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  • CT Enough is Enough

    When will we get over this constant search for holy grail therapy targets in the body?
    When will we run out of tissues to build castles of sand, dogma, gurus, and money out of?
    When will people realize the basic facts of pain perception and pain physiology? To treat painful problems, our target is and always has been the nervous system.
    Some days I just get so tired of people trying to convince each other of the supreme relevance of some connective tissue they are all excited about.
    Enough is enough already.

    First it was all about joint dysfunctions. Manual therapy was about finding and correcting misalignments and restoring normal position or movement to these dysfunctional segments. Then the research started to come in. Poor reliability between clinicians to find these misalignments. Plenty of "dysfunction" found in the asymptomatic. No valid way to demonstrate them or to connect them to any painful problem or show them changing as a result of treatment. But wait, the JointHeads say. We know that facet joints are innervated. We know they might play a role in proprioception. They are innervated for nociception, too. Its too early to not consider how important facet joints might be, they say.
    The treatments they propose to change these facet joints involve touching skin and moving joints, muscles, fascia, nerves, blood vessels, and lymph channels - whether its a treatment or exercise program. So the JointHeads can't even be sure its the facets that are being primarily targeted by their treatments. There are nonspecific and placebo effects to consider as well as natural history of mechanical pain disorders to consider.

    Then it was all about the intervertebral disk. Therapy was about finding and correcting bulges in the disk through exercises. Then the research started to come in. Poor reliability between clinicians to find these misalignments. Plenty of "dysfunction" found in the asymptomatic via imaging. No valid way to demonstrate them or to connect them to any painful problem or show them changing as a result of treatment. But wait, the DiskHeads say. We know that disks are innervated. We know they might play a role in proprioception. They are innervated for nociception, too. Its too early to not consider how important disks might be, they say.
    The treatments they propose to change these disk derangements involve touching skin and moving joints, muscles, fascia, nerves, blood vessels, and lymph channels - whether its a treatment or exercise program. So the DiskHeads can't even be sure its the disks that are being primarily targeted by their treatments. There are nonspecific and placebo effects to consider as well as natural history of mechanical pain disorders to consider.

    Then the MuscleHeads came around. Physical therapy should be about identifying postural dysfunction, weakness, trigger points, or inhibited muscles, and correcting them with various manual therapy or exercise techniques - hey maybe even poking them with needles. Then a little research came in. Poor reliability between clinicians to find these supposed problems. Plenty of "dysfunction" found in the asymptomatic. No valid way to demonstrate them or to connect them to any painful problem or show them changing as a result of treatment. But wait, the MuscleHeads say. We know that muscles are innervated. We know they play a role in proprioception. They are innervated for nociception, too. Its too early to not consider how important muscle dysfunction might be, they say.
    The treatments they propose to change these muscle problems involve touching skin and moving joints, muscles, fascia, nerves, blood vessels, and lymph channels - whether its a treatment or exercise program. So the MuscleHeads can't even be sure its the muscles themselves that are being primarily targeted by their treatments. There are nonspecific and placebo effects to consider as well as natural history of mechanical pain disorders to consider.

    Then the FasciaHeads came on the scene. Manual therapy should be about identifying restrictions in fascia and fascia mobility and correcting them with various manual therapy or exercise techniques - hey maybe even poking them with needles. There's almost no research on identifying these supposed fascial problems, and it's likely that its similar to other manual assessments - you know how this goes. Poor reliability between clinicians to find these supposed problems. Plenty of "dysfunction" found in the asymptomatic. No valid way to demonstrate these fascial restrictions or to connect them to any painful problem or show them changing as a result of treatment. But wait, the FasciaHeads say. We know that fascia is innervated. We know it plays a role in proprioception. Fascia is innervated for nociception, too. Look how it connects all these body regions like train tracks connect stations. Its too early to not consider how important fascial dysfunction might be, they say.
    The treatments they propose to change these muscle problems involve touching skin and moving joints, muscles, fascia, nerves, blood vessels, and lymph channels - whether its a treatment or exercise program. So the FasciaHeads can't even be sure its the fascia itself that is being primarily targeted by their treatments. There are nonspecific and placebo effects to consider as well as natural history of mechanical pain disorders to consider.

    People, we don't need any of these things to be important. If we are talking about pain, we are talking about something that occurs in the brain, not in the spine, or the muscles, or the joints. The nervous system and the complexity of perception and processing of pain is more than adequate as an explanatory model to drive our treatments. Approaches that target the brain or nervous tissue first would seem most concordant with the existing science. Traditional types of manual therapy are perfectly aligned with modern science if they rely on patient response to drive treatment decisions rather than stories about joint positioning, alignment, or "restrictions" of some kind.

    We need to collectively get over this pointless speculation about fascial restrictions, joint positioning, and trigger points. If people want to handle or treat their patients in ways traditionally associated with these methods, that's fine. But keep the neuroscience of pain at the forefront, pay attention to the great research coming out on manual therapy mechanisms, and for crying out loud don't give patients a giant nocebo by telling them they have fascia restrictions, inhibited muscles, or joints out of place. Because then I have to explain to them that that's not accurate. And that's exhausting. It's less about what you do and its more about how you explain it to patients and colleagues. You can explain it like a science-based practitioner or you can make up a story.

