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  • #31
    Frederic,

    I think your assumptions are to be expected and further bring into focus the problems poor theory creates.

    Another question: Can we further define the difference, say, between a placebo response and a profound placebo response. After all, a headache-producing brain tumor isn't going to go away with a sugar pill but the headache itself might. This relief just won't last.

    If a headache that has its origins in an abnormal neurodynamic is improved in the presence of any number of therapeutic methods, and if the effect is enduring, can be reproduced in the absence of the therapist and educates the patient in some way, can't we say that the placebo response was sufficient to justify the care? In this case, the patient is satisfied but some therapists might not be, depending upon the method, of course.

    Try this:

    Palliative therapy method = Placebo response

    Truly therapeutic method = Profound placebo response
    Barrett L. Dorko

    Comment


    • #32
      Another consideration is this: A patient enters a room which is perceived as threatening in some way, and a nocebo response is elicited. This may persist despite any therapist's methods.

      I wonder if there is a neutral sort of phase between the nocebo and placebo responses? Where the patient can easily slip either way and this is dependent on the therapist's attitude and perhaps methods?

      Nari

      Comment


      • #33
        Having arrived, each therapist considers the painful patient before them and formulates a plan for movement in the direction of relief. Many simply point and talk, hoping the patient will see and respond appropriately. Many have the patient mount a machine of some sort that they feel will take the patient there. Many get behind the patient and push, sometimes not too gently. Many use various combinations of all three methods.

        These therapists often succeed in getting the patient to report relief.

        Luke, Diane, Cory, Eric, Chris, Jon, Jason, Gil, myself and several others here take the patient in our hands and speak softly. We communicate what we can about what we’ve learned about the brain’s preferences and time our handling just so, creating a context that will allow a placebo response to emerge. This may not be as specific a method as we’d like but it is, in my opinion, more in line with prior plausibility, more pliable in application and, perhaps most importantly, less invasive than those used traditionally in the treatment of pain.

        No less than Ramachandran suggests that this is what modern neuroscience would lead us toward. In a word, it is sufficient, for the most part.

        Fair enough?
        Barrett L. Dorko

        Comment


        • #34
          The "out to sea" analogy

          Perhaps this will fit: The patient in pain is, in a sense, out to sea. Solid footing that would normally propel them toward relief; toward “home,” isn’t available and can’t be manufactured by any therapist. Under such circumstances it is no wonder that traditional methods are often elaborate and irrelevant. If, however, the “winds” of healthful behavior - often found in today’s therapy department - blow strong enough, the patient may wash up on the shores of mobility and strength and blood flow; relatively relieved and convinced that the therapy prescribed and endured was what they needed. The placebo response is important here and now it’s clear that discounting exercise entirely would be inappropriate, or it seems so to me.

          The practitioners I mentioned in the last post don’t wait for the “winds of wellness” (I just made that up) to blow the patient ashore – they teach them how to swim. They understand that the stability provided by protocols manufactured from clinical prediction rules and generated by some categorization of disability cannot be trusted out on the ocean - maybe on dry land, but not there.

          Over two years ago in post #28 of the manual magic thread I wrote:

          …most of this world is water, and if we refuse to learn how to navigate it we will never venture far into it without undue fear and superstition.
          Maybe the ectodermal perspective helps us navigate more surely while mesodermalism is far less reliable, illusory even.

          Still and all, both groups must contend with unexpected weather.
          Barrett L. Dorko

          Comment


          • #35
            Love your "out to sea" analogy. Love it.
            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


            • #36
              Hey Luke,
              How does Bud Craig's labelled lines construct fit into this discussion of specific versus non-specific effects of the manual therapy intervention/interaction?

              It seems that DNM, aside from any explanatory and contextual information used to introduce it, works along labelled lines from the Ruffinis directly to S1.

              Ideomotion seems to work along the covergent aspects of the nervous system, primarily. What part of the "contact" in "simple contact" is specific, if any?

