Another reason therapists don't know

[PatrickL]

Nari

If you can understand/ think that for many of us it has been a long slow wade through a lot of hypotheticals and downright tooth fairy stuff to get at where we are now, then maybe you might interpret our position differently.

Diane

Do you still think that among us we haven't already done about a hundred years of professional self-examination/self-questioning cumulatively?

Interesting sentiments. What's the message here? That you've done your share of self critiquing? Is there no need for to continue in that vein?

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

That is not relevant. The question, which I thought I had made clear, is whether you think you can come up with anything better? Based on the daily, relentless mutual reinforcing of your shared perspective, I don't think you guys ever see a reason to dig deep and challenge your preferred ideas. There doesn't appear to be any motivation or incentive for critical analysis of your preferred ideas. In my most recent response to john, I pointed out that it's not self correction if resolution is dependent on the provision of a non threatening context and/or education by another person. No response yet. More importantly, I haven't seen you guys ask the question.

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?

I think it's important to separate two issues here. First is "other/traditional "manual therapy methods and the understanding/beliefs that underpin them. The second is the shared perspective of yourself Diane, john, Barrett and nari. I don't think it's reasonable to equate my calls for deconstructing of the latter with some sort of veiled attempt to build an argument in support of the former. I think you guys do a great job of deconstructing "other/traditional" manual therapy practices.

However, as long as our understanding of the pain producing neural architecture and organization is limited enough that we can best describe pain as an emergent property of a complex system, well, your ideas will remain supposition. That doesn't mean you're limited in understanding, but the suppositions built into your ideas are untestable, thus they remain suppositions.

Personally I don't think we have to "know" in order to apply such ideas. Supposition is probably the best we can do. But geez, you guys have been at it on this site for years, defending these suppositions as if they're self evident truths. Well, they're not. All I'm suggesting is that the degree of certainty you guys express re your ideas just isn't justified given the strength of supporting evidence.

Overt certainty is, I think, at the heart of many indefensible practices in PT. I find it disconcerting that you guys do not appear to be aware of how certain you are in the correctness, rightness defensibility of your ideas.

[PatrickL]

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.

I answered this within my last post, but just to be clear...
If the therapist has to provide anything, then it raises some pretty obvious doubt over the premise that we are self corrective, no?

[Barrett Dorko]

Patrick says:

...the degree of certainty you guys express re your ideas just isn't justified...

I always see myself much like the weather forecasters in Northeast Ohio. We can't be certain and have on numerous occasions taken the opportunity to say that specifically. I'll let someone else supply the links.

There's what the forecasters in The Greatest Location in the Nation call "lake effect." In our patients in pain there are many other things and I supplied the list earlier. The butterfly effect within the fractally shaped nervous tissue makes certainty impossible.

Somehow, you haven't heard us say that.

[PatrickL]

We can't be certain and have on numerous occasions taken the opportunity to say that specifically. I'll let someone else supply the links.

I can't recall you ever stating that you can't be certain of your premise. When have you said "hmm, if resolution is sometimes dependent on an altered context, or some form of altered understanding, or physical touch, maybe we aren't self corrective after all."

Isn't it conceivable that people sometimes need each other to "correct". We are social primates, after all.

[PatrickL]

We can't be certain and have on numerous occasions taken the opportunity to say that specifically. I'll let someone else supply the links.

I can't recall you ever stating that you can't be certain of your premise. When have you said "hmm, if resolution is sometimes dependent on an altered context, or some form of altered understanding, or physical touch, maybe we aren't self corrective after all."

Isn't it conceivable that people sometimes need each other to "correct". We are social primates, after all.

[Diane]

Indeed.
Given that nothing is certain (and wouldn't you agree, Patrick, that certainty was what manual therapy was and still is after for decade after sorry decade?) what is "defensible", other than to cut away everything that was built upon "certainty", or some promise therein, and learn to ride your bike with no training wheels?

