Ref Crossing the Chasm - Meso to Ecto

[Jason Silvernail]

In a recent thread called The Chasm, we were discussing the distance between two groups of therapists in physical therapy, though this applies equally to other manual medicine professions.
One group is typically referred to here on Soma Simple as "Mesodermalists" and the other as "Ectodermalists". Many people on both sides are attempting to figure out how best to cross this chasm, and how best to integrate the kind of evidence found here on Soma Simple - the neuroscience of pain in particular - to their practice without leaving their previous practice patterns behind. I hope to provide some ideas here and welcome your suggestions and feedback as well.

Mesodermalists refers to the majority of those in the manual medicine professions, those who were taught models of pain and human function centered around posture, joint movement, and biomechanics. People hurt because they aren't keeping proper posture, or a joint has a mechanical fault, or their muscles are too tight or too weak or are imblanced in some way. Background for the mesodermal approach can also be reviewed in The Problem with OMPT. As of this writing, I think its fair to say that this is the predominant school of thought and teaching paradigm used in physical therapy schools.

Before anyone gets too upset about any "political" ramifications of using names for the groups, be advised that everyone concedes that there are many patients and many problems for whom a mesodermal approach is perfectly appropriate. Conditions requiring reconditioning or restoration of movement due to connective tissue injury or repair are good examples of this. The literature shows that physical therapy has an excellent track record for these patients - and the post-surgical literature is a good starting point to see that borne out. The Problem with OMPT post has more positive things to say about the mesodermal approach in the appropriate patient.

The second group of therapists is typically referred to here as "Ectodermalists". This group has accepted a model of pain and human function centered around the nervous system rather than around connective tissue biomechanics. While acknowledging the value of mesodermal reasoning in appropriate patients, they question its value (some more stridently than others) for certain patients. Specifically, ectodermalists see the traditional biomechanical model as inadequate and often counterproductive when attempting to deal with a primary complaint of pain that is typically not associated with a connective tissue injury. See The Problem with OMPT for more on that.

Many therapists read the evidence presented in favor of ectodermal reasoning and become confused as to what their next step should be.
Should I stop doing what I've been doing?
Do I stop doing [insert manual therapy or exercise technique here]?
How should this change how I treat?
Where do I go from here?

In this thread, we'll answer some of those questions.
Your feedback and suggestions are welcome.

[Jason Silvernail]

What it isn't - the Toolbox.

What this change DOESN'T involve is a large change in "your toolbox". In fact, just about every treatment technique itself could be ectodermal or mesodermal, depending on:
# the rationale for its use
# the way it is used
# the explanatory model used for both the patient and other stakeholders (other colleagues, payors, etc)

In The Chasm, I tried to provide a brief blueprint for how to move a traditional OMPT-based impairment model of treatment toward ectodermal reasoning. I'll reproduce it here for ease of reading. It's Post #81 in The Chasm.

I think this has to proceed in stages, this transition from mesodermal thinking to ectodermal, the process of crossing the chasm.
I think the others are right to make sure you know it isn't about the tools you use, its about the science and your understanding of it.
The moderators here would probably all self-identify as ectodermalists, but we use a wide variety of tools from DNM and ideomotion to neurodynamics to spinal manipulation and joint mobilization to exercise therapy.

First, don't focus on your tools. Just use what you already have. But use them in a way that's consistent with your understanding of pain science.
If you come from a traditional manipulative background, then let's start using those tools in a different way.

You can start with assessments - things like stiff muscles and hypomobile joints. Realizing the overall poor reliability and validity of these assessments, and the fact that they are in all probability defenses and not defects, you can significantly cut down on your time spent hunting for these.
I suggest you find one or two of these "impairments" that you can reason as related to the patient's primary complaint, and track those as you go along. Leave the rest alone.
That alone with save you boatloads of time.

