Joined: March 23, 2006
Thank you. I will agree my style may sting where it hurts in many cases. I am passionate about maintaining professional integrity.
I get frustrated when I hear orthopedic surgeons claim that they do not trust Physiotherapists and would rather refer to a "massage therapist"( yes, I have heard this direcly from a very reputable surgeon). They claim that they don't know what kind of "funny" things we might do. Physiotherapy has too much available research to work with to have our medical pers refer to us as "funny".
You just gotta back it up somehow. That is all I am trying to say. My apologies to Drexey.
I will adjust my tone, but stand my ground on the issue of professional accountability.
Don't twist words. The rotator cuff patient I evaluated who had 65 deg AROM did nothng on the eval day except TMR and had 100% AROM. No, it's not a miracle. I would echo Drexey's comments about your ability and/or desire to use wit and ridicule. Those who use sarcasm as dicredit people with no basis save for what they pull up on GOOGLE, etc usually do so to make up for their own insecurities. I'm sorry that you find it hard to believe that a PT was able touse a technique that relieved pain in a patient with cervical problems in 5 minutes. Would you be happier if it took 5 weeks? I'm sure that the patient would not. I thought that you might end your posting repectfully, but you chose to reserve this for proud. It seems your best source of material to degrade TMR are the testimonials placed on the website by the obviously-money hungry-quack who teaches the course. Forgive my sarcasm. I agree that they seem far fetched. It almost kept me from taking the course until I spoke with a PT who had attended before me. My patients and I are glad that I made another choice. The founder of TMR came up with these techniques because he was skeptical, inquisitive, intuitive, and wanted more for his patients. And research is beginning. Best of luck. Channel changed.
proud: I respect the importance you place upon research and professional accountability. But, let's face it, we DO things in physical therapy that are often art based on science. We all have modified versions of exercises, joint mobs, soft tissue techniques, because we had to based on our patient's presentation. We do so with a sound, scientific basis and professional education. I would not be so concerned with orthopaedic surgeons, who most, quite frankly think that we are "those guys that use US and exercise people". Best of luck.
Joined: March 23, 2006
But may I ask, why do you suppose that they think that we are "those guys that US and exercise people"?
In my estimation it is because we have far too many PT's who practice without regard for the literature. And guess what? There are still PT's that use US on almost all patients!
I just don't think saying "it works" is good enough anymore.
Keep it objective. Keep your assessment finding reliable( intra and inter). And keep your feet firmly planted on the EBM model. Like it or not, that is going to be the required direction for everyone involved in healthcare delivery.
My apologies if this is percieved as offensive. But I don't think I am asking too much.
Joined: November 15, 2003
There is a lot of sense in your posts. In fact everyone who has posted here since the start all state some inaccuracies and some quite accurate thoughts. I would not take notice of orthopaedic surgeons' opinions of PTs; they really do not know what we do above exercise routines that seem, after weeks of trying, to work. if they don't know, then they get worried, and send patients off to massage therapists because they might help and won't do harm. Notwithstanding the fact that I have seen three patients who were harmed by MTs - one with a dislocated CMJ. There are techniques, some validated by neuroscience, some not, which can work (ie, reduce pain, increase ROM and function) in 5 minutes or less. We, indeed, do many things in the profession that are not backed up by the minutiae of research studies. Putting someone with a sensitive nervous system on exercise bikes and treadmills is daft, but it is done. Mobilising someone's neck gets results, but nobody know why.
Moving someone's legs in order to "release" the shoulder makes perfect sense neurologically. But if someone teaches this, without a full explanation of reasons *why* this phenomenon occurs, amongst dozens of other movements, then they are simply fostering the notion of "I-don't-care-why-it-works-it-is-just-another-trick". That's not progressive or healthy for the profession.
Joined: March 23, 2006
Nari. Everything well stated. But I will say it is one thing to not know "why'. Quite another to not know why or even care that you are unable to back yourself up if ever required( that folks, is coming).
The days that a patient claims that ultrasound "cured" their back pain and we all applauded this "device" without proper scrutiny are gone( as well it should be). Again, just because someone claims to have gotten better, does not mean this is accurate. Further investigation generally finds the truth if you care to look.
I personally think that anything we do, we should do with the best available research in mind. And contrary to what some believe...there is tons:
1. Specific cervical mobilization and stabilization: Korthals etal; BMJ 2003 April 26;326(7395):911
Any suggestions for some good, updated neuroscience references? Specifically, in relation to pain, pain modulation, central pain. I read with great interest some of the comments that you and ginger posted regarding the gentleman with knee pain.
