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Old 27-02-2008, 12:44 AM   #1
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Default 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.
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Old 27-02-2008, 01:02 AM   #2
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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.
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Old 27-02-2008, 01:06 AM   #3
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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.
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Old 27-02-2008, 01:14 AM   #4
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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.
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Old 27-02-2008, 01:20 AM   #5
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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.
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Old 27-02-2008, 02:11 AM   #6
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Quote:
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.
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Old 27-02-2008, 02:43 AM   #7
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Cory wrote,
Quote:
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.
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Old 27-02-2008, 03:00 AM   #8
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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

Quote:
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,

Quote:
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.
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Old 27-02-2008, 03:04 AM   #9
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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.
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Old 27-02-2008, 03:26 AM   #10
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Thoreau, in On Walden Pond wrote;

Quote:
“…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.
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Old 27-02-2008, 03:47 AM   #11
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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....
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Old 27-02-2008, 03:52 AM   #12
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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.
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Old 27-02-2008, 03:53 AM   #13
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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.
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Old 27-02-2008, 04:05 AM   #14
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Quote:
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).
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Old 27-02-2008, 04:10 AM   #15
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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.
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Old 27-02-2008, 04:26 AM   #16
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Thanks Barrett. If anyone isn't sure what Barrett is getting at, read Incantation from his site. Though you'll have to endure a little more American literature.
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Old 27-02-2008, 04:59 AM   #17
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Rod,

I think what you are getting at is what level exists for skin based treatments. Yes?

As Jon said, the ectodermal approach could be applied to any manual care.

If I am correct on the skin deep thing:

Luke has published a study on Simple Contact that would I believe be at level 6 in your hierarchy.

There is lots of basic science and expert opinion.

If you accept that the patellar taping studies were in fact studies of skin based treatment (and I have made that argument on MyPTspace although it was contested. JohnW, what are your current thoughts on this?) then some do exist at the level of RCT (level 4) and Clinical Guideline (level 3). Meta-analysis and syt. review (lev 1 and 2).
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Old 27-02-2008, 06:18 AM   #18
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Quote:
Is it necessary or more effective to utilize coercive manipulative techniques versus gentler skin-deep techniques to help resolve the painful condition?
John, I could be wrong about this, but it seems you’re asking a question you and everyone here already knows the answer to. If it’s a game of oneupmanship, I’d call it a draw. Ortho wins, due to the fact some of its methods have been studied enough to achieve a level of evidence not demonstrated by the less coercive techniques. On the other hand, the less coercive techniques win in the basic science department.

I’m going to allow myself to write freely again tonight. Warning – strong opinions ahead, not to be taken personally…

The ectodermal viewpoint argues convincingly, I think, that the basic science underpinning the traditional orthopaedic viewpoint needs reconsidering. It is leading our research towards a dead end and it truly is encouraging to hear from John that this shift may already be underway, even if it’s moving too slowly for some of us here. If you spend enough time with it, the ectodermal (basic science) approach quite logically leads to less coercive techniques for the treatment of pain; many of these are documented on this site. It does not necessarily exclude traditional orthopaedic technique!

Interestingly, there appears to be a strong aversion to implementing ‘novel’ techniques into ones practice. The sentiment goes so far in some circles as to chastise anyone who tries. It is true that some of these techniques may be descendants of a pseudoscientific lineage. They may also lack higher order evidence, but only because this is the current state of the science. People conducting research have after all traditionally done so from the orthopaedic perspective largely ignoring the pseudosciences – and quite rightly. That’s just the way it’s been, and we all have to live with it.

However on the other hand, vast quantities of research has already been performed on traditional orthopaedic approaches and overall the outcomes leave much to be desired. See the red file for examples of this. In spite of this, many many therapists today still use techniques in their treatment of pain that originate from the very ortho mold that has already been found wanting of a valid theoretical construct and higher order evidence, yet receive no substantial grief for it. Why? These techniques were fortunate to have once been fashionable enough to become tradition. Why is a practice descended from tradition more palatable than one built on a logical scientific construct?

