CT More than Placebo

[Luke Rickards]

Diane,

Do you believe that there are no 'specific' effects relevant to the changes you see following your care?

Luke, would you care to explain to me why anyone would believe the opposite? Maybe on another thread..

The opposite of thinking there are no specific effects is thinking nothing but specific effects are responsible for improvement. Reasonable explanations for such a view would be either ignorance or conceit.

However, my question was not concerned with the opposite. I take it from your answer that you do think there is nothing in manual therapy other than placebo. I find this answer curious because it suggests some considerable contradictions with the application of the deep models of treatment we discuss here, including DNM. Or perhaps we have a terminology issue.

A few examples to elucidate my point:

A quick glance through your manual reveals hypothetical elements regarding specific effects of your technique application that are fundamental to your approach: eg, lateral stretch of skin is necessary to excite slow adapting mechanoreceptors which "puts a constant non-nociceptive input into the nervous system to help it downregulate nociception from mechanical deformation"; specific positioning of nerve trunks aids oxygenation; skin stretching should be applied with the anatomy of underlying peripheral nerve tissue in mind.

If we look at SC, there are also hypotheses regarding specific effects: eg, ideomotor movements are responsible for the resolution of peripheral nerve tissue deformation; ideomotor movements result in a reduction of sympathetic tone and improved blood flow.

Even pain neurophysiology education involves inherent propositions regarding specific cognitive/affective effects in altering dysfunctional pain behaviours.

If all attention here should be directed at methods of increasing patient expectation and developing the most convincing medical (or PT) rituals then it seems that, for example, basing manual care on the minutia of ruffini receptor response to the specific dynamics of mechanical input to the skin, or positioning neural tissue for the purposes of improved oxygenation, might be considered a waste of time.

[Barrett Dorko]

Luke,

One year ago you wrote a post in the Suppose this were true thread that helped me immensely during a real crisis in my understanding. This is a portion of post #57:

…it is clear that input to map representation at various levels may be sufficient to convince the brain that threat has been resolved, eg, CRPS is reduced by both higher level motor input and visual input representation. The existence of placebo would rule out the claim that any aspect of therapy, other than expectation, is necessary, but that doesn't mean that input into the motor representation maps is not sufficient to resolve a discordance (if that is truly the problem).

This brilliant distinction between what is necessary and what is sufficient helped me again see the worth of my efforts and dedication to study and actual practice - at a time when I felt a creeping despair regarding both. This was no small thing and I will be forever grateful.

If I’m not mistaken, this thread is in a similar vein, and I hope many look in.

[Diane]

The opposite of thinking there are no specific effects is thinking nothing but specific effects are responsible for improvement. Reasonable explanations for such a view would be either ignorance or conceit.

However, my question was not concerned with the opposite. I take it from your answer that you do think there is nothing in manual therapy other than placebo. I find this answer curious because it suggests some considerable contradictions with the application of the deep models of treatment we discuss here, including DNM. Or perhaps we have a terminology issue.

A few examples to elucidate my point:

A quick glance through your manual reveals hypothetical elements regarding specific effects of your technique application that are fundamental to your approach: eg, lateral stretch of skin is necessary to excite slow adapting mechanoreceptors which "puts a constant non-nociceptive input into the nervous system to help it downregulate nociception from mechanical deformation"; specific positioning of nerve trunks aids oxygenation; skin stretching should be applied with the anatomy of underlying peripheral nerve tissue in mind.

If we look at SC, there are also hypotheses regarding specific effects: eg, ideomotor movements are responsible for the resolution of peripheral nerve tissue deformation; ideomotor movements result in a reduction of sympathetic tone and improved blood flow.

Even pain neurophysiology education involves inherent propositions regarding specific cognitive/affective effects in altering dysfunctional pain behaviours.

If all attention here should be directed at methods of increasing patient expectation and developing the most convincing medical (or PT) rituals then it seems that, for example, basing manual care on the minutia of ruffini receptor response to the specific dynamics of mechanical input to the skin, or positioning neural tissue for the purposes of improved oxygenation, might be considered a waste of time.

I wonder why you suppose that something as complex as a human nervous system would not be capable of
1. inputting (i.e., reading an input, carefully calculated from an operator standpoint, to assist in a non-nociceptive manner with peripheral downregulation on one level) and,
2. outputting (i.e., responding in a manner that deconstructs a pain experience, i.e., mounting a placebo response, as an interactor)
.... at the same time?

