Starting conversations – has Jason hit the Silvernail on the head?

We had a BiM team meeting on Tuesday, as we do every Tuesday.  We got talking about the BiM blog – revisiting our objectives and how best to meet them. A key objective is to facilitate dissemination AND conversation. Well we have been well and truly trumped on that front by Jason Silvertail and his post for somasimple.com.  Jason has taken a ‘no holds barred’ approach to the vexed issue of chasing the pain in manual therapy.  His anthropological narrative on Jointheads, Diskheads, Muscleheads and Fasciaheads is confronting I imagine to those currently identifying themselves as a member of one of those groups.  Reading the post, one might presume that Jason is a SilverTail – a posh kid who has taken a holier than thou dig at those ‘beneath’ him. However, Jason is, in fact, an insider. This is a courageous and insightful conversation starter. You ought to read it. We don’t want to paste it all here because that would seem like stealing, but here is a teaser –

“First it was all about joint dysfunctions. Manual therapy was about finding and correcting misalignments and restoring normal position or movement to these dysfunctional segments. Then the research started to come in. Poor reliability between clinicians to find these misalignments. Plenty of “dysfunction” found in the asymptomatic. No valid way to demonstrate them or to connect them to any painful problem or show them changing as a result of treatment. But wait, the JointHeads say. We know that facet joints are innervated. We know they might play a role in proprioception. They are innervated for nociception, too. Its too early to not consider how important facet joints might be, they say…”

Go and read the rest. Join the conversation.

Comments

  1. Fantastic discussion here folks. You probably don’t remember but I introduced Jason’s piece on the back of a BiM lunnch in which we decided we would try to foster conversation. Tick that box. There are some pearls in here and I for one will be coming back over time to re-perouse. Thanks a million to all of you who contributed – really really good stuff. I wonder if JohnB in his suggestion to get on skype to chat about it could have gone one step further – get into a room, with good wine, good food and good cheer to chat about it. Keep those conversations going folks.

  2. @Paul> “EBM has become obsessed with data from RCTs to the near exclusion of all other considerations, especially recent pain science. If that science were actually taken to heart and given proper emphasis in our consideration of manual therapy, it would clearly suggest that most popular treatment modalities are implausible, why decades of outcome studies produce underwhelming evidence of modest benefits and never suggest any compelling explanation for the chronicity of pain, and why chronic pain is still a major health problem despite the best efforts of legions of therapists. Howzat?”

    I think that paragraph is a keeper, Paul.

  3. Dr. Hush,

    Thank you for your further clarification of your paper. I tried to make a similar point way up towards to top of this thread that therapist attributes were much more substantive than just “personality”, but you now how PTs sometimes tend to over-simplify stuff in the journals. Maybe someday a larger percentage of our profession will actually read more than just the abstract and editorials.

    I’m compelled to give credit where it is due. That video you linked was made by Matt Rupiper, PT, who at the time he made it was an upstart PT student that possessed the rare gift of critical thought- while plowing through the drudgery of PT school, no less! Here’s a link to the original thread in case anyone doubts me: http://somasimple.com/forums/showthread.php?t=8006

    By the way, thanks for reprising this “classic” that was also published in a thread at the Evidence in Motion blog. I can’t believe that’s been a year ago.

  4. Julia Hush says

    Wow, I have just read this entire conversation – my mind (and body?) are reeling.

    I just wanted to clarify that our review in PTJ on patient satisfaction identified therapist attributes as a determinant of patient satisfaction. But this doesn’t mean the therapist’s personality. Attributes considered important by patients included professionalism, competence, friendliness and caring, but also, importantly, the ability to communicate effectively, particularly to explain the patient’s condition and educate about self-management strategies.

    We have just completed a study on patient satisfaction in Australia (submitted to PTJ last night), in which we found again that global satisfaction did not correlate strongly with global rating of change (r = 0.22). Items with the strongest correlations with global satisfaction were those regarding therapist communication, such as providing instructions about self-management, answering the patient’s questions and thoroughly explaining the treatment.

    Also, with myofascia entering this debate, I couldn’t help post this (first sent to me by Steve Kamper one day when he should have been writing his thesis)
    http://www.xtranormal.com/watch/5929499/
    Essential viewing for those who have not seen it. Even if you have… watch it again.

    I am fascinated by the SBM and EBM debate… thanks for all the great links and discussion.

    I wish I had a job where I could just be on the BiM website all day.

    Julia

  5. (Still referring to threaded responses above, linear in time but not in space.)

    David has rejected several premises of the discussion. I think. It’s hard to tell. However, I can translate one of his statements: “I hope we’re not just replacing a tissue philosophy with a neurosciences one – fascinating and all as it is?” What he meant was: “I hope we’re not just replacing a flat-Earth philosophy with a round-Earth one – fascinating and all as it is?”

    David FitzGerald Reply:

    Entertaining interpretation but not sustainable, and nor is Earth the centre of the universe…

    So tissue biology sciences, mechanics, physics and identifying peripheral nociceptive target’s = Flat earth?

    Neurosciences = Round earth?

    Uhhmm, now that’s a big leap – and a tad presumptious….

    David

  6. The previous is in reply to post #86.

  7. “Tissue philosophy”?? What is that supposed to be?

    You’re confusing terms, positions and auguments. Your point (if it can be called one) has now exceeded my ability to reply because I can’t figure out what it is this time.

    David Fitzgerald Reply:

    Re Thread topic “Jointheads, Diskheads, Muscleheads and Fasciaheads”

    The theme of the discussion is a critical review of selected target tissues to explain symptoms. In that context I don’t see why you allegedly find it so hard to understand the phrase “tissue philosophy”. Insert specific tissue model, tissue based model, peripheral nociceptor generator tissue to name but a few – I think you’re well capable of connecting those dots.

    If you don’t want to reply to a comment then don’t – you don’t have to post that you don’t want to reply. Your amongst your peers here not the school yard.

    As a professional courtesy your point of view would be better served with a less derogatory style in the presence of conflicting perspectives. I don’t particularly enjoy your poetic quotes to substantiate arguments – but I don’t see it as a reason to write pedantic critiques. You don’t have ownership of an exclusive, intellectual moral high ground.

    Lets keep this valuable forum for it’s intended purpose of information exchange please.

    David

    Jason Silvernail Reply:

    Hi David.
    I won’t answer for Barrett but I would suggest that there’s a difference between these two positions that I’ll outline for you here:
    1. Being cognizant of the relevant pain physiology and neuroscience and still seeking peripheral targets with therapy – if I read correctly this is your stance (and mine) and we are talking about this very topic at SomaSimple now here: http://www.somasimple.com/forums/showthread.php?t=10029
    2. Not being aware of anything related to pain beyond the gate theory and using the tissue to explain the pain and drive the treatment – this is what the thread lead article was about and as far as I can tell, the way most of medicine (including physical therapy) views the problem.

    I would suggest that those in camp #2 are definitely flat-earthers for the purpose of our discussion here. We’ve all had plenty of time to absorb the science (much of which is many years old) and I for one have less and less tolerance for schools and practitioners that don’t update their knowledge base or explanatory models as things change. How many orthopedic surgeons treat the same problem the same way they did 20 years or 30 years ago? How does physical therapy look through that lens? Behind the times? You betcha. Clearly the “being nice and having a tea party” approach isn’t working for most of our colleagues. If Barrett and others are willing to be more edgy about it, then it seems to me its time for a change.

  8. Jason Silvernail says

    I agree with Paul and Barrett about the prevalence of critical thinking and I think the emphasis on EBM-as-statistics rather than EBM-as-reasoning at the various schools is a central issue at play there.
    But nobody wants to talk about that. We’re all “evidence-based”, right?

    This is a central issue for the EBM/SBM discussion and the authors at SBM do a great job on that.

  9. I keep thinking about ways to make the connection between manual therapy and SBM. Even EBM philosophy is pretty rarefied stuff for the busy clinician (leap 1); the SBM twist is downright exotic (leap 2); and then you need some knowledge of pain research (leap 3), before you can really see the relevance of SBM to manual therapy (leap 4). That’s a lotta leaps, and few professionals feel motivated to take even the first one.

    So I’m going to try — wish me luck! — to state the relevance of SBM to manual therapy in one very short paragraph.

    EBM has become obsessed with data from RCTs to the near exclusion of all other considerations, especially recent pain science. If that science were actually taken to heart and given proper emphasis in our consideration of manual therapy, it would clearly suggest that most popular treatment modalities are implausible, why decades of outcome studies produce underwhelming evidence of modest benefits and never suggest any compelling explanation for the chronicity of pain, and why chronic pain is still a major health problem despite the best efforts of legions of therapists.

    Howzat?

  10. On that matter of any significant numbers of therapists attending to these issues and NOT misrepresenting “evidence-based” as a statistical justification only, I fulfilled a request from a major PT program director to provide links about science-based (she’d never heard of it) reasoning and where discussions about the neurobiologic revolution might be found.

    I complied that very day.

    Now complete silence in the three months since.

  11. Jason Silvernail says

    “Finding the occasional straw of truth awash in a great ocean of confusion and bamboozle requires vigilance, dedication, and courage. But if we don’t practice these tough habits of thought, we cannot hope to solve the truly serious problems that face us – and we risk becoming a nation of suckers, a world of suckers, up for grabs by the next charlatan who saunters along.”

    “Because science carries us toward an understanding of how the world is, rather than how we wish it to be, its findings may not in all cases be immediately comprehensible or satisfying. It may take a little work to restructure our mindsets. Some of science is very simple. When it gets complicated, that’s usually because the world is complicated – or because we’re complicated. When we shy away from it because it seems too difficult (or because we’ve been taught so poorly), we surrender the ability to take charge of our future.”

    — Carl Sagan, “The Demon-Haunted World: Science as a Candle in the Dark”

  12. One more. 😉

    Like Barrett, I have a good perspective on large numbers of manual therapists and see almost no sign at all that they are keen on discussions like this.

    Don’t let the length of this page fool you: we are are a teeny tiny minority, well below 1% I think. I get a great deal of email from therapists and patients all over the world about SaveYourself.ca, and I’m afraid I see an epidemic shortage of clinical reasoning skills and scientific literacy, and no evidence that pain research has made the slightest impact on the average manual therapist.

  13. About perineal threats and treatment intensity.

    Sandy thinks Ruth’s “excellent question back in #60” was not really answered, despite many efforts, and she eventually asked: “If the proposed mechanism is a calming of the nociceptive response and less sensitization / decreased threat – how does that work when the technique is so darn painful?”

    Unknown, of course … but there are several possibilities, and plenty of plausible explanations. Most importantly, CONTEXT IS EVERYTHING. It’s not your perineum that decides if nociception is threatening. That’s your brain’s job.

    A major take-home message of central sensitization is that “pain is an opinion on the organism’s state of health” (Ramachandran, Blakeslee): sensitization is significantly regulated by executive function, which in turn is awesomely sensitive to context and meaning.

    I daresay if anyone tried to skin-roll your perineum without explanation, your brain would judge it to be pretty threatening! But the same sensations in a therapeutic context — with assurances that there is some method to the madness — is a completely different kettle of fish. When an intense sensation is contextualized as “therapeutic,” its intensity can flip around and actually become proportionately reassuring. No pain no gain… when you actually believe that, anyway.

    I suspect that it doesn’t much matter what a “myofascial” therapist does to meat to produce intense sensations, just so long as the technique is introduced to the patient with ceremony, good intentions, and a fine story about why it supposedly works.

  14. About that pesky reduction stuff.

    David wrote: “The reductionist approach …” etc etc boiling down to “I don’t trust science to determine if therapies work.”