My big question tonight is; how would the traditional advocates of the orthopaedic approach, like to see the state of the science progress? To perform credible research, expert practitioners are required. I have been critical traditional practices and concepts, but not without some merit. If the opinions of posters of from other forums are to be believed, anyone practicing outside the narrow scope of traditional practice is worthy of scorn, suspicion and ridicule; likewise anyone who attempts to ‘educate’ anyone in the theory and practice. It’s not hard to see how this attitude acts to suppress progress in our science. Is it not illogical to demand that there should be 'A' level evidence before something can be considered, taught and practiced? Or am I completely missing something?

How are we to move forward? Please advise.

(thanks for allowing me to get some mental exercise tonight)
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Old 27-02-2008, 09:25 AM   #19
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Surely if we waited for "A" level evidence, we would end up doing practically nothing?
Not the nothing that Barrett refers to with respect to eliciting ideomotion; but what strong evidence exists seems to be limited to certain methods for small groups (qv SM). There is thankfully a lot more evidence around which indicates what should not be done, eg US, traction, etc, because of general ineffectiveness.
SM has been shown fairly strongly that its coercive nature is helpful for some people. My eternal question is: what needs to be done for those who do not respond to physical coercion, for example, persistent pain people?
Those of us with a keen interest in chronic pain are certainly interested in 'novel' techniques; if they are supported by a neurophysiological process which makes more sense than the current neuromuscular process, then they shouldn't be avoided.

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Old 27-02-2008, 01:52 PM   #20
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Eric,

Again, brilliant.

While waiting for a panel discussion on EBP and manual care to begin at the Sections meeting in Nashville a few weeks ago I was quietly asked by one of the panel members to come to the microphone and say something in order to offset what they feared would be too one-sided an opinion given the panel's makeup.

I chose to quote briefly from Nicolas Lucas' interview on Soma Simple. He speaks there of what he calls "evidence only" practice and was thanked afterward for "a perfect quote." I also asked a question about the validity and reliability of the testing prior to manipulative care. That question was, of course, never answered.

I'd suggest another reading of Lucas' interview here in light of this discussion.
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Old 27-02-2008, 07:11 PM   #21
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Thanks for all the replies. I will be looking over them in more detail this evening when I get home from the clinic.

Again many of the posts seem to revert back to a skit from the old Monty Python movie "Life of Brian". The "What have the Romans ever done for us?" bit. Folks we know there is more work to be done in the way of orthopedic manual therapy, this is not the issue. At least the data exists and is left out there for debate.

Apart from Luke's case study which I have yet to read, is there any other evidence supporting the "ectodermal" approach? It seems that even some of the research cited (patellar taping) is actually cherrypicking off orthopedic research and saying the results must be "ectodermal" vs "mesodermal" pheonomenon.

Why? Because there is a tons of evidence to both support and refute many orthopedic approaches, whereas there seems to be next to nothing out there to support or refute the ectodermal approach.

And again, evidence does not equal proof. I don't think anyone is talking about devoting yourself to EBM (Please refer to the quote in post #1 of this thread). It would be good to see some hard data in a format the rest of the medical community could embrace...not just the delicate genius of a select few.
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Old 27-02-2008, 07:17 PM   #22
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Since nerve are ectodermal things then this thread may help?
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Old 27-02-2008, 07:59 PM   #23
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If we are realistic we will realize that what we do in PT are science projects, not "real" science. Yes, I'm talking about ortho "science" being the level of science projects. Harriet Hall refers to projects that are not based on a scientifically acceptable theory, Tooth Fairy Science. (You will find her description of this in the replies on this thread from Science Based Medicine, dated Jan 20/08.) She is talking about studies that pseudoscience supporters use to loudly proclaim that "energy" must exist because things like Tai Chi are helpful.
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These studies are prime examples of what I call Tooth Fairy science. You can study how much money is found under the pillow if you leave the tooth in a baggie compared to leaving it in a Kleenex. You can study how much money children in different socioeconomic groups get. You can study whether the money for the first tooth is the same as for the last tooth. You can get all kinds of statistically significant results. You could publish those results as telling us important information about the Tooth Fairy. But that research would be worthless, because you have not established that the Tooth Fairy is real, and you are not actually testing what you think you are testing.
See Jason's EIM thread for Carol Davis' reply that she's doing case studies to show effectiveness of JFBMFR. However, and in no way to defend Carol's research stance, I'd say pretty much all of what PT "science" studies, falls into the same boat, including studies on SMT. At least the PT SMT people have the grace to not try to suggest that based on their research, therefore subluxations exist, or any other pseudoscientific belief system/position... still they are comparing tooth fairy issues because they are NOT basing their study on the disproving of false hypotheses. Which makes much SMT research a tooth fairy science project, comparing kleenex to baggies, essentially "worthless" as opposed to "worthy" by strict science definition (although still worth something to PT I suppose..)