I don't think that anyone is disagreeing with you. What I fear is that if you adopt the philosophy of "if it isn't SPECIFICALLY backed up by research", you may be limiting yourself. I must clarify by saying that the treatments one chooses to employ should still be rooted in reputable science. I am not continuing an arguement for TMR. But rather, for the appreciation that we treat with our hands and with our minds. We assess and treat and modify manual techniques and exercise. If I only did straight plane exercises for lumbopelvic dysfunction because I could only find a SPECIFIC case study on supine abdominal bracing, I would miss the boat.
As nari previously stated, we operate on theories, not fact. We start with the science and continue with the practical application of these principles. Sometimes we come up with new techniques or variations on the tried and true. This is how we evolve.
You stated that if a patient tells us they are better, this is not necessarily accurate. Do you mean that they are not better? I would hope that you mean that we should figure out why they did get better. Although, it is much easier to chalk up everything that isn't heavily researched to placebo effect. Interesting that you should mention cognitive behavioral therapy in conjuction with PT....
Joined: May 11, 2004
LOL proud... and even if you try to light up the way for some, they're still in the dark.
There have been such leaps and bounds and awesome research done in the last 5 years. It is so fun to learn all the new things that we didn't know or maybe knew but didn't know why.
I've wondered how some therapists can just find peace screaming and shouting that something works and falling into a pattern of utilizing some technique with the majority of patients treated without any hardcore proof. This is especially so with all the various research indicating subgroups of patients that respond to "X."
I'm beginning to realize that our minds and our thoughts are in a way molded to a degree by what we read and the stuff out there that we let influence us. If we choose to associate ourselves with high caliber influences, we begin to have a comfort level for high caliber everything and of course don't mentally understand accepting anything less than optimal or better than optimal. If we choose to associate ourselves with lower caliber influences, we begin to have a comfort level for lower caliber everything and of course don't mentally understand pursuing something of a higher caliber. I think our exposure to external variables does have an impact on how we think.
For some reason, the new posters here at this site specifically with this topic have a high amount of comfort and maybe lower expectations to such a degree that testimonials of a particular technique is good enough to meet "optimal." It seemed to me that many of them had within the last 6 months or so taken the course. Well... one month of trying out some technique is never really enough to determine if outcomes have changed. All patients shouldn't be assessed all in one category. The new posters obviously are not just utilizing the new technique. The numbers mentioned by posters are low n values. And, hey, as with anything new... anything new is great for at least 6 months, right? What happens in 1-2 years after learning the technique? Is the technique tried and true or is it just what I'd term a "learning high" that happens combined with placebo?
Whenever it comes to continuing education, I not only read the crap that is sent to me... but I look for supporting literature, I look for recommended readings, I google the presenter's name to see if anything has been published in particular in peer reviewed journals, I may google the technique being advertised. If I don't find anything - a case study is fine by me... but if I find nothing, I don't spend one dollar on that course.
I am glad to share as much of the technique as I possibly can, however with three small children, a clinic, and teaching I do not have much time to monitor this site. For me, a phone call is the best way to get answers to your questions. I welcome phone calls and often times answer the phone. If you have to leave a message I usually can call you back the same day. Call me anytime up to 9pm Eastern Standard time.
My number is 919 749 2106. If the expense of the phone call is a problem I will gladly call you back.
I can share with you details about the research that has started and I love to share a couple assesment and exercises over the phone. You can try these on yourself and then on your patients.
After this I ask that you call me back in a couple days and tell me how it went. And then I can share a few more tidbits. You will only get a one dimensional view of TMR, but it will show you a lot about it and give you the opportunity to explore it on your own prior to making any decisions on taking a course.
Currently we have a DPT student from USC starting a research project the end of the summer and probably won't be in the literature until Dec 2007. Drexey has been tracking some case studies and a few others have expressed interest in further research. I would love to see those who have posted with a research focus to come forward and help out. I need additional help developing research studies and implementing them. We will be contacting area colleges over the next two years and if you have school contacts please let me know.
If you need more research prior to attending a coure, I understand, but TMR is not for you at this time. I know for some this is putting the cart before the horse, but I have chosen to allow TMR to evolve in this fashion: As therapists become more familiar with TMR there will be more research minded people wanting to do research. More and more research will happen as TMR's concepts become more familiar in our profession and I look forward to it. Research is an integral part of what we do as a profession.