    My eyes glaze over whenever anyone starts moaning about how “reductionist” science.

    David, you’re assuming that efficacy can only be tested by controlling the life out of a therapy. This is a very common assumption, and a wrong one. Any therapy can be tested for efficacy with minimal isolation of the therapy from other intervention variables. It’s called outcome testing, and it’s routine. In outcome testing, treatment can be a black box — anything can happen in there! All you have you to do is study the outcomes for patients on the far side. This is always how broader treatment philosophies and paradigms are tested; i.e. if you hand over 100 patients to physical therapists and let those therapists do whatever they want, or prescribe freely within certain constraints (i.e. exercise therapy only), what happens to those patients compared to a hundred who got no therapy, or some other kind of therapy? In such a case, every patient is getting care as lovingly multi-dimensional as you could possibly hope for.

    Of course, if you want to test for the outcome of a specific treatment, then, yes, you have to make some effort to ensure that study subjects receive mostly that therapy, and not something else. You might try to argue that those limits ruin the therapy and invalidate the test, but … what kind of a crap therapy is so lame and unpredictable that its benefits become unmeasurably miniscule when it is delivered in a modestly controlled environment?

    David Fitzgerald Reply:

    “The reductionist approach”

    Paul, at the risk of contributing further to your “glaze” I have repeatedly stated my view in threads 14,15,16,68 that Outcome is the Raison D’Etre of the clinical process. I don’t subscribe to the view that research needs to be reductionist but I have major concerns about the interpretation of validity of information which is gained under such rigorous methodology if it doesn’t reflect clinical reality. It was in that context to the issue of the reductionist approach was raised.

    Is this the old Lyndon B. Johnson strategy of throwing enough mud to see what sticks? I think we may well have more in common then you imply but I,m all for healthy debate as it can only be good.

    PS. I hope we’re not just replacing a tissue philosophy with a neurosciences one – fascinating and all as it is?

    David

  15. About effective-but-unexplained treatments.

    David asked: “Do you think not understanding the mechanism of effect is a legitimate reason to withhold intervention?”

    I do not. If a therapeutic effect is actually confirmed, by all means, let’s use it.

    However, such treatments are vanishingly rare. What is this mythical beast you’re asking about, this treatment that is proven and yet unexplained? I’ve never met one, myself. Your question has the common, dubious premise that they exist, or that they are common enough that they are relevant to this discussion. Practitioners of all kinds are fond of defending their unproven therapies by disingenuously exaggerating the prevalence of effective but unexplained mainstream medicine, as though doctors everywhere are constantly providing good care without understanding why it works. Certainly there are handful of examples, mostly stale ones of primarily historical interest, but by and large the story of modern medicine is of care that works precisely because someone worked out the biology first.

    David Fitzgerald Reply:

    “Effective but unexplained benefits”

    Paul , I don’t think it’s that hard to determine if one’s intervention is being effective clinically.

    This script goes something like this……

    How are you?

    What are your main problems?

    What are your primary functional limitations?

    Do the physical signs correlate with the functional limitations?

    Do the physical signs represent legitimate targets for intervention?

    Is there evidence of multifactorial pain mechanisms at play which may or may not be influenced by the spectrum of physical treatments I can provide?

    What are the most functionally relevant objectives you seek to improve by which we can measure the effectiveness of our input?

    How were you after the last treatment?

    Are you better, worse or the same?

    Let me re-evaluate the functional deficits which you described on initial assessment which we were working to improve upon.

    I find this a transparent encounter and the decision making process about whether to intervene, refer, investigate or deliver a prognosis which has been avoided by some healthcare providers, pursue a trial course of intervention of 3-4 treatments for evaluation and can be mutually agreed or not.

    David

  16. As usual Jason, well said. For many years I’ve been asking therapists what they should know first before they carve into a piece of word. Almost no one answers, “What kind of wood is it?”

    Speaking of crazy explanations, I understand that at this moment there is a prolonged discussion on the “chat line” of the most prominent myofascial schools regarding the “reality” of angels and their place in healing in conjunction with treatment by a therapist trained in their technique. It has been suggested by their foremost practitioners that the presence of angels be taken seriously.

    I’m not kidding.

    Oh yes, they also don’t want anyone not in complete agreement with their theory and management principles (amorphous though they may be) to know about this discussion or that one.

    Too bad.

  17. Jason Silvernail says

    I think as a start, we ought to ditch some of these ideas and explanatory models in manual therapy training that focus around a specific tissue.

    Here’s an example of this partitioning of the body around specific tissues that’s so frustrating for me: http://charlieweingroff.com/2010/06/manual-therapy-options/
    I’m not trying to pick on Dr Weingroff, but the whole idea of dividing things by tissue (a “joint technique”, a “soft tissue technique”) is just breathtakingly simplistic given what we all should know by now about pain. His explanation of the mechanism behind Mulligan (“reducing positional faults”) is just as bewildering. This is a national-level speaker and presenter, by the way. (sorry Dr Weingroff nothing personal)

    I read the first 4 chapters of The Sensitive Nervous System and realized that the science covered there made the term “myofascial pain” make absolutely no sense. Should we just call it all “Nervobrainial Pain” to keep people focused on what at least the late 20th century has to tell us about human physiology?
    If carpenters knew as little about construction materials as many medical professionals seem to know about pain, our houses would be falling in around our ears.

    At the very least I would expect people have more “skeptical levelheads”, and just use more general terms like “manual therapy” in the study Ruth gave as an example. Is the “myofascial” therapy there any less “nerve” or “skin”, especially as Sandy has described it?
    At the very least let’s stop making up stories about how these things work and stop building empires around the explanatory models of Fasciaheads, Jointheads, and Muscleheads. At the very least our language should represent our understanding. We don’t know it all, but we know what its not. And it ain’t fascial restrictions, folks.
    At the very least we should know enough about basic science and modern neuroscience to be circumspect about our use of terms and be willing to put some professional pressure on outliers using the craziest of explanations – like “energy-based myofascial release”.

    So here’s my suggestion – we start to call this “Manual therapy for Nervobrainial pain in the [insert body area]” – not very catchy huh? I could always start a VeinTherapy CEU course series. Only five courses and you can test for CVTP – Certified VeinTherapy Provider – credential! I could build my own manual therapy empire and not have to work too hard on explaining things, or…. you know….sciency stuff. Oh wait – that’s been done, hasn’t it?

  18. “I also agree that the theories in many con-ed classes are lacking in plausibility. Some don’t pretend to have any, others just make stuff up. Isn’t that why therapists come to places like this to read quality information?”

    I can’t disagree and can only speak from my own experience as a workshop instructor – hundreds of times.

    What I found repeatedly was that plausibility and popularity were entirely unrelated, if not inversely correlated. And if the profession is “coming to places like this” I never saw any evidence of it. By that I mean that the numbers of therapists who knew about such discussions was about one in several hundred.

    I get around, and I still don’t see the percentages growing.

  19. I like the “Big Lebowsky” analogy a lot. In fact, I like it better than my “Star Man” one. I particularly like the comparison of PTs to “screenwriters”. In yet another brilliant thread at Soma Simple, Cory Blickenstaff described PTs as “contextual architects” (http://somasimple.com/forums/showpost.php?p=92550&postcount=14).

    A good screenwriter remains faithful to the original work while manipulating it as little as possible so that it plays well on the screen. If you’re a joint-, disc- or fasciahead, can you remain faithful to the original work? I don’t think so, and I think that is precisely the problem in current PT practice. We’re mangling a perfectly good story to fit our own set of biases.

    The result is less than entertaining.

  20. neil o'connell says

    Heh Johbarb,

    That really tied the thread together.

  21. Sebastian Asselbergs says

    Sandy, “Bindgewebst Massage” is just a German word with the same poor theoretical basis in science as MFR. Teirich-Leube and other teachers/developers of this technique proposed that with the application, organ “zones” were treated. “Zones” that had become “tight” in the subcutaneous fascia, due to organ dysfunctions. Painful technique.

    Its positive effects in some cases can be attributed to patient expectation, cultural expectations (ever had a “vigorous” massage done in the 50’s in Germany?), local circulatory effects leading to neurological effects etc etc.
    But hardly due to any changes in the actual fascial tissues.That requires much more force than even Bindgewebst Massage uses.

    With regards to the study you mentioned: there is no way to conclude that it was the technique that did the trick.
    Your uncle may have been right, or the expectations of the patient were along those cultural lines (“It’s gotta hurt before it can get better”).
    The basic assumption is wrong. Fascia simple does not respond to skin rolling – the morphology of the tissue does not allow that.

    Sandy Hilton Reply:

    Sebastian, I agree. Connective tissue/fascia/whatever you want to call it is not “the thing”. Nor are joints, discs, muscles, or any other bit of anatomy acting in isolation. The “M-word” distracted the question, did it not? And thanks for the “B-word” clarification – I didn’t bother to look it up, just knew the technique from school (as just another form of massage) and that it is what the study used.

    The practical basis of both of the arms of this study are pretty much the same thing (hands-on touch vs hands-on touch, but one is in the ‘area of pain’ and one is a whole body technique – reminds me of some acupuncture studies) nor does the study answer the ‘what worked’ question – which I think was the point that Dr. Ruth was trying to make? If there were quality pelvic pain studies without the accompanying herd of confounding variables she coulda used one of them. We lack those in manual therapy in general, and pelvic pain in particular.

    I also agree that the theories in many con-ed classes are lacking in plausibility. Some don’t pretend to have any, others just make stuff up. Isn’t that why therapists come to places like this to read quality information?

    I expect that it is not the technique that a therapist uses that would have a chance of making lasting change so much as that manual therapists have an opportunity to provide some non-threatening input that allows a sensitive nervous system to make changes. (see the many excellent references on this site).

    Neil mentioned elsewhere that his goal for 2011 was to find a positive LBP study. I look forward to seeing such a thing.

  22. Kowabunga Man! When I became involved in the longest running novella in the history of neuroplasticity blogging (didn’t we start this last year?), I did it because I was fascinated by the reference to Jeff Bridges. Now if my wife checks my emails, she will think that Heidi and I have a Thing Going On! Luckily she knows that Heidi is on the other side of the world. To add a bit of whimsy to this set of blogs, I cannot help but think that the movie the “Big Lebonsky” is a great allegory for this and back pain in general. (It is a great movie that can be used as an allegory for almost anything.) As for the allegory to LBP, it is even more relevant since it deals with chemically induced neuroplasticity. For those of you who have not seen it, it is the story about how The Dude (Jeff Bridges) goes about getting his rug (life) back after someone destroys it by pissing on it. This occurs for no reason just that he had the wrong name, in the wrong place at the right time. I love the scene where he is attacked in the bathtub by the ferret. All of his friends and enemies use him for their own purposes (money, pregnancy, bowling, his car, etc.) often in the guise of helping him. It is only through the help of clever screenwriters (hopefully us) and himself (self efficacy, natural history, etc) that he takes control of the plot and solves the problem by himself. In processing the conversations in this blog, past blogs on BIM, and the general research, aren’t we (as screen writers) just about getting patients to take control and find how to treat themselves. After all, most patients just want their rug back and the opportunity to go bowling. The Dude Abides.

  23. Any careful reader of the literature on pain and manual therapy over at least the last 5 years would choose to use a different term than this completely corrupted one, which can mean anything from a light, skin-deep technique to down-regulate pain to an “energy-based” technique based on quantum theory that has the power to undo connective tissue restrictions by releasing trapped emotional trauma as far back- even further- than the birth event.

    Why would anyone want to use a term in their scientific paper that could be construed as the latter?

