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  • I am curious what others here think of the following............ Achilles tendonosis patients with a palpable and visual nodule that is reduced in size palpably and visually with ART/manual therapy. This seems to be at least anecdotal evidence that unhealthy CT can be remodeled with manual therapy.
    Under microscopic studies part of the reason there is an area of widened diameter (lets get rid of the nodule word for starters) is due to increased fluid within the region due to the increased hydrophilic nature of the different form of extracellular matrix being created by the tenocytes at the region. Do you propose that ART is squeezing out the fluid? Altering the hydophilic properties of the ECM? If we're to start at an anecdotal evidence level of discussion then what plausible, and thus verifiable, action of biological or physiological activity are you proposing in conjunction with your action? This is before even going into what biologically/physiologically plausible rationale are you proposing for 'smoothing out bumpy bits'? Or how that relates to alteration in pain perception and changes in functional motor programme activity? What biological or physiological activities may be concommitantly occurring that created the environmental demands that the tenocytes reacted to by producing a different form of tendon? Knowing tissue demands and the duration and intensity necessary to initiate altered cellular activity long term would these environmental demands be better altered by a client initiable form of activity and movement than a 3rd party physical intervention?

    Why comes before how in my dictionary. (Hence my use of ? more than !)
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    Last edited by Mark Hollis; 07-11-2013, 10:41 PM.
    "Whereof one cannot speak, thereof one must be silent." ("Wovon man nicht sprechen kann, darüber muss man schweigen.“) Tractatus Logico-Philosophicus Ludwig Wittgenstein
    Question your tea spoons. Georges Perec

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    • No, I am not arguing that.
      You are arguing that you can reliably determine the presence of a degenerated tendon.
      You can't, with your hands.
      And you can't simply say you changed CT with your hands either - see post hoc ergo propter hoc logical error.

      I like what Mark put forward there as well.
      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

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      • Mark,

        Good questions.

        I agree that part of the reason for the widened diameter is fluid. Another part of the reason maybe a thickening of the actual tendon though, yes? I had not thought about ART squeezing out the fluid. Do you think this would be beneficial?

        In regards to proposed physiological action......my thoughts are starting an inflammatory process that would help the degenerated tendon begin to heal. Does this make sense?

        In regards to the rationale for smoothing out bumpy bits.........my thoughts are a tendon with less degenerated tissue will send "better" afferent information to the brain. Does this make sense?

        In regards to activities that caused the tendon to degenerate.........If I am understanding your question right this could be any number of things. I would think mostly some activity that required to much load for the tendon's capacity over time.

        In regards to the client altering their form of activity as opposed to 3rd party intervention..... I am not sure I fully understand your question. I think you are asking about eccentric exercise in this achilles tendonopathy example?


        Bas,

        I don't think I ever said I could reliably determine a degenerated tendon via palpation.

        I am fully aware of post hoc ergo propter hoc logiacal error........Why I started the sentence with this only anecdotal.

        Comment


        • Weston, you say that you can palpate a nodule in a tendinosis:
          Achilles tendonosis patients with a palpable and visual nodule that is reduced in size palpably and visually with ART/manual therapy. This seems to be at least anecdotal evidence that unhealthy CT can be remodeled with manual therapy.
          Did you come to the diagnosis of "tendinosis" or "degenerated tendon"? Or did the patient come with that referral?
          If you diagnosed it, how did you come to that conclusion?

          And lastly, it is NOT anecdotal evidence that CT is remodelled - it is anecdotal evidence that a change in tissue may have occurred. What do you think made the nodule go away? Sudden tissue reorganization?
          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


          • Bas,

            I am saying that I can palpate a nodule or increased diameter in the achilles tendon of a subset of patients with achilles tendonopathy. Have you ever seen or felt this widened diameter in an achilles tendon?

            I come to the Dx of tendonopathy. Typical sx pattern of achilles tendonopathy. I wrote tendonosis here to denote that we were talking about a degenerated tendon instead of the inflammatory process of tendinitis. We can not know 100% for sure if the tendon is actually degenerated without histopathological exam but tendonosis seems to be more common. At least that it was I am getting out of the literature. Do you agree?

            I agree, anecdotal evidence that a change in tissue has occurred. Is it possible that this change it tissue was in part CT remodeling?
            I am not sure why the nodule goes away.....maybe an inflammatory process? Can tissue reorganization happen that fast?

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            • one of my favorite examinations from chiro school was PNS class and the question was simply, "there is a cheeseburger in front of you, eat it and from a peripheral nervous system perspective describe what happens from grasp to exit". Made me think of the mechanism behind things and being a being in health care, it helps with also being a raving skeptic.
              Weston, sit back and really think about the treatment you performed on the achilles region, and ask yourself the question, "what did I do"? From hands on to hands off, what was the mechanism of your treatment from a neuromusculoskeletal standpoint.
              Then let us know about your "theories" behind ART and what you really think makes it tic...
              PS... ART certified pre Y2K

              Comment


              • docjohn,

                I have sat back and thought about the mechanism behind ART and I doubt some of the proposed mechanisms which is why I am here asking questions. What do you believe to be the mechanism of action of ART?

                Comment


                • Mark Hollis,

                  I just read the article you posted, The Pain of Tendonopathy. Good article, thank you for sharing it.

                  It seems that the article leaves open the possibility that a subset of patients with achilles tendonopathy may have symptoms due to changes in structure. From the article, "To be a practical theory, tendon pain must be explained across the range of clinical presentations. These presentations may be a combined result of changes in structure, biochemical levels and cell function that interact to cause pain."

                  I think the last sentence of the conclusion sums it up quite nicely......"Importantly for clinicians, tendon pain is complex and requires thorough assessment of both musculoskeletal and neural contributors as well as excellent clinical reasoning to account for nociceptive input from local tendon pathology as well as potential central mechanisms."

                  Local tendon pathology could be a degenerated tendon. Is it possible that this degenerated tissue could be remodelled via manual therapy? Do you have any evidence to the contrary? I am aware of the negative proof logical fallacy and is not what I am looking for with this question.

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