Where's the Revolution? II

[Barrett Dorko]

This is what I wrote in February 2004 to begin a thread titled Where’s the revolution?


I’ve been slowly plowing through a new book by Carl Zimmer titled Soul Made Flesh: The Discovery of the Brain-and How It Changed the World. This is the story of Thomas Willis’ work at Oxford in the 1600s where he became “the father of neurology” by demonstrating through careful experimentation and revolutionary methods of dissection that it was within the brain that consciousness began and that through the nervous system it controlled the rest of the body. This book contains a tremendous amount of information concerning the nature of scientific investigation throughout the 16th and 17th centuries and how that was vitally dependent upon the mood and beliefs of those in power at any given time. To put it simply, no matter how clearly your argument was stated or how carefully done your investigation, if it didn’t sufficiently coincide with conventional wisdom you ran the risk of having your head removed. I’m not exaggerating. (This is the subtext of the "Dark Matters" thread, of course)

I’m just now getting into the section of the book dealing with Willis’ landmark work on the brain and look forward to what happens next, but this morning I read a description of his work with fever that stopped me a while and started this thread in my head. Hang on, I’m nearly to the part about therapy practice.

In 1656 Willis published a book about the nature of fever that diverged markedly from Galen’s ideas of “humors” (semi-mythical substances or spirits) supposedly in control of the body and mind. Instead, Willis suggested that it was a change in the chemical constituents of the blood itself that led to the overheating that killed so many. This thinking eventually led to the field of biochemistry and was truly a new science proposing to replace the dogma of Galen, firmly entrenched since his death in 200AD. As you might imagine, Willis had every reason to fear for his well being. He probably felt that at any moment his brain might be the next one extracted. Instead, his book grew in popularity and his fortune grew. His was the dominant theory behind fever for the next century.

According to Zimmer, “…one reason that they held onto it for so long was that Willis explained the cause of fevers in a new way but he didn’t change their treatment.” He means he went ahead and bled his patients as prescribed by Galen. As you might imagine, this didn’t work especially well, but at least now the doctors were doing the wrong thing for a better reason, or something like that.

Okay, here it is-The neurobiologic revolution has introduced us to ideas about neural mobility, nutrition and pathology that have remarkable implications. It is as if a new science has been invented to explain much of what we’ve never before understood about chronic pain. Accordingly, the findings encountered when examining patients in the new ways described are meant to reveal what we now know about the consequences of abnormal neurodynamics and I have no problem with that.

My concern lies in the methods of management for these problems that appear (to me at least) as little more than the application of joint mobilization principles to tissue that doesn’t possess the qualities of any joint. I have tried this upon occasion (not recently) and been dissatisfied with the result. I know others who feel the same. Is the popularity of this method a result of its parallels to orthopedic technique? Is that appropriate? Doesn’t this new science call for a new method of care?

Where's the revolution?

Any thoughts?

[christophb]

In Csickszentmihalyi's book on creativity, there is a chapter called "Where Is Creativity?" He talks about different type of creativity, but focuses on what he feels is Creativity (with a big C). He defines this as creativity that changes some aspect of culture and never being solely in the mind of a single person. To have any effect on culture, the idea must pass with the "experts" in the field in question and finally must be included in the cultural domain where it belongs. So the climate of the culture is important for ideas to pass along. He states that Creativity can be observed only in the interrelations of a system made up of three main parts. The first is the domain, which consists of a set of symbolic rules and procedures. The second is the field, which includes all the individuals which act as gatekeepers to the domain. The third is the person, when an individual using the symbols has a new idea or sees a pattern, this novelty is selected by the appropriate field for the inclusion into the relevant domain. He gives an example of Galileo and Freud that if they had been unable to enlist followers who came together in distinct fields to further their respective domains, their ideas would have had much less of an impact, or none at all.

He also states that not all domains are equal in their structure and organization. Mastery of the symbolic language of the domain is usually necessary before novel ideas are formed. Some domains are structured so their symbols and ideas are learned fairly quickly. Mathematics for example, is highly organized with strict internal logic, the system is set up to maximize clarity and reduce redundancy. It is therefore easy for a young person to learn the rules quickly and jump to the cutting edge of the domain relatively quickly. Then it is possible for a novel idea to be recognized, pass a proof and become assimilated back into the domain. By contrast, it can take decades for social scientists, philosophers, or psychologists to master their domains and if they produce a new idea, it takes the field many years to see if it is an improvement worth adding to the knowledge base.

It may be that the symbolic rules of manual therapy applied to the human body/brain, while changing, are still held by the majority of the field to be highly organized and logical. Push this direction with x amount of force, do x number of reps x times and increase weight by x every week... Not every manual therapist practices like this, but a lot of the ones I meet do seem to think pain resolution is as simple as this and when it accidentally proves to be true, further strengthens their belief without questioning why. It seems that the people thoughtfully exploring pain are finding the field to be more like the social scientists, philosophy and psychology and it may take a while for these new ideas to pass through the gatekeepers. Or we may be in an identity crisis, we thought we were A domain, but now we are finding out we are B domain, and the transition can be confusing. Just a few thoughts.

Chris

[Barrett Dorko]

Great stuff Chris,

I reviewed The Tipping Point six years ago on another site and feel that the third part of the system you allude to; person, is dealt with pretty well there.

I think that the domain and field of our work may one day recognize and yield to our reasoning, but that it will take mavens, salesmen and connectors to gain acceptance by those who are primarily concerned with the financial aspects of therapy.

