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  • Ectodermal approach and Evidence

    Ok. I am trying to see how the approaches on this forum falls in or out of line with evidence based medicine. I am not a slave to EBM and stick with Sackett's definition:

    EBM is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

    Where would you say the ectodermal approach/philosophy would be located on the following hierarchy of evidence:

    1) Meta-analysis
    2) Systematic review
    3) Clinical practice guidelines
    4) Randomized control trials
    5) Cohort studies
    6) Case control studies
    7) Case studies
    8) Opinion from respected experts
    9) Basic science research

    If you don't agree with this particular hierarchy of evidence, could you explain or propose an alternative? I have only been around for a short time and I have definitely seen a good deal of expert opinion and basic science, but I would like to know if there is more out there.
    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

  • #2
    Hi Roderick,

    Your question is phrased in a way that I find hard to answer. For example, reverse the question and ask

    Where would you say the MS/biomechanically focused approach/philosophy would be located on the following hierarchy of evidence?

    It seems to me that the main point of contention is not which levels of evidence are being used as much as how a clinician is interpreting what it is they are reading. At least I think so. Now that may break down (or become a more helpful question) when you cite a very specific example.
    Last edited by Jon Newman; 27-02-2008, 01:05 AM.
    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

    Comment


    • #3
      Actually no Jon. I was specifically wanting to see what level of evidence the ectodermal approach has me t in treating various conditions. I think your question (MSK approach and evidence) should be addressed in another thread. Right now I'd like to stay focused on my original question. I am trying to find support above expert opinion and basic science for this approach.

      Keep in mind. I am only asking for evidence...not proof. There is a HUGE difference.
      Last edited by HeadStrongPT; 27-02-2008, 01:12 AM.
      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


      • #4
        I suppose I didn't communicate clearly (one of my strengths).

        I don't think an "approach" has a level of evidence. For example, someone may use the CPR for manipulation and have an ectodermal approach and someone may use it and have a MS/biomechanical (mesodermal) approach.

        It is my contention that the person with the ectodermal approach is probably on better explanatory footing than the person using the mesodermal approach in this case even if they are both doing the same thing. And the differences may (or may not) even extend beyond the explanatory (interpretive) aspect to more subtle or less tangible aspects of the PT/client interaction.
        "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

        Comment


        • #5
          I agree with Jon in that interpretation is very important. Evidence can be drawn from pretty much every level to support an "ectodermal approach." Maybe we should go back a step and define what you mean by this approach.

          If all pain is neurogenic, then any approach that modulates the nervous system effectively to reduce pain is "ectodermal." The mesodermalists just don't know that...yet.

          I think Barrett highlighted the role of communicating with the ectoderm in another thread. As Diane has written at length, the hands-on component of skin deep work is kinesthetic education - another way of communicating and a particularly important one for movement therapists.

          I like this link as a start and I think you've already been pointed in Butler's direction. Explain Pain is an essential starting place.
          Nick Matheson, PT
          Strengthen Your Health

          Comment


          • #6
            The mesodermalists just don't know that...yet.
            I don't even think the developers of the SMT CPR think that the effect is achieved through the mesodermal derivatives. I have heard Tim Flynn talk on the supposed effects of spinal manipulation, and the consensus seems to be that it is neurophysiological. A follow-up study by Flynn et al concluded that the "pop" often heard with manipulation was not necessary for a successful outcome, thereby discounting the importance of joint cavitation, which to many in the past seemed an important determinant of a successful manipulation.

            So, I think the lines have already begun to blur. The question that I have referred to in the other thread that Diane started on this topic is: Is it necessary or more effective to utilize coercive manipulative techniques versus gentler skin-deep techniques to help resolve the painful condition? Certainly, current evidence, based on the heirarchy Rod provided, is on the side of SMT for certain conditions. But that may be because the SMT research has just stumbled in through the back door.
            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


            • #7
              Cory wrote,
              it seems the more coercive a technique the more narrow the population that it can effectively be employed with. The inverse would also make sense. The less coercive the technique the broader the appropriate population.
              Maybe it could be shortened to just Cory's Inverse Coercion Rule or something...

