CT EIM Orthopedic Residency

[TexasOrtho]

Or just not make a video...there was that option. Still trying to shake the image of Flynn doing Uhura's fan dance in that stupid video.

[Jon Newman]

The storyline was that if you move a certain way you might experience pain for which manipulation is the solution.

It's a common enough story--see here.

[Barrett Dorko]

John's allusion to Abbott and Costello says something about this many may not realize.

Abbott got 60% of their fee as a team because good straight men were hard to find. (Straight, as in straight chiro, get it?).

Now we see therapists running about in a frenetic manner, both clueless and inappropiately confident. Remind you of someone?

Still, EIM's sponsors and the few like them that have done a little research are certainly more popular than the small group here.

They're on first.

[tonyf315]

Originally Posted by TexasOrtho

Or just not make a video...there was that option. Still trying to shake the image of Flynn doing Uhura's fan dance in that stupid video.

LMAO! Hey TO you realized you just admitted to watching Star Trek V don't you??? Wait....oops guess I just did too!

[TexasOrtho]

I'm a closet Trekkie Tony. Actually just a fan of the genre in general. I'd be at Comic-Con every year if I didn't have a life.

With all due respect to Nichelle Nichols, I'd much rather see the latest version (Zoe Saldana) pull it off. Notice Tim Flynn did not make my top two.

[Jon Newman]

Are you sure you're a treckkie and not a trekker?

[Jason Silvernail]

Tony-
Sure no problem.

[Jon Newman]

A clip from the Star Trek episode The Devil In the Dark opened the current (as of this posting) To the Best of Our Knowledge segment--Eerie Silence.

[mrupe82]

My recent posting. I asked an individual to provide evidence that suggests soft tissue work creates plastic deformation resulting in better outcomes. This is in response to a suggestion that aggresive soft tissue work improves muscle length and decreases muscle guarding. I was then ask what my thoughts were. Please understand this is only a response and not meant to be exhaustive.



Thanks for the reply to my rhetorical question. You are correct that this continues a dogmatic debate. I think it's only dogmatic if you adhere to a school of thought, belief system or paid a lot of money at continuuing education for tools.

I have not and do not disagree with the idea that soft tissue handling has its place. I feel light manual therapy has its rightful place in patient care. I use this intervention myself and feel it definitely has a role. I, like you, have seen this as an effective intervention for range of motion and within session pain reduction. I've seen it work well for between sessions as well. Sometimes no other intervention is needed. I would argue we don't need 'evidence' to say why it improves an objective measure in the short term. Simple understanding what is not happening and what science says justifies this in my opinion.

The Graston and Astym crowd 'believe' that adhesions in superficial connective tissue cause pain, so we need to grind and push hard to break 'adhesions' or we need to grind harder to create inflammation in the tendon to force it to repair itself. I could go on and on about this belief system. Simply put, if you are required to purchase ‘tools’ to utilize a system, the alarm bell should begin ringing. A knowledge of tissue biomechanics and how it responds to force make this a difficult system to buy into (1).

Releasers like to 'release' tissues with forces that cannot create any change in the anatomical make-up of tissues. They ‘believe’ these connective tissues cause pain. They even have a congress every year made up of pseudoscience to perpetuate this myth.
http://www.fasciacongress.org/2012/

Trigger point folks like to push really hard with the belief that these cause pain when in fact they are probably a result of a primary issue or a form of peripheral sensitization/hyperalgesia

http://humanantigravitysuit.blogspot...er-points.html

http://www.pain-education.com/referred-pain.html?

Of course, if pushing harder doesn’t work, then we need to inject it (2,3).

How many other systems/mechanisms do we need to press on sore spots?

A more plausible and defensible idea is manual contact impacts skin. The science to support this is difficult (if not impossible) to refute. The most important aspect, in my opinion, is it does not make outlandish claims not supported by research or science. First, this approach accounts for and excepts an important component of manual therapy: placebo. It takes in neuro/pain science, physiology, and basic anatomy by accounting for the afferent input of the skin (nervous system) with the understanding that pain is an output. It doesn’t require us to continue ‘therapizing’ or try to mold humans like clay sculptures. In my opinion, the only tool needed to justify light manual contact or soft tissue therapy is Occam’s Razor.

Threlkheld. The effects of manual therapy on connective tissue. Physical Therapy, 1992,72, 893-902.

Ernberg et al. Efficacy of botulim toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double blind multi-center trial. Pain, 2011, 152, 1988-1996.

Finlayson et al. Botulim toxin injection for management of thoracic outlet syndrome: a double blind, randomized controlled trial. Pain, 2011, 152, 2023-2028.


Thoughts?

[Diane]

My only thought, is, yay, great thoughts Matthew. Hey, thanks for the shout for HAGS.

In my opinion, the only tool needed to justify light manual contact or soft tissue therapy is Occam’s Razor.

[John W]

Oooh, Matt, you introduced the "p" word into a discussion about manual therapy. Very bold and certain to seal your status as irretrievably dead.



