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  • Tip The first ever DNM study the planet has seen

    Posted originally to one of those tedious Facebook threads where fascialists and non-fascialists try to knock each other out.
    Since DNM has been raised as a topic, and a call has been made for evidence, I would like to inform Flowers and others that, yes, DNM has been subjected to preliminary study. Full data was collected on four subjects. (Yes, I know, not very many.)

    We could have collected data for just 2 weeks, pre and post: two weeks is a standard for this A-B-A study design. But I objected - I thought 2 weeks didn't really say much at all about long term improvement from a treatment which included pain education and the manual part of which focused strictly on the nervous system as a continuously self-signalling entity from skin cell to sense of self. I wanted that pre-and post treatment phase to be as long as possible. We agreed to 8 weeks.

    Treatment period was 2 weeks, and contained three treatment sessions of an hour per except for the initial visit which was 90 minutes and included interview, assessment, pain ed. and some manual treatment.

    Subjects collected and submitted standardized pain score data for 8 weeks prior to to treatment phase and 8 weeks post. We started out with 7 subjects who met inclusion criteria, but 3 dropped out post treatment (we think they just got tired of collecting and submitting), so we chose not to include their data at all. Eight weeks was too long for them, probably.

    The data, once crunched into trend lines, showed decreasing pain in three subjects, while in the 4th, pain scores declined but went back up again post treatment.

    The data showed decreased variability in pain scoring. According to Dr. Susan Tupper at U Sask, whose PhD has to do with extracting pain information from juveniles with rheumatoid arthritis, decreased variability correlates strongly with "less suffering" from pain - if it becomes less unpredictable it becomes easier for people to manage.
    Overall the data showed "weak" (because the N was small) but "statistically significant" (take that however you like) support for the method. The study is ready to be written up and published somewhere. I plan to polish it up this winter. There has been no particular rush - the basic draft has been done and final writing will have to be as precise as possible which will mean many drafts, much word smithing etc.

    It's small, but it's solid, watertight, and it's a start.
    My opinion (FWIW) is that big isn't necessarily better. Furthermore, it isn't ever going to be possible for one's explanatory model to be completely "right" when treating something as nebulous as pain with something else as nebulous as manual therapy, but I think it IS important to continually strive to become ever "less wrong" by taking heed of the whole (i.e, neuroscience, not just tissue) and continually integrate it, so that manual therapy can eventually leave its ghetto existence by laying aside all explanatory models that are clunky, restrictive, and simply no longer fit modern 21st century concepts of full human organism function.
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
    HumanAntiGravitySuit blog
    Neurotonics PT Teamblog
    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
    Canadian Physiotherapy Association Pain Science Division Facebook page
    @PainPhysiosCan
    WCPT PhysiotherapyPainNetwork on Facebook
    @WCPTPTPN
    Neuroscience and Pain Science for Manual PTs Facebook page

    @dfjpt
    SomaSimple on Facebook
    @somasimple

    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

  • #2
    I want to update this thread. :sad:
    Disappointingly, Angela, the head researcher on this, has decided not to pursue publication. After Susan Tupper had a close look at the data and ran some very sophisticated analyses on it, she noticed problems with the post-treatment data, i.e., it looked like it had been backfilled. The consensus was, between Angela and her, that it was a ruined effort, mainly because of problems that were inherent in the design itself.

    Dang, I hate when that happens. :cry:
    I
    worked
    so
    hard
    treating
    all
    those
    people
    for
    free
    plus paying
    them
    to
    participate.
    :angry::thumbs_do

    I trust Susan's opinion about this - she has a PhD based on a research project she did to bring apps into existence whereby children with rheumatoid arthritis can tap an iPhone that alerts them that it's time to tap, at strategic intervals throughout the day, to record pain scores: she managed to validate the process as being closer to accuracy than paper entries or relying on memory.

