Another reason therapists don't know

[Jo Bowyer]

I'm wondering if the unplanned movement that emerges in this context is really instinctive movement that corrects us or more something akin to the movement version of speaking in tongues.

Infant babble and dysphasia in adults contains words and parts of words as well as sounds that work the mouth "blellum" and "ffffuk" are two that come to mind. Intonation produced by dysphasics and infants is often more advanced than word based content. I have heard "fffuk" repeated by an adult who has produced it, in an exploratory mouth feel context and I have heard it used meaningfully as an expletive. Babies who play with "fffuk" will let it go after a few days if older family members can restrain themselves.

Child development requires guidance. Rehab can be a mixture of guidance with regards to emerging patterns and retrieval of those temporarily mislaid.

[gerry the neck]

""Humans move in ways that can most reasonably be described as unplanned. Sometimes this is to reduce mechanical deformation. Sometimes not. I don't know why differentiating this matters. The fact that it exists and could play a role in our patients' persistent pain seems like something therapists should know about. ""

Interesting. Most persistent ( or chronic, as I prefer ) pain seems to result from internal self-corrective attempts, orchestrated by whatever (possibly the N/S) to continually make adjustments which might benefit an ongoing issue, such as a compromised nerve root. Except in instances where an injury/infection is obviously worsening, and any resulting pain is not persistent as such, but is continually or temporarily 'renewed' pain. Persistent pain usually denotes that the 'internal operator' is active and responding, despite any external interventions, whether simple or not.

[Jo Bowyer]

""Humans move in ways that can most reasonably be described as unplanned. Sometimes this is to reduce mechanical deformation. Sometimes not. I don't know why differentiating this matters. The fact that it exists and could play a role in our patients' persistent pain seems like something therapists should know about. ""

Interesting. Most persistent ( or chronic, as I prefer ) pain seems to result from internal self-corrective attempts, orchestrated by whatever (possibly the N/S) to continually make adjustments which might benefit an ongoing issue, such as a compromised nerve root. Except in instances where an injury/infection is obviously worsening, and any resulting pain is not persistent as such, but is continually or temporarily 'renewed' pain. Persistent pain usually denotes that the 'internal operator' is active and responding, despite any external interventions, whether simple or not.

I really really like this. It beats anything I have heard to date from my expert patients :thumbs_up :thumbs_up :thumbs_up

[Mason]

I think it's more than just a guess, although I admit that it requires a "creative leap" as part of an abductive reasoning process:
-Resolution of pain is reported (along with measurable functional improvement) following the creation of a non-threatening context that includes, through education, a change in the patient's cognitions/attitudes about their pain (which is also measurable).
-This would be explainable if patients with non-pathological pain of mechanical origin (a scientifically plausible condition characterized by an abnormal neurodynamic) possess an ability to self-correct.
-Therefore, there's reason to think that patients with this condition are self-corrective.

If an input is provided in the form of education or permission to move then perhaps there is a better term than self-correction for the process that results in the resolution of pain.

Child development requires guidance. Rehab can be a mixture of guidance with regards to emerging patterns and retrieval of those temporarily mislaid.

I see parallels between what's being discussed here and child development. When a person is able to complete the action that leads to resolution without guidance or input then I would call the process self-corrective. Saying the movement is culturally suppressed implies that instinctual behavior to relieve mechanical deformation existed prior to emerging. Withdrawal and protection are innate behaviors. The ability to relieve mechanical deformation may be in part a learned response. Is this possible? That ability may never have developed, it may be misplaced, or it may be contextually inhibited. Learning undoubtedly occurs during the interplay of context, cognition, and action during the therapist-patient interaction so figuring out what was there before would be difficult.

[Barrett Dorko]

Evanthis says:

...I'm not the one who is claiming that I touch patients and they move instinctually.

No, I haven't "claimed" that. Ideomotion is already there. Context, which may or may not include touching, has a profound effect upon its expression. The sensations reported by the patient as they express it aren't unimportant here.

In discussing this briefly with an OT yesterday I asked her why she had adjusted the position of her forearm on a table. "To make it more comfortable," she said.

Is there a lesson or two there?

[PatrickL]

Of course you can put it any way you want, but you haven't answered my question. Do you think it matters if a therapist is able to defend his practice scientifically?

Of course it matters.

I think you unfairly diminish what Barrett is trying to convey with his method by reducing it to relaxing music, dim lights, and a pillow under the patient's knees. You and I both know that this is done routinely down the streets from where we work, while the therapist waxes on confidently about meridians, energy fields, and all manner of indefensible nonsense.