    Frankly, I'm tired of correcting the messes people make by transmitting these ideas to patients about pain and function that don't have any relation to modern pain science.
    Are you a JointHead, a DiskHead, a MuscleHead, or a FasciaHead?
    Don't change your tools, change your explanatory models.
    The thread "Crossing the Chasm" might help.

    Because really - enough is enough.

    ps Hey have you read this great new book by Professor/Doctor/Master [insert name here]? He's a [insert impressive credentials] who studied in all these cool universities in [insert countries here]. He says these problems have to do with restrictions in the mobility of the veins. He's shown in the lab they are innervated and look how they spread through the body like a web! Just pay $1000 for our three-day Level One VeinTherapy course and totally change your practice! Take the Level One Certified VeinTherapy Practitioner test (additional testing fee applies) and...
    Attached Files
    Last edited by bernard; 22-01-2011, 09:44 AM. Reason: added pdf
    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.

  • #2
    Sounds like someone needs a holiday.
    :lightbulb vox clamantis in deserto

    Geoff Fisher
    Physiotherapist

    Comment


    • #3
      :angry::clap2:

      Rant appreciated.
      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

      Comment


      • #4
        Geoff-
        Yeah I really do. Thanks for noticing.
        Jon-
        Sometimes you just gotta rant. I feel better after writing it though.
        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


        • #5
          http://www.hihh.com.au/Pages/default...FQbVbgodxxqA1g

          http://www.goldcoastinformation.com....FYE3pAodbWtb1g

          http://www.queenslandholidays.com.au...vents_home.cfm

          check these out for a start Jason. It's been a bit wet in the top end these last few weeks, but always room for another burnt out bloke with a fondness for warmth and sunshine.
          :lightbulb vox clamantis in deserto

          Geoff Fisher
          Physiotherapist

          Comment


          • #6
            VeinTherapy! lol you make my day!
            physiotek.com ------ __@
            Eric aka pht3k ---- _`\<,_
            ----------------- (*)/ (*)

            Comment


            • #7
              Jason,

              I share your toughts.

              thanks.
              Frédéric Wellens, pht
              «We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.»
              «
              Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate.
              »
              Friedrich Nietzsche
              www.physioaxis.ca
              chroniquesdedouleur blog

              Comment


              • #8
                Jason,

                Is that your graduation speech to the FAAOMPT Class of 2010?
                "The views expressed here are my own and do not reflect the views of my employer."

                Comment


                • #9
                  Well said, Jason.

                  The silliness of ongoing "new" clinical approaches in a mesodermal nutshell.

                  Nari

                  Comment


                  • #10
                    Oh , Jason , on the subjects you've attempted to cover, like most rants, you've managed to throw out a fair heap of perfectly good healthy babies with that bathwater. I'd touch on a few, but , the sun is shining.
                    Seriously though, start taking those chill pills or better still, get yourself over here and I could show you where the waves are . As I'm second in charge of the beer fridge I must go and see to the important work of the day. Cheers
                    :lightbulb vox clamantis in deserto

                    Geoff Fisher
                    Physiotherapist

                    Comment


                    • #11
                      Jason!! :thumbs_up:thumbs_up:thumbs_up

                      :clap2::clap2::clap2::clap2::clap2::clap2:
                      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


                      • #12
                        Thank you Jason, that was a great read. As I read your words, in my mind, I thought about those who are trained to be a hammer and everything looks like a nail-- or even in order to find balance one has to go from one extreme to the other. Or, even of those, who happen to be of high intellect, who teach certain methods, yet don't acknowledge ANY neuroscience-- ONLY what fits into the mindset beliefs they already have at a great disservice to the rest of us. I like what you wrote, thank you!

                        On another note, is the brain the holy grail because that is the final physical thing we can see? We think that at this time, but as we evolve will we realize more? And what more would there be to realize?
                        "The danger is not that the soul should doubt whether there is any bread, but that, by a lie, it should persuade itself that it is not hungry" (Simone Weil)

                        Comment


                        • #13
                          Jason,

                          I’m right with you, of course.

                          I see it this way: You've described colleagues that lack a quality any real opponent must possess – awareness that they are in a battle.

                          In my experience, the vast majority do not know that their explanatory model has been discredited, assuming of course that they even have one. They stopped fighting long ago and live quite comfortably within the fortress walls guarded by the “tissue-based” therapists that are hired by the universities to usher in a new generation or the therapists hired by con ed companies because their course has a catchy title. Neuroscience remains a “secret” of sorts, and if the schools know about it, they’re saying nothing to their students.

                          How do we get inside those walls?

                          The new therapists leave school and land in a PT culture now designed to discourage anything other than doing what’s always been done and thinking what’s always been thought. In order to overcome that resistance the new PT will need some friends; people with whom they don’t work but are always available and who understand. These friends should ask nothing in return.

                          Here we are.
                          Last edited by Barrett Dorko; 06-01-2011, 09:02 PM.
                          Barrett L. Dorko

                          Comment


                          • #14
                            Way to go Jason.
                            It is rare that a "rant" is done with such eloquence.
                            We don't see things as they are, we see things as WE are - Anais Nin

                            I suppose it's easier to believe something than it is to understand it.
                            Cmdr. Chris Hadfield on rise of poor / pseudo science

                            Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                            We don't need a body to feel a body. Ronald Melzack

                            Comment


                            • #15
                              Jason, several comments and at least one possible teaching gig await you on FaceBook.
                              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

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