    Anyway. My little study is headed for the trash can, looks like. :cry:
    Not because DNM doesn't help people clinically, but rather because
    a) there were so few complete data sets to work with
    b) the ones that were complete were also suspect (see above)
    c) the design didn't work:
    - the data collectors and crunchers lived 1000 miles away, and had to instruct participants by phone, and hope that they understood everything
    - the pretreatment and post treatment windows were too long (my bad - in newbie enthusiasm mode, I suggested 8 weeks instead of the usual two weeks: someone who had already run studies like this should have put their foot down and said, no Diane, those windows are way too long - people will get bored entering data for that long, and the study will be ruined. Which happened.)
    Angela is soon retiring, so my shot at having any chance of doing another study, myself, in collaboration with her, is pretty much over and done. :sad:

    On the bright side, even if it is never to be published, it has been presented (Congress 2010, St. John's), and... there is some interest in running a new study, in Portugal, where PT contains a thick current of traditional and well-respected spa history. :thumbs_up

    So, we shall see. I am deeply uncertain I'll live long enough to see any fruits emerge, but one never knows. :thumbs_up

    Oh well.
    Life eh? You can make lemonade out of lemons, but only if the lemons are any good in the first place.
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
    HumanAntiGravitySuit blog
    Neurotonics PT Teamblog
    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
    Canadian Physiotherapy Association Pain Science Division Facebook page
    @PainPhysiosCan
    WCPT PhysiotherapyPainNetwork on Facebook
    @WCPTPTPN
    Neuroscience and Pain Science for Manual PTs Facebook page

    @dfjpt
    SomaSimple on Facebook
    @somasimple

    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

    Comment


    • #3
      Diane,

      It depends on how you define fruit.

      Making therapists think, defend an argument and not just blithely offer an opinion based upon their sacred experience, which I think is way overrated, and explain to others by legitimately simplifying the research already done in an effort to make us less wrong in our limited observations is FRUIT.

      You're the one usually refering to composting (which often involves fruit), and you've done far more than any therapist I know.

      I know you'll do more.
      Barrett L. Dorko

      Comment


      • #4
        Hi Diane!

        Anyway. My little study is headed for the trash can, looks like. :cry:
        Not because DNM doesn't help people clinically, but rather because
        a) there were so few complete data sets to work with
        b) the ones that were complete were also suspect (see above)
        c) the design didn't work:

        - the data collectors and crunchers lived 1000 miles away, and had to instruct participants by phone, and hope that they understood everything

        - the pretreatment and post treatment windows were too long (my bad - in newbie enthusiasm mode, I suggested 8 weeks instead of the usual two weeks: someone who had already run studies like this should have put their foot down and said, no Diane, those windows are way too long - people will get bored entering data for that long, and the study will be ruined. Which happened.)

        From my perspective, what this does is enhance the credibility of the researchers who looked closely at what they had done and found flaws that peer reviewers would have concerns about.

        What has been accomplished is corroborating once again that quality research is really hard, slogging work for those with enough professional integrity not to engage in, as Goldacre would say, "selectively quoting [which even Linus Pauling did ]or cooking the numbers."

        Comment


        • #5
          Thanks for the bone, Barrett.. but you do realize, I think, that the scientific world demands evidence too, methodologically attained.

          I am more ambitious that just convincing people based on other peoples' evidence. I want there to be data to support the inclusion of human primate social grooming into the culture itself. Nothing less will do. (Is that aiming too high?)

          Hey, you have to aim high, right? I want the culture to change. I want to change the culture. (Or die trying, but I'm already dead, so what does it matter?)

          Yeah, I know this is only an atom, and it takes a lot of atoms to make a molecule, and a whole bunch of molecules to make a drop, and a lot of drops to change a whole ocean of culture, but what the hey. I might as well die (for real) trying, or at least having tried my best.
          Diane
          www.dermoneuromodulation.com
          SensibleSolutionsPhysiotherapy
          HumanAntiGravitySuit blog
          Neurotonics PT Teamblog
          Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
          Canadian Physiotherapy Association Pain Science Division Facebook page
          @PainPhysiosCan
          WCPT PhysiotherapyPainNetwork on Facebook
          @WCPTPTPN
          Neuroscience and Pain Science for Manual PTs Facebook page

          @dfjpt
          SomaSimple on Facebook
          @somasimple

          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

          Comment


          • #6
            I see your point Diane. Perhaps I currently have a greater sense of mortality and time left. I imagine someone in the future saying, "Dorko described this..."