Music, dim lights and attending to the patient's comfort might be the primary reason those therapists banging on about meridians actually help anyone. My point was that attending to therapeutic context is not Barrett's original idea, and is not unique to simple contact. So if a treatment session involves context setting but no touch, well i don't think that constitutes sc as it was taught to me. But it a moot point really. If Barrett defines sc as understanding (of the importance of context setting) as well as a method, then that's what it is. Personally, the provision of a non threatening context is common practice for many physios I work with, of which none are especially familiar with Barrett's ideas. Of course there are many ignorant ones out there too.

I think it's more than just a guess, although I admit that it requires a "creative leap" as part of an abductive reasoning process:
-Resolution of pain is reported (along with measurable functional improvement) following the creation of a non-threatening context that includes, through education, a change in the patient's cognitions/attitudes about their pain (which is also measurable).
-This would be explainable if patients with non-pathological pain of mechanical origin (a scientifically plausible condition characterized by an abnormal neurodynamic) possess an ability to self-correct.
-Therefore, there's reason to think that patients with this condition are self-corrective.

Well, no. It's not self-correction if the outcome was dependent on education or the provision of an altered context by another person. I think that is straight forward

Moreover, a measurable decrease in pain and improvement in a functional measure following education and provision of context setting could conceivably occur for a pain of any origin. That would lead one to suspect that descending modulation has occurred, not necessarily a homeostatic self corrective mechanism for keeping peripheral nociceptive flow in check. You'd have to be certain of the origin of pain for your abductive reasoning sequence to make sense. And as far as I know, the question "can you alter your pain with position or use" does not only apply to pain of mechanical origin. People with phantom limb pain have pain that varies with position or use. Of course, one could have pain of mechanical origin overlaying another origin of pain. I don't know how one could ever be sure about a patient's origin(s) of pain.

To be clear, I subscribe to the view that we do have a capacity for self correction, and that for the most part no form of intervention is required to help this process along. What concerns me is how these debates continue to unfold. I don't know that there exists a measurable criteria for a "scientifically plausible defense" of a premise and method. It seems to boil down to a self directed determination of which literature is most relevant, and a self directed assessment of who has read and understood the most. It concerns me that yourself (john), and Barrett, Diane and nari seem to have reached a final conclusion with regards to the relative "defensibility" of your preferred ideas. But the best you've got is abductive reasoning, which by definition has built in assumptions (a creative leap). Is this as scientific as it gets? The abductive reasoning makes sense, it might be right... That constitutes a "sufficient enough scientific premise" to doggedly defend day after day on a website?

Well, where is your null hypothesis? Where are your efforts to disprove it? Why do these debates predictably unfold with one or two of us ( myself, Blaise, Evan , josh, Greg, Nathan) questioning the premise/ideas that we all subscribe to, while yourself (john), Barrett, Diane, and nari defend said ideas til the death? When was the last time you openly challenged the premise that we are self corrective, john? I can't help thinking that you guys assume that anyone who does question your preferred premise and method(s) just hasn't quite found their way to your lofty heights of understanding. There is something decidedly unscientific about a group of PTs who spend their time on a science based website posting articles that support their preferred ideas, swapping mutually agreeable anecdotes that support their preferred ideas, and closing ranks around anyone else who dares to challenge their preferred ideas.

I reckon you guys think you have this treating human pain caper as sorted out as it can currently be sorted out. I don't see any effort to question your own ideas. And I don't think it's an approach that will drive our knowledge forward.

[Barrett Dorko]

Patrick says:

Personally, the provision of a non threatening context is common practice for many physios I work with...

As I've said, I've spent so many years in ankle weight city where the therapist's knowledge of such a thing, the "closed shop" of patients in the facility is present and the constant pressure from every superior to "get your productivity up" is such a pervasive message, context is unknown, if not counterproductive. Neither do these therapists understand the importance of threat. Posters proclaiming "no pain, no gain" are on the wall and emblazoned on t-shirts. I'm not kidding.

The fact that your list of regulars here commonly explore the absolute failure of their efforts forms the null hypothesis you seek. We all know that such failure to understand, be a certain way and satisfy the expectation of every patient is beyond us. If, however, we can defend the premise "we're self-corrective" in a variety of ways that are defended with arguments (not anecdotes and opinions), we have a starting point.

We can.

