Are things getting hot on twitter?

[PatrickL]

You don't have to care what I think. But you should care about the holes in your own thinking that I've pointed out.

[Diane]

What might look like holes to you, I prefer to think of as space I've managed to open up by decluttering.

[Diane]

One last post from me, and I will declare this thread done to death.

1. Manual therapy is not a "thing" - it's an intrinsic behaviour evolved from social grooming in vertebrates and conceptualized by human primates, taught from the time humans could talk, bottom-up/operator style.
2. Manual therapy should be about pain and pain relief.
3. Pain, and relief of pain, is strictly a top-down phenomenon. It occurs only in ectodermal derivatives, specifically the brain. Nerves and spinal cord are antecedent, and very important physiologically, to a emergent pain production.
4. Manual therapy models must adapt, teach about pain, teach top-down, not just bottom-up, and interactively, not only operatively.
5. The senses are the only way into any patient's brain. Talking/education are paramount; furthermore, touching is allowed us; skin receptors have the fastest highway into the brain (DCML), and to its output mechanisms, by any manual therapist, so these should be in sharp focus.
6. People who get stuck in a bottom-up mindset because they ponder far too hard about what deep receptors are where, how to affect them, are going to lose sight of the whole point of touching somebody on their skin, i.e., stress and pain relief.
7. Nociception is mostly irrelevant to the brain and is handled immediately, effectively, automatically, by the internal regulation system, without ever becoming or having to become pain.
8. If anything out in the periphery needs moved, by a manual therapist, it's nerves themselves: neural anatomy is unique, crossing many tissue boundaries, and the connection to accompanying vascular supply is vulnerable to mechanical deformation (e.g., simple inactivity, habitual resting positions, or repetitive strain); enough signalling from these, over a long enough period, will challenge spinal cord cell interaction/immune cell physiology enough to change it, which can give rise to an actual pain situation.
9. Worrying or perseverating about anything else, i.e., receptors that may lie in deep tissue other than nerve tissue, or arguing to include them/it in a treatment or in an explanatory model of manual therapy, is a massive waste of time, and would serve to keep the profession mired in mesodermal mutterings, whereby we see misled therapists misleading ever more therapists into the fogbound foreseeable future.

[Barrett Dorko]

Diane,

I wouldn't argue with any aspect of this.

I wish I had written it.

[PatrickL]

I think you're obliged to spend time thinking about "receptors that may lie in deep tissue other than nerve tissue" so long as you are (even just incidentally) activating them and until you can rule out their influence. That is straight forward. These receptors are part of the nervous system too.

The only PT who is off the hook, I think, is someone who exclusively practices sc, where any activation of deeper receptors is likely to be mostly internally generated.

[Diane]

I think you're obliged to spend time thinking about "receptors that may lie in deep tissue other than nerve tissue" so long as you are (even just incidentally) activating them and until you can rule out their influence. That is straight forward. These receptors are part of the nervous system too.

The only PT who is off the hook, I think, is someone who exclusively practices sc, where any activation of deeper receptors is likely to be mostly internally generated.

Carry on until you can rule out their influence then.
I for one am never going back into that particular swamp.

[PatrickL]

And about what is best for the profession. Good luck driving change by constantly sending the message "you're wrong" to all and sundry. I tried that for 12months over at linkedin. It's pointless. There's gotta be a better way. I suspect that better way involves some sort of meeting in the middle with those PTs we wish to educate.

I get that you guys "have been dead for too long" to take that approach. But an uncompromising, rigid approach seems counter productive to me. I think getting PTs to think about changing their explanations via the introduction of the idea that it is receptor activation that counts, is the first step towards the position you currently hold, Diane. Perhaps once there's been some generational change in curricula, edging more towards an interactive approach, there will come a day where that post of yours above might form the intro page to a PT university manual.

I'm opting for a different means to the same end.

[PatrickL]

With regards to what a "waste of time" it is to ponder the relative influences of different tissue's receptors to any observed clinical phenomena. I don't waste any patients time on such matters. If I'm holding a patients leg while he lies in supine, and carrying out a sustained traction longitudinally along the leg, and the patient reports that it relieves his pain, I will wonder if there is a relevant sensory/discrim component to the reported pain relief. I will wonder if the key sensory/discrim input was derived from mechanoreceptors in the skin, or from movement of nerve trunks, or from mechanoreceptors in spindles or other dare I say it mesodermal derivatives. I wonder these things and conclude that there's no way to know. I accept that. I'm certainly not going to pretend I know and tell the patient as such.

My job is to provide a narrative that is broad enough to cover that which I can't rule out, while being confident enough to convince the patient that I know what I'm doing.