              Anyway, I sense a shift in direction - perhaps you are thinking more "ectodermally" John... perhaps you are starting to agree that it makes more sense that anything we do to any patient manually amounts to neuromodulation, as Eric pointed out. (I'd go so far as to say dermoneuromodulation, because the skin/nervous system can't be removed, so it has to be accounted for.. but that's a separate thread.)

              If we accept that manual therapy exists on a continuum instead of in separate camps entirely, manual therapy becomes simply a matter of varied speed, force, and angle of "entry" into the nervous system. Then one either
              • uses bones as levers to push things around within the mechanoreceptive neural net that exists within the mesodermal derivative layer, or
              • ignores bones completely as irrelevant lumpy objects within that will either remain closer together or move further apart as the nervous system wishes,

              ...while realizing:
              1. that they have little or nothing to do with pain production or persistence when not actually pathological, like cancer or fracture or something,
              2. that what matters in the end is how that body feels to that patient when they stand back up again and move.
              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


              • #8
                Hi John,

                I think you're correct that there has been some change in thinking since the original research that developed the CPR and I think this stemmed from the CPR itself. Specifically, there was some understandable thought about joints and alignment being particularly important and hence many of those types of exams were included in the pool of potential predictors. Of course few of the orthopedic special test reached significance in the regression analysis. Still, we find what appears to be an interpretation of the findings from a biohmechanical/MS standpoint.

                From Flynn's CPR research

                Manipulation is thought to be indicated in the presence of hypomobility. Interestingly, although the technique used in this study is described as affecting the SI region, it was lumbar hypomobility that entered the prediction model. This finding reinforces the idea that the manipulation technique is not specific to the SI region but impacts the lumbar spine as well.
                But interestingly, later in the same paper there is explicit downplaying of the pathoanatomy,

                In our opinion, clinicians performing these tests are not as interested in pathoanatomic speculations (i.e., is the SI joint generating the pain?) as they are in determining if the patient will respond to a particular intervention.
                They also deserve kudos for even considering adding the FABQ (and a few other nervous system focused assessments) to the list of potential predictors. They get credit for being the first to introduce me to the FABQ.
                Last edited by Jon Newman; 27-02-2008, 03:04 AM.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • #9
                  As you say, John W, there are not really sides. You cannot say there is evidence for coercive versus non-coercive because no such study has been done. There is reasonable evidence for SMT for some subgroups of people with mostly acute and subacute pain. If you look at Moseley's work, you will see some pretty good evidence for neurophysiological education alone. You can't get much more non-coercive.

                  I know you have stated you include neurophysiological education in your approach. This type of inclusion and the shift in consensus that you reference would indicate that OMT is more "ectodermal" than most have learned. I welcome this revelation, but the paradigm still needs a lot of pruning. I give full credit to those who are researching and challenging the status quo. I look forward to more evidence on various ways to modulate the nervous system - especially non-coercively.
                  Nick Matheson, PT
                  Strengthen Your Health

                  Comment


                  • #10
                    Thoreau, in On Walden Pond wrote;

                    “…if one advances confidently in the direction of his dreams, and endeavors to live the life which he has imagined, he will meet with a success unexpected in common hours. He will put some things behind, will pass an invisible boundary; new, universal, and more liberal laws will begin to establish themselves around and within him; or the old laws be expanded, and interpreted in his favor in a more liberal sense, and he will live with the license of a higher order of beings. In proportion as he simplifies, the laws of the universe will seem less complex, and solitude will not be solitude, nor poverty poverty, nor weakness weakness. If you have built castles in the air, your work need not be lost, that is where they should be. Now put the foundations under them.”
                    Orthopaedics has built some castles in the sky. Neurophysiology will put foundations under some of them and build some new ones on the way. We should all be excited about the opportunity for stability and clarity of thought that the ectodermal approach can bring to our practice and our research. It is the responsibility of physical therapists from all sides of whatever fences there are out there to a) knock down the silly fences, shake hands, and b) start doing the basic research to build the foundation.