[Diane]

It concerns me that yourself (john), and Barrett, Diane and nari seem to have reached a final conclusion with regards to the relative "defensibility" of your preferred ideas. But the best you've got is abductive reasoning, which by definition has built in assumptions (a creative leap). Is this as scientific as it gets? The abductive reasoning makes sense, it might be right... That constitutes a "sufficient enough scientific premise" to doggedly defend day after day on a website?

Do you think you can come up with anything better?
Have at it then.

You seem to think that these ideas came out of thin air with no pre-evaluation, or chucking out of ideas that were immiscible (to other broad vistas of science)?

Well, where is your null hypothesis? Where are your efforts to disprove it? Why do these debates predictably unfold with one or two of us ( myself, Blaise, Evan , josh, Greg, Nathan) questioning the premise/ideas that we all subscribe to, while yourself (john), Barrett, Diane, and nari defend said ideas til the death? When was the last time you openly challenged the premise that we are self corrective, john? I can't help thinking that you guys assume that anyone who does question your preferred premise and method(s) just hasn't quite found their way to your lofty heights of understanding. There is something decidedly unscientific about a group of PTs who spend their time on a science based website posting articles that support their preferred ideas, swapping mutually agreeable anecdotes that support their preferred ideas, and closing ranks around anyone else who dares to challenge their preferred ideas.

Ooh, arguing from 'I am more scientific than thou' authority.
I think you are aiming at entirely the wrong target.
Turn around and aim this at the profession itself.

I reckon you guys think you have this treating human pain caper as sorted out as it can currently be sorted out. I don't see any effort to question your own ideas. And I don't think it's an approach that will drive our knowledge forward.

Deconstructing all the nonsense in the profession is at least a start... Wouldn't you agree?
Do we need to drive any of what passes for current "knowledge" forward? Wasn't most of it based on supposition to begin with? Hasn't neuro/pain science already eroded most of what we "think" already?
Aren't Moseley and many others already doing a good job of building a new science base under the profession?

Would you like to take on some of that, instead of complaining that we (Nari, Barrett, me) don't self-critique to the extent you think we are supposed to? Do you still think that among us we haven't already done about a hundred years of professional self-examination/self-questioning cumulatively?

Do you actually think you can do better? Then please, do go ahead and show us.
Please. Before another 900 posts ensue.

[Barrett Dorko]

Thanks Diane.

Perhaps I don't state often that I was one of the first three therapists to take all of Paris' (easily, the most prolific speaker and teacher of manipulative method that existed in the profession of physical therapy from the mid-sixties up until a very few years ago) courses and that he chose ME as his first hire at The Atlanta Back Clinic in '75. I had snuck through graduated from the Ohio State University in '73, having slept through most of my classes.

Finding that manual coercion, as I began to call it in 1979 didn't attend to the patient's own motion, ramping up my attention to cultural influences, reading Breig, attending Feldenkrais' course, getting Rolfed, reading, treating patients, reading, teaching, failing and struggling to understand more, treating patients, reading, writing, listening to an incredible variety of practitioners, watching some of them lose it, hearing of their death, treating patients, closing my practice, finding I had gained a reputation, reading Wall and Melzack, discovering Butler's first book in 1990, putting up a web site in about '98, reading Spitz and then Eagleman, working in nursing homes next to therapists I found I couldn't stand, growing quiet at work, reading, finding the web (several other regulars remember back to about '02), writing for PT Forum and a few others, going to and writing on Rehab Edge, being invited to Soma Simple...well, there's more.

Did I mention anything about reading?

I didn't end up where I am because it was my best guess, but I understand things may change.

Not everything though.

[Diane]

Truly mind-boggling:

When was the last time you openly challenged the premise that we are self corrective, john?

What would a null hypothesis of that be, to be tested?
"Humans are not self-corrective and therefore society requires a vast hoard of "therapists" to correct everyone's movement"

??
When you look around you see that being tested all the time. Furthermore, piles of toothfairy science have sprung up everywhere to support, rather than ax, that particular null hypothesis. Everything went inside out thanks to profession-wide confirmation bias.

Please do your best to correct this.
All anyone really cares about, at the end of the day, is pain and its alleviation so they can move better.

[Diane]

This video, minute 59.
[YT]EcueZ0LJ9ys[/YT]

"Hyper-reductionism", defined by Steven Novella as a propensity to single out one factor as being the only important one and ignoring all others as being inconsequential.

