Enough is Enough

[Randy Dixon]

I know I like it here on $oma$imple.

[Jason Silvernail]

John you are exactly right about the Mobili$ation industry.

Randy I am offended. Clearly you aimed that at me, and I demand an apology! [kidding]

[bernard]

What i$ the problem Ja$on $ilvernail?

[Jason Silvernail]

Ju$t too $en$itive I gue$$...

[bernard]

Ah, I thouht it wa$ a k€¥board probl€m.

[MaxG]

enjoyed your post. agree with many of your statements , however, the one thing that catches my attention is that you continue to talk about "pain treatment"
Stanley Paris in the 80's "treat function not pain", Vladimir Janda in the 90's "treat the cause of pain , not the site", Karel Lewit " he who chases the site of pain is often lost, and so is the patient"....so
I totally agree that there is a need for a better understanding from our pts side that their pain is not just in the affected tissue (specially when dealing with chronic conditions)
there is a need for a better understanding from the clinicians standpoint that this is happening.
there is a need for approaching pts in a different way...

It seems to me like janda and lewit's quotes actually support a ecto-centric view of the pain problem, no?

but again... as I understand Craig Liebenson also meant to say (hope I'm right) there is also a need and a time for applying years and years of scientific work (either that be muscle, joint, fascia, facet or whatever they will find soon) ... we could potentially say the same for the ones who try to approach a msk problem "just " using a neuro approach (pain modification , modulation, re-organization or whatever name they will find soon!!)

It's not so much about applying the scientific work, but recognizing the actual message and the limits of the work done on "muscle, joint, fascia, facet or whatever they will find soon". Just because there have been studies done, e.g. on the efficacy of trigger point therapy techniques, doesn't mean the theory behind trigger points holds up. It just proves that finding a painfull spot that has referred pain patterns and putting pressure on it relives pain.
A lot of the studies done on various techniques use exactly such reasoning to "prove" their theoretical construct.

I have this theory that magic elves pull everything to the ground, which is why we don't fall off the face of the earth. Want proof? Here, if I hold this apple and let go of it, it falls down. The elves exist!

This is an absurd example, I know, but it exemplifies the general criticism quite well.

we are now at a moment in which many "neuro" theories on how to approach pain are coming to light, so..... lets be careful, this approach will not improve a posterior glide, nor elongate a shortened muscles, nor re-create a muscular balance in an affected region!!

It might help if you define the "many" neuro-theories you are talking about.
The point is not really to throw around different theoretical constructs and trying to prove they are true (otpimally by cherry picking evidence), but about finding a scientific basis that explains the clinical success of the highly varying therapeutic methods we use.
This is necessary of course, so we can ethically use them on patients that expect expertise on our part and second, to improve clinical reasoning and development of an adequate treatment plan for each patient.

I think your comment is a great wake-up call for many. Let's not just take the path of least resistance(Sahrmann) as many of our movements tend to do.
if there is dysfunction, then it needs to be treated, maybe not just by itself though...
as Gregory Grieve said. "technique is not of outmost importance, but a deeper understanding of the problem is"

Some questions re: treating dysfunction.
Can a dysfunction be protective? If so, would you treat it?
Can you permanently correct a dysfunction?
Do you reliably improve other factors such as pain or disability when treating a dysfunction?
What is a dysfunction? How do you prove it?

Dysfunction is a loaded word and means very different things to different practicioners.
Is a lack of knee flexion a dysfunction?
Is a "vertebral subluxation" a dysfunction?
Is a lack of "visceral osscilation" a dysfunction?
Is a lack of "cerebrospinal-fluid pulse" a dysfunction?
Is an abnormal gait a dysfunction? What is abnormal?
Is a stiff neck a dysfunction? Might it not be protective?

[Jason Silvernail]

Great points Max.

I'd also like to reiterate (again) for everyone that taking a primarily neuro- based approach does not mean we don't use peripheral treatment, manual therapy, or exercise. It just means we explain it differently. Crossing the chasm, etc.

[valpospine]

enough is enough?

just to answer a few comments.
Diane: you wanted to know something about me. briefly: Certified Manual Therapist (Paris), trained with Lewit in Prague, Janda in the US, finished Muscle Imbalances with Sahrmann.
hope that helps to identify the approach I follow . (Barrett: sorry to hear your opinion on Stanley Paris) (he did change the way I approached our profession)(maybe you did not stay long enough)
Jason , John and Barrett: I'm not a fascia guy, nor I intend to be.
Jason: you had questions about the main idea of my comments. Just to summarize it: again, you said it at the beginning "if we are treating painful problems..." from the beginning , I do follow a different philosophy which is "treat function , not pain "
my comment was intended just to be a wake up call since you mentioned that you are tired of the FasciaHead, and MuscleHead, and so on..., so none of us becomes a NeuroHead nor a PainHead. cause you know what? ... that could potentially be dangerous too.
glad to hear that you do utilize peripheral treatments too, for a while it looked like you were so tired of them that you could not use them anymore. as you mentioned, there is a lot of evidence based manual therapy that could very well be utilized in the care of our patients. hope there is equal or better evidence in the "neuro based" theories!!
anyway, maybe I was misinterpreted. as I said it, I do accept that in the care of pts, specially chronic ones, there is a need for a much more complex approach that the pure mechanical one. maybe the pain perception, behavior, physiology theories have a piece in this puzzle too. not just the whole puzzle though.
ps: hope that your fill in the blanks final quote wasnt talking about the PainHeads!!(just kidding)
anyway, it is great to see this happening. I think it helps us all. best regards, and Jason , thanks for starting it.