Then to treatment. Realize that the bulk of the evidence shows we can't change mature connective tissue with manual therapy, and that the techniques we do use are nonspecific. So feel free to use the techniques described in RCTs, but realize they have been found sufficient to assist in recovery, and not necessary. For example, instead of carefully localizing manipulative techniques, I do several general area techniques and I don't worry about which joint I'm working with. So that takes about half the time since I'm not concerned that much about opening left facet at C6 or trying to fix a torsioned rib at T4. Those who aren't candidates for manipulative techniques can be helped with either gentler mobilizations (target areas associated with pain, not with hypomobility, or related to the patient's primary complaint) or even gentler skin-level manual therapy as described through DNM. Just make sure people know you're not aiming for fascia or anything.

Now you've saved time through fewer assessments and smaller numbers of treatment techniques. On to exercise therapy.
Teach exercise therapy as movement treatment for pain - skip the mandatory sets and reps and don't do strengthening until the pain is almost gone. For painful problems teach slow easy performance of the movements and tell the patient to learn to listen to their body and do the exercises when they have pain and a couple times a day besides. Only 1 or 2 exercises. Consider the feldenkrais suggestions Barrett provides and discuss positioning of hips and deep breathing/relaxation exercises also.

Now we're coming to the end of the session. We have saved time on assessment and treatment and only taught 2 exercises. Use the rest of the session for pain education that you can find in Explain Pain (I humbly recommend my handouts also- though sorry they're only in English), and give the patient plenty of time to give you feedback about how they are feeling during the session.

Now when the mesodermalists read your notes for peer review they're happy to see you finding stiff muscles and hypomobile joints. They're happy to see you using manual therapy and noting whether those impairments have changed or not. They're happy to see you tracking your outcomes with a patient self-assessment. They're happy to see you prescribing exercise. You're happy that your treatment makes sense, finally. Then when you're comfortable with that, reach out for other tools that fit the science. Get a Butler or Shacklock book on neurodynamics. Download and use Diane's DNM manual or post a case in her forum. Read Barrett's essays on manual care and ideomotion and read the published case report on ideomotion.

There you have it. Traditional tools, ectodermal reasoning, and a blueprint for chasm-crossing. The thing is, you have to build your own bridge.

[Jason Silvernail]

Ectoderming Repeated Motion Exercise

Currently, the use of subgroups of patients to drive treatment choice is very popular in physical therapy. I use subgrouping currently as the basis for my approach to spinal pain complaints, especially in the lumbar spine, so I thought I'd go through the major subgroups in the model and explain how they can be "Ectodermed" - which in this case means how they can be used while remaining cognizant of the relevant pain science that is widely available here.

The first subgroup I'll choose is the repeated motion group. This is a group which centralizes with repeated motions or sustained postures. The subject of centralization and the pursuit of such is a large and valuable discussion which I will deliberately not get into here. If you are a member of the MyPTSpace discussion group at Evidence in Motion, you can look up the keyword "McKenzie" and get more than enough of that if you'd like.

This approach originated with Robin McKenzie, who proposed (among other things) that certain movements and positions reduced a derangement in the spinal disk that was responsible for the patient's symptoms. He also proposed an organized and progressive examination to find the corrective exercises for each individual case and how to progress to manual forces if necessary. When this topic comes up on web forums, McKenzie Mechanical Diagnosis and Therapy (MDT) trained therapists inevitably show up and loudly proclaim that the disc model is no longer taught at the McKenzie Institute. Having been down this path with many McKenzie supporters in the past, I've no wish to reignite this particular issue. Generally speaking, I think there is much to recommend this paradigm for the appropriate patients. Overall, I have a lot in common with MDT-trained therapists, and McKenzie's books have a great deal of useful basic science information in them that lays a good foundation. There's even a detailed discussion of chemical vs mechanical stimulation of peripheral nociceptors. MDT-trained providers tend to understand the basics of mechanical pain better than most which is, in my opinion, a great opportunity for common ground.

However, the issue of how to incorporate pain science into a repeated motion/centralization scheme of evaluation and treatment is on the table here, and that's what we'll deal with in this post. To my knowledge, MDT does not approach the Neuromatrix theory of pain or provide much neuroscience of pain to their students.