    Let’s face it: the term is used because some people think it’s “cool”.

  24. John’s right.

    The term “myofascial release,” whatever use it may have once had, has been mutated to such a degree that it is irreparably damaged. Its negative connotations (well deserved, by the way) render its invocation as questionable at best.

    That’s just the way things have gone, and I think we know who to blame.

  25. “…myofascial release” as a term has no definition…”
    Sandy,
    Unfortunately, to some, as I’m sure you’re aware, the term has a very specific meaning, which is imparted to the vulnerable patient. And then, the mythology blooms in whatever sub-culture that is taken in by the charm and charisma of the purveyor du jour.

    Sandy Hilton Reply:

    John, If you’d like to substitute Bindegewebs Massage for every time you see the word Myofascial in the above article, would that make it easier to discuss the question Ruth asked?

    This is a great example of how difficult it is to discuss treatment interventions when there are many ill-defined terms and poorly conceived theories within the giant catch-all of manual therapy. Perhaps it is these poor definitions that lead to the “diskhead, jointhead, fasciahead, muslcehead, nervehead” thing.

    My question of this study: If the proposed mechanism is a calming of the nociceptive response and less sensitization / decreased threat – how does that work when the technique is so darn painful?
    And are we attempting to measure the wrong thing in our “clinical studies”?

  26. Sandy Hilton says

    Ruth’s excellent question back in #60 was really not answered, I think. I am not wanting to leave a fellow Pelvic Rehab physio hanging… and: http://xkcd.com/386/

    Ruth’s question was on this study from 2009: http://goo.gl/zxKtr
    “IF this RCT has similar results as their prior study designed to assess the feasibility of conducting the full-scale trial (48 patients with urological CPPS, the global response rate of 57% in the myofascial physical therapy group was significantly higher (p = 0.03) than the rate of 21% in the global therapeutic massage treatment group (Fitzgerald et al 2009)) …..although not brilliant (but I reckon its clinically significant), couldnt we realistically attribute some of the improvement in pain/function to myofascial therapy ?”

    The Myofascial technique referenced was a technique similar to Bindegewebs Massage – skin rolling and short, quick strokes to the tissue that can be picked up and rolled… applied in this study in the perineum. This is not a fluff technique, really. Skin rolling. In. The. Perineum. Oww. I personally think that having 44 of the 48 people complete this study speaks to how much a problem pelvic pain is for our patients. That is dedication. The placebo arm was not a noxious technique. The authors are looking to complete a more robust study and will repeat the multi-site design with more consistent training of the therapists.

    If the repeated study also finds improvement in the more noxious technique group to be more significant in pain reduction – what caused the difference? I find it most plausible that it is somehow removing the threat response – although how such a painful technique could be interpreted as not a threat I don’t know. Maybe my uncle had it right when he offered to step on my foot if I had hurt some other part “so you won’t notice it anymore”. Clearly I don’t use this particular technique.

    Ruth again: “So, yes the therapeutic intervention has prior scientific plausibility, BUT when you treat internally (rectally or vaginally) & reproduce a familiar sensation that “no-one” has been able to “find” before, I have little doubt that irrespective of what we think we are doing to the tissue…we are essentially reducing the threat and hence reducing the pain….As Dr L would say…fearfully and wondrously constructed” Given that Paul is right even if a particular study shows a treatment approach had a degree of success, that doesn’t tell us much about why it worked or by what mechanism. Especially in this case where the terms are poorly defined and used in wide variety across a few professions – essentially, “myofascial release” as a term has no definition. Doesn’t stop it from being used often and with a wide variety of interpretation.

    I suspect we are just “a magnificent walking breathing placebo” when we do manual therapy techniques. There are sufficient studies showing that nerves, organs, muscles, whatever… need blood, space and movement. If manual techniques are providing a degree of facilitation to restore movement, circulation and space, wouldn’t we see effectiveness in studies? Is that what we are really measuring?

    I have more questions than answers. I think Neil has it right, “lets have sceptical levelheads”.

  27. Samuel Homola says

    Spelling correction: vagaries. Sorry about that.

  28. Samuel Homola says

    Thanks to Dr. Silvernail, one of my favorite DPTs, for a thought-provocating, insightful article on the vagries of manual therapy. When discussing “Jointheads,” throw in a little “mechanoreceptive reflex” with proprioception and nociception and you’ve got a “chiropractic subluxation.”

    http://www.sciencebasedmedicine.org/?p=6839

    Is the poster Mark Szlazak, D.C., the same chiropractor who co-authored the very fine critique on chiropractic vertebral subluxation 16 years ago?

    2. Nansel D, Szlazak M. Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manipulative Physiol Ther. 1995;18:379-397.

    Samuel Homola, an old retired chiropractor

    Mark Szlazak, DC Reply:

    Yes, I’m that co-author with Dale Nansel.

  29. Mark,

    I think you’re going to run up against some pretty stiff theological resistance to your assertion that mind and soul consist of the same stuff- at least in Judeo-Christian theology.

    Theologians talk about a natural and supernatural order of being, which gets into a lot of metaphysical discussion that I don’t think is an appropriate subject for a forum such as this. You consistently conflate soul and mind and as long as you do, you won’t make sense within the fact-based realm of scientific discovery.

    I know that many chiros are bent on this irresistible urge to discover the “life force”, and if that’s what you want to do, then fine. Just don’t try to make some kind of scientific sense out it. You’re continual attempts to mix oil and water only make an incoherent mess.

    Mark Szlazak, DC Reply:

    Nothing speculative here. The data is the data and we are moving into another conception of reality with more dimensions and of different qualities than what’s classically thought as space-time. The “physical” is becoming an out-of-date concept. As to religions, I don’t know everything that will be found right or wrong about them. I’m not religious nor am I a religious scholar so reluctant to say how all this will mesh together.

    These posts are just “heads up” or warnings of things to come. Many experiments (e.g, Scole. http://www

    NDE’s explorations, http://www.youtube.com/watch?v=u1vWoUoiaP4&feature=mfu_in_order&list=UL) are pointing in a direction of an after life. It’s all hard to believe unless you study the experiments and data. This points to dualism in the classic sense and not to materialism.

    More, high strangeness is coming into broader awareness that is and isn’t related to parapsychological (psi) phenomena. Adding this maybe too much all at once but be open to a reality that will dramatically change culture. The problem is when, how much and the amount of spin used to minimize the “trauma.”

    I think you need to see current orthodoxy like establishment religions of the 1400’s. There was an “invisible collage” working behind the scenes. Over time the culture came to a “deal” which accommodated it’s findings and we moved into the Renaissance.

    It’s 400 years since then and there is a similar phenomena going on but what came of the Renaissance is now looked at like the establishment church’s and power structures of the 1400’s. I suspect the transition will be quicker like everything else these days. However, I hope it’s not to fast because that could be a catastrophic.

  30. Mark Szlazak, DC says

    Oh my my Barrett, you don’t have to look if the subject bothers you or if you don’t want to. However, you really don’t know what you are talking about when it comes to the things I’m pointing to.

    I think there is a connections between myofacial trigger points, acupuncture points, central sensitization/pain states, placebo and the mind. Since I see the mind/soul/spirit as interacting with the brain to cause conscious experience and do not view the mind or consciousness as a causally inert epiphenomena then that means minds have psychokinetic abilities. This surely relates to the experiences most have had over thousands of years. The science, the experimental work supports this, much is of the highest quality and has great significance.

    The “chi” thread on somasimple to which I recently posted has some starter references to this research or at least books describing it. Here it is and I start posting at #47

    http://www.somasimple.com/forums/showthread.php?t=9837

    In addition, a fairly recent book has just come to my attention from a post on Dr. Radin’s blog

    http://deanradin.blogspot.com/2010/12/my-comments-on-alcocks-comments-on-bems.html

    It has relevance to people like Jason, Diane, Barrett, Lorimer and so on, who focus on neurobiology to explain pain and the treatment of pain. It will be an “undiscovered country” or reality which eventually will become mainstream. Believe me when I say that research on this is happening quietly behind the scenes in many labs. Anyway the book is called:

    “Mysterious Minds: The Neurobiology of Psychics, Mediums, and Other Extraordinary People”

    Here is it’s discription:

    “Krippner (psychology, Saybrook U.) and Friedman (psychology, U. of Florida, Gainesville) assemble nine articles that examine claims of parapsychological experiences like telepathy, psychokinesis, and precognition from a neurobiological perspective. Instead of promoting a position on the existence or non-existence of these phenomena, they aim to introduce readers to pioneering efforts exploring the mind through neurobiological perspectives and technologies like neuroimaging and EEG. They consider such phenomena as ESP, trance, and paranormal experiences, as well as the skepticism of mainstream scientists, the neurochemistry of these phenomena, and the relationship between the mind and the body. Contributors are psychologists, neurobiologists, and specialists in behavioral medicine and parapsychology from North America, Europe, Australia, and Brazil.”

    “There isn’t space here to review every chapter in this timely volume, but each one offers worthwhile perspectives on psi and neurobiology. The editors are to be applauded for assembling this range of informative material. The anthology shows that there could be real value in bringing neuroscience into the realms of parapsychology, with potential benefits to both areas of research…”

    Have a look.

  31. And another reply for you, Ruth, because your question really gets to the heart of this conversation. This is an expansion on what John and Barrett just said.

    It’s really hard to design experiments to determine if a complex manual therapy works, but harder still to know WHY it works, even if it actually does, which is rarely actually clear in the first place. For the sake of argument, let’s assume that a great experiment produces very strong outcome evidence showing that patients who receive “myofascial” therapy end up with less pain, more function, brighter rainbows, and a pony.

    Pretty good stuff, right? Probably means the assumptions of myofascial therapy are correct?

    BZZZ! Wrong, thank you for playing.

    Unfortunately, although that information is useful, it tells us next to nothing about how that successful therapy actually succeeds, and the history of science shows us that almost nothing ever turns out to work quite the way that we thought it did, or even close … and indeed even the efficacy itself routinely turns out to be a mirage, an artifact of intervention enthusiasm or any one of a hundred other confounding factors. The history of the science of manual therapy in particular is a story of chronic, major oversimplifications. Time and time again, entire modalities of treatment have been founded on emotionally appealing, marketable concepts that have later been clearly shown to utterly suck as an explanatory model for how people hurt and get better.

    The story of prolotherapy is a good, clear example: a compelling therapeutic idea (“toughen up” those ligaments!), championed by a charismatic physician, who got genuinely fantastic results in his own clinic … results that couldn’t be replicated anywhere else, by anyone else, ever again, did not even begin to stand the test of time, and we now know that the etiologic assumptions of prolotherapy are thoroughly bogus (i.e. low back pain does not correlate at all with the “looseness” of ligaments).

    Another fun non-therapy example: biodynamic farming, almost a gardening cult inspired by some remarkable gardening results in some crappy soil in Scotland. Biodynamic farming involves some howling-at-the-moon crazy rituals, like stirring fertilizer potions counterclockwise nine times under the full moon. Biodynamic farmers produce some great vegetables … but it’s clear (to everyone else, at least) that their success isn’t actually explained by their magical rituals. They’re doing something right, but it’s probably not the druidic voodo.

    So when we see research like you cited, we have to take it with a grain of salt the size of a brick. And its etiological implications are nearly null. But we do know that there is a shwack of pain neurology science that is a much better candidate for explaining what’s going on.

    strongly overshadow the explanatory power of “myofascial” theories of pain … which is not really supported by much knowledge of physiology at all.

