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Ectodermal approach and Evidence

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  • Originally posted by Jon Newman View Post
    Rod, I thought you were kidding with that peyote comment.
    Being from Texas (particularly as a Longhorn alum), I know good a good pile of BS when I see it. Nice catch Jon.
    Rod Henderson, PT, ScD, OCS
    It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

    Comment


    • Well, that sure I'm futile and stubborn and many times I found myself acting and speaking like an idiot.
      I do not care since I found some same evidences all around the world.

      Often I bring this cut off and wait endlessly for a reply:



      It may be applied to many "ortho" methods.
      • Are you able to move a muscle or a vertebrae or a fascia without touching the skin?
      • Does your action begin before or after you touched the skin?
      • Did evidences have ruled out any skin possible action in their protocols?

      I'll stay in futility and I'll be happy with a single yes or no reply.
      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


      • Just a newbie here and I suspect that this post will make my ignorance painfully obvious to all but:

        Surely any 'ortho' technique is going to have a 'neural' effect as well. If i'm gliding a joint i'm creating proprioceptive afferent input.
        And if i'm doing a slider i'm also moving facet jts (in most cases).

        We can't in any meaningful way separate 'ortho' and 'neural'- can we?

        Comment


        • Jono,

          If you do a minimal ULNT1 with movement only 20 or 30 degrees of wrist DF on a patient with pain in that arm....how do you explain the following: a) pain in the neck and/or b) pain in the contralateral shoulder and/or c) head pain as well as linear pain in the tested upper arm?

          With no joints being moved except the wrist where there is no pain?

          Just wondering....

          Nari

          Comment


          • Jono,

            A body is effectively a whole and it is where we may disagree with the ortho side.

            We want to add a neural component that fills the gaps found in "traditional" therapy.
            We just ask for a simple recognition of some forgotten components that may explain results found that have poor theory as premise.
            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


            • Rod-

              I said:
              -Do you understand that the treatment is the same, the physical treatment given, the actual manipulation?
              -Do you understand that the reason the treatment is given, the theory, the explanatory model or "reason why" is different?
              If you can agree to these two points, we can move on to the next step.
              And you said:
              Originally posted by TexasOrtho View Post
              ...we're good.
              Glad we've got the difference between a treatment and it's rationale down.
              The next step is to understand that the evidence base (both basic science and outcomes) does indeed support one "perspective" over the other, even if the treatment is the same.

              We'll stick with spinal manipulation for low back pain and the CPR studies.
              We can say each perspective has a level of support based on the CPR findings. We can look at predictive factors and see that there are things relevant to each perspective that we can use to determine this.
              If the following things were found important in determining who would benefit from manipulation, that would support that particular perspective:

              Group 1: Orthopedic/Meso/Structuralist
              -Health of connective tissues by exam or imaging
              -Orthopedic tests of the connective/meso tissue of the lumbar spine and SIJ - things like positional diagnosis (FRS, ERS, etc) of the spine
              -If having an FRS dysfunction or a positive Yeoman test or the presence of facet arthropathy or disc degeneration was indicative of the success with manipulation, that would be support for the ortho perspective
              -This is often referred to as a "biomedical" or "pathology-based" perspective

              Group 2: Neuro/Ecto/Functionalist
              -Health of neurological tissues by exam or imaging
              -Neurological function tests, a patient's complaint or felt sense, or their beliefs about the problem
              -If having a positive SLR test, the patient's descriptive symptom pattern, or their beliefs about their pain was indicative of success with manipulation, that would be support for the neuro perspective
              -This is often referred to as a "biopsychosocial" perspective

              So you see we have the same outcomes data, but we can see (based on the CPR findings) that one perspective has greater support than the other. Perspectives can't be compared with outcomes research in most cases, only treatments can be compared that way. But for each treatment one perspective may have more scientific support relative to the other.

              What do you think?
              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


              • That's really good, Jason.