In manual therapy, training wheels, to me, means getting a black belt in ortho moves and grooves, thinking that solves the problem.
What is the problem? Pain.
Honestly, people don't flock to see you because you have a bunch of papers on your wall.
They come because you slowly develop your own reputation as someone interested in helping each individual who comes in to see you, with their pain problem.

To me, riding a bike without training wheels (and making a living) means staying on the surface of another person as much as possible and thinking about helping nerves/nervous system.

Nothing is certain because you never know what somebody's neural anatomy might be like. Nothing is "right", therefore, - it can only (and ever) be "less wrong".

I think this thread is over 900 posts because you (and Evan, and others perhaps) seem to not like the attitude, that the attitude itself is indefensible, and are poking at the method instead.
I don't like your attitude either. It seems to me that you think that "less wrong" is "wrong" because it isn't (and never will ever be) "right."

I think "less wrong" is better than either
1. "absolutely right" (which doesn't exist) or
2. "dead wrong" (which most manual therapy based on outdated assumptions are)

Give up. We're all dead and you're trying to kill dead things. How useless is that?

Manual therapy is simple individualized physicalized human primate social grooming.
It won't ever be more than that. (Yup, I said that with a huge amount of certainty!)
It's good enough for me, and should be good enough for anyone.

[Jo Bowyer]

What is the problem? Pain.

Really? Is everyone a pain specialist here?

Pain may be part of the problem, but most people I see don't know what is troubling them or where. They come in because there is dysphoria between what they feel should be and what is.

[PatrickL]

Manual therapy is simple individualized physicalized human primate social grooming.
It won't ever be more than that. (Yup, I said that with a huge amount of certainty!)
It's good enough for me, and should be good enough for anyone.

Thanks for making my point for me

I think this thread is over 900 posts because you (and Evan, and others perhaps) seem to not like the attitude, that the attitude itself is indefensible, and are poking at the method instead.

No, I don't pretend to be able to know (and I honestly am not fussed by ) what attitude accompanies your words as you type them. I just pretty much think you're more certain in your position than is warranted.

what is "defensible", other than to cut away everything that was built upon "certainty", or some promise therein, and learn to ride your bike with no training wheels?

By all means cut away. While you're at it what about cutting away for example, notions of hierarchical processing by the cns of afferent input from mesodermally vs ectodermally derived tissue? That notion seems built on unfounded certainty too.

Give up. We're all dead and you're trying to kill dead things. How useless is that?

No thanks, this thread has not been useless for me. Thanks for your input.

[Diane]

Hopeful Certainty-ists versus Hopeless therefore staunch Uncertainty-ists.

[gerry the neck]

Concerning the self-correcting debate, I think one of the issues which is overlooked is that self-correction is vulnerable to collapse, particularly where there might be an overload of external interventions which might confuse already activated internal corrective measures. Being able to read how to properly accommodate the 'internal operator' is really what this debate should be about. There isn't one simple standardised overview available, because the nature of internal responses will differ with various conditions....for instance, the nerve response behaviour from a neurological problem, say a threatened nerve, will differ completely from the nerve response behaviour of a broken toe. Being able to read the meaning of the different responses is the only way to assess what type of intervention, if any, might be appropriate. A good question to ask oneself, before any intervention, might be ' Is the internal operator requesting assistance ?'.

[Diane]

Pain may be part of the problem, but most people I see don't know what is troubling them or where. They come in because there is dysphoria between what they feel should be and what is.

Thank you. Quite right. I stand corrected.

[BB]

Jumping in here. Might have to dust off my helmet for this one!

There is an appalling absence of evidence to inform this debate in many respects. For example, non-coercive as compared to coercive care. Just because there is an absence of evidence doesn't mean that there is not a scientific approach. In the absence of evidence the scientific approach is to assume the null, which in this case would be "no difference." We have to work from assumptions every day. One assumption that is most guiding in health professions is "do no harm." As a result of this ethical guidance, an assumption I make is that non-provocative care is preferable. Passive or active, doesn't matter on this count. So long as it follows this assumption.