    Dr Ruth Lovegrove Reply:

    Short & sweet, ’cause its bed time here in the UK, but exactly… my question sort of gets to the heart of the discussion cause as we know treatment is influenced by both the practitioner’s & patients perspective, their personal knowledge, values and beliefs. These belief systems are rarely considered in clinical trials studying the efficacy of a particular treatment. Deconstructing any erroneous assumptions in patients, fellow clinicians and researchers can be quite exhausting Zzzzzzzzzzzzzzzzzzzzzzzzz

    Ruth Reply:

    So the issue I have today is that, rather than wave dead chickens over my CPPS patients , I could understand how if I lengthen an overactive pelvic floor (which with it’s constant contraction affects urogenital function such as frequency, urgency & pain on urination, ejaculation, deafecation, etc etc) I could inflence the input to the viscera… whereas waving a dead chicken I couldn’t see/ understand how it could help. I recognise that my treatment effect could be solely associated with me being a magnificent walking breathing placebo, however, if it makes sence (to me) that inhibiting an overactive muscle, creates greater length, less compression & therefore mechanical stimulation of the urogenital viscera (as seen onnultrasound) it will reflexly inhibit neuronal input to the viscera. So where do I go from here? X

    David Fitzgerald Reply:

    Paul

    I think there is a real distinction between an intervention which produces a beneficial effect and understanding how that effect was achieved.

    I would concur that medical practice is littered with historically “bizzar” interventions and many, no doubt, were harmful. However, for those that weren’t harmful but produced positive patient benefit (albeit of debatable origin) do you think not understanding the mechanism of effect is a legitimate reason to withhold intervention?

    David

    David Fitzgerald Reply:

    Paul
    on the second issue…
    “It’s really hard to design experiments to determine if a complex manual therapy works, but harder still to know WHY it works, even if it actually does, which is rarely actually clear in the first place.”

    This is precicely why many clinicians distrust the interpretation of musculoskeletal research. The desire to control measurable variables for research purposes is often divergent to the clinical process – with all the multi-factorial elements we have discussed above.

    The reductionist approach to facilitate data collection is the anthesis of how many contemporary clinicians attempt to incorporate the multitude of variables we know to influence outcome.

    It seems so much of the musculoskeletal research methodology is structured around interventions which lend themselves to simple double-blind evaluation (pill V’s placeo, Ultrasound on V’s off, Laser v’s interferrential etc) and transferring this methodology to “sham” manual therapy techniques (with such broad physiological attributes) is a dubious practice I feel – even if it is the best we have.

    David

  32. Dr. Ruth,

    The study you cite reveals precisely the problems with EBM in isolation. Substitute “waving dead chickens over the painful part therapy” for “myofascial therapy” and we’d have to conclude, well, you know.

    Dr Ruth Lovegrove Reply:

    Ah Barrett…. but I’m unlikely to wave dead chickens being veggie an’ all that 🙂

    David Fitzgerald Reply:

    Barrett
    I might consider “waving dead chickens” as a treatment option but I’d need some stronger evidence and it would need to be more beneficial that existing choices.

    Is your beef with the research Ruth quoted in the methodology, terminology, biological plausability, interpretation of outcome, mechanism of effect – or some other perspective?

    David

  33. Jason Silvernail says

    Ruth-
    I suppose I’d have to get an idea of the design and effect size in the study, but if we find a good result in the treatment group that doesn’t tell us anything about the validity of any “myofascial” constructs used. Just as spinal manipulation research doesn’t validate any ideas about chiropractic subluxation. This is a key SBM/ EBM issue that I tried to address in the EBP, Deep Models, and Scientific Reasoning thread.

    Dr Ruth Lovegrove Reply:

    Hi Jason
    Thanks for replying. Completely agree, will read your thread because I keep feeling I need to nail the question down. I have roles as a researcher/ lecturer and one as a clinician, so merging propositional knowledge with procedural knowledge acquired through 20+ years of clinical practice and making sure I get the appropriate message across to patients and other clinicians often feels like an uphill battle. Truly merging art and science.

  34. Dr. Ruth (couldn’t resist),

    Do you think that a therapeutic intervention based on the “myofascial” construct has prior scientific plausibility? Do you think there may be a better, more parsimonious explanation for the effects seen with a light, skin-deep technique than one claiming to effect a change (“release” or whatever) in connective tissue properties?

    Dr Ruth Lovegrove Reply:

    Dear John

    No need to resist as its an appropriate handle given that my PhD evaluated pelvic floor muscle function 🙂
    So, yes the therapeutic intervention has prior scientific plausibility, BUT when you treat internally (rectally or vaginally) & reproduce a familiar sensation that “no-one” has been able to “find” before, I have little doubt that irrespective of what we think we are doing to the tissue…we are essentially reducing the threat and hence reducing the pain….As Dr L would say…fearfully and wondrously constructed

  35. I just re-read Eyal Lederman’s paper, “The fall of the postural–structural–biomechanical model in manual and physical therapies.” I’m sure most of the participants in this discussion are already familiar with it …

    http://www.cpdo.net/Lederman_The_fall_of_the_postural-structural-biomechanical_model.pdf

    For anyone who hasn’t come across it before, it’s pretty much required reading on this topic.

  36. Mark Szlazak, DC says

    This

    “BTW, what I’m also pointing does only threaten beliefs in certain sciences but also religions as well.”

    should be:

    BTW, what I’m also pointing to does not only threaten beliefs in certain sciences but also religions as well.

  37. Mark Szlazak, DC says

    Jason, it’s not anti-science if the best evidence and reasoning backs it up. That’s pro-science if science is understood as a process not a particular ideology or ontology. BTW, what I’m also pointing does only threaten beliefs in certain sciences but also religions as well. It’s at least a big double whammy. What I’m pointing to is definitely anti-ideological, and ideologues like Barrett have to resort to the ridicule tactic so people won’t look. Where I come from I try to follow the best evidence and not play follow the leader/guru. My advice is to look for yourself and I suspect you will at some point.

    It will be “tough cheese” for out-of-date ideologues and stall tactics are and will continue to happen to keep up the status quo as long as possible. Nothing new here, we all know or have read that paradigm shifts aren’t easy things even in science. Current beliefs, lines of funding and various power structures are always threatened when reality suggest significant change. In the end these tactics will fail. Why wait? Get ahead of the game. As a clinician you are not as tightly tied to orthodoxy and it’s funding structures.

  38. ‘Belief” is not part of science. What science does is attempt understanding, and it considers all knowledge provisional. However, what you say is “extremely good scientific work” is claptrap and blather.

    Let’s return to Jason’s point.

  39. Dr Ruth Lovegrove says

    So, quick question….currently there’s an ongoing multicentre RCT comparing 2 methods of manual therapy; myofascial physical therapy and global therapeutic massage in patients with urological Chronic Pelvic Pain Syndrome (CPPS). IF this RCT has similar results as their prior study designed to assess the feasibility of conducting the full-scale trial (48 patients with urological CPPS, the global response rate of 57% in the myofascial physical therapy group was significantly higher (p = 0.03) than the rate of 21% in the global therapeutic massage treatment group (Fitzgerald et al 2009)) …..although not brilliant (but I reckon its clinically significant), couldnt we realistically attribute some of the improvement in pain/function to myofascial therapy ?

  40. Jason Silvernail says

    Mark S and I have talked informally on and off on discussion boards for some time and while there’s an earnestness in his writing I appreciate, we don’t agree on much of anything beyond the importance of looking past overly tissue centric approaches to pain and the importance of neuroscience.

    Unfortunately there are people out there in healthcare in general and physical therapy in particular who advocate a view of health and medicine fairly divorced from a scientific worldview. Many in the myofascialrelease release community especially feel this way- I reject that position, I feel it’s anti-science, and it is to be resisted in the strongest possible terms.

  41. Mark,

    I’m with you!

    What we really need to do is bypass the brain altogether and head directly for the 17th dimension. There we’ll find all manner of explanations and, perhaps, a few of today’s health care providers.

    I’m being sarcastic while trying not to be cruel. It’s hard.

  42. Mark, I’m not sure that’s really what Jason meant for anyone to get out his article, or this discussion. But let’s ask him. Jason: were you hoping your essay would inspire health care professionals to embrace a spookier, X-files approach to therapy for pain? I really, really look forward to your answer.

  43. Mark Szlazak, DC says

    I’m glad that there is a shift to have more focus on the psychology and neurophysiology of pain. However, I agree with the warnings that remind clinicians not to fully abandon damaged or dysfunctional tissues and embrace neurophysiology as the only and final answer. There is another problem that also needs to be faced and that is the highly dubious assumption that mind and consciousness are solely generated by the brain. Materialist philosophy is waning but still has far to prominent a role in mainstream health care education. Materialism itself has been dead in physics for nearly a century and much extremely good scientific works exists on para-psychological (psychic) phenomena, life after death, and the existence of a subtle body/soul/spirit. Psychic healing and spirit guides are now part of evidence based spirituality and these of course are used in body work and laying-on-of hands healing.

    So there are two levels of deprogramming that need to go on. First, less focus on the “it’s all muscles and joints” and the second is to move away from “mind is nothing but the function of the brain.”

    Many vested interests will resist both of these but as clinicians we don’t have to wait for organized health care to get up to date.

  44. My professor Dr. Scott powers – big name in the exercise field- always use to say that good studies are mechanistic which try to understand the why and how of things. The problem is that when we do these mechanistic studies it is lot more easier to just focus on the ‘why’ part and do it with animals and in vitro. We studied cardio protection of exercise and how to prevent atrophy in rats.

    I think the problem is that in one extreme we need basic science studies and the other end we need studies to show if this can help people. And both studies can have different requirements, different focus, different funding guidelines and both are evolving at a different pace.So researchers who look at both aspects are very rare breed.

  45. That last one, the absence of an incentive, went right through me and is at the heart of the matter.

    As long as therapy is considered a fungible commodity by those who control our employment (and thus reap the benefits of our billing) there is little hope that we will grow intellectually as a profession.

    We can’t wait for the schools to change and to the medical profession we’ve become little more than a revenue stream.

    It’s up to us individually to take an education and not wait for it to be given.

    Sites like this can help enormously.

  46. 1. Patient satisfaction may effect outcome in certain instances and to a certain degree, but overall it is not a determinant of a successful outcome for MSK conditions treated by PTs.

    2. More than just personality I think would be included here. Based on the Hush et al study, such qualities as ability to communicate effectively and competence were included. These go beyond just personality attributes, which were also included, i.e. friendliness, professionalism and caring attitude.

    3. I don’t think outcomes are all we have to rely on. If we did, you could just take me out in the pasture and put a bullet between my eyes. We’ve got our ability to think, create and innovate ways to interact with another nervous system that can by immediately recognizable as therapeutic. Getting back to the ability to communicate attribute, the ability to draw on meaningful metaphors which the patient can relate to is extremely valuable in my experience. Dr. Moseley wrote an excellent book about this called “Painful Yarns” that has provided me many ideas and insights into at least obliquely communicating with the patient in pain.

    4. I don’t see it as a competition between different frameworks. I’d refer you to Paul Ingraham’s post #30 in this thread for a good explanation of what SBM is and what EBM has become. I see prior plausibility as an element of SBM, not a separate framework or mode of thinking. All interventions should have at least prior plausibility as a criterion for their use. What’s more, those that don’t should be discarded.

    5. I don’t know, but I doubt it.

    6. I think we have to first acknowledge that the paradigm upon which our interventions have traditionally been based is tragically flawed, and needs to be radically revised. I’m referring to the orthopedic/mesodermal/tissue-based/peripheral inputting/operator stance- driven model. We simply have too little understanding and respect for the role of the CNS in the output of pain. What’s worse, we have no incentive for overcoming this knowledge void- other than the altruistic one of wanting to sincerely help people. However, we all know that isn’t enough to shift an entire system of health care in a more rational and ultimately sustainable direction.