On the website you will find under the second tab "Want to Know More" and then under "A Brief History" you will find a description of my first encounter with using a simple step up exercise on the left side to fix a right sided step up problem. This is a starting point, and I can provide other exercises.
To provide a quick exercise that shows results is to find someone (or yourself) that cannot do a ONE LEGGED sit to stand on one leg, but can on the other leg. Sit in a chair or on an object that is either high enough or low enough until you find a height that when the ONE LEGGED sit to stand is performed there is a large enough difference between the left and right side. Most of us can find a difference relatively easily. Once you have found the "good" side then exercise it by doing 2 sets of 12 ONE LEGGED sit to stands. Once completed on the good side re-test the bad side for just one rep and see if it is better than when you started. Continue the exercises until no more improvement is seen on the bad side.(this can make people very sore at times so please let them know) Remember you are simply re-testing 1 REP to see if the bad side has improved.
For example - find a person who is unable to do a one legged sit to stand from a chair height with lets say the right leg, but can do it relatively easy or easy on the left leg. Have them perform 2 sets of 12 one legged sit to stands on the left leg. Re-test the right one legged sit to stand just one time. Are they now able to do it?? If they showed improvement continue until they can perform the sit to stand on the bad side quickly and easily for one rep.
If you perform this on 10 people who are unable to sit to stand on one leg, but able to on the other leg, approximately 6 will immediately be able to do it on the bad side after the exercises. And a large degree of this ability will last.
The unfortunate thing is you will not have enough information to know what to do if they get sore, or if they have a bad knee and what to do when they get better. But, if you love to experiment this will lead you down the same road I started on.
The ONE LEGGED sit to stand also will increase shoulder ROM, and decrease back pain. So be sure to have them test and retest Shoulder range of motion before and after the one legged sit to stands. That will help connect what TMR is about when you experience this happen on yourself or a patient
Good luck and please call me if this doesn't make sense. It really can be an eye opening experience. If it works also call me and I will share more. Additionally, a TMR course can help facilitate your learning into the arena of treating the good side versus the bad side. For what it is worth, I hope that helps. I do not have a lot of time to continue to post and track the questions being asked - so please contact me and I'll help out in whatever way I can.
Joined: August 15, 2006
I am a new poster, (just learned about this site) not planned or coerced to be stating what I am about to say. In fact, I don't usually comment, but I am saddened at reading what my fellow PT's are communicating in this column and others. Do you remember our profession began "without evidence" of it's credibility. It's taken years to get to a place where we have evidence currently on techniques that have been used for years. I have been practicing for 25 years in various settings and presently have my own successfull practice for 5 years. I have lived the history, how many of you that sit in the luxury of what my generation and those that came before mine have set up for you are included in the negativity on this forum and others. I do not know yet how successful or not TMR will be in my practice, but I would never begin to pretend to be "authoritative" on the efficacy of a treatment or topic without experiencing with my own ears, eyes, intellect, what it is about and then making my own judgement based on my experience with it and other methods I have already successfully utilized. If this method doesn't resonate for you as something you would do in your practice, that's fine, we all use different methods that can lead to the same result. We have enough problems with our profession being recognized for it's value without tearing each other apart. I am very proud of our profession and how we can improve the quality of the lives that are entrusted to us to treat. Let's keep our integrity intact and dialougue honorably. Thanks for listening.
Joined: November 15, 2003
Where do I start??
Patrick Wall, Ronald Melzack, David Butler, Lorimer Moseley, Barrett Dorko, Michael Shacklock, VS Ramachandran....the studies and references that have been done on neurophysiology and pain are everywhere.
I think your best bet is to do a PubMed hunt for Ronald Melzack, Moseley as a start, and here is a ref for one of Melzack's papers:
Pain and the Neuromatrix
Journal of Dental Education, Vol 65, No.2.
Butler's book: The Sensitive Nervous System, available from [URL=http://www.noigroup.com.au]www.noigroup.com.au[/URL]
Shacklock's book: Clinical Neurodynamics, also available from the above source.
Both may be available on Amazon - not sure about that. Actually, just googling pain; neuromatrix or pain; physiology can turn up interesting stuff.
Re what ginger and I have been posting: Referred pain has been known for many years, starting with Maitland's work in the early 1980s. Same principle, and ginger does it differently from most, but from my point of view, it is the CNS which does the good work, not some idea of flexibility, 'good posture' and increased ROM resolving pain.
It is not the joint movement by itself, it is the brain's perception of movement which counts. If it is the wrong movement to correct a problem the pain can increase. It's the patient's brain's way of informing a PT that he/she stuffed it up.... usually no harm done, but probably best avoided.