            There's also the possibility that I've watched more TV than you and can remember Tony Soprano saying to his psychiatrist, "I been coming here too long. I know too much about the unconscious."

            Its power is just now being discovered, and, when considered, will call into question many previously done studies while it means others will be abandoned.

            I have bowed to that.
            Barrett L. Dorko

            Comment


            • #7
              I was given a copy of Barrett's essay 'Without Volition' by a patient here in the UK in '06, I had worked with ideomotion since the late '70s without really knowing what it was and he was one of the few patients who not only recognised it but wasn't freaked out to some extent. I was so blown away I couldn't sleep that night.

              Those of you brave enough to put yourselves out there are so very much appreciated by many who don't know how to tell you.

              Jo
              Last edited by Jo Bowyer; 01-06-2013, 07:25 PM. Reason: spelling
              Jo Bowyer
              Chartered Physiotherapist Registered Osteopath.
              "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

              Comment


              • #8
                Thanks Jo. I must remember that the Internet has made such things possible while highlighting the fact that I can't fill a course in my region.

                One makes you understand how many people think like you while the other reminds you that they aren't nearby.
                Barrett L. Dorko

                Comment


                • #9
                  Originally posted by Diane View Post
                  but you do realize, I think, that the scientific world demands evidence too, methodologically attained.
                  :thumbs_up

                  like this one.....not just someone has described something

                  Weni

                  Comment


                  • #10
                    Hello there Diane,

                    Would you consider redoing the DNM study using the 2 week format instead?

                    I am very much interested in research. I've always wanted to do it, but in PT school, I had no idea what was going on and what I wanted to research.

                    Two years ago, I was doing a lit review for a study to describe hip, innominate, and sacral mobility testing and treatment for hip pinch / impingement. Yes, very mesodermal. What I learned during the lit review was that there is little validity and reliability with palpation. This lead to the questioning of myself as a manual therapist and eventually I was guided here.

                    I am now fascinated with the study of palpation and I am now working on a study with our speech therapist regarding cervical / thoracic restrictions and swallowing.

                    Anyway, if you are still interested, the non-profit Orange Coast Memorial Foundation where I work has funded many research projects through grants requested by employees. There is even a research team that deals with the IRB and statistics. Data collection is all on us.... feel free to send me a message, email, or phone...

                    Extra time is scarce, I am no able to travel, ....but I am up for the challenge.

                    Rex
                    Rex Fujiwara, MPT,OCS
                    Physical Therapist
                    www.painsciencecenter.com

                    Comment


                    • #11
                      This type of situation is extremely common in clinical research, and highlights the great effort on the part of patients, clinicians and statisiticians to produce research. The sheer number of invested hours for the smallest project at once demonstrates how difficult science is to do and what a steep slope there is for a clinician to climb.

                      Very often the project can't be brought to completion for reasons entirely beyond the investigator's control. My sympathies Diane, I've been there too - literally.
                      Jason Silvernail DPT, DSc, FAAOMPT
                      Board-Certified in Orthopedic Physical Therapy
                      Fellowship-Trained in Orthopedic Manual Therapy

                      Certified Strength and Conditioning Specialist


                      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                      Comment


                      • #12
                        Originally posted by rex08 View Post
                        Hello there Diane,

                        Would you consider redoing the DNM study using the 2 week format instead?

                        I am very much interested in research. I've always wanted to do it, but in PT school, I had no idea what was going on and what I wanted to research.

                        Two years ago, I was doing a lit review for a study to describe hip, innominate, and sacral mobility testing and treatment for hip pinch / impingement. Yes, very mesodermal. What I learned during the lit review was that there is little validity and reliability with palpation. This lead to the questioning of myself as a manual therapist and eventually I was guided here.