    John Ware Reply:

    [For those still reading this thread, this was a response to David Fitzgerald’s last reply in the sub-thread starting at post #16. Not sure why it ended up posting way down here.]

    David Fitzgerald Reply:

    John
    I find myself agreeing with most of what you say – which begs the question of your initial disagreement?
    I don’t see why patient outcomes elicit’s such a nasty emotion for you – for me thats why I do this job, it’s part of the job spec. and certainly a negative when not accomplished. Don’t rush out to the pasture just yet – there’s unfinished business.

    I,m getting a sense that if therapist qualities are legitimate tools to manipulate patient responses (I agree), “creating innovative ways to interact with the nervous system (I agree)” and “observing recognisable therapeutic effects (I agree)” we are getting dangerously close to completing the circle of clinical evaluation which I suggested in the first instance?
    Acknowledging the peripheral /central mechanism debate and that all peripheral input has a CNS correlate and probably visa versa we end up doing the same treatment but with a different explanation.
    In practice it seems to me that the additional new options for musculoskeletal treatmet derived from neurosciences involve imagery, illusion (much of Lorimer’s work) and behavioural modification strategies to influence modulation or descending inhibition. The debate is whether this is coupled with peripheral interventions, advice, or just a wait and see approach.

    David

    John Ware Reply:

    “I don’t see why patient outcomes elicit’s such a nasty emotion for you…”

    I don’t understand where you get this idea that I reject patient outcomes. Measuring outcomes in a reliable and valid way is essential to ethical practice. What I reject is the excuse-making of empericists who have become either so enamored with their own method or so lazy in their exploitation of a flawed reimbursement system that they refuse to read about or listen to compelling scientific discoveries that might threaten their comfortable existence.

    We should not be satisfied with good outcomes alone. Don’t forget about those poor patients who aren’t getting helped, and also don’t forget that our health care systems are moving inexorably towards financial insolvency.

  47. Hi John,

    I think most of the confusion is due to the lack of understanding of EBM. I had emailed asking the CEBM if they have any courses for EBM in USA, he said no and he don’t know if there is any which is really surprising.I serahced and couldn’t find any either.

    And I am guessing you are talking subgroup analysis when you talk about clinical prediction rules. It is clearly written in the EBM books about when you do subgrouping the first thing you have to look at is “does it make any biological or clinical sense” , “was it hypothesized before the study began” among others. There is right way and wrong way of EBM as you said, and most people are just doing the wrong way of EBM but sill calling it EBM.

  48. Hi Tasha,

    If I understand it right, SBM is based on science and this can come from basic science, bench science and animal studies. So if someone shows a pilot study in animals or in vitro showing bacteria can indeed live in stomach acids, there is biological plausibility. What SBM is opposing is money spent on large human trials which skipped the basic science or bench science part. Make sense?

  49. “One of the principle qualities of pain is that it demands an explanation.”
    — Plainwater, by poet Anne Carson

    Fun Jeff Bridges riff. (I also just saw him in the Coen brothers’ new take on True Grit. Fascinating film, but all of the Acting and Talent on display may have been a bit too conspicuous.)

    Anoop, I don’t know if any of the ScienceBasedMedicine.org contributors are planning for journal publication on the topic of SBM, but I would guess not. SBM exists primarily as conversation starter, a focus for intellectual activism. And it certainly is succeeding at that.

    For a formal/scientific approach to EBM’s problems, John Ioannidis is already doing an admirable job of studying and publishing on the trouble with evidence. His work is sure relevant here. Take home message: it takes a lot more convergent and high quality evidence to “know” something than most professionals realize. Indeed, most experimental findings are probably wrong, and most evidence doesn’t actually mean what it seems to mean (or what we want it to mean). See:

    http://SaveYourself.ca/ioannidis-article

    Ioannidis makes it clear that even a really large amount of low-quality evidence about biomechanical/meat-o-centric causes of pain could be quite misleading. A lot of research is actually muddying the waters by adding yet another dubious data point to the pile, rather than actually getting us any closer to a useful understanding of how pain happens. For instance, does yet another study showing a weak correlation between [muscle group] weakness and leg injuries really tell us anything?

    Garbage in, garbage out.

  50. Johnbarb,

    In 1985 Elaine Scarry wrote most of the following and I quoted her in a speech I made in ’04:
    “Physical pain deconstructs the territory of creating-it brings into sharp focus the relation between it and the ability to imagine.” While in pain, patients will commonly tell you that they don’t have any idea in which direction they should move though, since their pain is intermittent in nature, they must have done this many times before. Scarry is certain that it is only through some creative act that the consequences and perception of pain might be reversed. She says, “Though the capacity to experience physical pain is as primal a fact about the human being as is the capacity to hear, to touch, to desire to fear to hunger it differs from these events and from every other bodily and psychic event by not having an object in the external world. Hearing and touch are of objects outside the boundaries of the body, as desire is of x, fear is fear of y, hunger is hunger for z; but pain is not of or for anything-it is itself alone. This objectlessness, the complete absence of referential content, almost prevents it from being rendered in language…”

    Perhaps this is another way of stating your difficulty with, in effect, “putting your finger” on the pain of another, or identifying the actual Jeff Bridges.

    Then again, I think we’re all actors. Bridges just gets paid for it.

  51. Fascinating conversation. In reading through these comments I sometimes wish we could all get on Skype and argue this out. In thinking about EBM, SBM, I(individually)BM or what ever initials we want to use, I would like to go back to Jeff Bridges. At times in reviewing the research, thinking back to my own practice, and considering the thoughtful additions of the people in this blog, I feel that defining rational care for chronic pain is like trying to define who Jeff Bridges is by the characters he plays in his movies. Is he the starman, one of the Baker Boys, The Big Lebowski, or Rooster Cogburn? He is probably parts of all of those characters and more. I am sorry that I will never meet the man so I can never have a true answer, even then he will most likely be too complicated and multifaceted to really know. I know all of the definitions of pain, I know most of the supposed physiological/behavioral correlates for the experience, I have experienced it, but, in my own mind, it is not well defined like a cancer, strep throat, Parkinsonism, etc. It is hard to reach out to touch, grasp, and physically hold it. Without that physical presence it becomes difficult to measure it. I wish someone had not made the reference to Jeff Bridges. That got my mind going in all different directions.All I can think of is the words from the Big Lebowski- The Dude Abides.

  52. Anoop,

    There are several examples provided in this thread that support my characterization of EBM- as it is commonly practiced in the therapies- as studious detachment. And I think that’s being rather charitable because most therapists read very little anyway and couldn’t tell you the difference between an RCT and SSRD to save their lives.

    I realize this is not your realm of practice, but take a look at the clinical prediction rule (CPR) for treatment of acute low back pain as a prime example of wayward EBM. Many professional statisticians will tell you that the number of variables analyzed in the original and subsequent validation studies on this CPR place these results on very precarious methodological grounds. There are simple too many interacting variables to be able to draw useful conclusions from this research. If you just use your common sense and look at the variable identified, it makes you scratch you head as to why manipulation would even be indicated at all. Yet, the validations studies marched forward and editorials appeared in widely read and reference PT journals telling is to “move it and move on” and other such advice to the rank and file, who probably only read the editorials.

    I just don’t like this tendency in our field to jump the gun with results like these and then start coming up with cute little catch phrases and course titles (including the odious “manipalooza”), and then justify it all in the name of “EBM”.

    You and I know it really isn’t EBM because it’s not scientifically critical and stringent enough to qualify as such, but that doesn’t stop those who should know better from printing “evidence-based” all over their course brochures.

    So, EBM-the term- has been hijacked it seems. SBM is the effort to restore some common sense and a little ego restraint back into the EBM movement.

  53. Jason Silvernail says

    Hi Tasha.
    I think we start by reviewing what we know and don’t know about the relevant biological and psychological processes related to the subject we’re dealing with. I think the wider “SBM vs EBM” discussion is better served over at the SBM blog (www.sciencebasedmedicine.org), where many questions posters are asking here are answered in greater detail.

    The instances in which I’ve noticed SBM being of most use in physical therapy is when we can use it to rule out traditional but disproved theories (your disk is bulging, your joint is out of place, check out those trigger points, you have bad posture, etc) and that we can use it to confidently dismiss the plausibility of alt med methods that are sufficiently divorced from a scientific worldview (myofascial release releases bad memories stored in the tissue, energetic medicine and craniosacral foolishness, fascia has memory and gets bound up and must be released manually, etc etc).

    Even many things more mainstream like therapeutic ultrasound only make sense if we don’t understand the basic science of pain. After the first four chapters of The Sensitive Nervous System, I realized that much of modern physical medicine is just unnecessary and unlikely to be helpful beyond placebo because it doesn’t address what we know the underlying processes are.

  54. Tasha Stanton says

    Hi all,

    Brilliant discussion going on here! I’ve really enjoyed reading it and many of the links posted. Cheers!

    I do have one question that probably is best directed to John, Jason, or Paul: with SBM, how do we validly determine biological plausibility? It seems to me that because we are still making advances and discoveries in the basic sciences, how can we actually rule something out and state, with confidence, that it is NOT biologically plausible? It just seems to remind me of the situation of H. Pylori and ulcers. For ages, this explanation for the cause of ulcers wasn’t considered biologically plausible because it was thought that no bacterium could live in the stomach due to the extensive amounts of acid the stomach produces. Yet we now know that treatment for h. pylori is effective in healing ulcers.

    I like the overall idea of SBM and I look forward to discussion on how you feel we can make valid decisions re:biological plausibility.

  55. An Paul do you know if Steve or any of the SBM contributors are planning to publish an article abt SBM in any journals? I just think more people in the position of power will get to read about it if it is in well known journal.

  56. Hi Paul,

    Not trying to dismiss anything. I use a lot of plausibility approach in the exercise field. i was just confused from your post “If science can’t “help with other hypothesis,” what exactly would you propose?”. My bad.

    I was saying there are hypothesis which cannot be analyzed with just a basic science approach. I totally agree with science based approach for the voodoo stuff and maybe that will be included someday in EBM.

    And on, do you know there was 90 commentaries on his Mark Tonies article which were mostly saying that there is right way of EBM and he is just pointed what is the wrong of doing EBM. And I really don’t think EBM is studious detachment as you say John.

    Here is the conclusion of the commentary posted by Lipson in reply to Tonelli’s article: “Decisions made purely on the evidence, or on the
    basis of the application of the evidence to a hypothetical
    paradigmatic case, must inevitably exclude two
    or three of Tonelli’s five topics. On the other hand, a
    clinician who uses EBM skills to understand the consequence
    of the evidence for an individual patient is
    adding to its usefulness within the broader context of
    the five topics. The ability to do this remains rare and
    Tonelli’s analysis adds to our understanding of why
    the attempt to compensate for this through evidence based
    guidelines is uncomfortable for many clinicians,
    and often perhaps unsatisfactory for their
    patients. So rather than set out ‘an alternative to
    evidence-based approaches’, Tonelli has shown how
    evidence-based approaches, when used in the right
    way, can form part of a more patient-centred, casuistic
    approach to clinical practice.”

  57. Wow! 41 comments! Is this a record conversation topic?

  58. Jason Silvernail says

    Totally agree with Paul on the exaggerated use of a couple studies to generate a smug “evidence-based” industry. That quoted term is all but useless by now.
    This only goes further in demonstrating the importance of mechanisms-based reasoning and a higher bar for biological understanding in the context of evidence.

