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RE: Does reading my posts make you stupid?

 
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RE: Does reading my posts make you stupid? - July 30, 2008 11:46:11 AM   
Sebastian Asselbergs

 

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OK, SJ. If you make your point this way:

quote:

Diane supports skin stretching.  Unless she's changed her "theory," her intervention is focused on the skin in the periphery and focused on alleviating deformation of nerves.


you are wrong. The treatment is focused on alleviating pain through the nervous system. That it uses a peripheral input/facilitation is not exactly foreign to PT now is it? This is like saying that you treat only the ears of a patient when you are instructing or educating them.  How is talking to a patient going to improve their knee?!? LOL

And to suggest they do not address the central/chemical/other issues of pain is, well, flying in the face of the many SS threads about the research and studies about brain, pain and brain function. I for one, have learned a hell of a lot more by reading those threads, than trying to find things that WEREN'T done or looked at.  It is called a work in progress.

There is so much to do and study for and in PT at this time. And I completely agree with Rod that Cory's statement is bang-on :

quote:

For one, when we find ourselves in the frequent position of being in front of a patient who doesn't fit any current outcome study (ie. there is no outcome data to guide your treatment) all that is left is theory.  In these situation the effective EBM therapist who understands the relationship between outcome and theory will be better equipped to proceed.  Not only that they will be more within the confines of EBM as most supported theory will still be guiding their treatment.


It would be a disservice to ignore one aspect of EBM over another.

_____________________________

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Post #: 81
RE: Does reading my posts make you stupid? - July 30, 2008 12:07:37 PM   
SJBird55

 

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Cory, you are making a huge assumption that an effective understanding of theory PT truly exists.  Is there actually an accurate theory (that's been tested and determined accurate) out there for anything we do?  

From the patient perspective:  There was discussion over at MyPTSpace over this already... the only example I can think of that has definite outcomes and a faulty theory is McKenzie extension.... now changing to directional preference with no concrete theory.  Maybe knowing and telling patients the "real" theory will affect outcomes?  The inaccurate theory of the disc, although inaccurate, was a good story that the patient could visualize and made logical sense.  People like stories and with that particular story they could visualize what they thought was happening in their bodies each and every time they performed their exercises.  Will the "real" theory have as good of a story that the patient will connect with?  If the patient doesn't connect with the story or explanation of the theory, will effective outcomes still be achieved?  What if the effectiveness IS actually reduced?  Does the therapist go back to the inaccurate story so those that are candidates for McKenzie extension/directional preference achieve better outcomes?

I tend to think we first need to know what is real - are we effective, to what degree are we effective?  I'd tend to think that if we have something concrete from which to work, all other things just might fall into place.  Right now, PT professional life is a smorgasboard of options with no real responsibility or accountability and because there are a shortage of PTs, anything goes - employers just want a hot body doing a job.  In a way, I tend to think that hurts us professionally more than whether a PT knows a theory or not.

(in reply to TexasOrtho)
Post #: 82
RE: Does reading my posts make you stupid? - July 30, 2008 12:15:30 PM   
SJBird55

 

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Bas... not sure why Diane doesn't just chime in herself - she's around.  Yes, I'm sure she knows of all the variables I mentioned, but she ignores them and instead focuses on the narrow approach of skin stretching and nerve deformation but never comments on what else may be occurring with all the other variables I have directly, bluntly mentioned in the past.  Her theory has remained static in light of a whole slew of variables - she continues to mantain removal nerve deformation is what alleviates pain.  She and I have had our back and forth for years... she's pretty solid in continuing to maintain skin stretching decreases the nerve deformation.  All of the light touch manual therapies will have peripheral input/facilitation... other light touch manual therapies are ineffective... so, what gives?  Is hers different?  (she's still working on whatever.... but if hers is different the key is going to be in the qualitative aspect of it - the how is it different aspect)

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Post #: 83
RE: Does reading my posts make you stupid? - July 30, 2008 12:22:15 PM   
Jon Newman

 

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quote:

I tend to think we first need to know what is real - are we effective, to what degree are we effective? --Sj


It's an interesting question Sj.  Given your concern in the previous paragraph:

quote:

Will the "real" theory have as good of a story that the patient will connect with?  If the patient doesn't connect with the story or explanation of the theory, will effective outcomes still be achieved?  What if the effectiveness IS actually reduced?--Sj


What would be some possible research designs to determine "real" effectiveness?  Given your concern, there could be effective treatments out there that are rendered less so due to their accompanying story or treatments that aren't "really" effective but their stories make them so.  In other words, how do you control for story?  Is there an ethical way to accomplish this?

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Post #: 84
RE: Does reading my posts make you stupid? - July 30, 2008 3:23:09 PM   
SJBird55

 

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I'm not sure that effective treatments are withheld due to the story behind them.  Effective treatments are probably not utilized because clinicians probably don't like change... or the treatment doesn't fit into their previous training/education... or the clinician just doesn't believe the treatment can be effective because of the clinician's previous experience or preferred intervention.

We know that there are "ineffective" treatments showing benefit and effectiveness at least short term - look at placebo literature.

At some point in time, we will need more qualitative studies to help describe the scenario/interaction that assists in efficient and effective care.  I think it's a mixture of the story, some characteristics/qualities of the physical therapist (maybe physical therapist perceptions/beliefs/expectations - if anything Jensen found "patient centered" to be key between expert and average), patient perceptions and patient beliefs.  There might even be some value to the "relationship" that occurs between clinician and patient.  A qualitative study isn't unethical at all - somehow use video to assist in analyzing physical therapists - therapists that are effective and those that are not as effective.  What's the difference?

(in reply to Jon Newman)
Post #: 85
RE: Does reading my posts make you stupid? - July 30, 2008 3:45:05 PM   
Jon Newman

 

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Beyond controlling for story, "In what way is the story influencing outcomes?" is another intersting question.  My thoughts are that stories influence actions and that it is the actions that produce outcomes.  Stories do nothing until they influence an action.  Thus a story can be effective if it animates an action that produces the desired outcome.  However, it is possible for a story to animate a helpful action in some contexts and not others.   

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RE: Does reading my posts make you stupid? - July 30, 2008 3:59:47 PM   
Tom Reeves DPT ATC

 

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I agree with Jon on this last post.  The story is what gets the patient to buy in and do what you ask them to.

This is a very interesting thread to be a voyeur on.  You guys are real smart.

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Post #: 87
RE: Does reading my posts make you stupid? - July 30, 2008 4:28:13 PM   
Hpsg

 

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quote:

The treatment is focused on alleviating pain through the nervous system. That it uses a peripheral input/facilitation is not exactly foreign to PT now is it?


That is correct.

quote:

Unless she's changed her "theory," her intervention is focused on the skin in the periphery and focused on alleviating deformation of nerves.


The intervention is focused:
1. on the skin (and therefore on the somatosensory cortex)
2. on the cutaneous nerves (i.e., the sensory/autonomic nerves that innervate skin and travel directly through cutis/subcutis) therefore on the input into various laminae at the dorsal horn

quote:

she ignores them and instead focuses on the narrow approach of skin stretching and nerve deformation but never comments on what else may be occurring


See above.

The ultimate target is the pain itself as experienced by the patient and described to the therapist.

The treatment aim in the periphery is to reduce mechanical allodynia, to permit painfree or pain-reduced movement by the patient.

The plausible mechanism is downregulation at the dorsal horn (which is PNS/CNS transition zone) by descending modulation (from CNS) and by reduction of hypoxia of the intervened-upon cutaneous (sensory/autonomic motor) nerves (peripherally).

The downregulation at the synapses in the dorsal horn plausibly include the microglial population.
Microglia are macrophages of the nervous system.
They are attracted by neuronal stress (i.e., to a substance or substances neurons express on their surface membrane when they are stressed - see Watkins).
When microglia are active they excrete substances that upregulate nociception.
They are hypothesized to become de-activated when incoming neurons, which express certain molecular features when under stress, no longer do so. When the chemo-gradient microglia find attractive no longer exists, they deactivate.

