Enough is Enough

[zimney3pt]

Had a horrible experience the other day when I was up helping with lab class at the University that I do some adjunct work with. The primary instructor was teaching the old typical open/closed facet biomechanical model joint mobilization info and assessing based on flex or extension and if the transverse process on one side moves or doesn't move and how you would determine if stuck open or closed and then which mobilization and position you should put the patient in based on that assessment.

I think my lip started to bleed I had to bite it so hard, plus my blood pressure was going off the chart.

Then after this wonderful instruction he gave, with the students staring in almost total confusion, he states that these palpation techniques have not been shown to be very reliable and we can't trust them very much. And later he went off how important that use of joint mobilizations are and that clinicians not using it are not practicing very good evidence based practice because of the effectiveness of them. I wanted to scream and therapist using this biomechanical model are also not using very good evidence based practice either, stop hoarding old rationals for treatments!!!!

So during lab time I would go around and try to help explain the whole open/closed facet thing in respect to sidebending, flexion and rotation. Then I would go into my rant (making sure the lead instructor was on the other side of the room) explaining why trying to use that reasoning is bunk and needs to just be gotten rid of and not hoarded any longer based on the evidence that we have. The response from every student when I got done was: "I like the way you think and explain things better." It could be so much easier if I didn't have to be so covert about trying to get good info into their heads.

[zimney3pt]

Steve, I have had a couple of these as well in my almost 20 years, and your statement sums them up perfectly.

And man is it easy to handle!

[John W]

it is true, pain is what brings the pt to us and it is from the pain that they seek relief from . while we seek to manage their pain, we must adress our attention to the cause of pain. (treat the underlying dysfunction which is probably why they hurt!!)

Will you acknowledge these two statements?:
1) Many patients have evidence of "dysfunction" that don't hurt, e.g. bulging discs, degenerative facet joints, etc.
2) Many of the "dysfunctions" that PTs have traditionally made so much of a stink over, e.g. joint asymmetries, muscle imbalances, trigger points etc. lack diagnostic accuracy.

I suggest you read Jason Silvernail thread "The Problem with OMPT" and then take a look at several of the links and resources there and in the "Moderators' Current Consensus on Pain".

[Jackson]

a couple of interesting things: pain is not always a warning sign, pain is not in proportion to the severity of the pathology, lessening of the pain does not always signal improvement and pain is affected by stimuli other than dysfunction. (hope you all agree with this!!)

Improvement is too ambiguous a term. Is improvement in your mind the same as improvement in your patient's mind? Where do you draw the line of treating non-painful "dysfunctions?"

Nick

[Diane]

Steve, I have had a couple of these as well in my almost 20 years, and your statement sums them up perfectly.

Yeah, you see people once in awhile who simply do not seem to be nociceptive. I treated a woman, in her 60's, like this recently. She came in with just one place that felt cranky to her, just behind the greater trochanter but her main complaint was she having trouble bending her knee. It didn't hurt, it just felt tight.

I really think there are different ways people are wired, peripherally and centrally, when it comes to nociception and pain. She had given birth to 4 children. I asked her how her births were. She said, really easy, no more than three hours, even with the first one.

Her entire leg was swollen, compared to the other one. All the way from top to bottom. She told me her doctor didn't think there was anything wrong with that. I was a bit concerned about possible blood clot, so I avoided the knee/lower leg, treated her at the hip (which had pretty good range), did my thing with inguinal nerves, treated her around the GT. When she got back up her leg was already smaller and she could feel more room inside her leg. And she needed to visit the bathroom, probably because her leg was finally draining. I talked a bit to her about how it might be a good idea to sleep on her other side half the time (she was one of those 'sleep on the same side for 40 years' kind of people). She hasn't had to come back. So yeah, easy.

[Jason Silvernail]

Yes, when I was talking about the neuro-based approaches , I was talking about the "non contact intervention" (pain physiology) , not about neurodynamics .

We addressed the mistaken conflation of "no contact interventions" with neural explanatory models above.

Jason and John W: yes, I did say that that I was glad to see Jason using peripheral approaches too because for a while, in his initial comment, it looked like he was throwing it all away, since he was so tired of us (the MuscleHeads, JointHeads etc)(plus , his thread title says a lot: "enough is enough" ) but anyway, good to see it's still happening Jason.

I think if you consider this an "us vs them" issue you will needlessly personalize the discussion to an extent that isn't helpful. You're certainly free to do what you like of course.

Jason: no, I do not work in an uncommon facility, and we do see the same type of pts, with the same issues. we just approach them in a different way.

I'm sure we do from an explanation standpoint. Whether we are different from a physical intervention standpoint is yet to be determined I think.

it is true, pain is what brings the pt to us and it is from the pain that they seek relief from . while we seek to manage their pain, we must adress our attention to the cause of pain. (treat the underlying dysfunction which is probably why they hurt!!)

If you think you can find the "cause of pain" and that it is dysfunction of some kind, you are expressing opinions that are contrary to the published literature, and that's putting it gently. We have reasoning models (e.g. Maitland, MDT) that can help us establish relationships between certain impairments and painful problems, but this is far from causation. How you can talk so confidently of the cause of pain and also use the term "evidence based" in your post is beyond me.

a couple of interesting things: pain is not always a warning sign, pain is not in proportion to the severity of the pathology, lessening of the pain does not always signal improvement and pain is affected by stimuli other than dysfunction. (hope you all agree with this!!)