It seems to me it does that continuously for a living anyway.

It seems to me that when a patient comes for treatment, the result, i.e., pain relief, (which is going to be tied in with placebo response by their own brain) is what matters most, to the patient. Pain relief in a live conscious non-medicated individual is ONLY going to happen when the brain of that individual changes itself. The initial molecular intrinsic change will be chemical, will be placeboic. Hopefully after that neuroplasticity will have been rerouted and can take over favourably instead of unfavourably.

The steps to get there require the therapist to be as catalytic as possible.
Being effectively catalytic usually involves setting up a treatment construct to follow, which will obviously be from a third person perspective, and which as we all know, historically have been based on anything whatsoever, even things that make no sense at all from a rational standpoint or things which have been shown to be impossible.

Developing a construct that at least gets us onto the appropriate tissue is an improvement.

I won't go so far as to say that adhering to a treatment construct from a third person perspective is always going to be necessary - once the treatment has begun, and interaction is rolling along, the kinesthetic zones in the brains of both patient and therapist will usually do fine without any conceptualizing. However, IMO the "concept" is the "story" or interpersonal bridge, that one needs to have ready in order to move things from a) to b) in:

1. the patient's mind
2. the therapist's mind
3. the minds of any to whom you are trying to teach human primate social grooming.

Maybe all of it is a colossal waste of time.

[Luke Rickards]

I wonder why you suppose that something as complex as a human nervous system would not be capable of
1. inputting (i.e., reading an input, carefully calculated from an operator standpoint, to assist in a non-nociceptive manner with peripheral downregulation on one level) and,
2. outputting (i.e., responding in a manner that deconstructs a pain experience, i.e., mounting a placebo response, as an interactor)
.... at the same time?

In fact, I completely agree with this. The issue here, though, is the relevance of the "carefully calculated input". Carefully calculated practitioner input is what we refer to as specific treatment effects, and the enormous efforts given to this process (especially here) might be seen as an indication that such input is believed to play an active role, at least to some degree.

I wonder why someone would bother with carefully calculated input if they believed it was essentially irrelevant.

[Diane]

In fact, I completely agree with this. The issue here, though, is the relevance of the "carefully calculated input". Carefully calculated practitioner input is what we refer to as specific treatment effects, and the enormous efforts given to this process (especially here) might be seen as an indication that such input is believed to play an active role, at least to some degree.

I wonder why someone would bother with carefully calculated input if they believed it was essentially irrelevant.

In fact, I completely agree with this. Why would someone bother with carefully calculated input if they believed it was essentially irrelevant?
Why do I bother?

Very good question.

I think I bother simply because a crutch of some sort, so the conceptualizing part of the brain can get to the kinestheticizing part of the brain, seems to be necessary in this non-sexualized-human-primate-social-grooming deficient, kinesthetically anorexic world, not just for the groomer and the groomee, but for the hive-mind.

[Frédéric]

Wow, you guys are intense today!

[Frédéric]

For my part, I think if the placebo response can be optimalized, then we do have a specific effect.

But I don't entirely discard a specific effect not placebo like for now.

[Diane]

Wow, you guys are intense today!

I think that was Luke punching me!

[BB]

Great thread idea.

Perhaps some clarification of terms could be useful. It would for me anyway.

I've been under the impression, perhaps mistakenly, that a non-specific effect is one that cannot be specifically attributed to the mechanism in question. For example, the act of spinal manipulation may bring about temporal summation, but can it be attributed to the manipulation alone or the interaction of expectation, action, and therapist role, etc.?

So, the act of manipulation may be found to bring about specific actions, like activation of ascending pathways, but the effect brought about may still be non-specific as it is able to be nullified with the addition of the role of expectation.

So, DNM may be found to have specific actions, like Ruffini activation, but the proposed effect brought about by the application, pain relief, could still be non-specific.

No?

[Jon Newman]

Cory,

I think your question gets to the difference between cause and origin--discussed here for example.

[Barrett Dorko]

Realization

It seems to me that we’ve arrived somewhere. Not a place, but a realization. Ironically, many, many of our colleagues now stand beside us. I’m guessing that they aren’t quite sure where they are or how they got there.

