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  • #31
    What can be asserted without evidence can also be dismissed without evidence.
    --Christopher Hitchens
    The types of evidence being presented so far haven't led me to appreciate the mesoderm as the structure we are having our primary affect on as it pertains to pain relief. I think Diane would agree that the skin itself also remains unchanged in any enduring sort of way by her approach.

    I think the patient's movements, which can be strongly influenced by our therapeutic interaction including our words and stories (and theirs) is the big deal. Physically contacting someone likely catalyzes that interaction. I think there is an inverse relationship between the story told and the force used by the therapist. Specifically, the degree of veracity of the (commonly told) pain relief story decreases with increasing externally applied forces.
    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

    Comment


    • #32
      >I think Diane would agree that the skin itself also remains unchanged in any enduring sort of way by her approach.

      Absolutely. But what does seem to change, enduringly too, are all the little gnarley tender bits one can feel inside it, beneath it. Oh, and perceived pain. Oh, and movement. That improves. Enduringly.
      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


      • #33
        Diane,

        I agree. Of course, as you've pointed out in the past, changes in the ectoderm are just harder to measure - it isn't that they're less important or relevant.

        Jon,

        Those last two lines from you are pretty good. What of the ways a therapist might be convinced that their story regarding dysfunction and recovery is true? What if they’ve grown unconvinced? Will they be able to continue to convince others? What sort of personal pathology would be necessary to tell a story convincingly that you yourself know not to be true? Would such a situation encourage you to run from the knowledge that might produce it?”

        It seems we’re in the midst of connecting several threads, including My Driver’s Story.
        Barrett L. Dorko

        Comment


        • #34
          Originally posted by Jon Newman View Post
          Hi Ole,

          Are the manual forces used in ART graded similarly to other manual approaches (if there is more than one grade)?

          What is the "Active" part of Active Release Technique?
          The "active" part of ART is that the patient actively moves his/her body part whenever possible. This helps block pain at the lateral thalamic tract and gives the patient a sense of control. In addition it helps to maximize the relative motion between the tissues.

          Comment


          • #35
            Hi Steve,

            Can you expand on this?

            "The "active" part of ART is that the patient actively moves his/her body part whenever possible.
            Is this in addition to the release or while the release is happening?
            "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

            Comment


            • #36
              Diane,

              No one has argued that we can get past skin in manual therapies. What I have argued is that we can't put down the effects of all manual therapy to the effects of skin manipulation. Your argument can be reversed, we always touch skin when treating manually but we don't always get results, we touch skin a lot when not doing therapies and the pain continues. These DNM effects haven't been shown, I know you are working on it, but right now it comes down to you saying. I feel it, trust me. I have tried doing what you suggest, it hasn't worked for me. Is your argument then, "You are doing it wrong, you don't have the right touch or right attitude"? That too is an argument you regularly dismiss, and rightly, when made by mobipulators.

              Comment


              • #37
                Randy,

                I think the context of the moment of contact with skin is important. What I have found helpful is the very little I say to the patient before some DNM. I'm neutral - this may work very well or it mightn't work at all - and leave it to the receptors to sort that out.
                One may think that there is a nocebo in the second phrase; but it does not seem to come over that way. To me it gives the patient's CNS two options, and I promise nothing.
                Maybe you do this too, I don't know.

                Nari

                Comment


                • #38
                  Originally posted by Jon Newman View Post
                  Are the manual forces used in ART graded similarly to other manual approaches (if there is more than one grade)?
                  Yes and no. As in a theoretical grade I, II, II and IV - no. You would want to go as hard as possible - but the patient needs to be able to complete the movement and not try to run away so that really puts a limit on it

                  Originally posted by Jon Newman View Post
                  What is the "Active" part of Active Release Technique?
                  Patient does a movement to elongate the targeted tissue while one applies a pressure directed longitudinally to the tissue. Or one holds back one structure while the patient does a movement to cause another structure to slide past.
                  Ole Reidar Johansen, Musculoskeletal Physiotherapist
                  "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                  Comment


                  • #39
                    Originally posted by Randy Dixon View Post
                    No one has argued that we can get past skin in manual therapies. What I have argued is that we can't put down the effects of all manual therapy to the effects of skin manipulation...
                    Thanks Randy for saying what I was thinking too.

                    I assume Diane has good success with what she does. And perhaps the success I have (gives me very consistent and predictable results) with patients is due to the stretching of the skin that comes with the techniques I use.

                    Two more points you make me think of Diane.

                    1. There is another thing you must "pass through" on your way to the skin as well. And that is the patient interaction. Perhaps we're just agreeable people who the patients get along with and we persuade our patients to get better.

                    Someone once said - I remember who told me but not who originally said it...

                    It doesn't matter what you do as long as you do it well.
                    2. What about TENS? Why is this not the gold standard for resolution of chronic pain as it mostly causes a sensation in the skin. Applied to the appropriate area of skin - what makes it differ from DNM.
                    Ole Reidar Johansen, Musculoskeletal Physiotherapist
                    "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                    Comment


                    • #40
                      Originally posted by BB View Post
                      So, we are looking at 2 different mechanisms here. The first involves mechanically breaking, severing, a link. If this link is scar tissue, collagen fibers, I still don't see how you can break it without creating an inflammatory response.
                      I don't want to break any collagen fibers. The adhesions of which I speak are much weaker structures. You know that yellow stuff that you get on a wound? That's fibrin. That's glue. Imagine that inbetween your muscle fibers.