The management of pain is becoming more popular as a method to increase function and ROM; rather than trying to focus on single joints or muscles, which can be time consuming, even if the results are good. It is the premise behind joint/muscle work that seems to be wrong: a focus on the visible musculoskeletal system without any understanding that it is ruled by the brain and CNS.
Well Junction - that is very well put. I particularly like your questioning of the underlying mechanism - in other words "why".
I AM a historical part of PT - practising for 23 years in many settings - and have discarded more PT-techniques/tools than remote controls. And am very sceptical of ANY new techniques/approaches, precisely because of my experiences and reading research.
Joined: May 11, 2004
I don't know Tom... you have very big claims with your protocol example. I'm definitely not buying it. Sounds like there are some issues with it regarding reliability... if I try that sit to stand and I am "normal" and I have what I guess I'd say are deficits or problems... but then a patient with a definite problem comes in and has problems... ummm, how do I know "normal" from not normal?
So, if you do it on 10 people and 6 will show improvement in the sit to stand ability. That would be a 60% response rate, right? Okay... so what happened to the person's complaint? And a 60% response rate is a far cry different than a 90-98% success rate I read somewhere.... Obviously not every person responds.
Tom, you are in the clinic every day, aren't you? You could easily do your own data collections. Use some standardized outcome measures, document pain intensity prior to initiating services, categorize patients in a way that other therapists would recognize.. use the same tools throughout the provision of services, crunch the numbers and see if a positive change greater than minimal clinical difference occurs. You don't have to depend on some grad student or resident to do the work.
Many new posters are "saddened" by critical questioning... heck, I'm disappointed that there isn't an overwhelming understanding of professional accountability and the importance of clinical thinking. It amazes me the easy acceptance of exercises/protocols just because someone says they work. Tom has a lot of work to do to bring whatever he does up to a quality level that is acceptable to those of us choosing to think before paying.
Joined: March 23, 2006
I stand by my last post. claim all you want. I have no problem with new techniques and style.
But read the coment on evidence in motion( 15 august 2006). It really points the way.
I feel that if someone thinks they found a new technique that is fine. Then bill it under that technique( not PT). Of course no third party payer would pay for it( and they should not until we can justify on some level the claims). But that is the way it must be.
Does this limit ourselves? Perhaps it does but it also maintains our professional integrity.
Joined: August 15, 2006
Hi SJ Bird,
My "saddened" response refers to posters such as "proud" stooping to personal attacks on Tom and other therapists that have attended his course without even knowing who we are and are backgrounds. It's not refering to accountability of our practice methods and evidence based requirements. I openly appreciate and dialouge with therapists all the time regarding evidence based and outcomes, no problem there. And, I agree with Sebastian that I too have thrown out many things over the years that didn't work, but that is the process. We have techniques in our profession that research supports and doesn't support. Just like the public jokes about what we should eat or drink because every new study either supports or rejects the same product it seems almost everyday. For me, the proof is in the pudding...if I show consistent measureable outcomes in my patients with a high degree of success in response to objective goals and patient satisfaction with regards to their complaint, then I use it. SBJ your response to Tom gives credibility to why it's hard to share with you the full scope of his theory. His 60% was for the first treatment. By 5 treatments it's at 90-95% based on measureable outcomes in his clinic such as you describe that he is to do. That's why he then goes on to discuss the research parameters that are being developed. There were many therapists, like myself, SBJ in the Chicago class that were "proof it to me." Now, this week in my practice I am trying it because I saw enough in others and myself that gives it enough credibility to try it. As far as Tom's passion and drive it's no different than others that I have attended over the years when they get started...Gary Grey and his closed chain techniques; Duane Saunders and his spinal techniques; Sandy Burkhart and his shoulder and spinal techniques; and many others too numerous to mention. Please don't tell me how they did or didn't have loads of research backing their stuff before starting, that's not what I am refering to here, I am refering to their marketing and passion for what they do. Appreciate at the very least that you have first time posters dialouging with you on this topic and probably others, now that we know this is here as a result of Tom's course. Look at the amount of people talking, isn't that a "good" thing. For those of you who want your message of credibility and accountability for the profession through evidence based research, look at how many new people your reaching in this forum as a result of Tom. So yes, agree, disagree, and I am happy to dialouge and listen to your responses. I have learned more "listening" over the years than talking and I am sure many of you out there agree. So thanks Tom for bringing a topic to the foreground that at the very least has people talking and thinking. Have a great day everyone!