My main point here is that no particular special interest group in PT has any claim so far or corner on being more science-based than any other group in PT. Many of us can point to the hypotheses underlying JFBMFR and declare them ludicrous, which is a start, and many of us can decide to hook our wagons to/base our studies upon neuroscience, which, even though it has lots of internal struggle of its own, is at least unanimous in saying that yes indeed there does exist a nervous system.. we have neuroanatomical and neurophysiological evidence of its existence and can study its function.. To ignore it or take it for granted or deny its relevance is to deliberately practice tooth fairy science by omission. To try to bolster some other hypothesis (e.g. energy medicine rather than neuroscience) is to practice tooth fairy science by commission. To include neuroscience as fundamental to human function and treatment construct is to at least start to base our own PT science on actual (real) science.
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Old 27-02-2008, 09:26 PM   #24
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Default Pragmatism vs. Idealism

Diane,
I think the EIM guys are pragmatists. They spend a lot of time on their site posting threads about marketing and trumpeting PT. The studies they have done on spinal manipulation are possibly an outgrowth of their scientific bent combined with a realistic view of the current health care system that we are forced to exist and struggle to thrive in.

I know idealism when I see it because I tend to lean that way myself, and many at this site have more idealistic inclinations, in my view. It's the science first, then let the chips fall where they may in terms of how we might be able to get paid for what comes out of it. Am I right?

I suspect you'll answer that you have a cash-based practice that does just fine, but I believe you're the exception to the rule, and also, you're working in a socialized health care system, which is not necessarily comparable to what we're dealing with in the US.

I sincerely hope the idealists win out in the long run, but we need the pragmatists to keep us grounded in the reality of the health care system that most of us are forced to deal with. I think that's an important reality to acknowledge.
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Old 27-02-2008, 09:47 PM   #25
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John, I can't disagree with anything you've said in your last post, and I have to agree that the US health care system is quite different from the Canadian one, not just structurally, but also in that US PTs have more pseudoscience to swim through per capita probably.

And it is true that I have the luxury of a cash based practice, from which I can take Wednesdays off if I like, and be a thinker and a stirrer.

The only thing I might quibble with you over is that I'm not an "idealist", I'm more a materialist (in the philosophical sense, not the fancy toy sense) - but we won't go into that here, because such discussion is outside the frame that has been built around this forum. Besides I agree with the gist of what you said.
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Old 27-02-2008, 09:55 PM   #26
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Rod,

As you said in another post, there is a bit of a language barrier right now.

Ectodermal vs. Mesodermal is based in background theory. Orthopedic is based in tissue strain and pathology (at least that is the definition that I operate from). I believe neuroreflexive is a term you've used to define an approach to the nervous system in absence of tissue pathology.

Diane also named a dichotomy between working skin deep, vs. working joint deep. Both still neuroreflexive in nature.

So, I don't believe I've cherry picked from the orthopedic literature because patellar taping doesn't appear to be operating at the level of tissue strain or pathology according to the research. I feel it is an example of a skin deep neuroreflexive intervention. Manipulation could be viewed as a joint deep neuroreflexive intervention.

Yes?

JohnW,
I believe you are right about idealism vs. pragmatism and I'm glad that there are people fighting to keep us a player in the healthcare system. I see it as bridge building. But, as the insurance companies make exceedingly clear, the more we play their game, the more we surrender. So, I'm comfortable with being an idealist even in this landscape and the path of learning it leads me down.
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Old 27-02-2008, 10:05 PM   #27
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John-
I think what you've just said is an important and worthwhile distinction - and I think it's a very even-handed interpretation of what's going on. I couldn't agree more.