              This is a fascinating thread.
              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


              • #37
                I think its premature to consider only placebo here. I think there are many possibilities of engaging specific mechanisms with intelligent therapy in terms of relief of mechanical deformation as an origin. I would agree 100% with Luke's statement about central nonspecific effects playing a greater role than we would like, but that doesn't mean the existing data rule out a local/ peripheral /specific effect.
                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


                • #38
                  Originally posted by Jason Silvernail View Post
                  I think its premature to consider only placebo here. I think there are many possibilities of engaging specific mechanisms with intelligent therapy in terms of relief of mechanical deformation as an origin. I would agree 100% with Luke's statement about central nonspecific effects playing a greater role than we would like, but that doesn't mean the existing data rule out a local/ peripheral /specific effect.
                  And those might include... what, Jason? Luke?
                  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


                  • #39
                    I don't think I understand your question, I thought part of beauty of mechanical pain is that it is closer to an essential diagnosis.
                    Relief from pain of mechanical origin comes about most likely from reduction of the deformation in the relevant tissue to a level within its tolerance or to a level that the brain no longer finds threatening. If you can engage central mechanisms like descending inhibiiton and/or expectancy while addressing the cognitive/evaluative aspect of the matrix, then the model predicts you'll be more successful. It's certainly possible that central mechanisms such as expectancy and descending inhibition can do the trick without any change in the level of deformation in the system - I just don't think there's any reason to think that there isn't a role for such a mechanism in patient treatment.

                    When a patient with radiating arm pain comes in and I get them supine and manually glide their neck so as to open the foraminal opening on that side and the patient reports instant change for the better, are you saying that is due only to a central effect such as placebo? If that were true, wouldn't it not matter if I did the opposite and "closed down" that side? I've seen people throught my 11 year career (as of this writing) respond in just such an immediate and positive way in many situations. I grant its possible that it's always expectancy, but the model we're working with doesn't seem to point that direction.
                    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


                    • #40
                      I think you understood it fine, and your answer is fine.
                      This is the key piece, IMO:
                      Relief from pain of mechanical origin comes about most likely from reduction of the deformation in the relevant tissue to a level within its tolerance or to a level that the brain no longer finds threatening.
                      The thing is, dear Jason, it is still going to be the brain having the final veto power, the final yea or nay say in whether or not it accepts the proffered "reduction in mechanical deformation." And its acceptance or rejection is still going to depend on a lot of other context, other variables. Right?

                      Hence the difficulty in controlling for variables in manual therapy or ever being able to replicate the same maneuver twice the same way on different people or ever being able to get much in the way of reliability between different practitioners. Right?
                      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


                      • #41
                        .
                        ..it is still going to be the brain having the final veto power, the final yea or nay say in whether or not it accepts the proffered "reduction in mechanical deformation." And its acceptance or rejection is still going to depend on a lot of other context, other variables.
                        Placebo response, in my mind, is one of those variables. It is not the only one, and I don't think anyone has suggested this. Nor could it ever be accurately measured.

                        Nari

                        Comment


                        • #42
                          Dear Diane-
                          I wouldn't disagree with that, but just as context and threat are important to the brain, so is the incoming afferent message. I don't think at this time we can be so certain that placebo is it - certainly the research into NSAID effectiveness for example shows an effect larger than placebo so I'm not sure why we would think that mechanical input would not be an important consideration. I mean, the brain is deciding things there in the presence and then subsequent decrease of a chemical afferent signal, right?

                          I think we're coming close to therapeutic nihilism here and neither my read of the relevant literature nor my overwhelming anecdotal experience would support your position. I think you're wrong on this one.


                          ps just another example of how all the moderators here always agree and push a dominant paradigm of thought by ostracizing those who disagree.
                          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


                          • #43
                            Originally posted by Jason Silvernail View Post
                            Dear Diane-
                            I wouldn't disagree with that, but just as context and threat are important to the brain, so is the incoming afferent message. I don't think at this time we can be so certain that placebo is it - certainly the research into NSAID effectiveness for example shows an effect larger than placebo so I'm not sure why we would think that mechanical input would not be an important consideration. I mean, the brain is deciding things there in the presence and then subsequent decrease of a chemical afferent signal, right?

                            I think we're coming close to therapeutic nihilism here and neither my read of the relevant literature nor my overwhelming anecdotal experience would support your position. I think you're wrong on this one.


                            ps just another example of how all the moderators here always agree and push a dominant paradigm of thought by ostracizing those who disagree.
                            All I'm saying is,

                            1. that your example... --->"When a patient with radiating arm pain comes in and I get them supine and manually glide their neck so as to open the foraminal opening on that side and the patient reports instant change for the better, are you saying that is due only to a central effect such as placebo? If that were true, wouldn't it not matter if I did the opposite and "closed down" that side? I've seen people throught my 11 year career (as of this writing) respond in just such an immediate and positive way in many situations. I grant its possible that it's always expectancy, but the model we're working with doesn't seem to point that direction." ..... is from an operator stance, and may be a "Post hoc ergo propter hoc" fallacy ("the logical fallacy of believing that temporal succession implies a causal relation") as much as any other is.

                            2. that like it or not, skin is being stretched and therefore the neural bits within it are too, and the brain is reading that first, before any "gapping" could have any specific effect.

                            3. that you cannot rule out (nor can we really measure, except perhaps by real-time fMRI some day), interactor effect - and lean toward operator effect, i.e. specific effect specifically from joint gapping - unless you're working on an unconscious patient, without skin. (Are you? I guess I probably should have asked that first! )

                            4. that no reported effect, however close temporally to whatever "technique" you use, will last, if the brain decides for whatever reason to not mount a placebo response, i.e., a chemical, synaptic, neuroplastic brain change generated from within itself and its own processing.

                            5. that some of this may well be at a cord level, but won't last without descending inhibition, which has to come from a brain change (see 4).

                            That's all I'm saying. [/gettingreadyforthenextpunch]
                            Last edited by Diane; 17-07-2009, 03:17 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


                            • #44
                              Excellent exchange and a very good thread. Diane at the risk of sounding pedantic, I think there is ample evidence to suggest the existence of mechanically induced nociception from a nerve root within the intervertebral foramen. The fact these symptoms often evolve into anesthesia and eventually a predictable pattern of muscle weakness (at least for me) strongly implicates the nerve root as a major player in the process.

                              In this context I am trying to see how sensitizing a convergent cutaneous afferent through skin stretch can influence this nerve root deformation to the same degree Jason's mobilization could. In this case I believe the gapping has a very specific effect of relieving mechanical deformation. We all would agree this is only one piece of the puzzle of course, but it is a pretty important piece.

                              It seems that pain is such a heterogeneous experience, but yet identifiable patterns of mechanical deformation remain fairly homogeneous. I see people experience the pain of shoulder pathology on so many different levels yet there are many common threads such as a painful arc of motion...you get the idea. If there is homogeneity to some forms of mechanical deformation, then there is likely a specific peripheral origin. If there is a specific peripheral origin, can't their be a specific effect to a manual intervention? I'm asking just as much as I'm implying here...I could be way off.
                              Last edited by HeadStrongPT; 17-07-2009, 04:18 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


                              • #45
                                Diane-
                                I don't disagree with you specifically about what could be happening, I find it hard to refute specifically the possibilities you bring up. I just think that's not necessarily the whole story.

                                Just as I can't rule out that it's 100% a central process, I'm saying you can't rule out that there isn't a peripheral component.
                                The issue for me is how much is central and how much peripheral. I think generally we can say in more acute presentations that that trends peripheral and in more chronic that it trends central, but who knows the relative contributions? That's why addressing all factors of the neuromatrix, including the sensory/descriminative through targeted examination and treatment, shouldn't be dismissed.

                                I think the data so far don't allow us to say "It's all peripheral" (classic manual therapy operator stance) or "It's all central (placebo?)" - which is what I'm reading here.

                                Am I wrong or isn't the placebo response tied necessarily to expectancy?? In DNM isn't descending inhibition and possible peripheral reduction of deformation through positioning part of the rationale?

                                First rule of forum posting reminds me of "The Rule" in boxing: protect yourself at all times. Diane's last bracket reminded me. All in good fun and good sparring sessions make a better fighter.

                                Rod-
                                Agreed and good point.
                                Last edited by Jason Silvernail; 17-07-2009, 04:51 AM. Reason: I cannot spell tonight.
                                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

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