This "stress" and the resultant exudation of molecular substances which microglia find attractive, is hypothesized to have been from hypoxia further out along the neuron's axon, in turn hypothesized to have been due to mechanical deformation.
Hopefully this will reduce confusion.

On another note, Diane cannot come here herself, by name, because she has been banned from this site. Twice. (Presumably for her well-known anti-chiropractic views.) I can answer specific questions on her behalf. That is all.

(in reply to Jon Newman)
Post #: 88
RE: Does reading my posts make you stupid? - July 30, 2008 4:48:59 PM   
Jon Newman

 

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Hi Tom.  I didn't actually say that.  Couldn't the person do what you ask them to simply because they're cooperative regardless of the story being conveyed by the therapist?

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Post #: 89
RE: Does reading my posts make you stupid? - July 30, 2008 5:06:54 PM   
SJBird55

 

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Hpsg... your "real name" states "Diane Jacobs."  I'd assume Hpsg = Diane Jacobs.  So, if that is true, Diane IS here... LOL  Whatever.  You were mean-spirited toward the chiropractors.  You can disagree all you want with chiropractic treatment, but you don't have to be mean spirited toward the individuals.  I'm pretty sure Hpsg IS Diane because Diane, you are on some microglial kick now with LOTS of hypothesization going on.  LOL  To think that microglia might be derived from mesoderm... that has to be a hard pill to swallow!  Did you about crap your pants when you read that there are 2 opposing viewpoints on where microglia are derived?  I got a chuckle out of it.

Anyways..

Jon, I do believe the story does have some sort of an impact - to actually influence an action though, the story has to connect with the person's emotions and the person has to visualize something occurring that the person wants to occur.  Whether it is less lives lost due to cancer - so the person financially supports the American Cancer Society.... or whether it is no leg pain (and following the old school of thought) so the person does the extension exercises to smash the disc back to where it belongs off the nerve.... or kids receiving chemo told the story of how the chemo helps power up their natural army.

If the story doesn't connect with the patient and the "story" is instead some anatomical/physiological explanation, the "truth" just might not be as effective because explanations don't always motivate individuals.

Tom, exactly... I completely agree that the story assists with the buy in.  I truly view my initial, first impression time as a sales person.  In that 30-45 minutes, I have to have the patient sold on me and whatever it is that I am suggesting.  I also have to have commitment to the process at a high enough level that active participantion occurs.   

< Message edited by SJBird55 -- July 30, 2008 5:16:38 PM >

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Post #: 90
RE: Does reading my posts make you stupid? - July 30, 2008 5:12:12 PM   
Jon Newman

 

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A true story, well told, should be just as effective as a make believe one.  See this similar thread (<--click) going at SomaSimple for more.  Ideally, a true story will be more effective than a make believe one when conditions are such that the accuracy of the story becomes important.  It is quite possible to run around with an inaccurate story without it affecting one's action simply because it's good enough for the current conditions.

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Post #: 91
RE: Does reading my posts make you stupid? - July 30, 2008 5:16:44 PM   
SJBird55

 

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In order to have an impact on action, the story, whether it is true or false, has to capture the person emotionally.

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RE: Does reading my posts make you stupid? - July 30, 2008 5:40:22 PM   
TexasOrtho


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If that is Diane..welcome!  That's a pretty funny catch SJ...you are quite the detective!

This thread has taken an interesting turn.  The physiology of what we do is fascinating to me, but how the patient experiences the physiology is REALLY interesting and relevant.  I think if we are going to look at how the patient experiences pain, we also have to see how the patient experiences the resultant dysfunction associated with the pain.  I think we all acknowledge that the perception of pain and dysfunction aren't always in sync with what we can objectively measure in the form of ROM, flexibility, or strength.  To this I try to really understand how the patient sees their problems.  One of my favorite questions to ask each patient is, "Tell me what you think is going on?".  It may sound like a silly question, but their answers are always revealing.