Roderick (can I call you Rod?)-
I'd like to answer your question and give you some examples of ectodermal research. I consider myself an ectodermalist and a fan of ectodermal therapy.

Example #1. The spinal manipulation CPR validation study (and the original study, too).
Link here.

This is an ectodermal study because it showed that most of the supposed "orthopedic" tests usually used to predict spinal joint position for manipulation weren't relevant. This is probably one of the most "ectodermal" studies I'm aware of. In fact of the five factors, only two could rightly be called "orthopedic" in nature (hip rotation and Lx hypomobility) and in fact the construct validity of the PA lumbar mobility assessment procedure has recently come into question here.

I use lumbar manipulation quite frequently and I never tell people their bones are out of place or that I have to realign something. It's my explanation and rationale, not the treatment, that makes it ectodermal. I tell them they have pain due to the excessive mechanical strain in their nervous tissue and that the manipulation might reduce some of that strain or induce some automatic relaxation that will help them move better to reduce the strain. This same treatment would be "mesodermal" if I told someone I was adjusting the position of their spinal bones to better their alignment.

Example #2. Evidence for efficacy of patellar taping.
Cory has pointed out that the balance of evidence supports patellar taping in the treatment of patellar pain and that that same evidence pool also shows we cannot change the position of the patella with tape. This is all ectodermal evidence because it has nothing to do with the patellar position or changing connective tissues. The effect must be neuromodulatory through the skin. When I tape a knee, I specifically tell people that it doesn't change the patellar position, but that it reduces the pain by the skin stimulation so that people can feel better and do more. This same treatment would be "mesodermal" if I told people that it changed their patellar position and that we were moving bones and cartilage around.

Example #3. The current state of evidence regarding "spinal stabilization" treatment. The work of the PT researchers shows that the treatment targets motor control and not mechanical stability. The work of McGill and Cholewicki, among others, shows that the motor control approach cannot and does not provide mechanical stability. So my rationale for teaching "lumbar stability exercises" - which many of my patients do learn - consists of improving their ability to control their muscles so they can move to reduce the mechanical strain in their back. To improve the "brain to back" connection.

I hope that helps clarify the meso vs ecto thing - it's a perspective, not a collection of treatments or studies.
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Old 28-02-2008, 12:03 AM   #28
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This has been very helpful to me. Between Diane's post #14, Cory's post #17, and Jason's post #27, this is a nice summary of the state of evidence for this approach. Plus all the science that underpins most of the discussion on this board every day. Thanks all!
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Old 28-02-2008, 12:08 AM   #29
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We might also consider all cognitive approaches (or components) as ectodermal in nature, thus Moseley's neurophys education or just about any CBT research becomes relevant. In addition, all non-specific effects (placebo) resulting from any clinical treatment are ectodermal responses and cannot be discounted - anyone out there going to argue against the efficacy of placebo?
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Old 28-02-2008, 12:34 AM   #30
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Speaking of hierarchies of evidence, we might also consider this one -

Quote:
1. n-of-1 randomized trials
2. Systematic reviews/meta-analyses of randomized trials
3. Randomized controlled trials
4. Systematic review of observational studies addressing patient-important outcomes
5. Observational studies addressing patient-important outcomes
6. Physiologic/laboratory experiments
7. Unsystematic clinical observations
Guyatt G, Haynes B, Jaeschke R, Cook D, Greenhalgh T, Mead M, Green L, Naylor CD, Wilson M, McAlister F, Richardson WS. Introduction: The philosophy of evidence-based medicine, In: Guyatt G, Rennie D, eds. Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago: American Medical Association Press, 2002:3–11. 284:1241.
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Old 28-02-2008, 01:15 AM   #31
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Originally Posted by Luke Rickards View Post
We might also consider all cognitive approaches (or components) as ectodermal in nature, thus Moseley's neurophys education or just about any CBT research becomes relevant. In addition, all non-specific effects (placebo) resulting from any clinical treatment are ectodermal responses and cannot be discounted - anyone out there going to argue against the efficacy of placebo?
So basically anything that cannot be explained by a mesodermic phenomenon must, by default, be an ectodermic phenomenon? Isn't this a little like saying if the answer isn't "true" it must be "false"?