                    It would be wise to remember, we are all only at the beginning…lest we build any more castles in the sky.
                    Eric Matheson, PT

                    Comment


                    • #11
                      The question seems to get turned around to the mesodermal approach. (God now I'm using that phrase...thanks guys)

                      Let me try to be more specific. Pick your favorite and most commonly treated diagnosis - I don't care what it is. Can you please take me through your clinical decision making regarding the management of this problem.
                      ----
                      Quick digression: I understand this is of course the problem within the profession of orthopedic manual therapy wherein we do not have a uniform language in which to consistently exchange information. It doesn't mean the information isn't there, but we are all using such different terminology the profession has become the Tower of Babel.

                      One recommendation to foster standardization of diagnoses, treatments, and outcomes is to speak the same language. For example, there is no way to come to any agreement on an assessment if there isn't a clear understanding of the diagnosis. It follows if the assessments are not reconciled that treatments and outcomes are likely to be even more difficult to sift through.

                      So, the problems within the "mesodermal" communities are well documented both in the peer reviewed literature and very well opined on this forum. One could make the argument that there is more data in the "mesodermal" literature to pick apart, where I have found little comparable data in the "ectodermal" literature. If course this leaves "ectoderms" in the enviable position of debating data while, mesoderms can only argue against the higher levels of "ectodermic" literature. Namely basic science and expert opinion.

                      -----
                      This was not my initial question however.

                      I will restate my question in a slightly clearer version: Is there direct evidence (not proof!) linking a specific "ectodermic" treatment of a pathology with a specific outcome?

                      A few points, I know people out there dig it and it has strong roots in basic science, but this simply isn't enough to meet the standards of evidence the medical community will and should require.

                      Don't impale me....
                      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


                      • #12
                        Ok....so I just hit "submit" and noticed Eric just quoted a passage from Thoreau. This is what I'm talking about people!!

                        Thoreau was awesome and he has a place in the discussion. But he never has performed a case study on the interventions you describe! Give me something...anything. Preferably a little more concrete and relevant than 19th century naturalist literature.

                        Keep in mind I am typing this with a great big smile on my face. I truly enjoy this forum and am not trying to be mean in any way.
                        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


                        • #13
                          Jon,
                          I think the authors of the CPR study felt the need to clarify the point about where the effect of the manipulation was occuring because the original publication of the technique was published by Cibulka in a(flawed) study using the same technique. In fact, (and I know you'll like this, Diane) the technique has been affectionately referred to as "the Cibulka slam".

                          So, I think Flynn et al were just highlighting the fact that the effects seemed to occur where movement is more likely to occur, which is in the lumbar spine. I am inferring from this (and based on what I've heard Tim Flynn say about the study) that the neurophysiological response, therefore, is a result of a mechanoreceptor barrage in the region of the pain.

                          Eric,
                          Very well said. I'm all for being a bridge- not a fence- builder.
                          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


                          • #14
                            Thoreau was awesome and he has a place in the discussion. But he never has performed a case study on the interventions you describe! Give me something...anything. Preferably a little more concrete and relevant than 19th century naturalist literature.
                            Well, Rod, there has been a case study published, by Luke, about simple contact. He's working on writing up a series he did. Jason is publishing a case study soon. I'm in the middle of a series I'm doing on DNM. I'm just finishing up a paper on the cutaneous nervous system based on an anatomical dissection. Luke and I have some large plans (plans only at the moment) to write a long paper on skin and manual therapy.

                            So to answer your very specific question, yes and mostly no. Or at least, not yet. Please be patient with this emergent third way. We've only started to define it in the last 4 or 5 or 2 years.. we're new at science making and science writing. But we intend to lay good groundwork, as we think we already are doing.

                            The main advantage we have is we are entering the process at a new place, after the huge surge of pain science/neuroscience already created a tail wind for us. Much of this is simply a reordering, not a complete new reinvention.

                            See Nick's posts 5 and 9 for more information (much more).
                            Last edited by Diane; 27-02-2008, 04:33 AM.
                            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


                            • #15
                              I really liked the post by Eric, and I think it speaks to something a lot of therapists may know, and it is this: We can't always make human beings exist in ways that lend themselves to a clear,confined essential diagnosis that can lead to the studies we crave.
                              Barrett L. Dorko

                              Comment

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