Having a sound theoretical understanding of what is truly happening allows me to redirect the patients perspective away from maladaptive behaviors.  To me this is like turning the patient into their own home therapist who is ready to take ownership of the situation.  It's often pretty empowering, but sometimes very tough for some patients who want us to "heal them" to handle.  In the end, I think the time/effort I spend orienting the patient to what is truly happening does influence the outcome. 

You may justifiably ask what I consider to be "sound theroretical understanding". Interestingly, I have noticed an even better response from my patients since I began integrating pain science and motor control theory into my previously anatomy/biomechanics dominant description.  Again, always learning.

As an aside...if that is Diane, I propose a moratorium on her ban from RE in the interest of continuing along this productive dialogue.  I hope I'm not stepping on toes from proposing that and I'm willing to take the heat for throwing that out there.        

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to SJBird55)
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RE: Does reading my posts make you stupid? - July 30, 2008 6:51:39 PM   
Bournephysio

 

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First it is important to remember that a theoretical framework does not exist separately from ?data?. Instead, ?data? is essential for developing a theoretical framework. Theories can?t be built out of nothing but are based on some sort evidence.

Can theories be used to determine if a treatment is effective? The short answer is no. What if you don?t have a rct to help? Then you do need to rely on a theoretical framework but you use that framework to bridge other evidence. If you have related rcts that you can tie in with a theoretical framework it is much more likely that your treatment will be successful. Pain science would not be very helpful on its own if there weren?t rcts validating its use in patient populations. This is not the ideal use of a theoretical framework but unfortunately we need to extrapolate from the evidence to treat many if not most of our patients.

Why can?t we use theories to determine if a treatment is effective? Biological systems are incredibly complex and non-linear. The chances that you weighted all the important variables correctly in developing your theory is quite low and the chances that you missed an important variable are high.

So what is the optimal use of a theory? An ideal theory explains your current data and suggests questions or makes predictions that can be tested.

I think that a good analogy is a web of chains. Each link in the chain is its own bit of evidence. Some links will be really strong and some weak. If you have enough well connected weak links you may be able to compensate for not having any strong links (like an rct ). Smoking and cancer may be an example of this. There aren?t any smoking rcts but there is an incredible amount of supporting evidence from basic science and epidemiology (nothing in physio without an rct comes close to this amount of evidence). A straight piece of chain is only as strong as its weakest link. This is often forgotten. Some of the SS people claim that their theories are really strong because they are based on pain science. If you look closely you see that their relatively strong pain science link is connected to links without any support. In Barrett?s case there needs to be a dysfunctional nerve somewhere, the brain needs to know how to relieve the dysfunction but for some reason won?t do it, the practitioner needs to be able to somehow induce the patient to perform this maneuver and finally this maneuver needs to lead to a somewhat permanent change in the nerve dysfunction. None of these links are strong. Diane?s theories on ectoderm are almost completely riddled with weak or nonexistent links. Diane?s skin stretching technique relies on either (a branch in the web) on the technique freeing nerves or having a neuromodulatory effect. The freeing nerves is quite suspect. There is evidence that other techniques work by a neuromodulatory effect (acupuncture, manipulation) but no direct evidence that Diane?s technique does. Another weakness of relying on a neuromodulatory effect is that it doesn?t differentiate the treatment from other techniques that (if they work at all) likely have a neuromodulatory effect but no direct evidence to support it (MFR,CST,etc).

We as physios have a habit of making these complex webs of theories and base our treatments off of it without making sure that the essential links can support the weight. Just look at some of the rather complex manual therapy systems out there.

Ideally, our theories suggest new links, we test the new links and move on. In practice we can?t test all the links but we need to know what links are strong and what links our weak and be very hesitant on performing a treatment that relies on a weak link.

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RE: Does reading my posts make you stupid? - July 30, 2008 7:24:01 PM   
Hpsg

 

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quote:

Diane?s skin stretching technique relies on either (a branch in the web) on the technique freeing nerves or having a neuromodulatory effect. The freeing nerves is quite suspect.