I find myself agreeing with a lot of what has been said. Specifically, but only empirically, I believe neurological processes are primarily responsible for early gains in ROM and strength within many of my "orthopedic" techniques.

However I'm not sure ruling out a mechanical explanation automatically suggests a purely neurological explanation, UNLESS there are only two choices: mesodermal or ectodermal. Again, this seems as intuitive as if it isn't false, it must be true.

By the way...anyone is welcome to call me Rod. I'm sure you'll all want to call me much worse down the road.
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Old 28-02-2008, 01:27 AM   #32
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So basically anything that cannot be explained by a mesodermic phenomenon must, by default, be an ectodermic phenomenon?
Ok, let's roll with this for a minute. What is an example of a "mesodermic phenomenon"? Is there really such a thing? That isn't "tooth fairy" science?
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Old 28-02-2008, 01:30 AM   #33
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Ok, let's roll with this for a minute. What is an example of a "mesodermic phenomenon"? Is there really such a thing? That isn't "tooth fairy" science?
Diane, are you a psychiatrist? You keep answering questions with questions.
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Old 28-02-2008, 01:32 AM   #34
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Diane, are you a psychiatrist? You keep answering questions with questions.
No I'm a physical therapist, as opposed to a physical therapist.
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Old 28-02-2008, 01:37 AM   #35
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No I'm a physical therapist, as opposed to a physical therapist.

Thank you Yoda...

Still waiting on an answer-answer vs a question-answer.
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Old 28-02-2008, 01:40 AM   #36
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Rod, it is you who brought up the notion of a mesodermic phnomenon being able to explain something.. I want to know an example of that to which you refer.
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Old 28-02-2008, 01:48 AM   #37
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Rod,

A lot of basic science and the deconstruction of biomechanical hypotheses points in the direction of a neurophysiological explanation. Keeping with good science, this remains a hypothesis that requires either rejection or further support. At this point, you are encountering a group insistent that this hypothesis deserves much more consideration than it has been given. And several are taking the steps necessary to create a common language.

I think where the biggest fence becomes erected is in defence of particular techniques or explanations that are challenged by basic science.

Admittedly, the SMT outcome literature is challenging to someone who chooses to utilize a different approach with such clients. For me personally, those subgroups are a very small percentage of my caseload. When I think it is warranted, I judiciously employ lumbar or thoracic HVLA. Much of the literature suggests that a different approach is required for those with persistent pain. These patients are too frequently labelled as having psychological issues and the physical treatment offered is very limited in its creativity (and outcomes). One great hope offered by neurophysiology is a bridging of the Cartesian divide. Manual therapists must go beyond the A-O joint to remain relevant.
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Old 28-02-2008, 02:03 AM   #38
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Rod,

Quote:
'm not sure ruling out a mechanical explanation automatically suggests a purely neurological explanation, UNLESS there are only two choices: mesodermal or ectodermal. Again, this seems as intuitive as if it isn't false, it must be true.
Check out the Origin of Pain portion on the Five Questions thread.
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Old 28-02-2008, 02:04 AM   #39
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Rod, it is you who brought up the notion of a mesodermic phenomenon being able to explain something.. I want to know an example of that to which you refer.
Again, I am simply using the words mesoderm and ectoderm in trying to speak the native tongue of this forum. I, along with the vast majority of outlanders, commonly refer to it as a connective tissue event or musculoskeletal pathology.

I sincerely hope you are not implying that there is no such thing as musculoskeletal pathology. Tell me this is not the "tooth fairy" to which you referred?

I also sense a trap here Diane. If I say...plantarflexion contracture following an achilles tendon repair, you will likely respond with "Well how could that not also be an ectodermic phenomenon with all the afferrent this and efferrent that....".

Slow you roll just for a moment Diane and read this carefully and slowly to yourself:

"ROD UNDERSTANDS NERVES ARE CONNECTED TO THINGS...MANY THINGS...LIKELY MANY, MANY THINGS. He also has an appreciation for neurological phenomenon as they pertain to orthopedic conditions.