    Probably the biggest push-pull among those in the therapies that read the research (I recognize this is a small number) is the argument about how much of therapy is a specific vs a nonspecific effect.
    People that have learned/taught a lot of operator models and tissue-based examination schemes (like the original post for example) tend say the primary issue is mechanical nociceptive and therefore specific effects like examination and treatment skill in the periphery are most important. People that have learned/taught a lot of interactor models and neuroscience tend to say the primary issue is central and therefore nonspecific effects like placebo, education or cog-behavioral is most important.

    There’s no way to reconcile these views other than to take what seems to me the most reasonable position- that the therapy should be tailored to the presentation and both views may be more or less operative in any patient at any given time.
    In my opinion, we should be comfortable enough with neuroscience to abandon the strict tissue-based explanations and reasoning while being comfortable enough with mechanical nociceptive-origin pain to understand that there’s a place for comprehensive skilled assessment and treatment also. This is essentially what the “Crossing the Chasm” thread was about that I linked above.

    I don’t see too many people advocating this view, but it seems to me the only rational one left, and certainly it was the overall approach of the manual therapy fellowship I just completed.

  59. To bring this back to Jason’s post a bit, what I see happening with EBM in the physical and manual therapies is simply that nearly any evidence is embraced as a justification for clinical choices, regardless of how weak that evidence may be. Practitioners cherry pick from PubMed for a couple of citations that kinda-sorta seem to back them up — and they are considered the diligent ones, “doing EBM.” If a scrap of evidence can be distorted into a positive conclusion, then their clinical choice is justified.

    This is most evident in the steady stream of interventions that become extremely popular waaaay in advance of adequate evidence. A little weak preliminary evidence seems to be all that is needed to launch a smug new “evidence-based” industry!

    There are similar issues among researchers, where there is clearly an epidemic of over-reaching the evidence to write conclusions and press releases that are pleasingly consistent with “mesodermal stretchy corpse concepts” (Diane Jacobs), and which give physical therapists something to therapize.

  60. Anoop, no one has said that EBM “is devoid of science approach.” That is not written down anywhere. The point of SBM is merely to encourage an revitalization of EBM with an emphasis on science and plausibility, in attempt to compensate for some issues that have arisen with EBM-in-practice over the years.

    By your own admission, Anoop, you don’t understand SBM … but then you make dismissive assertions about it. I can’t correct every straw man you erect. Your approach may not be the best way to learn what SBM actually is.

  61. Anoop has a point. The problem is not entirely what “evidence-based” was meant to be originally, but what it has come to mean to many who use it as a cudgel.

    It was meant to be used as a scalpel.

  62. First, basic science is indeed used in EBM. I just don’t think people can say EBM is devoid of science approach just because they never thought of homeopathy ,energy medicine and other voodoo stuff. And they might add this criteria for judging idiotic interventions like these. There are CAM reas like herbal medicine, where the hypothesis still need to be tested with an RCT. No sort of basic science will help us there. And I do think Novella agrees that.

    If you look at the definition of EBM in the classic EBM book which clearly says” By best research evidence we mean valid & clinically research, often from basic sciences of medicine, but especially from patient centered clinical research…”

    “An example would be which antibiotic for an infection which can depend on local resistance patterns. We need the trials to know they work, but the choice may depend on basic microbiology. ” This is an email from Paul Glasziou -one of the authors of the EBM book because I had asked this question a few months back.

    Even the interpretation of systematic reviews and met analysis , the highest in the hierarchy, is based on basic science approach. Maybe not news for people here, but I just get the feeling that there is some misinformation that EBM only considers evidence from RCT’s & reviews.

    i will reply to you later Jon.

  63. Anoop,

    Do you remember the movie “Star Man” with Jeff Bridges? If not, you should rent it. This alien comes to earth in the body of the recently deceased husband of the movie’s protagonist, played by Karen Allen. I don’t even remember why the alien was there- maybe to get or learn something about Earth people. Bridges plays this role spectacularly. Although he’s obviously a clone of the dead guy- looks and kind of sounds like him- his movements, mannerisms and speech are staccato and bird- or reptilian-like.

    The alien must have had an EBM mindset when he decided to clone himself as a human . Everything looked just like the real thing, but he grossly under-estimated the importance of the myriad subtleties and contextual nuances that make a human human. The outcome of the experiment in recreating a human being was obviously implausible, and Karen Allen’s character recognized that as soon as she began to interact with him. In fact, she was scared to death of him.

    EBM seems to have this lack of real-world interactiveness that SBM appreciates and understands. SBM is thoughtful immersion, EBM is studious detachment. There’s an excellent, albeit rather dense, article by Mark Tonelli (Journal of Evaluation in Clinical Practice, 2007;12(3):248–256) that describes the philosophical flaws in the current interpretation of EBM. He argues that the mistake that has been made with EBM is in the ranking of different *kinds* of evidence within a single hierarchy. He argues that this makes no sense. He goes on to describe the “casuistic” approach to clinical decision-making, where different kinds of evidence are given due consideration based on the the complexities of the patient in front of you.

    Since it doesn’t get much more complex than humans in pain, a science-based, casuistic approach to care simply makes more sense.

    Barrett Dorko Reply:

    John,

    Great analogy to Star Man. I think this movie predates the discovery of the Uncanny Valley but describes it perfectly. Google the phrase.

  64. It’s just SCIENCE-based medicine, not some-other-unclear-way-of-evaluating-claims-medicine. If science can’t “help with other hypothesis,” what exactly would you propose?

  65. As I said, I don’t have a good grasp of it.

    So even if it goes against the conventional science, if there is evidence from basic science it is ok to be tested. So though the neuroplasticity theory goes against the current science, the evidence from bench and animal science makes it plausible to be tested further based on SBM. Did I get this right?

    I think science based approach is good for things like homeopathy , energy medicine which are so screwed up and goes against basic laws of everything. But I don’t how much it can help with other hypothesis which can go either way.

    And I am note sure if this Novella’s concept. The Brad hill criteria involves coherence and plausibility as some of the criteria for assigning causation in e epidemiological science.

  66. Paul states: “Nor do I think it’s fair to imply that neuroplasticity was implausible a decade ago.”

    Certainly not. Clifford Woolf’s experiment on rats demonstrating the presence of central sensitization- a hallmark of neural plasticity within the CNS- was published I’m pretty sure in 1983. This concept has been building steadily over at least 3 decades.

  67. Anoop, no proponent of SBM would ever argue any such thing about neuroplasticity or any other intriguing basic research, and it does not logically follow from the principles that Drs. Novella, Atwood and others have described ad infinitum.

    Nor do I think it’s fair to imply that neuroplasticity was implausible a decade ago. Craniosacral therapy was implausible. Reiki was implausible. Neuroplasticity was just the next interesting, surprising big news in neurology. Investigations at that time were certainly justified by the science that preceded them. Remember, Steve Novella is a neurologist: I’m confident that he was aware of current events in neurology when he started the process of defining SBM.

    The concern that you have described is the most common of all the common objections to SBM, and it has been rebutted effectively many times. The only research that should get the boot from an SBM perspective is that which is much more egregiously at odds with scientific consensus than neuroplasticity ever was.

    As for the efficacy of SBM, you may as well have asked about the efficacy of science itself. The tools of science are the only ones SBM endorses. Nothing new has been proposed, just that we renew the emphasis on the importance of science to medicine … not to evaluate claims in some new-fangled way that we need to sniff suspiciously.

  68. Thanks for the links. I do understand the benefit of SBM for ruling out interventions. I think atleast the definition in EBM says the ” evidence from the basic sciences of medicine” in the classic EBM book, though they don’t use it as well I guess.

    My question is how effective is the SBM approach when it come to questioning existing theories. For example, the whole concept of brain is plastic, which is the basic of modern pain science, was only discovered a decade ago. Before that the saying brain is plastic was going against the fundamentals of current neuroscience. So based on SBM they shouldn’t be bothering even studying the “brain is plastic ” hypothesis. How will SBM tackle problems like these and still complement the EBM approach?

  69. Anoop, if you missed it above, I have a concise explanation of SBM’s raison d’être. Here it is again:

    http://SaveYourself.ca/ebm-vs-sbm

    It includes a list of links to all relevant articles on ScienceBasedMedicine.org itself, including a recent series by Dr. Kimball Atwood that re-visits the topic very substantively. In particular, he responds to every common objection to the idea of SBM.

    For my part, I am always a little puzzled and intrigued that there are so many objections to the idea of SBM in the first place. Is it really so hard to see that EBM has weaknesses in practice? That SBM is not intended to replace EBM? That SBM suggests an important, fresh, and useful perspective?

    But I suppose SBM is inevitably a bit boat-rocking and feather-ruffling because it’s impossible to embrace it without confronting some awkward questions about business-as-usual in the physical therapies … which have virtually ignored the implications of decades of pain research, and remained fixated on explanatory models that lead to scads of underwhelming evidence. There’s a million of ’em: an endless stream of little RCTs finding small effect sizes and correlations, but the authors play mental Twister to make it sound like a promising needs-more-study validation of their biomechanical assumptions. The mental dissonance is deafening, and it’s been going on for decades now.

    Nowhere else in science have I seen so much ado about nothing! How many lame effect sizes do we need to see before we start questioning the underlying assumptions of the research? An SBM perspective on pain care quickly leads one to say, “Hey, maybe we’re asking the wrong questions here!”

  70. anoop,

    This thread started by Barrett over at soma simple gets into the distinction between evidence-based and science-based practice pretty deeply: http://somasimple.com/forums/showthread.php?t=5828.

  71. Somebody should start a thread in Somasimple about this.

    I think even in the SBM blog there was a few comments that people really don’t understand the need of SBM. What is the need for SBM? What are the limitations of SBM. I still feel I don’t have a good grasp of it so I will wait someone else to post the topic.

  72. I wrote The Wrong Question here http://www.barrettdorko.com/articles/wrongquestion.htm years before I ever heard the terms “evidence or science based” and think it expresses the issue pretty well in a very few words.

  73. Supposedly, evidence-based practice is there to guard against both errors that Barrett describes by reducing both false negatives (minimizing safety concerns for the patient) and false positives (minimizing financial concerns for not only the patient, but society at large).

    However, it’s not doing either in the area of persistent pain, despite the acceleration of outcomes research and clinical prediction rule development in our field. The designs of many of these experiments have been exquisite, the methodology and statistical analysis complex, yet seemingly sound and the populations more or less relevant to actual practice. Yet, patients with persistent pain aren’t getting much better and costs for their care continues to skyrocket. How can this be?

    There’s a gaping knowledge void that has been traversed by multi-variate statistical 3-card monte (which seems to have accelerated during the relatively recent proliferation of highly evolved statistical software). As Barrett mentioned above, our new graduate DPTs in the U.S., despite being highly conversant in research methods and EBP, have scant awareness of the burgeoning field of neuroscience and its relevance to the vast majority of patients that we treat.

    We’re rarely inflicting harm on people’s bodies, but we’re probably doing something even worse: we’re using their bodies to justify our existence through myth propagation and quasi-scientific obfuscation.

    In the immortal words of Biff Barf, the sportscaster, made famous by George Carlin: “If I don’t see ’em, I make ’em up.”

  74. Hi Barret,

    Thanks for the thoughtful reply.

    I should have been more clear about the harm. I meant we have thought that the drug , for example, will be extremely useful because it was biologically plausible . And it was so plausible that experts didn’t bother to do some large RCT’s. Unfortunately, after a large RCT it was shown that the drug was killing more than people than it was saving. My point is that it is pretty easy to make something biologically plausible.