Next up is this idea of self-expressive or self-corrective processes. Ideomotion is secondary to intention. Volitional movement is all secondary to intention, therefore all volitional movement is ideomotion and the phrase is helpful only so far as it differentiates this and brings intention into view. Since all volitional movement is ideomotor, this means both "corrective" and "non-corrective" movements are ideomotor. There is some evidence to support the stance that self efficacy in recovery is preferable to a lack of self efficacy. So, what we're REALLY looking for is volitional movement that fosters self efficacy.

Instinctive vs. not. Someone give me an example of non-instinctive movement, please. My stance is that, similar to ideomotion, ALL of our movements that are not coerced are instinctive, corrective or not. The point, as I see it, of the instinctive narrative is that the processes for movement recovery comes from the patient, processes that are internal to the patient. Although, they come from the patient (ie. self corrective) clearly there is no guarantee that these process will come without outside influence. We have competing desires and intentions constantly. This is accounted for in the mere set up of the scientific process. Preferably, there is a treatment group and a placebo group, both of which usually outperform the control group. The control group representing natural course history in absence of outside influence. The outside influence has an impact, is sufficient in cases, and may be necessary in cases. Identifying the necessary cases for application of a non-specific effect is the biggest opportunity for research in manual therapy, in my opinion. The cases where this is the case is likely very few as natural course history will most often catch up given enough time.

When it comes to manual therapy, my stance is that the scientific approach is to assume the null, which is that any effect is non-specific in nature. However, non-specific effects still provide benefit as outlined above. So, my inclination to use manual therapy is based on the assumption that I can do so 1) without being deceptive, without pretending that the effect is something other than non-specific and due to the magic of a needle or a special tissue, etc. and 2) it poses no greater risk than natural course history and 3) the patient can maintain self efficacy so there is no danger of worsening outcome and taking the unacceptable position of being worse than natural course history. These assumption direct my care and are based on a philosophical stance.

Hopefully this adds some fodder for fruitful discussion. If not, my apologies for the distraction.

[proud]

When it comes to manual therapy, my stance is that the scientific approach is to assume the null, which is that any effect is non-specific in nature. However, non-specific effects still provide benefit as outlined above. So, my inclination to use manual therapy is based on the assumption that I can do so 1) without being deceptive, without pretending that the effect is something other than non-specific and due to the magic of a needle or a special tissue, etc. and 2) it poses no greater risk than natural course history and 3) the patient can maintain self efficacy so there is no danger of worsening outcome and taking the unacceptable position of being worse than natural course history. These assumption direct my care and are based on a philosophical stance.

That's my approach in a nut shell. Thanks!

[Evanthis Raftopoulos]

Thank you for sharing valuable thoughts Cory.

In the absence of evidence the scientific approach is to assume the null, which in this case would be "no difference."

When it comes to manual therapy, my stance is that the scientific approach is to assume the null,

The questioning of Simple Contact here is in accordance with the above.

I'd like to add that science is not limited to that. With or without evidence we still need to examine the plausibility and falsifiability of the claims. I’m trying not to reduce any science based discussion to just evidence. As my understanding evolves in this thread, I find out that SC and its therapeutic claims have major problems in many aspects that constitute the scientific paradigm (see post 833 ).

Volitional movement is all secondary to intention, therefore all volitional movement is ideomotion and the phrase is helpful only so far as it differentiates this and brings intention into view.

Only if ideomotion = movement caused by an idea/thought. We have to leave the level of consciousness and awareness out, but then we are also changing Carpenter’s definition. Moreover, this contradicts many of the thoughts here (including Barrett’s) that lead to the speculation that idemotion is non-volitional movement. I'm interested in hearing what Barrett thinks about this.

Since all volitional movement is ideomotor, this means both "corrective" and "non-corrective" movements are ideomotor.

The problem is that the ideomotor effect was not created to be linked to corrective/non corrective movements in the context of pain resolution. So one could easily accuse us here that we are making things up.