I would like to briefly editorialize on the the term "believe" since it shows up here rather conspicuously in quotation marks with the implication that those who hold these beliefs are mistaken and perhaps even something less flattering.

I'd like to see all of us who use science to explain natural phenomena get away from this word altogether because it seems to be loaded with judgments about others' motives for expressing their understanding of how natural things- in this case human beings- work. An examination of the etymology of the word demonstrates that it has Germanic origins related to the emotional act of loving:

believe: O.E. belyfan "to believe," earlier geleafa (Mercian), gelefa (Northumbrian), gelyfan (W.Saxon) "believe," from P.Gmc. *ga-laubjan "hold dear, love" (cf. O.S. gilobian, Du. geloven, O.H.G. gilouben, Ger. glauben), from PIE base *leubh- "to like, desire" (see love). Spelling beleeve is common till 17c.; then altered perhaps by influence of relieve. To believe on instead of in was more common in 16c. but now is a peculiarity of theology; believe of also sometimes was used in 17c.

My point is that I think people can be mistaken in their understanding without being "in love" with what they currently think about how something is or works. They're just wrong, not necessarily emotionally betrothed to an idea. I know that this happens, but I think it's unfair to automatically assume that this is the case. Given the load of nonsense that PTs get- and pay good money for- during their professional education, it would be surprising if they weren't mistaken about many things related to human movement and its relationship to the lived pain experience. I'd argue, in fact, that all of us have been in that shroud of ignorance for varying portions of our careers, and it took quite a bit of effort to extricate ourselves from it.

Furthermore, the insinuation attached to "belief" tends to alienate people since it implies that the one who "believes" is superstitious. This, again, is certainly true of some, but not all people who have incomplete or erroneous ideas about a subject that is amenable to scientific investigation are whack-jobs who read their horoscopes every morning. Many, if not most, of them are earnest people trying to make a living in a very irrational and biomedically dominated health care delivery system.

Anyway, I've gone on much longer than I intended... but I'd like to see us simply "call a spade a spade" in this regard: when our colleagues have an idea that lacks a sound, scientifically defensible rationale, then let's just use words like "think/thought", "conceive/concept" or "understand/understanding".

This word "believe" is loaded and unhelpful as we try to move the profession across the chasm.

[amacs]

John

I think that is a worthy endeavour but I wonder if we can evade the use of the B word. It seems to me that ultimately it is beliefs that we deal in and with and an attempt to avoid usage could trivialise the argument. I do agree that it can so often seem pejorative but perhaps that tells us something of the wider culture in which we swim (with or against the flow)

regards
ANdy

[John W]

Andy,

I think we deal in thoughts, ideas and concepts and then, sometimes-particularly when we disagree with them- judge these as beliefs. All I'm suggesting is that when the judgment is made, we alienate some of our colleagues, and this hasn't been helpful to advancing the dialog.

Don't get me wrong- there are those among us whose ideas have all the hallmark signs of beliefs: persistent indefensibility, appeals to implausible and ethereal powers and energies, the attribution of affective-emotional characteristics to peripheral tissues (i.e. fascia), invocation of an "innate life force". I could go on...

This stuff is nutso, of course. But the vast majority of our colleagues don't "believe" in this stuff, they just lack adequate understanding of how pain works, so they rely on what they can use in the clinic (I almost said "what works in the clinic", but there are too many other reasons that PTs use different techniques in the clinic other than their apparent effectiveness.)

The rationale given for the Graston and ASTYM techniques that Matt refers to above is weakly supported in the literature and ignores the afferent system in the skin. To think otherwise is not necessarily because you "believe" in the rationale provided by the purveyors of these techniques, rather it may, and I would argue more likely does, reflect a gap in one's knowledge of the neurophysiology of the afferent system.

I think most therapists-if they had their druthers- would prefer to use the most effective, efficient and defensible techniques for the treatment of pain. But given the inadequacies of their education and the punitive remuneration for implementing a more streamlined approach to care, why should anyone wonder why these techniques remain popular?

[Jon Newman]

In Defense of Belief by Michael De Dora is a thoughtful reflection on the word and concept. I don't mind using the word and don't typically mean it in the manner you use it John. I know Barrett is not a fan of the word "belief" either, preferring "understanding" in it's place. I guess I just don't see the word as having the same baggage as something like "healing" or "release".

[John W]

That's funny that I and the purist secularists are on the same side of this debate- strange bed-fellows, indeed.

The things is, Jon, the manner in which I use the term is based on its actual historical meaning and etymology, which, like it or not, has very deep religious roots. The word was originally meant to describe the nature of a loving relationship expressed by loyal and committed action between individual beings. To the millions of faithful people who understand "belief" in this sense, it seems ill-fitting to describe it as an assent to intellectual knowledge.

Can someone have a committed relationship with an idea? While I acknowledge that people can get very emotionally attached to their ideas and hypotheses, this is something that science is in fact designed to guard against. All scientific knowledge, after all, is provisional.