[Diane]

In this link, a few other concepts are mentioned in addition to maven, connector, and salesperson, such as "stickiness" and the number 150 , and this:

there is a bell curve of adaptation to the new phenomenon: first are innovators, then early adopters, early majority, late majority, and laggards. Each category corresponds to one standard deviation worth of width, and the apex of the bell curve is between the early and late majorities. Innovators lie 2 or more standard deviations to the left of the mean, while early adopters are between 1 and 2 standard devations to the left, and so on. Laggards, the last group to adopt a new fad, lie at least 1 standard deviation to the right of the mean, thus make up about 16 percent of the population.

Here is a bit more to add to what Chris mentioned from "Flow", written by a computer programmer who heard a live talk on the topic from the author.

When we look at something like treatment though, we have to deal with real time, interaction in the moment between two people, not just in the personal experience of one, or starting a trend within the many. The issue of consciousness arises too. Ideas of sensation (in our case kinesthesis) versus perception, of sensation "thickening" time. Maybe the reason we haven't ignited any sort of revolution yet is because these ideas have yet to become "sticky" enough with a solid enough evolutionary/biologic basis.

[EricM]

Where's The Revolution? I

[Luke Rickards]

Nari has referred to an interest paper in - Are PTs starting to take notice. Perhaps the revolution has started.

Here is the paper Mechanism-based clinical reasoning of pain

[Barrett Dorko]

Thanks Eric.

Aside from waiting for a revolution in understanding and dissemination of the literature (which actually appears to have begun, somewhat) I am waiting for those who have a firm grasp of an accurate deep model of the ectoderm to acknowledge what we can’t do manually in an effort to alter it as we would prefer.

As much as I admire both Butler and Shacklock and openly promote their writing and teaching at every workshop I teach, I continue to disagree sharply with their actual method of treating the abnormal neurodynamic with movement. I won’t repeat here the many things said previously about the nature of ideomotion and its use (which is an ideal, instinctive correction of the problem). I want to bring up instead the geometry of the peripheral nervous system, which is, without question, fractal.

This means that we simply cannot know with certainty which portion of this phenomenally redundant, complex and continuous organ is actually responsible for the patient’s complaint and that we cannot test its movement passively with significant confidence in any test’s validity. No doubt this creates a problem: Neurogenic pain in many cases is a perfectly reasonable and defendable assumption (thanks in large part to the genius and hard work by my aforementioned colleagues) but the geometric nature of the anatomy at the problem’s core makes testing difficult to perform with appropriate accuracy and, in my opinion, often irrelevant.

But there’s more. If the nervous system’s geometry makes testing difficult to justify it follows that passive movement or choreographed exercise will face the same problem, and, in my experience, they do. Neural flossing and tensioning movement are notorious for their tendency to worsen the pain, even if done with great care. I say this on the basis of a couple hundred conversations with therapists over the past several years. Perhaps they’re doing something wrong, but to me this consequence of consciously chosen movement for a system we can neither see nor easily predict in terms of response (another consequence of fractility) is no surprise.

Back to the original question: If our knowledge of the system we’re trying to examine and alter has grown to such a degree, why do the techniques proposed for its management so closely resemble the same ones used to for the mesoderm? Are we making the same mistake Willis made?

[nari]

Barrett,

I take the view that conversion from mesodermal thinking to ectodermal is a large leap into what many PTs regard as a 'sea of uncertainty'; but to take the figurative step towards the nonconscious in order to elicit corrective movement is a very large leap. For you, it seems a logical move, it makes perfect sense, but you have been there for many years, to the point where it seems natural and why do something else that is merely fiddling about with structures we don't understand or signs we can't interpret properly.

The system is indeed fractal; but how many PTs understand the nature of fractals?

Re neurodynamics: I think it is an interim step to make the very large leap less formidable. I don't know what other PTs do with neurodynamics that creates such negativism other than they see the techniques as a variant of stretches, which is disastrous.
To go back to BSC (before Simple Contact), I had considerable success with neurodynamics; they worked where nothing else did. The pain simply ceased; it tended to return, but a few sessions and lots of education tended to solve that problem; and the patient can be independent with self-management. To me that was a vast improvement on the daily dozen routines of exercise and stretches which are basically hit and miss; that is, the CNS is missed.

The gaps that David and Michael are filling are important; it is still mesodermal and choreographed to some extent, but the focus at least is on the CNS/PNS, and not some arbitrary muscle group or joint.
I think that is a valuable move away from the muscle/joint focus.

For most of us, I believe, maybe wrongly, this should be a step towards your own understanding of the deep model. Most PTs aren't base jumpers or high flyers or leapers of chasms. They like safety and assurances and choreographed guidance.

Nari

[Barrett Dorko]

Nari,

I agree entirely and hope that nobody hears me disparage the work Michael and David have done. Without them my explanations wouldn't amount to much. I am also aware that your personal use of their methods is described as something far more subtle and carefully done than what I've seen it translate to here in the states.

It is a leap, this embrace of creative movement, which is why I'm now emphasizing an examination of Bobath's method for the neurologic disorder that affected me so profoundly while I was still training (I contributed to their biography), the writing of Oliver Sacks (see Oliver, Ian and Me) and the gently choreographed recoordinative movements devised by Feldenkrais. This is what I teach and employ because the anatomy and functional capability of the involved tissue dictates this.

You're right - it's only logical.

Maybe it's the future. It sure isn't the past or present.

[Mike Terrell]

There is a quote, attributed to Victor Hugo, that I read recently that I had considered using as the basis of a thread starter. Essentially, I have been beaten to it, but I will offer the quote anyway:

"Nothing in the world is so powerful as an idea whose time has come"

Has the time come? Is the idea really so powerful that it will drag even the reluctant with it, kicking and screaming?

If you look at the world of politics/government, things do change, but excruciatingly slowly. My feeling is that the neurobiolgic revolution will take hold. Will any of us still be practicing when it is the accepted deep model governing most care? Not likely.

mike t

[caro]

Bumping.

Part I is here.