                        I am now fascinated with the study of palpation and I am now working on a study with our speech therapist regarding cervical / thoracic restrictions and swallowing.

                        Anyway, if you are still interested, the non-profit Orange Coast Memorial Foundation where I work has funded many research projects through grants requested by employees. There is even a research team that deals with the IRB and statistics. Data collection is all on us.... feel free to send me a message, email, or phone...

                        Extra time is scarce, I am no able to travel, ....but I am up for the challenge.

                        Rex
                        How do you see something like another stab at a DNM study with a two week window happening through your workplace?
                        Diane
                        www.dermoneuromodulation.com
                        SensibleSolutionsPhysiotherapy
                        HumanAntiGravitySuit blog
                        Neurotonics PT Teamblog
                        Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                        Canadian Physiotherapy Association Pain Science Division Facebook page
                        @PainPhysiosCan
                        WCPT PhysiotherapyPainNetwork on Facebook
                        @WCPTPTPN
                        Neuroscience and Pain Science for Manual PTs Facebook page

                        @dfjpt
                        SomaSimple on Facebook
                        @somasimple

                        "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                        “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                        “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                        "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                        "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                        Comment


                        • #13
                          Diane,

                          I should rephrase my question to you.... Would you be interested in redoing the treatment portion of the study if I can get funding for you to do it?

                          The only difference would be the length of data collection. We can re-do your study but collect data for 2 weeks only, since you mentioned that duration is standard for an ABA design. Do you think that it would make a difference?

                          I also think that descriptive studies are also important using case series to get the DNM information out to the general practice. Using case series, you can collect outcome scores such as a modified Oswestry, lower extremity disability index, and etc. If you would like to go that route?

                          Rex
                          Rex Fujiwara, MPT,OCS
                          Physical Therapist
                          www.painsciencecenter.com

                          Comment


                          • #14
                            Hi Rex,
                            Sounds tempting, but I have got to say, I'm a bit hesitant. Trying to do this long distance was a nightmare. The contact between the statisticians who wanted the data, and were trying to handle data collection, and the participants who were selected (met the inclusion criteria) and ended up in my clinic being treated by me, was by phone.

                            In the end, they got free treatment from me and screwed up the data, because there was no local oversight available, and they didn't really understand the process, filtering it only through their auditory systems.

                            The statisticians needed to have some face time with the participants, we all agreed later. Post huge wasted effort.

                            On the upside, the study was cheap to do. Other than the university making a lot of wasted long distance telephone calls. My own bill came to under a hundred dollars, for postage, and paying the participants a token amount for parking. My downside: the hours and hours of lifespan I spent treating people for free, just to try to have something in the literature, will never be recovered or compensated.

                            If someone else wanted to do this (test DNM), I'd sound more enthusiastic.
                            Diane
                            www.dermoneuromodulation.com
                            SensibleSolutionsPhysiotherapy
                            HumanAntiGravitySuit blog
                            Neurotonics PT Teamblog
                            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                            Canadian Physiotherapy Association Pain Science Division Facebook page
                            @PainPhysiosCan
                            WCPT PhysiotherapyPainNetwork on Facebook
                            @WCPTPTPN
                            Neuroscience and Pain Science for Manual PTs Facebook page

                            @dfjpt
                            SomaSimple on Facebook
                            @somasimple

                            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                            Comment


                            • #15
                              Hi Diane!

                              Goldacre noted the following, which I thought you might find interesting:

                              "From the current knowlege, around 13 percent of all treatments have good evidence, and a further 21 percents are likely to be beneficial. This sounds low, but it seems the more common treatments tend to have a better evidence base."

                              He further notes that, as a result of the 90's, when lots of things were being done, it turns out that between 50 and 80 percent of all medical activity is "evidence based."

                              "It's still not great," he said, "and if you have any ideas on how to improve that, do please write about it."
                              Last edited by Ken Jakalski; 02-06-2013, 06:37 PM.

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