If we don't tell the patient that we are reducing a disk bulge with those positions and movements, what DO we tell them?
I'll tell you what I tell them and we can reason together whether this is a good approach or not.
My educational foundation for most of my ectodermal patients (meaning those with an abnormal neurodynamic - I do see a lot of patients requiring mesodermal care in my practice as well) is my "Understanding Mechanical Pain" handout in the preceding link. I say that sometimes an organized and choreographed examination can help us find the the appropriate exercise to help them. If it works, it points a way forward. If it doesn't, we move on to something else. I say the tissue needs movement. Either I can introduce that with manual therapy, I can choreograph it with exercise, or I can help the patient find their instinctive movement to assist in its resolution (ideomotion). I may use all or any one of these options in any particular case.

I emphasize that if they feel better as a result of this treatment, we are most likely reducing the mechanical strain in the nerve tissue, but I deliberately do not discuss disks sliding around in response to movement as I believe I am at risk of transmitting a nocebo at worst; and at best an incomplete and unhelpful understanding of pain to the patient. I don't give posture advice unless there is a particular position that clearly worsens the problem, in which case the patient probably doesn't need me to tell them what not to do. My understanding of the posture correction and the use of the cervical and lumbar rolls that often accompanies this repeated motion exam is that it is related to disk forces in the biomechanical disk model of pain. Therefore I don't use the posture rolls nor do I tell people they need to sit or stand in a contrived and choreographed position in order to avoid pain, as I don't believe that is scientifically defensible.

So there you go. Repeated motion exam and treatment while fully cognizant of the relevant neurophysiology, and deliberate de-emphasis of disk mechanics to the patient.

How the treatment got ectodermed:
- no disk model of pain explanations. Stick to the basic physiology - mechanical strain in the nervous tissue reduced through the appropriate movement
- no exhortations to maintain contrived static postures
- avoid the sets and reps and focus the patient on movement to reduce the symptoms. More on exercise advice in the manual and manipulative therapy post.

[Jason Silvernail]

Ectoderming Manual and Manipulative Therapy

See The Problem With OMPT (link in a preceding post) for a broad discussion of the basics of an OMPT manual and manipulative therapy approach.

My previous comments about education and exercise prescription post manual therapy apply, and we have another thread about Post-Manual Therapy Exercise Prescription that you might enjoy as well.

The OMPT approach is often explained in terms of classical mesodermal reasoning - essentially people have pain because their joints are malaligned, their muscles are too tight, too weak, or unbalanced, or they aren't sitting or standing with proper posture. I covered the posture angle in a preceding post about Repeated Motion exercise, so I won't repeat it here.

When approaching an impairment manually, manual medicine practitioners commonly use graded mobilization/manipulation, thrust mobilization/manipulation, or muscle-energy technique in an attempt to correct a movement or positional problem at a joint. For our part here, we'll use the spinal facet joint as our example.

In the earlier post, I mentioned the idea of finding one or two particular impairments that we could reason are related to the patient's primary complaint and attempting to address that. We'll start with this idea.

My traditional OMPT training tells me that when I find a hypomobile joint or stiff muscle, I should attempt to move it into the restriction. If the patient has a relatively low muscular guarding response and low pain provocation to gentle handling, I might start with an oscillatory mobilization into the restriction. I will consider a thrust technique for a joint if the mobilization is unsuccessful or if the patient has good prior experience with it and a low irritability of symptoms. I don't use thrust manipulation in the upper cervical spine, but I tend to do thrust manipulation first in the lumbar and thoracic spines.

If the patient responds well to oscillatory mobilization, I talk about mechanical pain and then teach a movement exercise designed to improve motion into the restriction. I teach them as movement awareness exercise, with slow movements and deep breathing. This is designed to help reduce threat by putting the patient in charge of the motion and to reduce the sympathetic nervous system activity. I don't like to teach sets and reps of these exercises - rather they should do them when they hurt and a few times a day beyond that. I tell them about pain being a "need state" just like thirst and hunger(from Patrick Wall) and that it makes no more sense for me to tell them how many reps to do than it does for me to tell them how much water to drink or food to eat- they have to learn to listen to their bodies and treat themselves.