Why do I keep answering his questions with questions of my own? Ist it because I don't have a salient answer? Hmmm...maybe I don't. You know what Diane? That's..o...k."

Still waiting on an answer!
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Old 28-02-2008, 02:10 AM   #40
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Cory, Nick, Luke and others...thank you for your responses. I will continue reading and learning.
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Old 28-02-2008, 02:15 AM   #41
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Honestly, it's hard for me to conceive of mesodermal derivatives being able to "explain" any kind of "phenomenon" whatsoever. They just sit there, filling up space, hanging onto each other, not using much oxygen, minding their own business unless given an homonal or neurologic message/request/order.
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Old 28-02-2008, 02:43 AM   #42
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About this patellar taping issue that's come up a couple of times. Jason suggests that current research "shows" that we can't change patellar position with tape. I don't know that we can say that conclusively yet because I'm not convinced the methods used to measure patellar position are sensitive enough to pick up a valid change in position.

The movement of the patella in the trochlea is still unclear, particularly in early flexion. Yet another study by Herrington in the February JOSPT found a relationship between lateral patellar position and PF pain using a clinical test that accounts not only for lateral displacement in the frontal plane but also lateral tilt.

I'd have to go back and look at the previous study that compared the various taping conditions of the patella, but I wonder if placing any tape over the patella, regardless of direction of pull, might help to compress the patellar chondral surface over a wider surface area of the trochlea, thereby off-loading the trouble spot presumably under the lateral facet? It would seem that if lateral tilt were more problematic, that a laterally applied force across the patella may compress the medial facet into the trochlea, even though the frontal plane vector may be more lateral.

I also wonder about what effect taping directly over the patella may have on the fluid dynamics in the a painful knee. Just today, I got a referral from a orthopod who wrote on his assessment/PT referral "No joint effusion." Well, there most certainly was joint effusion, it just wasn't obvious. You actually had to touch the patient to appreciate it. How much fluid in a knee joint does it take to muck up the works? I know of one study that took healthy knees and injected them with saline/dextrose solution and found an immediate drop in isokinetic extension torque of 30% (McNair et al in Arch of Phys Med Rehab, 1996).

I'm not discounting the possibility that a neurophysiological effect via the skin is not at play, but I don't think we can state unequivocally that there is no biomechanical effect as well.
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Old 28-02-2008, 02:47 AM   #43
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The only possible exception I can imagine to post 41 is this: there are some tissues that look like mesoderm, but actually are later ectodermal (i.e., neural crest, "4th germ layer") derivatives in disguise. These are ectodermal cells that split off the neural tube just before it closes and migrate throughout the organism, giving rise to the whole PNS and its coverings, along with lots of other things.
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Old 28-02-2008, 03:00 AM   #44
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About your post #43 John, let's be logical and deal with the increased mechanical forces that tape may involve, logically, from the outside out, in the same order in which they would occur, hypothetically, were tape applied over the knee.
1. The skin (cutis/subcutis layer) is slippery over the other "stuff". It slides around over deep fascial containers.
2. The tape is on top of the skin, not under it. The tape sticks to skin, not anything else.
3. When the "stuff" of the leg (bone, muscle, patella, cutaneous neural structures) moves beneath the skin, the skin slides over the "stuff" in a novel relationship, if the tape has been applied directionally. Mechanoreceptors in underlying advential connective tissue will be triggered slightly differently. Cutaneous neural structures forking off from cutaneous nerves at acute angles, within skin ligament sleeves which are also mechanoreceptive, will be tugged differently.
4. At the very least, the mechanoreceptors at the skin surface will be stimulated from beneath as the "stuff" moves relative to the skin.
5. How could there not be firstly, a skin stretch reflexive neural phenomenon (see Collins et al on movement illusion) ahead of anything else?
6. How about eliminating false hypotheses, using Occam's Razor, and try to test for/elimate hypotheses in their proper order, outside in?
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Old 28-02-2008, 03:51 AM   #45
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John,

There may well be mechanical forces at play.
I learned my lesson some 5 years ago now, with a woman who was keen to help herself in managing a diagnosis of quite disabling PFS. All the indications were there. Including joint effusion.