[Barrett Dorko]

(Barrett: sorry to hear your opinion on Stanley Paris) (he did change the way I approached our profession)(maybe you did not stay long enough)

I worked and taught alongside Paris for four years during the late seventies, talked to him intermittantly, saw him present over the years, conducted a workshop for Stan, his faculty and staff in Florida in '08 and listened to him interviewed recently.

No real change as far as I can see.

[Bas Asselbergs]

"treat function , not pain "

Valpo, I need some further explanation. What function do you treat? My credo is: "I treat people in pain, not parts or systems". And my background is Cyriax, then Maitland and Kaltenborn, then Janda, Sharmann, Dos Winkel, Mitchell and Greenman, Kuchera - and despite the many many hours I spent learning from them, there was not one with enough understanding of pain.
Not one.

Now that that knowledge is available, I have been able to shed all that luggage from those methods and principles. Since it is not about function - it is about pain resolution.

[Ken Jakalski]

Hi Jason!

What continually amazes me about you is that you're also an S&C guy--who doesn't think like most S&C guys I know. That you are able to separate yourself from so many who have a "collegial certainty" on many of this issues is pretty impressive.

[Ken Jakalski]

Hi Diane!

pain is an opinion the brain has about the body, that it isn't always right

I really like this line. It's easy to remember...and essential to share with others serious about treating pain, but seriously mired in approaches that make little sense.

[Jason Silvernail]

Thanks Ken. My S&C background happened after I started my career in therapy so I didn't spend much time in the S&C industry per se. My online discussions started at the NSCA forum where I was humbled by some great coaches who had a lot to teach me about motor control, skill acquisition, and training effects.

Valpo-
Maybe we just work in different environments. It makes sense for me to be focused on pain (painhead if you like) because that's what my patients come to see me for. I use my knowledge of biomechanics, exercise phys, motor control, pain neurophys and rehab science to help my patients feel better. I do plenty of functional stuff but in most cases pain is the primary issue. Maybe you work in a place where people come in because they aren't functioning well and they want your help. I've never heard of a place like that but i guess those places are out there. If that's the case I suppose it makes sense to not focus on pain because your patients don't really have that as a complaint, they come in not being able to do something and you help them with that (or something).

I don't think that would work for me since my patients have issues with pain primarily and when that's sorted out their function seems to return without too much trouble. Its been my experience that for mechanical pain cases i can't get function unless most of the pain has resolved. Trying to get function too soon just over-exercises them and exacerbates the problem and that's usually what they are doing on their own that lead them to see me. In order to help them, I have to get them to slow their function down so we can resolve the mechanical problem first. If they could stretch or strengthen their way out of pain they wouldn't have come to see me in the first place, since my patients are Soldiers in the US Army (currently).

For those with more central sensitization (eg Fibromyalgia) issues I guess focusing on function over pain might make sense since we aren't as likely to influence pain given the mechanism, but we do need to improve quality of life - taking more of a graded exercise/graded exposure approach is a viable option. Ironically you kind of have to be a painhead to recognize that. Funny huh?

[MaxG]

just to answer a few comments.
Diane: you wanted to know something about me. briefly: Certified Manual Therapist (Paris), trained with Lewit in Prague, Janda in the US, finished Muscle Imbalances with Sahrmann.
hope that helps to identify the approach I follow . (Barrett: sorry to hear your opinion on Stanley Paris) (he did change the way I approached our profession)(maybe you did not stay long enough)
Jason , John and Barrett: I'm not a fascia guy, nor I intend to be.
Jason: you had questions about the main idea of my comments. Just to summarize it: again, you said it at the beginning "if we are treating painful problems..." from the beginning , I do follow a different philosophy which is "treat function , not pain "
my comment was intended just to be a wake up call since you mentioned that you are tired of the FasciaHead, and MuscleHead, and so on..., so none of us becomes a NeuroHead nor a PainHead. cause you know what? ... that could potentially be dangerous too.
glad to hear that you do utilize peripheral treatments too, for a while it looked like you were so tired of them that you could not use them anymore. as you mentioned, there is a lot of evidence based manual therapy that could very well be utilized in the care of our patients. hope there is equal or better evidence in the "neuro based" theories!!
anyway, maybe I was misinterpreted. as I said it, I do accept that in the care of pts, specially chronic ones, there is a need for a much more complex approach that the pure mechanical one. maybe the pain perception, behavior, physiology theories have a piece in this puzzle too. not just the whole puzzle though.
ps: hope that your fill in the blanks final quote wasnt talking about the PainHeads!!(just kidding)
anyway, it is great to see this happening. I think it helps us all. best regards, and Jason , thanks for starting it.

Valpo, I'm fine with you not going into my previous post, but I repeat my question:
What is a "neuro" approach to you?

I think many people that oppose the general ideas surfacing here completely miss the fact that it's not always about questioning the therapeutic intervention, but the theory behind it, or the idea guiding its implementation.

I assume, and correct me if I'm wrong, that you mean non-contact interventions when you say "neuro-approach" (ie. explaining pain physiology, graded exposure).
Or do you mean neurodynamics?

[Jason Silvernail]

I think many people that oppose the general ideas surfacing here completely miss the fact that it's not always about questioning the therapeutic intervention, but the theory behind it, or the idea guiding its implementation.

:clap2: