabit any "spaces" that might appear. Have the "valence" rating apply to other kinds of sensations too, not just the painful ones. I'm thinking, for example, the sense of largeness or smallness of a body part, what "color" it appears in the mind's eye, this kind of thing. There must be a way to learn to track, maybe even "measure" these sorts of perceptions, encourage the pleasant ones in order to diminish the unpleasant ones.

It would be something that wouldn't be very transferable from patient to patient or objectively useful in terms of aggregation... each person's pain and kinesthetic experience is unique, so it probably wouldn't end up being an RCT tool or anything.. but it might be something helpful one person or one therapist/patient dyad at a time.

Just dreaming.

[EricM]

Diane, I can't remember where I heard it, but I have been using an analogy with my chronic pain patients that I think might reflect this use of the term valence. I ask them to imagine what it is like to walk into a room where there is a large captivating picture hanging on the wall. If you were to visit this room frequently for the next little while, the picture may continue to captivate your attention and imagination. One day comes when you realize you haven't really payed as much attention to it each time you entered into the room. The painting, like your chronic pain is still there hanging on the wall, but it's no longer front and center in your awareness.
If I've borrowed this from someone on SomaSimple, thank-you, my patients find it gives them a new perspective and hope.

[Diane]

Eric, exactly. The valence has become more "neutral." Maybe there's some other picture of something else in some other room or corner of the same room that is more interesting.
You might be encouraging "accommodation" with your analogy/metaphor.
I haven't heard this one before, here... as far as I know. It must be your creative original. :)

[Mary C]

In chemistry, there is no such thing as zero valence.

There are no inert ions.

Maybe this explains, in a way, the higher risk of flare in people who have had pain that was either severe or long-standing or both.

[Diane]

Mary, I think the use of the term "valence" is more metaphorical in psychology than it is a one-to-one correspondance with the term as used in chemistry.

[Mary C]

I realise that, Diane. Pushing interpretation to an extreme helps me sort things through. Might help me develop some critical thinking. ;)