I followed the protocol (McConnell) because I did not know anything different. But she was a bit distractable, and returned several days later saying she forgot how to tape it 'correctly' and had lost the diagram I drew post-appointment. She had stuck a piece of tape over the skin immediately superior to the patella over the site of the q tendon.
No wrinkles,no pulling, just a light bit of leukotape about 2" long.
She was excited because she could do steps, walk indefinitely and almost painfree; without the tape, it was good but not as good.

So, it is anecdotal, but I haven't explored further as I no longer am involved with outpatients-type work. The only way that bit of tape could have worked is ectodermally. Nothing else made any sense.

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Old 28-02-2008, 04:03 AM   #46
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As I said, Diane, I'm not discounting the neurophysiological effects for which you so succinctly provided rationale. BUT, I think that other effects that happen on a biomechical level under the skin are also possible. I don't think Occam would need his razor in this case. There is evidence of a positional fault of the patella in women with PFP. I realize there are "chicken and egg" issues with that observation, but until there is a definitive explanation, I think the most prudent and equitable position is that there are possibly several possible mechanisms, or combinations of mechanisms for this particular condition. In fact, there may be different combinations in different subsets of patients with PFP.

In terms of what order the effects occur in, I suppose cutaneous neuroreflexive is most likely, but I can't say that's the definitive answer. Can anyone?

I don't want to pull out Occam's razor and slice off my nose.
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Old 28-02-2008, 04:23 AM   #47
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Quote:
Originally Posted by Diane View Post
Honestly, it's hard for me to conceive of mesodermal derivatives being able to "explain" any kind of "phenomenon" whatsoever.
Not even a fracture...of a bone?

Quote:
They just sit there, filling up space, hanging onto each other, not using much oxygen, minding their own business
Um...I'm starting to think you may be some higher life form whose species was once enslaved by a hoard of boned and muscled creatures, forcing you to watch videos of Robin McKenzie.

Maybe we should back up and find where we agree. This may be an exercise in itself...can we agree that bone and muscle tissue exist? This may be difficult for you Diane as it requires only a yes or no response. [smiling while typing]
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Old 28-02-2008, 04:46 AM   #48
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I’m loving the sarcasm.

Rod, call me obtuse, but I’m having a hard time figuring out what exactly it is you’re asking. Of course connective tissues can become injured and undergo pathological processes. Barrett’s been writing about that for years and how healing of these tissues occurs in more or less a linear, predictable fashion. Maybe somehow you’ve missed the science that has shown how there is no correlation between tissue pathology and pain? Moseley goes into great depth to illustrate this in his lectures citing some wonderful research (not all of it his I don’t think). Does anyone have those references?

John wrote:
Quote:
I think that other effects that happen on a biomechical level under the skin are also possible.
This is also quite likely in many types of pathology, but it doesn’t explain how pain changes, often instantaneously with manual treatment. Connective tissue is slow to respond to stress making it unlikely any clinically applied manual intervention is going to have any immediate effect on the CT physiology and subsequent conscious experience of the patient, other than through effects mediated by the nervous system. Eg. Chondromalacia isn’t going to immediately resolve upon gliding the patella in a particular direction, is it?
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Old 28-02-2008, 05:18 AM   #49
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I’m loving the sarcasm.
Of course connective tissues can become injured and undergo pathological processes.
Not according to Diane.

Quote:
Connective tissue is slow to respond to stress making it unlikely any clinically applied manual intervention is going to have any immediate effect on the CT physiology and subsequent conscious experience of the patient, other than through effects mediated by the nervous system. Eg. Chondromalacia isn’t going to immediately resolve upon gliding the patella in a particular direction, is it?
I agree completely Eric. I think mediated is an excellent choice of words. Mediating means to act to reconcile differences between two parties. I think this leaves room for the notion that another system in addition to the nervous system may be at play here.
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Old 28-02-2008, 05:21 AM   #50
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I think this leaves room for the notion that another system in addition to the nervous system may be at play here.
Do tell. What system??
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