There is some evidence to support the stance that self efficacy in recovery is preferable to a lack of self efficacy. So, what we're REALLY looking for is volitional movement that fosters self efficacy.

We can call this exercise/movement. The whole concept of ideomotion and therapy mystifies the above IMO.

Instinctive vs. not. Someone give me an example of non-instinctive movement, please. My stance is that, similar to ideomotion, ALL of our movements that are not coerced are instinctive, corrective or not.

My suggestion has been let’s leave instincts out of this. Human physiology is too complex and does not allow us to clearly differentiate between instincts and learned behaviors and in the context of movement. My current understanding is that movement that occurs due to an idea cannot be instinctive.

The point, as I see it, of the instinctive narrative is that the processes for movement recovery comes from the patient, processes that are internal to the patient.

Processes that are internal to the patient also involve thoughts and attitudes (learned behaviors) towards the pain problem. It is plausible that a dysfunction exists at this level that also affects physiology. If that’s true, then the opposite can also happen, positive thoughts (including related to placebo) can influence recovery in a positive way. I approach this issue from this angle, I don’t feel comfortable talking about instincts, given the reasons I provided in this thread.

Identifying the necessary cases for application of a non-specific effect is the biggest opportunity for research in manual therapy, in my opinion.

I think BobV mentioned recently something important about non-specific effects . If for example the effects we are are trying to deliver is placebo-related analgesia then the effect becomes specific. Non specific implies that we are trying to deliver something specific, and on top of that some non specific effects occur. Bob if you are reading this correct me if this has not been your point.

So, my inclination to use manual therapy is based on the assumption that I can do so 1) without being deceptive, without pretending that the effect is something other than non-specific and due to the magic of a needle or a special tissue, etc. and 2) it poses no greater risk than natural course history and 3) the patient can maintain self efficacy so there is no danger of worsening outcome and taking the unacceptable position of being worse than natural course history. These assumption direct my care and are based on a philosophical stance.

In your opinion, aren’t we being somewhat deceptive to the patient if we deliver manual therapy with methods/rationals that not only lack evidence, but also plausibility and falsifiability? This is how I feel at this point in time, and this justifies my position/arguments on manual therapy that I presented earlier and here.

[zendogg]

I would like to make a statement regarding this thread and some posts made recently by Patrick and subsequently by John, Barrett and Diane. Preemptively I'd like to say that I am a better therapist by leaps and bounds because of what I have learned and unlearned here at SS. The discussions on other modalities, many of which I have paid dearly for have helped me to question what I was doing and who I thought I was. The result is a confident and caring therapist who can help or at least guide many sufferers of pain.
So why my interest in questioning the topics of SC and ideomotion? I really am not in this discussion to null a premise (perhaps the others discussing this aren't either). I want to understand this topic so I can be te most effective therapist I can and at the same time, not fill my patients with hogwash.

So, here are the questions that I feel have not been answered yet in this thread.

Is the movement that we FEEL (yet can't see) in our patients that is elicited or magnified by our touch, THE active corrective element that diminishes pain? I'm not naming this movement because I don't really care what it's called. It is present and I want to know if it is the thing that is diminishing pain.

How is this movement (which I will not put a name to) any different from any other movement a patient is currently performing on their own (and yet they remain in pain before seeing us?). Said differently, motion is motion! Muscles and tissues move. If we claim this motion associated with simple contact has special capabilities wouldn't those capabilities be attributable to the brain rather than the movement itself? I cannot understand any movement in a body can be be seen as superior to another. How the brain perceives the motion seems a much more valid direction to focus our attention.

I did this before in this thread and I hope it is not inappropriate, but I still cannot fathom how afferent information elicited through greater than skin deep contact doesn't have the same potential to cue beneficial non-specific effects? This questions from Patrick and Diane's discussion in a different thread.


I'll start with that. I sincerely hope those who would reply to my questions would simply address the points I raise.

Nathan