There has never been, to my knowledge, any implication that "nerves" can be "freed."
Potential neuromodulatory effects are definitely included. With any form of contact they are unavoidable in any case.

Nerves are well fastened to surrounding tissue, therefore any idea they can be "freed" is spurious.
Possibly you misinterpreted "freed" out of "feed."
Nerves carry their own vasa nervorum, vascular tubing within the various "neuriums," which is stimulated through movement in any given direction to open one side (of the neuron bundle) and (temporarily) close down on the other. Movement in all directions is hypothesized as necessary for "feeding" to occur on all sides of the nerve and be able get to every neuron in the bundle.
Mechanical allodynia can hamper this ordinary neural self-feeding mechanism, because full range of movement is usually inhibited by the resulting pain experience, perpetuating the problem.

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RE: Does reading my posts make you stupid? - July 30, 2008 7:48:07 PM   
SJBird55

 

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Bourne, I got your message.  It makes complete sense.  It doesn't surprise me that Diane missed the boat and would rather correct you for a minute detail issue versus reflecting on the big picure and your actual message.  Apparently, if it ain't moving, it needs freeing... if feeding is what happens when it is freed, so be it. 

Geesh... Diane, have you ever thought of reading and reflecting versus correcting or defending statements?

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RE: Does reading my posts make you stupid? - July 30, 2008 8:44:34 PM   
Hpsg

 

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quote:

Geesh... Diane, have you ever thought of reading and reflecting versus correcting or defending statements?

I'll pass it on. Diane rarely does anything but read and reflect.
But I'll pass it on anyway.
Meanwhile, it's good advice for self-regulation of avian species.

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RE: Does reading my posts make you stupid? - July 30, 2008 11:46:03 PM   
TexasOrtho


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Hspg...Please let Diane know you are doing a good job of speaking on her behalf.   Keep up the good work.  

Excellent post Bourne.

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Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

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Post #: 98
RE: Does reading my posts make you stupid? - July 31, 2008 4:23:52 AM   
bonez

 

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quote:

ORIGINAL: Bournephysio

  Diane?s skin stretching technique relies on either (a branch in the web) on the technique freeing nerves or having a neuromodulatory effect. The freeing nerves is quite suspect. There is evidence that other techniques work by a neuromodulatory effect (acupuncture, manipulation) but no direct evidence that Diane?s technique does. Another weakness of relying on a neuromodulatory effect is that it doesn?t differentiate the treatment from other techniques that (if they work at all) likely have a neuromodulatory effect but no direct evidence to support it (MFR,CST,etc).

.


While you are right that some techinques have these effects could we not agree that the effect in question represents modulation by some form of afferent summation? If we agree on that as a general reason for the effect then many other sensory stimulations are likely to cause similar modulation.(insert skin stretch here) These are likely to be short term in nature but allow some functional restoration to occur on it's own naturally.
I personally suspect that this is reason that the many people with straightforward problems may respond in spite of the kind of therapy, the real trick is to increase the outcomes to help the non straightforward conditions by getting the patient to buy in and follow the therapist over the more difficult terrain.

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RE: Does reading my posts make you stupid? - July 31, 2008 3:30:36 PM   
Tom Reeves DPT ATC

 

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quote:

ORIGINAL: Jon Newman

Hi Tom.  I didn't actually say that.  Couldn't the person do what you ask them to simply because they're cooperative regardless of the story being conveyed by the therapist?


Sure they could.  Problem is, as you know, the things that we ask them to do doesn't always seem logical to the patient without some explanation.  For example, someone with crappy posture, big breasts, poor ergonomic set up at her computer has headaches, shoulder impingement, TOS, and TMD.  You tell her to sit up straight.  She thinks you are cracked and how can that possibly help all of her symptoms.  You have to have an explanation. 

Some people just do what they are told, i know my kids say "why"  So do most of my patients.

(in reply to Jon Newman)
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