If the oscillatory mobilization doesn't seem to work, I'll move to a thrust technique if indicated as above. If the patient's level of muscle guarding doesn't permit passive movement (i've found this is common), I will move to a muscle energy technique or consider ideomotion also. I follow a MET or a thrust manipulation with the same approach to exercise as mentioned above.

How the treatment got ectodermed:
- focusing on patient's perception of symptoms rather than the manual measurement of the impairment
- passive movement against a patient's protective muscular splinting is not performed, instead encourage a way to get the patient to express the desire for motion through MET or other movement therapy (think Wall's protective phase to resolution phase here)
- education of patient and the rationale for treatment is concerned with movement as the appropriate approach for pain of mechanical origin and not the correction of a hypomobile joint or stiff/weak muscle
- the threat value of the therapy, especially passive techniques, is very important to evaluate. A thrust manipulation for a fearful patient or one with a great deal of muscular guarding is hard to justify and may in fact make the problem worse.
- little concern is placed on specific localization of technique to a particular joint, but more generalized techniques are encouraged
- the patient is constantly reminded that manual therapy from the therapist is merely a "jump start" to the problem, and it is the patient who holds the key to a long term solution, not the therapist

[Barrett Dorko]

Jason,

I'm just sitting back and letting all of this wash over my brain - a brain fried by too many unsuccessful attempts to make all of this clear to many thousands of therapists.

My sincerest hope is that we can discover something about your personal ability to see all of this so clearly. Then maybe we can find and identify others with the same potential. I know there are a few here already but we need more.

[Frédéric]

Good idea Jason,

I do understand that most of the «technics» are still good in the ectodermal world and that it is the rational that change but you transitionnal thread is very interesting for clarifing certain pratical aspect of the transition.

thanks

[Jason Silvernail]

Ectoderming Core Stabilization Exercise

I'll admit up front, my name is Jason and I'm a recovering core stabilizer.
[hi jason!]

This is a hotly contested treatment at the moment (as everything should be in science) and we're not going to explore the treatment rationale in much detail here. For those interested the thread "The Useless Core Strengthening" has a lot of good discussion about this. NB: I didn't name the thread.

Regardless of the reason we might teach these exercises, this can definitely be ectodermed. This usually involves a progression of exercises from static isometrics in nonpainful positions to the use of core muscular contractions during more functional movements as symptoms improve.

The old rationale involved muscular contractions to improve the physical stability of the motion segment. McGill and others demonstrated that physical stability was not best accomplished with individual muscular activation, and the theory behind the treatment has been in question since.

I still use it, but tend to do so as a motor control rationale and when pain is reduced and we are working toward reconditioning. I think it has some CBT implications as well in the group setting.

My patients (I'm in the US Army) often think in terms of sports and conditioning, and having an organized reconditioning process that they can work on and show improvement with is powerful for them and usually much appreciated.

How the treatment got ectodermed:
-don't talk about people having a physical "instability" as this can be a nocebo. Plus the recent research suggests that's not accurate.
- I use it as a way to build body awareness and in accordance with previous thoughts on exercise therapy
- I don't think or talk of it in terms of physical stability - but in terms of motor control. The jury is still out on this treatment in many ways but it can be ectodermed rather easily if we jettison the physical stability issue and talk about muscular control
- remember that when the origin of the pain is mechanical that movement (and not stillness or "stability") is the treatment that makes the most sense. Some kind of movement for pain relief is probably indicated here in conjunction with the "stability" approach depending on how primary the pain complaint is

[cathyph]

Jason,
This is one of the most brilliant pieces I've read here. Clearly outlined, it makes it irresistible to want to learn more about that neuroscience piece. This is a great example of providing clear guideposts for safe exploration.
Thanks!
Cathy

[BB]

Great stuff, Jason!

I often view the graded progression nature of many movement approaches (including repeated movement and "core" stability) to be working at the level of habituation (ectodermed) vs. strengthening (mesodermed).