    But it will be hard to convince even if it is biologically plausible,BUT if it goes goes against the established science. Then you need some extraordinary proof to topple the established science.

  75. Plausible doesn’t mean “safe.” Up to that point I agreed entirely with what you’ve said. The whole of the question I’ve asked in the past is “Is it biologically plausible and physically possible?” I think that covers a bit more simply what you said so well.

    In physics, as Victor Stenger points out, there are laws of permission and laws of denial. Many of the theories (and their consequent methods) mentioned by Jason in his original post violate the latter. That is a big mistake.

  76. I think instead of asking if it is biologically plausible, the question should be is it coherent with the current established pain science or fundamental biology or physics or whatever. If it indeed goes against the fundamentals of the field, then it should be looked at very critically.

    The problem with the biological plausibility is that you can come up with anything and easily argue for the plausibility . We have a lot of examples which were very plausible even by experts in the field, but showed to be harmful in the end when tested.

  77. Jason Silvernail says

    James-
    Great comments, and your crystal example is perfect. If only it were that simple. One look at the current (as of this writing January 2011) controversy regarding the serious use of homeopathic medicines (ie water) should be enough to convince us all that RCTs, while critical, aren’t enough.
    Far more often we are faced in medicine with a situation for which there is no applicable evidence or no rigorous evidence such as a good RCT. In fact, my own experience in musculoskeletal medicine and my conversations with other medical providers of various disciplines leads me to believe that this is by far the most common situation. It is precisely this everyday experience – a requirement to make sound medical and therapeutic decisions in the absence of rigorous evidence – where science-based practice can help us the most.
    Read more here in “EBP, Deep Models, and Scientific Reasoning” http://bit.ly/fbkS5l
    From the excellent blog at Evidence In Motion.

  78. Without a deep model that explains and predicts, empiricism drives practice in precisely the directions we’ve seen. Here’s an essay on the subject written ten years ago. http://www.barrettdorko.com/articles/no_deep_model.htm

  79. Amazing discussion. I agree with John that we shouldn’t lose sight of the fact that our interventions are far more complex than we often realize, and that they interface with a system that effectively “hides” its internal processes from us. Melzack’s model is both explanatory and predictive, but, to me, more the former.

    I’d also like to point out that all of this renders placebo an “effective” form of care when seen in light of the neuromatrix.

    I have long felt that the word “deformity” on the left side of the neuromatrix is an entryway for physical therapy when others there may be blocked because our education may not have prepared us to deal with them. In short, we’re looking for a movement. Ideomotion seems appropriate, but our colleagues focused on connective and contractile tissue seem not to know of it.

  80. James,
    Thoughtful comments. I’d take issue with your perception of the role of science in clinical practice, however. The health sciences operate within very broad “spec’s” as the engineers call them. We tolerate relatively high errors in our measurements. Therefore, we ask that trials be replicated by a variety of different researchers in different institution and parts of the world before we give much credence to even highly significant results.

    With these broad tolerances in mind, I don’t view science as a ruling in as much as a slow smelting process. We propose hypotheses in order to place theories to a test. If the theory withstands the questioning, then it becomes more stout and more refined. Then we can use it with a higher degree of precision to develop and apply interventions that are consistent with the theory, and then keep testing it.

    Current pain theory by Melzack is pretty darn stout, but we need more refinement through clinical trials for sure to focus in on the how much of this and how little of that is actually necessary. We’re dealing with an immensely complex problem (pain) in an intensely complicated organism (human beings), so there’s a ways to go yet to even say with much confidence that we “know” anything about how to treat it best.

    I certainly think that we can do a lot better about ruling some stuff out that’s beyond implausible at this point.

  81. James McAuley says

    Some very interesting posts in the blog…Science-based medicine – never heard of it until last night.

    From the admittedly limited reading that I’ve done since then I understand that the science part of Science-based Medicine (SBM) provides the biological context for a therapy and rules out those that are regarded implausible. Ruling out biologically implausible therapies guards against scientific fraud, mistakes etc in RCTs.

    On the face of it this seems fair but I’m having difficulty seeing how this works in practice, particularly in areas with any controversy about biological processes or mechanisms (and there are many). It seems to me that these general principles are pretty much implicit anyway – if a trial was published today that showed that a 2 session course of crystal therapy reduced pain intensity of chronic low back pain by 5 points on an 11 point VAS would we believe it?? Isn’t it more likely that we would think that there had been some error as it was biologically implausible and just ignore it? Occasionally though things that might initially seem implausible turn out to change our way of thinking. Generally I think that censoring scientific ideas and research has more against it than for it (obviously within ethical boundaries).

    The ‘science’ part of SBM cannot rule anything “in”. To rule a therapy in we still require an RCT of the therapy vs. a placebo (for efficacy). This isn’t easy and there are difficulties in designing adequate placebos for complex interventions (e.g. physiotherapy) particularly in areas where the underlying biological mechanisms are not clear. Still, it is the best way that we have of determining whether all that basic science knowledge can be used to actually improve a patient’s health. Unfortunately there are plenty of instances where despite the significant promise of basic science knowledge the therapy just doesn’t help at all (or is harmful).

    It seems to me that if you are a science-based practitioner working in pain management you are kidding yourself if you think you know what you are doing is effective. For that you need an RCT.

  82. Indeed, patient satisfaction has actually been shown NOT to correlate with positive outcomes. For instance, see Hush et al., who found that positive outcomes “infrequently and inconsistently associated with patient satisfaction.”

    “Every little thing a nice therapist does is magic”
    http://SaveYourself.ca/patient_loyalty

    John Ware Reply:

    Oops, sorry, Paul, I stomped all over your reference to Hush et al. Anyway, it looks like David may have missed it- what’s that phrase from my freshman year philosophy course?: “Repetitio est mater studiorum.”

  83. David,
    It’s hard to tell, but it sounds like you’re saying, “I get results, so I don’t really care how it works.” Please tell me that’s not the case. There are far too many patients who are not only NOT getting helped, but they’re getting maimed because of dubiously motivated empericism buoyed by entrenched biomedicalism (lumbar fusion comes to mind).

    On the less extreme end from irreparable-damage-to-persons’- bodies, is the wholly indefensible propagation of myth (myofascial release and “fascial thixotrophy” come to mind).

    In the end, I’m not quite certain which of these is more disastrous. And I’m certainly convinced that the “well, it works” argument will not help to mitigate either of them.

    By the way, patient satisfaction has never been shown to correlate with actual improvement in any outcome measure of which I’m aware.

    James McAuley Reply:

    Hi John,

    I’d be interested to know how you suggest David treats a patient with lets say chronic non-specific low back pain?

    John Ware Reply:

    James,

    I’ll have to wait for David to clarify exactly what it is he meant to say because I’m with Barrett that I don’t entirely understand what he was getting at with much of his post.

    It sounded to me like he was falling back on the “I get results, and that’s good enough” argument, while keeping the door ajar for the, by all accounts, seriously flawed biomechanical model for the treatment of persistent mechanical pain.

    Furthermore, the literature in general shows very modest effect sizes from physical therapy interventions for chronic pain, spinal pain in particular. A relatively small percentage of patients are responsible for the vast majority of costs associated with chronic low back pain. Notwithstanding David’s high patient satisfaction and positive functional outcomes, we’re generally not doing very well with these patients. Although, I’ll grant you that many of them probably give their therapist high marks for trying.

    I don’t know what he means by “existance [sic] within defined parameters” as an outcome, and I think I’ll stop speculating at this point and let David clarify if he so chooses.

    David FitzGerald Reply:

    James

    it seems we’re going to have to wait to find out? That’s a cliffhanger for sure!

    David

    David Fitzgerald Reply:

    John
    I must admit /confess /acknowledge /hang my head in shame that I am results focused. I’d love to know the mechanisms behind much of what I do but If i wait or that then there seem to be very few treatment options – unless I,ve missed a body of evidence somewhere.

    Point taken on not hurting patients – undoubtably I do hurt some but not catastrophically fortunately (although I have spent many hours in the High court where the patient has not been so lucky so I am well aware of the possibilities.

    Some examples spring to mind…
    whiplash pain that is latently reactive to physical testing.

    volatile acute disc’s which are soo sensitive to intervene

    partial meniscal tear which are not surgical but breakdown on progressive loading

    degenerate spines which are deteriorating in functional tolerance will often “pleateau” at level below prior baseline – we you only know by trying to re-establish basline and failing.

    I’m interested to hear about research on patient sasisfaction and outcome. All I can say is the fallout from patient dissatisfaction in the real world is an absolute disaster – so I try to avoid it at all costs.

    This does not mean being evasive but certainly recognising potential situations and altering managment accordingly. I,m not looking for an easy life hear just trying to prevent over complication. I will be frank enough to acknowledge that this situation has been the subject of a professional affairs enquiry as a direct consequence of patient dissasisfaction – and I can tell you that wasn’ta barrel of laughs!

    PS do we know biological mechanisms attributable to therapy in…
    ACL rehabilitation
    Ankle spains
    Post fracture

    I would be very familiar with the basic sciences pertaining but havn’t seen it documented other than patient outcome measures – dare I say it!

    Cheers

    David

    John Ware Reply:

    “I’m interested to hear about research on patient sasisfaction and outcome.”

    It just so happens an SLR by Hush et al was published in this month’s PT Journal titled “Patient Satisfaction with Musculoskeletal Physical Therapy Care: A Systematic Review”. What was the most consistent determinant of patient satisfaction? Answer: therapists’ personal attributes. Outcomes from care- surprising to the authors, but not to me- was “infrequently and inconsistently a determinant of satisfaction with physical therapy care”.

    There you have it. But, please, don’t stop using outcomes measures and even satisfaction surveys for your patients. I certainly haven’t and don’t intend to stop if for no other reason than the one you mentioned. I’m not above covering my a**. (Can we say that on your blog, Dr. Moseley?).

    David Reply:

    Indeed John – a timely review I shall digest.

    I would strongly agree with the view that “Therapists Attributes” are a major determinant. Having spent many years honing technical / analytical skills in manual therapy and exclusively recruiting staff with similar level training from Dr Moseley’s fair land I abandoned that criteria in favour of sociability and interpersonal skills some years ago.

    Maybe I’m stubborn but I still think my manual skills have an important function as part of a “care delivery system” but not of the significance I used attach. Perhaps a harsh reality but one I can live with.

    Now back to the debate. So far..

    1. The research say’s that patient sasisfaction does not effect outcome but the real world experience suggests /dictates we must factor this in.

    2. Therapist personality is an important component of patient perception of treatement effectiveness – no argument there.

    3. Relying on outcome is intellectually uncomfortable but the best we’ve got for many musculoskeletal interventions?

    4. Evidence based, science based or biologically plauasible explanations are the competing processes on which to direct choices for intervention? With any of these frameworks what sort of % of interventions fullfil these criteria?

    5. Last I looked on Cochrane only 15% of surgical interventions were proven – subject to criterion research methodology. Has that changed much?

    6. How do clinicians choose between using an intervention which “appeared” to help in similar cases but has not been proven? Is the implied suggestion not to do anything? If it comes down to a limited selection of proven interventions which curtail the use of treatment options not researched (or proven) versus trying safe (but unproven) alternatives which elicit demonstrable, meaningful clinical change then, for me it’s not a difficult choice.

    This then brings us back in a circular path and leaves me questioning why we had the debate in the first place and what has been achieved – which seems to a recurrant theme.

    Is this flawed logic, dillusional, luddite or simply a reflection of reality?

    I keeping with the latin theme as my old engineering lecturer used to sign off “quod erat demonstrandum”

    David

  84. David,

    I’ve read this four times, and I read a lot.