[Evanthis Raftopoulos]

Diane, with all due respect, I don’t think that your reply to my post addressed my points/concerns.

I still haven’t heard from you: what you think is going on at the peripheral receptors level when we experience stronger stimuli?

You say,

Too much info for the nervous system to process favourably (for the patient) in too short a time and too small an area. See spatial and temporal summation. See post 124.

That’s not true, how do you explain the fact that some people respond favorably to stronger stimuli?

We should be jet planes coming down on a patient on a long runway, low angle of entry, not helicopters plunking down then pressing down.

Stronger stimuli can be applied in accordance to the above. Nevertheless, what if the patient finds more helpful a relatively perpendicular pressure than a lateral soft tissue stretch? Who is to decide what parameters are optimal in the context of pain relief, us or the patients?

[Evanthis Raftopoulos]

adding to the above: assuming that all parameters to choose from are equally safe/ appropriate in the context of quality care.

[Diane]

what you think is going on at the peripheral receptors level when we experience stronger stimuli?

Same as when we experience weaker stimuli.
A sensory neuron either fires or doesn't. It either mounts an action potential or it doesn't.

The brain doesn't care about the strength of a peripheral stimulus. Only about how they mount up, temporally and spatially, and about how to predict and mount an output based on prior experience and context.
Which is why we have to grok that nociception and injury, injury and pain, pain and nociception are not, have never been shown to be, and never will be shown to be, quantitatively linked.
Why we have to realize that we aren't doing ANYthing "specific" when we do manual therapy, we are creating a treatment context and providing a storyline for an event called a "treatment encounter" which will either help (due to non-specific effects in the patient's brain) or won't (because of some dumb tissue-based nocebo comment issuing forth from the well-meaning but not very cognizant therapist.)

You say,That’s not true, how do you explain the fact that some people respond favorably to stronger stimuli?

See above. Context and expectation.

Stronger stimuli can be applied in accordance to the above. Nevertheless, what if the patient finds more helpful a relatively perpendicular pressure than a lateral soft tissue stretch? Who is to decide what parameters are optimal in the context of pain relief, us or the patients?

The patient has locus of control over the therapist. One hopes..
The therapist should not aggravate anything that already exists.

[Barrett Dorko]

Evanthis asks:

I still haven’t heard from you: what you think is going on at the peripheral receptors level when we experience stronger stimuli?

What of this?

[Evanthis Raftopoulos]

Thank you for replying Diane. I much appreciate your willingness to engage in discussing these issues.

Same as when we experience weaker stimuli.
A sensory neuron either fires or doesn't. It either mounts an action potential or it doesn't.

Of course, but what activation accounts for the variable experience/qualia of stronger stimuli via manual therapy ? IMO it cannot just be context/expectation. If you press lightly and then harder on your forearm, it feels differently, right? Earlier in this thread, you did not accept my speculation of blaming the counter-force on the ruffinin endings as the dominant mechanism and as a reasonable one. What is going on in your opinion?

Why we have to realize that we aren't doing ANYthing "specific" when we do manual therapy

How my understanding evolved, is that specific /non specific is only relevant to the targeted outcome. If the specific outcome is some form of relief and manual therapy achieved that, then manual therapy achieved something specific. Another example, if the targeted outcome is to help a patient complete a movement that has difficulty completing, and if manual therapy helped achieved that, then that is also a specific effect. Increasing blood flow towards the surface is another specific effect that manual therapy has the capacity to achieve. If manual therapy achieved other things that we have not targeted, then those are non specific effects.

The patient has locus of control over the therapist. One hopes..

So if the patient prefers the perpendicular pressure or stronger stimuli, then you agree that that this might be the optimal parameter in the context of locus of control and pain relief?

The therapist should not aggravate anything that already exists.

As I mentioned before, do you tell a pt never to wt bear on the injured limb to avoid increase in nociception? We can argue that even activating a little bit of nociception in the context of therapy can be beneficial (Whether the movement is active or passive). 1. beneficial to the peripheral tisssues, the benefit of movement might be at some cases greater than the risk of a little bit of temporary increase in nociception, 2. beneficial to the ‘cognitive-evaluative center’, it may help re-evaluative “danger” coming from nociceptors in a favorable way towards pain resolution.

[Evanthis Raftopoulos]

Evanthis asks:



What of this?

yes, I mentioned this in post #105

[Diane]

Evan, please read this, then if you have any further questions, get back to me.
None of this is explainable in any sort of bottom up way, which is kinda the point I'm trying to make, all the way through this thread.