E.g. glaring example of hyper-reductionism from our own profession:

There MUST be some specific effect from manual therapy.. otherwise, why bother doing it? We need to do more science so we can find it! Not only that, some kinds (of MT) are much more "specific" (in their target tissue) than other kinds, so there must be some kind of correlation between high levels of skill in the provision of specifically targeted manual therapy, and outcomes derived from it. Let's make manual therapy as minimal as we can by making it as fast as we can and targeting the joints as specifically as we can so we can "prove" that high velocity low amplitude manual therapy is superior, has a specific effect (which we'll figure out later..) and must be held up as the pinnacle of achievement (black belt-ism).

[Jo Bowyer]

All anyone really cares about, at the end of the day, is pain and its alleviation so they can move better.

Well that's going to cramp my style just a tad :thumbs_do

http://en.wikipedia.org/wiki/List_of_medical_symptoms.

Any other generalists out there ?

[Diane]

I send people with medical symptoms off to see a medical practitioner.

I'm just a therapist. A physical one. Not only can I not deal with most of the stuff on that list, I don't even want to have to try.

[John W]

When was the last time you openly challenged the premise that we are self corrective, john?

Let's see...I practiced like most therapists within the "null hypothesis" context that Diane just described and the one that Barrett refers to as "ankle weight city" for about 10 years. Acquired my OMPT "black belt" around the same time that I figured out it was all built on a crock of bullshit, personality cult, and a perverse reimbursement system. Frustrated with the state affairs of my profession and the inability to provide those many challenging patients with enduring relief from their debilitating pain, I ventured online and started participating in discussions about the science behind our profession. That was roughly 10 years ago.

For the next few years I went to battle with people like Diane, Barrett, Jason Silvernail, Cory Blickenstaff and a few others. Those conversations were not unlike what's going on here in this thread, but everyone comes in with their own frame of reference, intelligence, prior level of preparation and "personality". That went on for about 2 or 3 years, which is about how long it took me to read the references provided here, and many others.

A big influence on my frame of reference was being raised by a mother who worked in the field of alcoholism and drug addiction, and who's own life experience in large measure compelled her to find a better way to treat it. The medicalization of addicts has by-and-large been an abject failure, and my mother recognized that decades ago. I can't help but recognize the parallels in our profession. People in pain being drugged, cut open, and generally institutionalized within a health delivery system that has profoundly lost its way.

I often refer to the two years I spent in West Africa working within a tribal culture. The work I was involved in included very heavy labor building earthen dams without heavy equipment. People got hurt, but they didn't stay hurt. This made a huge impression upon me, but I didn't appreciate it until I became immersed in our health care system as a PT. Interestingly, in this same culture, the power of placebo introduced by Western medicine was very well established. Tribal West Africans would travel miles by foot or on a crowded bush taxi accompanied by chickens and goats while in a state of ill-health if they knew at the other end their journey awaited an injection of an anti-biotic. They would endure this despite the oral version of the same anti-biotic being available in their village. Injections of medications possessed an almost divine power among these people. I'm afraid it will be just a matter of time before the chronic pain epidemic grips sub-Saharan Africa.

So, the process that brought me to the point to "openly challenge" the idea of self-correction goes back a ways. I wish I could provide a link to the "discussions" that I referred to above, but I don't think they're even archived anywhere. They didn't occur here. I guess you're going to have to trust in my good will and earnest efforts to advance the discussion based on the current evidence (I've provided scores of links to articles, presentations- including my own- and websites over the years here and elsewhere). I guess you're going to have to make a "creative leap" of your own, Patrick. Or not.

Although I appreciate your skilled rhetoric and highly organized and systematic thought process, I think it would help at this point to provide some evidence from the literature that, based on your understanding, refutes item #8 in the "Forum Moderators' Current Consensus on Pain":

The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.

You and the others you mentioned could always start your own blog.

Who's Greg?

[Diane]

Lest we forget:

"Physiotherapy is about the return of thoughtless, fearless movement" - Louis Gifford, 2005

I do remember the conversations John refers to - once upon a time EIM had a little section deep in its Myspace vaults titled "Pain", so I decided to go there, thinking I had some right to.. impertinent old female pain-treating PT that I am.. I let people there (including John) lay in, on 600+-post threads, get all PO-ed, threads that went absolutely nowhere, much like this one, and eventually (long after that thread died), John (who wrote there that he wished he could reach through the internet and out through my own computer to strangle me, something like that... for which I've long since forgiven him).. was finally able to get out of the confining little pseudoscientific-boxed thinking the profession had ghettoized him into.

(BTW, John and I are fine with each other these days, thanks for wondering. :angel