    What on earth are you saying?

    David Reply:

    Barrett / gentlemen

    what a marvelous discussion…..

    In all fairness, I don’t this my comment was the most coherent thing I’ve ever written so let me try to articulate more precisely.

    The Cartesian model of separating mind and body which determined the medical model for centuries is pretty well accepted as obselete.

    This establishes a framework for integrating psychological / neurobiological mechanisms into clinical management strategies.

    As all “pain experience” is ultimately the summation of neuronal activity – as clinicians we are left with the challenge of “how to access the neural networks” and elicit an appropriate neural output which improves the patients wellbeing (dare I use such as ill defined term).

    The challenge is trying to prioritise legitimate targets for intervention and having necessary tools in the box to do so.

    We know that events such as severe trauma, acute anxiety, life threatening circumstances (and perhaps painful surgery) can bombard the neurobiological system temporarily to obliterate pain – but these are not sustainable strategies (the high incidence of pain with depression being a common example).

    My slightly tongue’ n cheek suggestion of inflicting pain as a counter irritant is not a serious suggestion other than to highlight that it is possible to bias an intervention to target higher centres and override peripheral nociceptive input.

    I make no claim to be a Clinical Guru and while I get tremendous enjoyment from exploration of the basic sciences,which this forum has such strong representation, I always revert to how can I apply this information to improve / alter my patient management.

    I,m working on the basis that patient / therapist interaction (which ultimately results in a neurobiological process) consists of, physical, psychological, social and basic human relationships. I try to draw on all each of these components to achieve the objective of improved patient status. I wish I knew what mechanisms were at play here but must confess to speculation / biological plausibility.

    PS; I don’t have a favorite tissue…

    Cheers

    David

  85. Seems Descartes is alive and well. In the late 90’s I spent alot of time in collaborative teaching about the medical model and Cartesian philosophy of mind and body separation. This was when we didn’t factor in the “Head”. Now I wonder do we need to factor in the “body”.

    It seems to me untenable to asertain than one musculoskeletal structure is ever going to be holy grail although there certainly enough “institutes” in one realm or another.
    Shouldn’t the focus be to identify mechanisms of Dysfunction (neurobiological and biomechanical) and select the relevant treatment strategy?

    Perhaps lobotomy, extreme fear, crisis exposure or major trauma should be the intervention of choice – as this will certainly surpress the peripheral nociceptive response in the short term?

    I have no doubt many of my peripheral interventions produce an effect by other mechanisms which I don’t loose too much sleep over any more. Patient satisfaction, return to function, existance within defined parameters are the outcome measures of relevance for me – and more importantly …the patient.

    David

  86. A silver tongued Silvernail with a point to make, now where’s the hammer to drive it home (through my thick 2×4 skull)?

    ANdy

  87. Well that was a little surreal for me. I was merrily reading through these comments, delighted with the topic, delighted with the tone of the discussion, contemplating how I might contribute, thinking about what I’ve already written myself that I could crib from to save time … and then I come across my own name and a particularly appropriate link to my own writing!

    Jason, you scooped me … with me. Surreal but fun. Thanks.

  88. Jason Silvernail says

    I also think James makes a good point. The primary implication of modern neuroscience in therapy, to me, is twofold.

    One, that we shouldn’t throw out what we are doing. We can continue to use rational therapies that came about as a result of old memes, but let modern science inform their use. There’s a thread I wrote on SomaSimple called “Crossing the Chasm” that shows how manual and exercise therapy can be used with an eye to neuroscience. Find it here: http://bit.ly/h6Hov8

    Second, that much of the talk in physical therapy today that unwarranted practice variation is bad may be missing the mark. Often this complaint about practice variation is coupled with the statement that things thought “biologically plausible”, such as therapeutic ultrasound, are part of the problem. I think practice variation actually is telling us something useful about modern medicine. It’s telling us that most practitioners don’t understand the nature and origin of pain complaints! The bar for “biologically plausible” is so low because we, as professions, understand the biology so poorly. This is why among the evidence-based community, that term has a bad reputation. Understanding the neurophysiology raises the bar for biologically plausible to where it should be, helping it be an important guide to a rational, science-based approach to therapy. And therapeutic ultrasound, for example, doesn’t make any sense when we better understand the neurophysiology. This is the primary difference between science-based and evidence-based practice: an understanding of prior probability and mechanism of effect. Here’s more, from Paul Ingraham, on the science-based vs evidence-based issue: http://bit.ly/ftNcpS. Or see the excellent SBM Blog for the original concept: http://www.sciencebasedmedicine.org

  89. Here’s a good example of what I’m talking about and what Barrett Dorko referred to as “the absence of the skeptical process”:
    “The SpiderTech Clinically Based Kinesiology Taping Theory and Application Course: Con Ed Update January 20, 2011”

    I just received the email notice of this taping course I suppose because I just bought their tape for the first time. Based on the elaborate marketing brochures, vast array of colors and stylish ways to apply tape to people’s skin, I suppose they’re going to charge me $295 to tell me all the things this tape can do, much of which is going to be inconsistent with current pain theory- and not by a little bit (I saw something about “superficial fascial thixotrophy [sic]” as one of the “microcirculatory” mechanisms of using this particular tape.

    Nonetheless, I’m sure scores of PTs and other professionals who deal with the pain population are going to shell out the cash to listen to some slick presenter tell them about fascial thixotrophy (if he actually pronounces it like that, I wouldn’t be surprised either) and the other almost miraculous effects of this tape.

    Well, it’s not miraculous, fascia is not involved in what’s happening other than in terms of it’s normal and predictable structural function. Any microcirculatory effects can be explained by a fundamental, well-established knowledge of skin neurophysiology, which I’m afraid most of our colleagues don’t possess.

    Jason’s post should be compulsory reading for PT students and drummed into their heads before every lecture on kinesiology, PNF, manual therapy, etc. We need to start breeding more skepticism among our colleagues and educators or their won’t be any students left to teach or profession to “unpack”.

    Many of us think it’s getting dire.

  90. I’m with John Ware on this. Jason simply recognizes the absence of the skeptical process in profession’s drive to help our patients and we have all seen the dire consequences of this. As a workshop instructor for many years, I listened to a high percentage of our colleagues with complaints of pain tell me that they had abandoned the methods of management they still used on their patients. To me, this situation is both absurd and surreal. It is also common.

    Neuroscience offers us a rational path from this, and the dearth of research demonstrating our effectiveness when it is applied has mainly to do with the complexity of the system we’re dealing with. Finally, our care can become science-based first and foremost and not immediately suffer from the problems inherent to the evidence-based model when it is applied in the absence of this.

  91. Neil O'Connell says

    Really nice piece Jason,

    I think James makes a great point. Therapies are driven by evangelist-style enthusiasm and models fail often because they are rushed through from a bit of basic physiology, to what seems a plausible model in which the physiology is often stretched super thin to fit what is perceived in the clinic (often to the point where it ceases to be true). When we finally get arounds to measuring the effect of the treatments that arise from these models we are shocked when they don’t work (although of course we know that they do because we’ve “seen it” and so we defend them with passion to avoid the uncomfotable implications of having been wrong all this time).

    What James is saying is that we need to go forward slowly, carefully and patiently and make sure that we don’t replace that unpacked baggage with more baggage.

    With regards Craigs comment “is probably why cog-behavioral strategies work”, the quality data is less compelling, particularly in back pain. Check out last years Cochrane review update (worth a blogpost I think). http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD002014/frame.html

    What we have in chronic pain is an evolving understanding of the physiological correlates of the phenomena. That of course does not mean that such correlates drive the problem, although they might some of the time, all of the time, or none of the time. So time will tell.

    So instead of muscleheads, jointheads, or brainheads – lets have sceptical levelheads.

  92. James,
    I appreciate your words of caution regarding the lack of outcomes evidence based in current neuroscience, but I don’t think it was Jason’s intent to recommend a particular approach based on the slowly developing understanding of pain in our profession. I think he just very succinctly and accurately summarized why tissue-based models have been so far off base to the point of virtually ignoring mechanistic and outcomes research evidence, much of which has been around now for decades. And the evidence continues to poor in, but seems to be lost on the vast majority of the clinicians and educators in the field.

    We can’t move forward until we begin to unpack the worthless baggage that we’ve carried for far too long, and I think that’s what Dr. Silvernail’s post was trying to convey.

    It’s not as if he’s going off half-cocked or anything.

  93. James,
    I would suggest that graded exposures to feared stimuli is a treatment of the mind (nervous system) not body (tissue). I hope you are not denying that pain is in the nervous system (i.e. phantom limb pain)? As Explain Pain says “the pain is real”.

    It is our job to reassure and reactivate patients after all the frustrating failure they have had with treatments attributed to structural pathology (orthopedic model) or tissue dysfunction (fascial, muscular, articular). How? By teaching them that the body feels better when it moves better. To do this 1st the threat value of pain must be reduced & this is probably why cog-behavioral strategies work.

    Conversely, as Gary Jacob said “NSAIDs are the gateway drug”. And, attributing to manual therapy instead of self-care is not much more likely to promote the W.H.O.’s goal of independent functioning.

    Kudos to Dr Silvernail for hammering these crucial points.

  94. Hi Lorimer,
    I don’t just like it…I LOVE it!! Yes in answer to your question, he really has hit the nail on the head, and hard.

    I only hope it reaches as many people as possible working in the field of pain. Maybe hard on Research tho? Maybe so…maybe not? Think about that!

    Thanks anyway for giving us this opportunity to read and digest such a wonderful article Jason. Jo

  95. James McAuley says

    Nice blog. Probably most of the people reading BIM wouldn’t disagree with Jason’s characterisation of contemporary physiotherapy, at least in relation to back or neck pain.

    But I strongly feel that people who are interested in the role that the brain plays in clinical pain need to be very careful about not going down the same path as these previous explanations that were very quickly turned into treatments and rolled out into clinical practice. Neuroscience provides a seductively neat explanation for why some people don’t recover from back or neck pain, but that is just a theory. Sure there are some interesting data that support it, tantalisingly interesting, but we need to be very cautious before we start saying that this stuff works in clinical practice, before it has been tested there.

    If we turn this theory into a treatment, or use it routinely in clinical practice without having its predictions fully tested then we run the risk of ending up like DiscHeads or MuscleHeads which have none (1) or very limited effects (2) when properly tested in a randomised controlled trial. If we are to learn anything from the past experience then lets try to avoid turning in to BrainHeads.

    (1) http://www.ncbi.nlm.nih.gov/pubmed/20102596

    (2) http://www.ncbi.nlm.nih.gov/pubmed/19892856

  96. Frédéric Wellens, pht says

    Two thumbs up Lorimer. We’d be honored to have the chance to chat with you on Somasimple!!!

  97. Jason’s words inspire many of us, scare others and, unfortunately, are unknown to most. It would be nice if we could count on rational thought alone but I fear that may take a long, long time. In the US new grads seem unaware of the battle between traditional thinking and the discoveries of neuroscience.

    Diane Madras Reply:

    Barrett,
    Too true! As one partially responsible for new PT grads in the US, what I see everyday are students who want to know the ‘right answer’ not the curiosity to try to explore alternative explanations or to think outside what they are told. I’m hopefully awaiting the day when one of my students says, “but wait, Diane, what about if we approached the problem this way,,,,” Wouldn’t that be fun?

    Andy Reply:

    Now there is a thought – that the interaction with patients, the exploration and resolution fo their difficulty could actually be “fun” !

    ANdy

  98. Jason Silvernail says

    Thanks BIM team!