                I would also add (as you wait in stunned silence) that the chance of veering off onto an ego-driven tangent with an overly pathoanatomical perspective increases if you stay in that realm for too long. This is how we got so stuck on the SI joint for so many years. The tests proposed by Cibulka to identify SIJ dysfunction have since been discredited by research that was unable to replicate the findings. A cursory look at Cibulka's study indicates that they completely ignored any "gold standard" to compare the results of the alignment tests that make up the cluster. The whole thing is just a bunch of hooey, but it did get published in a peer-reviewed journal (I don't think it would today, though).

                How many hours did perfectly intelligent PTs and students spend trying to understand the supine to long-sitting test? What a waste. I like Luke's suggestion that the "ecto" perspective could end up saving us a lot of time. I look forward to more concrete examples in the literature to support that notion. We may even be able to spend that extra time actually helping more people. What a concept!
                Last edited by John W; 01-03-2008, 04:12 PM. Reason: typo
                John Ware, PT
                Fellow of the American Academy of Orthopedic Manual Physical Therapists
                "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                Comment


                • Originally posted by bernard View Post
                  Well, that sure I'm futile and stubborn and many times I found myself acting and speaking like an idiot.
                  I do not care since I found some same evidences all around the world.

                  Often I bring this cut off and wait endlessly for a reply:



                  It may be applied to many "ortho" methods.
                  • Are you able to move a muscle or a vertebrae or a fascia without touching the skin?
                  • Does your action begin before or after you touched the skin?
                  • Did evidences have ruled out any skin possible action in their protocols?
                  I'll stay in futility and I'll be happy with a single yes or no reply.
                  I assume we are sticking with manual approaches only. As this inly applies to about 20% of my clinical time with a patient I might have different answers. If we say manual-only: 1) No 2)After 3)I have no idea - has someone actually proposed this?

                  Originally posted by Jason Silvernail View Post
                  Rod-

                  What do you think?
                  Good example, but again I wouldn't break it down into two approaches with the conclusion that one is superior to the other. I will take you through some of my low-logic in a clinical setting. I have a patient with the following characteristis: high fear avoidance, McGill off the chart, VAS that indicates they should be in the ER, often on antianxiety or antidepressants, physical exam that is minimally suggestive of mechanical pathology. This patient is going to be managed in a much different way than the patient who shows up with the following presentation: Low fear-avoidance, mild-moderate pain on VAS, active, and a physical exam consistenly indicative of mechanical pathology.

                  I typically take more of a cognitive behavioral approach with patient #1 as this is the dominant feature of their presentation. In my little orthopedic world, this usually means moist heat coupled with sensory-level TENS (applied to the skin no less! :clap2 along with simply sitting and talking with them while they lay in a position of ease. They often after a few visits begin to magically move and feel better in spite of the fact I haven't laid a finger on them.

                  Patient #2 is treated more mechanically. If I were to lay this patient down on "my couch" as I call it, these patients often get little to no relief unless there is some form of movement-based intervention.

                  My movement based approach usually starts with what the patient can achieve pain free. I encourage them to move in a manner that does not irritate the symptoms that brought them to me. This often involves quite a bit of cognitive therapy as (I'm sure you realize) pt's don't often intuitively see the connection between movements and position and pain. If this is unsuccessful and I've exhausted my arsenal of pain management, patient-generated movement, and education, we move to manual mechanical interventions.

                  I would get very little out of separating the two approaches in these cases, as they both involve a certain degree of neuro and orthopedic interventions. This is why I have difficulty looking at interventions like neural gliding as either distinctly neuro or ortho in nature as they are both part of the same organism.
                  Last edited by HeadStrongPT; 01-03-2008, 04:20 PM.
                  Rod Henderson, PT, ScD, OCS
                  It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

                  Comment


                  • Originally posted by TexasOrtho View Post
                    No we're good. You mentioned earlier that one approach was shown via evidence to be superior to the other, but now it is clear we see things similarly: there indeed can be no comparison or claim to head-to-head superiority. No worries...
                    Rod, does this mean your original question has been answered to your satisfaction?


                    Great posts by Jason and Luke. Great picture Bernard.