Before us, as always, is a patient in pain waiting for some help. We each have our own ideas about what form that should take and while some methods have been demonstrated as successful to the satisfaction of the evidence based crowd, others may only be reasonably defended from the standpoint of prior plausibility. It isn’t often that these two intersect, but, when I think about it, that’s what Luke’s studies seek to do for ideomotor movement and the therapy that employs it. It takes time. It’s difficult. But I believe it will be accomplished.

Here on Soma Simple we have a sense of how we’ve arrived; through a jungle full of traps and impediments. Our colleagues have had an easier trip. Across the gentle slopes of mesodermaland they’ve been guided by the programs and fellowships that don’t allow much in the way of dissonance or uncertainty. Traps are easily navigated or ignored - their hands have been held. Ultimately, they get the same positive reactions from a common patient population and can hardly be blamed for thinking and behaving as they do.

Together we now face the patient’s brain. Modern neuroscience has demonstrated its power to resolve pain with us, without us and in spite of us; and all we know or don’t.

In light of this it is no wonder we agree on where we are but cannot agree on what to do next.

Or not.

[Diane]

In light of this it is no wonder we agree on where we are but cannot agree on what to do next.

Or not.

Quite so.

Choices:

1. Stand back and let human primate social grooming go extinct (as science paints it into an ever smaller corner of existence, because of its inability to show (scientifically and unambiguously) that it deserves to exist)

2. Help science along by using Ocam's Chainsaw on HPSG

3. See if we can find any new trail in neuroscience that defends our right to continue doing what we do, interact with nervous systems in non-sexualized, brain-feeding kinds of ways, catalyzing non-specific changes/outputs which usually lead to pain resolution

4. Forget trying to do anything "understandable" or "verbal" or "conceptual".. just go non-verbal, primal, completely pre-human/kinesthetic.

[Diane]

I want to add that I think looking for specific effects for spinal manual therapy is a complete fool's errand. It smacks of tooth fairy science, or worse, Balnibarian science, testing ludicrous suppositions ludicrously:

"...at the Academy of Lagado, scientists are attempting to do the following: extract sunbeams from cucumbers, turn human feces back into food, erect buildings from the roof down, plow farmland with pigs, make marbles soft enough to stuff pillows and pincushions, breed sheep whose entire bodies are bald, and have students learn mathematics by swallowing wafers on which formulas are written.
.......So absorbed in these enterprises are the inhabitants that they avoid taking part in almost all other activities."

My bold.

Gandevia has already shown that skin stretching produces kinesthetic illusion in the brain. What's wrong with just going along with that? (Specific enough for you Luke?) Skin happens to be on the outside, which makes it very simple for human primate social groomers to work with, and contains Ruffinis, which one cannot avoid if one is doing skin stretching.. or even just contacting skin while thinking one is doing something else entirely. Skin is always in the way, isn't it? A confounding factor..

It was worked out long ago that Ruffinis are slow-adapting, fire continuously with lateral stretch, comprise 19% of all skin receptors (see Challenge of Pain for details). I don't know how one could eliminate them with Occam's Chainsaw.

Just in terms of sheer logic, I'd say that skin stretching has more going for it, both specifically and nonspecifically, probably, than aiming a treatment construct at anything deeper could hope to produce.

[Barrett Dorko]

Improving our chances

Back to my “arrival at a realization” analogy. Having landed here, each of us has a decision to make about how we might continue to practice. Having to satisfy the patient, the referral source, our bosses, the payer and our own curiosity regarding the deep model, many methods have emerged and each may be defended from one or more of these perspectives. That last one less often than the others, it seems.

As time goes on some of these viewpoints rise or fall in significance but the last one has always compelled me the most. No wonder my struggle to communicate or relate to my colleagues.

While teaching I will acknowledge the success often enjoyed by therapists employing methods they cannot defend or explain rationally without ignoring what science has taught us. I say, “Wonderful things happen with traditional methods, but there’s a lot of luck involved – isn’t there? (therapists always nod when I say this) Is it a good idea to walk up to your next patient in the waiting room and say, ‘Do you feel lucky today?’ (imitate Clint Eastwood when you say this and you’ll always get a laugh).

To me, the methods I use reduce my reliance upon luck – they will never eliminate it entirely.

Maybe that’s what this mild clash here is about.

[Diane]

Meanwhile... I suppose we still have this.
Swearing increases pain tolerance. :thumbs_up

Thank you Mo. :thumbs_up