I for one do not agree with your list of interesting things here. I do find it interesting that you label dysfunction the cause of pain above yet say it's affected by stimuli other than dysfunction here.

Lorimer said it so clearly in his speech in SAU, "the use of this tools (neurophysiology) does not imply that we must forget nor stop treating the periphery"
please understand: this is all I mean to say. there is a place for it. maybe you are just making it too big... but I guess its ok. it's your way of going.

If you are arguing that there is a place for peripheral treatment, then not only would I agree but I'd point out no one here has EVER suggested anything else, nor have I in the first post. What is the "it" that you feel I am "making too big"?

however, it does look like knowing neuroscience excuses you from being an evidence based manual therapist!!

How do you figure that?

modern neuroscience has a place in our tool box... just as much as the joint, the facets, and the muscles do.
best regards.

I disagree that all these things are equally important. The nature and function of the nerve tissue and the primacy of the brain in the pain experience is far more relevant to clinical practice than the state of the facet joint, for example. We have multiple imaging studies showing various degenerative states of the connective tissue in the absence of pain. Doesn't mean connective tissue is irrelevant, just means its relevance in the absence of trauma, injury, or systemic disease must be closely questioned. If you think they are "equally" important ("just as much...") then I would say I disagree with your ranking based on the relevant basic science of the tissues under discussion and our current understanding of the pain experience.

[Barrett Dorko]

It's no secret that I feel those who insist on not identifying themselves by name have some explaining to do and aren't ordinarily taken very seriously by me.

Jason's comments above will do for now, and I look forward to some sort of response. What form that will take is beyond my imagining.

Please explain what you mean by "cause." It's something we've discussed here many times in the past.

[MaxG]

Thanks for that John. I am continually disappointed in the extent people associate peripheral treatment with one particular connective tissue explanatory model.
I've said before,

I have had trouble getting this sort of thing across before and maybe my approach could use some assistance, I'm open to suggestions. Other examples from one of the most frustrating threads here, in my opinion here, here, here and here.

Them: "You don't think joint dysfunction isn't closely related to pain? You must not mobilize joints then."
Me: "Uh - what?"

I think this particular criticism is telling us something useful, actually. Its telling us more than we might want to hear of the catastrophic failure of our programs to produce clinicians who genuinely understand critical thinking, the difference between a treatment and the theory behind it, and the basic science that underlies our practice. There's some good news for us this friday.

When your approach continously evolves for over a decade or so in a particular direction, I think you sometimes forget all the crossroads and detours you've encountered along the way.
This leads to many misconceptions when talking directions to people who are on a completely different highway.
No offense intended, Jason.

[zimney3pt]

modern neuroscience has a place in our tool box... just as much as the joint, the facets, and the muscles do.
best regards.

I wish we would get away from this whole tool box analogy, it is worthless in how we seem to use it.

I can go down to the local hardware store and buy thousands of tools and get the largest toolbox in the world to store them all in, but unless I know how and when to use them they are worthless. More tools in my tool box does not make me a better carpenter. Knowing how and why a tool works makes me a better carpenter. Let's quit adding tools to our toolbox and just understand the tools we have. When we do this I think we will notice we can junk a lot of tools that we thought we needed.

[Bas Asselbergs]

"teammate" Bar does not think the same. he was able to "shed the luggage from all those methods"!!!(PainHead?)

I'll forgive you your typo of my name, but not misinterpreting what I say and do (I have not been clear, probably).

The "luggage" of all those manual specialization courses is mainly the associated explanation of the techniques or methods taught (joints, joints, joints, muscles, muscles, muscles); I got rid of those explanations.

Second, the "luggage" of forceful manipulations of any body part has been thrown into the luggage caroussel at Heathrow; it will never make it back to me.

I still use my hands, but more so my brain, and my thinking and listening capabilities.

I hope it is now very clear that none of us regulars here have thrown out our experience (short or long) with our hands, our knowledge of biomechanics and tissue pathology, and so forth.......

[Sheffphysio]

This thread brings back some memories as it brought me to SS from BIM.

Speaking of tools and toolbox. I was in a meeting recently discussing the problem of new grad therapists getting thumb pain and having to change what they do or leave the profession. My question was "Rather than worry about what to do when a therapist gets thumb pain, shouldn't the bigger question be why are we teaching out new grad therapist to thump patients in the back so hard it damages their thumbs". There was a silence.........we moved on.

[nari]

The use of the word "toolbox" is suggesting that we treat inanimate objects like planes, trains and automobiles.

We actually treat living critters whose systems react one way or the other to our interventions to a higher degree than we probably will ever know.

Nari

[amacs]

The use of the word "toolbox" is suggesting that we treat inanimate objects like planes, trains and automobiles.

Like machines - linear, organised, and unable to self repair. An approach that seems to reach beyond anatomical to mechanical and really doesn't seem to grasp the physiology of the process and in doing so risks depersonalisation of the individual.

regards

ANdy

[zimney3pt]

Great points Andy and Nari, once again looking at nouns instead of verbs as Diane always puts it.

[Jason Silvernail]

When your approach continously evolves for over a decade or so in a particular direction, I think you sometimes forget all the crossroads and detours you've encountered along the way.
This leads to many misconceptions when talking directions to people who are on a completely different highway.
No offense intended, Jason.

Thanks, Max, good comments, and no offense taken. I did ask for feedback. If you have some suggestions for getting me and them on the same road sooner rather than later, I'm all ears. Vielen dank-