Looking forward to the next installment.

[JimA]

Excellent!

Fantastic post Jason, I have been looking for clarity of thought on this subject for sometmie and this definately brings it together nicely for me. Thanks!

[Barrett Dorko]

I can only guess at a thread’s potential once it’s begun and often I’m surprised. I’ve seen what I thought were wonderful ideas die rapidly while others endure simply because they generate some sort of soap opera. This thread’s subject matter transcends that, I think, and, as the best threads do, it will inform both those who only read and those who contribute as they write. I certainly feel that way here.

In a Simple Contact Newsletter I wrote in ’07 there’s a reference to a book by David Berlinski titled Newton's Gift: How Sir Isaac Newton Unlocked the System of the World. Here the author makes it clear that Newton’s failure to transmute elements from one form into another while working as an alchemist (see The Last Sorcerer for more on this) had to do with a fundamental flaw in his presumptions. I wrote:

The alchemists reasonably assumed that differences in metals represented superficial variations in their common chemical structure, but, of course, they were wrong. Metals are connected at a level that doesn’t attend to the laws that govern chemistry, so alchemy was doomed.

Over the past couple of months I’ve come to see the meso-ecto thing as less a division and more a distinction; each is a perspective. Both can be useful in similar circumstances and may even be complementary within the same patient during the course of care. This distinction however has its origins in something fundamental that I feel we must address, and, as I wrote, it is this:

… many of our colleagues have assumed that successful biomechanical examination and training will translate readily to other painful problems, even those which include an abnormal neurodynamic. But, like the alchemists during the middle ages, they are mistaken. The connection isn’t biomechanical – it’s neurobiologic.

I think that crossing the chasm will require that we recognize this and bring the discussion to bear upon this point.

[Erica]

Jason,
A brilliant piece. You have the knack for writing in a way that inspires inward thought and poses questions for one's self that only can bring one to a better place in patient care. :thumbs_up

I often think how I can cross this divide as I work on someone and try to explain what I am doing without interjecting my biomechanical background. I admit it is tough at times but worth the effort in the end.

Erica

[Barrett Dorko]

I don’t watch TV for nothing you know. I’ve had a scene from the initial episode of Head of the Class seen for the first time (by me) in 1986. This popular sitcom began with a demonstration by several gifted students explaining how the same thing could be quantified and accurately described through several disciplines including chemistry, physics and poetry. There’s another but I can’t remember it.

In any case, I was struck by this display of what I now know Mary Midgley would call scientific pluralism.

She says:

Much of the time, we are exploring unknown or partially known matters, and we use whatever forms of thought turns out to be needed for them. (It is) our powers of perception that are central to our work, (not) consecutive reasoning…Different sources of knowledge seems to me very useful (and) as different questions are asked there are different answers.

Perhaps places to stand on this bridge show up unexpectedly in this way. It might be that the ectodermal ground has a bit more imagination beneath it.

[Erica]

I would agree. Barrett, it is funny that you mention imagination. I was working with a patient tonight and gave her a movement to do at home. She then asked me for a picture, visual in a book etc. I said that I did not have one as I actually made it up, so to speak. She was cool with that as it did not cause pain and felt pretty good.

I find myself more and more using my imagination as I try and reason the ectodermal approach with my patients. It makes sense to me as every patient will have a somewhat different movement which instinctively makes them feel better.
Erica

[Barrett Dorko]

As much as I admire Newton's second law (discussed here) I think that his first first law of motion:

Every object in a state of uniform motion tends to remain in that state of motion unless an external force is applied to it.

has something to do with the activity we see from each of the perspectives. Is it fair to say that the mesodermalists are more inactive and thus find it harder to change? Might it be better to say that they are more stable? Is "more entrenched" too much?

Consider people on an elevator. If most face the rear the lone remaining person will also. (There's a Candid Camera video on Youtube someone could link here) It's the numbers that are most significant, and as long as we looking out from the ectodermal side of the chasm are so vastly outnumbered we may repeatedly become dead men when we try to reach across.