                    This whole thread has me thinking about tension between Eastern and Western approaches to medicine (not that these are ecto- or meso-, but more the historic conflict and the need for reinterpretation). Maybe this example will recast our current debate since there is less investment in ecto- vs. meso- or neuro- vs. ortho-. As an example, if someone demonstrates that Tai Chi provides good outcomes for people with persistent pain, this does not confirm that there is such a thing as chi or meridians as some believe. A more plausible explanation would involve looking at the impact of active movement on the neurophysiological mechanisms of pain. The effectiveness of acupuncture in an outcome study does not confirm the tenets of TCM, but rather demonstrates its efficacy as a neuromodulatory tool. If outcomes-oriented evidence is higher in the hierarchy of acceptable science than the fact that coherence with a sensible deep model of "basic" science is more essential may be lost.
                    Last edited by Nick; 01-03-2008, 04:23 PM.
                    Nick Matheson, PT
                    Strengthen Your Health

                    Comment


                    • Rod,

                      I see we cross-posted and your post answers the first question of mine.


                      " and a physical exam consistenly indicative of mechanical pathology."

                      Can you define what you mean by this?


                      Do you see that neuro-thinking is inclusive of ortho-thinking, but cuts away what is unnecessary or incorrect? The biomechanical hangover has been seriously challenged. It is irrelevant for people with persistent pain.
                      Nick Matheson, PT
                      Strengthen Your Health

                      Comment


                      • Originally posted by Nick View Post
                        Rod, does this mean your original question has been answered to your satisfaction?
                        I think it has. My assessment is there is insufficient evidence to support looking at a patient in terms of a a neuro or orthopedic problem as they are inseparable phenomenon.

                        I agree with your comparison Nick. If Tai Chi were shown to have a significant impact on balance, strength, risk for falling etc...We could likely go round-and-round on the precise mechanisms, but it would likely be like the "Tastes great...Less filling" beer commercials of the 80's. It's likely both so we should all just shut-up and go teach Tai Chi.
                        Rod Henderson, PT, ScD, OCS
                        It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

                        Comment


                        • [QUOTE=TexasOrtho;48684]I think it has. My assessment is there is insufficient evidence to support looking at a patient in terms of a a neuro or orthopedic problem as they are inseparable phenomenon.[QUOTE]

                          If this were true, how could someone have pain in the absence of bone, joint, or muscle pathology? When it comes to understanding and treating pain, one is clearly of a higher order.
                          Nick Matheson, PT
                          Strengthen Your Health

                          Comment


                          • Yeah, Nick - I pass the baton to you. Good luck.
                            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


                            • Originally posted by Nick View Post
                              Rod,

                              " and a physical exam consistenly indicative of mechanical pathology."

                              Can you define what you mean by this?
                              Sure. I consider it any movement or position that consistently reproduces a patients symptoms. I will often use this in the context of their treatments to gague progress in either chemical or mechanical irritability of an area. I sometimes think if a specific tissue, but this is less important to me than the patients experience. If the patient improves it matters little to me that it was the disc v lig flavum etc...

                              Do you see that neuro-thinking is inclusive of ortho-thinking, but cuts away what is unnecessary or incorrect? The biomechanical hangover has been seriously challenged. It is irrelevant for people with persistent pain.
                              I see that they are inclusive of each other. What about people without persistent pain? It is possible to have a loss of motion without pain. We see this from time to time in TKA and ACL populations who develop a flexion contracture. I approach these patients again with a combined approach as addressing only one or the other would be often futile.
                              Rod Henderson, PT, ScD, OCS
                              It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

                              Comment


                              • Originally posted by Nick View Post
                                If this were true, how could someone have pain in the absence of bone, joint, or muscle pathology? When it comes to understanding and treating pain, one is clearly of a higher order.
                                It is one of a different order. Read my question above as it is possible to have bone, joint, or muscle pathology without pain (joint contracture). Again, I think we've all agreed but some seem to persist on this notion that one approach must be slightly better than the other. I don't see it as a pissing contest.
                                Rod Henderson, PT, ScD, OCS
                                It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

                                Comment

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