                      Originally posted by BB View Post
                      The second mechanism, re-establishing normal friction between adjacent structures by changing the interstitial content, sounds like the "stickiness" that Nari describes. Mechanically speaking, this sounds more feasible to me. What causes these interstitual fluid changes?
                      Ok - the second mechanism here was unintended. Probably important - but not part of my point. But like you say "stickiness" - that's what I call adhesions. It's fibrin aka "the glue" or "sticky stuff". Since this stuff is much weaker than actual CT it breaks easier and it doesn't create an inflammatory reaction of much magnitude just a little DOMS. Although some people have more of a soreness response than others.

                      Damn you ppl are a tough crowd! Not that I expected anything less.
                      Ole Reidar Johansen, Musculoskeletal Physiotherapist
                      "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                      Comment


                      • #41
                        Originally posted by Diane View Post
                        I think this suggests that "adhesions" on the one hand is something qualitatively different from "connective tissue" on the other. Really, all of it is "CT". Scars are "CT". Fibroblasts make both "CT" and "scar" and "adhesion". I don't see that any point is served by trying to differentiate them "as if" one were more amenable to handling than another, especially through a force dissipator /spreader like skin is, especially living, functioning, nervous system charged skin.
                        Here is an exercise for you. Flex your wrist. Put your thumb on the belly of your flexor muscles, press downwards a little and then angle it slightly proximal towards the elbow. Not hard. Then maintain that tension as you extend your wrist fully and push it against something so that you get it back as far as possibly. You should feel tension develop in your flexor muscles - and if you do it right it shouldn't be too much traction on your skin. If you do this right you should feel the pull on the tendons in the wrist and it should ease if you let go with your thumb but still maintain the extension in your wrist. Put your thumb back on there to see if you can get the same tension in your tendons.

                        Naturally we have to go through the skin and all sorts of things can happen there! But hopefully you will see that it is possible to differentiate the different tissues below and target them specifically. It gets easier with practice too. Muscle tissue is no less living, functional and neurologically charged than skin IMO - after all it too is filled with stuff that can be used to elicit reflexes (naturally skin is too).

                        Ole Reidar Johansen, Musculoskeletal Physiotherapist
                        "And if you gaze for long into an abyss, the abyss gazes also into you." - Nietzsche

                        Comment


                        • #42
                          At this point I think it would be a good idea to revisit the concept of abductive reasoning, as discussed in detail in this thread.

                          Abductive reasoning follows this form:

                          Some phenomena P is observed.

                          P would be explicable if H were true.

                          Hence there is reason to think that H is true.

                          Now, apply Cory’s investigative work here. If we can agree that we are successful when behaving in a non-threatening manner and attending to that portion of the nervous system we can easily touch; the skin, then we can say the following:

                          Favorable changes in ROM and comfortable functioning (P) is observed following gentle handling of the skin and some ideomotion.

                          P can happen if the only actual problem is an abnormal neurodynamic (H) and not any sort of significant connective tissue adherence.

                          Hence, H was the problem primarily if not exclusively.
                          Barrett L. Dorko

                          Comment


                          • #43
                            Ole, read Barrett's post carefully.

                            I have no quibble with the idea that people-handling skills are just as important as "tissue"-handling skills.

                            About point 2:
                            What about TENS? Why is this not the gold standard for resolution of chronic pain as it mostly causes a sensation in the skin. Applied to the appropriate area of skin - what makes it differ from DNM.
                            The answer is, TENS does not stretch skin. Only hands can. Stimulation of slow adapting type II mechanoreceptors, the Ruffinis, mentioned here too many times to count. They fire continuously and non-nociceptively to lateral stretch. I'm sure with your idea about art you are getting the Ruffinis big time. So you are likely accomplishing lots of DNM even if you disagree with it. Can't be helped. They're in your face no matter what you think you're treating.
                            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


                            • #44
                              Ole,

                              I guessed that your exercise was intended only as a demonstration that specific tissues can be isolated, and not as a treatment format. Is that so?

                              If not, I am confused about the purpose of this exercise. Sure I perceived strain on the flexor tendons. I also perceived the median and radial nerves having a grumble. But if the required tissue is isolated, and ART is then performed......we get skin stretch??

                              Nari

                              Comment


                              • #45
                                Originally posted by Ole
                                2. What about TENS? Why is this not the gold standard for resolution of chronic pain as it mostly causes a sensation in the skin. Applied to the appropriate area of skin.
                                Ole,

                                You can't use this argument since touch is a "polymodal" message that involves: heat/cold, pressure, direction over a large piece of skin.
                                TENS is just itching/tingling because it is unable to reproduce the complete process => that's a first good reason to think it is not a "natural" solution.
                                Simplicity is the ultimate sophistication. L VINCI
                                We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

                                Everything should be made as simple as possible, but not a bit simpler.
                                If you can't explain it simply, you don't understand it well enough. Albert Einstein
                                bernard

                                Comment

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