So, out of respect for those who have this conceptualization of the term "belief" and the slippery tendency for the term to be used pejoratively to imply superstitious belief (which could be inferred as an unfair judgment and thus an attack), I prefer to just not use it in purely intellectual, scientific discussions.

I can't speak for Matt, of course, but I think his use of quotation marks in his comment to his residency classmates demonstrates the inherent ambiguity associated with using the term "belief" in this context.

I don't want to get too far afield of Matt's EIM residency thread, so perhaps we could start a new thread about how to better relate to our colleagues using less threatening, judgmental or charged language. This has been an ongoing struggle for me, and I have alienated more than one of our colleagues on the other side of the chasm by failing to communicate in a way that is not interpreted as an attack on their ideas- however, erroneous or misguided they might be.

[Diane]

Would you say John, that a word like "purport", or "maintain" might work better?

[Jon Newman]

Well some pure secularists and you are strange bedfellows.

I now understand how you use the word and understand why you describe the hallmarks of belief as you do. I use the term differently but not inaccurately.

[amacs]

I get what your trying to do John

Originally Posted by John W

Andy,

I think we deal in thoughts, ideas and concepts and then, sometimes-particularly when we disagree with them- judge these as beliefs. All I'm suggesting is that when the judgment is made, we alienate some of our colleagues, and this hasn't been helpful to advancing the dialog.

Don't get me wrong- there are those among us whose ideas have all the hallmark signs of beliefs: persistent indefensibility, appeals to implausible and ethereal powers and energies, the attribution of affective-emotional characteristics to peripheral tissues (i.e. fascia), invocation of an "innate life force". I could go on...

This stuff is nutso, of course. But the vast majority of our colleagues don't "believe" in this stuff, they just lack adequate understanding of how pain works, so they rely on what they can use in the clinic (I almost said "what works in the clinic", but there are too many other reasons that PTs use different techniques in the clinic other than their apparent effectiveness.)

The rationale given for the Graston and ASTYM techniques that Matt refers to above is weakly supported in the literature and ignores the afferent system in the skin. To think otherwise is not necessarily because you "believe" in the rationale provided by the purveyors of these techniques, rather it may, and I would argue more likely does, reflect a gap in one's knowledge of the neurophysiology of the afferent system.

I think most therapists-if they had their druthers- would prefer to use the most effective, efficient and defensible techniques for the treatment of pain. But given the inadequacies of their education and the punitive remuneration for implementing a more streamlined approach to care, why should anyone wonder why these techniques remain popular?

[John W]

Yes, Diane, I like those better. There are lots of ways to express one's level of acceptance of a hypothetical without resorting to talking about "beliefs" or "believing".

Jon, it’s your choice, of course, to use whatever definition of the term you like. If it's an issue of accuracy versus transmittability of the message, then at this point I'm leaning more towards the latter.

[Jon Newman]

I'm unaware of research pertaining to improved communication utilizing your preferred definition so I don't have much of an opinion on that aspect. Improved transmittability is certainly a worthy concern.

[TexasOrtho]

Originally Posted by John W

Yes, Diane, I like those better. There are lots of ways to express one's level of acceptance of a hypothetical without resorting to talking about "beliefs" or "believing".

Jon, it’s your choice, of course, to use whatever definition of the term you like. If it's an issue of accuracy versus transmittability of the message, then at this point I'm leaning more towards the latter.

John I really like where you are going with this. I often have students the week after a lecture misrepresenting what I've said. They tell others (particularly other professors) that I don't "believe" in stretching or the notion of core training. That always makes my hair stand up just a bit...now I think I know why.

Beliefs often connote a great deal that may or may not be there. Regardless of the peer-reviewed support for its use over other similar constructs, we need something better to communicate concepts without alienating or further entrenching those we are trying to reach.

[Bas Asselbergs]

I think this is very important John. Thanks for bringing this forward.

And I like Diane's suggestions as well.
As an addition to "purport" and "maintain", "suggest" or "state" may work as well. As in: "JFB suggests that memories are stored in fascia".

[Barrett Dorko]

According to some, belief has a biological purpose. Read about that here.

I do my best to keep it to this: After arriving at work, I believe that my car will be where I left it when I walk to the parking lot. I can cite no evidence toward that end, and belief is necessary if I’m to head in the proper direction. Without belief, I wouldn’t know where to go.

[Diane]

"Implies" is another word that might indicate a perpetuation of a perceptual fantasy or conceptual hallucination by someone unaware or completely aware that's what they are doing.

[amacs]

Originally Posted by Barrett Dorko

According to some, belief has a biological purpose. Read about that here.

I do my best to keep it to this: After arriving at work, I believe that my car will be where I left it when I walk to the parking lot. I can cite no evidence toward that end, and belief is necessary if I’m to head in the proper direction. Without belief, I wouldn’t know where to go.

Hi Barrett

I found that metaphor quite useful and my appropriate it sometime (with permission!)

regards

ANdy

[Barrett Dorko]

You're welcome to. I never met anyone who didn't get that.