More on Cognitive Hemi-Neglect

[Diane]

I decided to start a thread here instead of under general discussion, because it involves Evidence in Motion, which prides itself on being THE most evidence based interactive PT site on the planet just now, and the attempt of PT marketers to promote ATM2.

Currently under discussion is something called an ATM2 device, huge and looming, to which standing patients get strapped in various ways that have been ascertained to work well, whereby some of their parts (i.e., pelvis) are fixed while other parts (i.e., upper body) are left moveable. You can check out a little video on this, while photos of various clinicians who seem to want to be in on all the goodies that may rain down from its sale, by lending their combined weight to its marketing, are shown in an adjacent window. Curiously, Weiselfish, another mesodermalist of a different sort, is also there. Nice touch. The bone mesodermalists have usually been allergic to the fascia mesodermalists, even though neither camp speaks ectodermese, so you'd think they'd be allies.. so maybe this is showing that they finally are. Becoming allies I mean.

The discussion was begun by Jason, who responded to the manner in which the device was being pushed onto... I mean, introduced to the rehab world. The lack of actual evidence in its favor, and lack of underlying concept, was noted; the various flimsy, promotive, and transparent marketing strategies were analyzed.

Here is a quote from an Aussie researcher who is working on this, bolds mine:

The ATM2 has taken a bit of a battering in this discussion. While I am not prepared to comment on the marketing of the ATM2 that started this discussion, I feel compelled as a physiotherapist (PT) and academic to provide some input into this discussion. Wearing many ‘hats’ – a clinician, an academic, a sceptic of ‘new’ devices, but also possessing an open mind that says to me – just because I do not know or understand how something works doesn’t mean that it doesn’t work. While I am firmly entrenched in the world of evidence-based practice with clinical reasoning forming the basis of teaching and clinical practice, I must also be forward thinking about ‘how can I contribute to the future of the clinical professions’ by my clinical practice, knowledge and preparedness for participation in research. My introduction to the ATM2 was not in clinical practice, but a series of single-case research designs that followed the clinical guidelines for use of the unit in cooperation with a colleague (Max Zusman) who has an interest in the neurophysiology of pain. Yes, I agree that a series of single-case research designs are not an RCT and do not provide robust cause and effect relationships, nor explore the theoretical concepts behind clinical practice, but the results were encouraging from a clinical perspective to encourage more research. That led to a pilot study in a group of young active sports people with chronic movement related back pain in which we investigated changes in muscle activation patterns during a controlled perturbation to the trunk before, immediately after, and then following a time-course of interventions (along with a control group). This is being prepared for submission to a peer-reviewed journal. Our study cannot answer all the questions that this discussion has posed but to have seen abdominal/trunk muscle activation patterns change closer to, or before, the onset of the perturbation, has provided support for the use of the ATM2 in changing muscle activations with respect to anticipatory postural adjustments. Concurrently, the subjects all self-reported decreased pain into their previously painful movement pattern and on video (no - not 3D kinematics, unfortunately) appeared to have an increased ROM and maintained that on follow-up. This of course poses another set of questions related to issues that may be captured within areas of ‘fear avoidance beliefs’ inherent within the biopsychosocial model of low back pain. So while each of us can propose concepts as to how the use of the ATM2 may or may not work, which may all vary based on our own ‘belief’ and knowledge systems, the use in a clinical and research setting encourages me to find out more.

I am also conscious, perhaps a little embarrassed but also encouraged that the winners of the 2005 Nobel Prize for Medicine were not able to pursue their belief in their research here in Australia back in the 1980’s; found it extremely difficult to get their ‘discovery’ published; and their claim was almost considered heresy in the 1980’s but set the example by going ahead and providing the evidence. I am prepared to accept the clinical and research results I see, while investigating ways in which to provide the evidence for the concept of its use that may encompass mechanical, neurophysiological, motor control and neurobehavioural domains of pain. From concepts, we can develop theories from which hypotheses can drive research.

Prof. Peter Hamer,
DipPT, BPE(Hons), MEd, PhD, FASMF
The University of Notre Dame Australia

Hmmnn. Correct me if I'm wrong, but does not the good doctor contradict himself in his own post? I mean, the last sentence sounds good, but he just wrote a whole post rationalizing why he didn't do exactly that. Shouldn't the concepts come before the research? Is this not a backwards way to do science? Is it just me?

My pet theory about this, about how it "works", based on everything I know, is that the belts are providing dermoneuromodulation while the patient is encouraged to move at the same time. They've got the skin pulled one way in the upper pelvis and the other way in the lower pelvis, pulling the long cutaneous nerves, iliohypogastric and lateral cutaneous, etc, into different directions relative to one another in addition to immobilizing the pelvis. But note that it isn't just immobilizing the mesoderm that is important; it's the direction in which the belts are pulled or ratcheted, relative to each other.

What are they pulling on? Skin obviously, through clothing.. What happens when they get the patient to bend forward? Neurodynamics of cutaneous nerves. What happens to pain if you move nerves? They get fed and watered, less hypoxic, and less nocioceptive. What happens when nerves are sending less nocioception up? The brain's level of perceived threat decreases and motor output increases. Hello, do we need some huge machine to do this? Hm, I doubt it. I can do that with my hands, move skin relative to mesoderm, with or without the patient moving, and they'll move better after.

The ONLY possible use I can imagine for a contraption like this is to do more Balnibarian research with it. I'm so glad Cory is building his Unified Theory thread. It's like scaffolding for building a new cognitive reality for PT, not the cognitive hemi-neglect we currently ..um, enjoy.

[Jon Newman]

Hi Diane,

I found this take on "the scientific method" informative as it pertains to how scientists come to know about the world around them.

The myth of the magical scientific method

I do think the problem the ATM guys are faced with is one of cash flow. They need people to buy their product before they can fund the research to demonstrate it's worth buying or at least to cover the cost of their investment. Very frustrating I imagine--for both producer and consumer. Consumers are understandably hesitant to fund research that may produce nada and yet want it to be done so they can justify for others what it is they're doing. The "look, I have a study" security is very nice to have but not so nice that people want to send their money that way.

None of this is a new problem and I don't expect it to go away--ever. Although as competitive philanthropy gets trendy, may it will go away.

[nari]

I agree, the good prof is rather contradicting himself.

The fact is, that hardly anyone with a sound but radical hypothesis can continue to work on it in Oz. It is a rather shameful aspect of science in our country; we produce some great thinkers that often have to go off to the Northern Hemisphere to think further.

This Balnibarian machine reminds me of traction - how does traction work ? Via the skin.....it can be nothing else. Traction units are probably cheaper, too.

Nari

[Diane]

Hi Jon,
Your post reminded me of this Alan Wallace video, which describes a lack of contemplation in science as a kind of cognitive hemi-neglect also.

If people just sat down and figured out what they are doing, and what's going on in the organism meanwhile, none of this stuff would probably need to be manufactured in the first place.

[Jon Newman]

Without having watched your video (I'll give it a shot sometime), I have a feeling the following video probably sums it up for many people (including the emotional content).

Pet petter

[Diane]

Jon, that is hilarious and makes my point better than I ever could. Thanks.

[Jon Newman]

I actually felt bad for the guy but it's not likely that he will spend a lot of his time and money on developing the product. Something that will likely only be appreciated in hindsight. I'm not sure how that relates to the ATM guys specifically. They certainly have their work cut out for them as well as having some decisions to make.

[Diane]

Well, he didn't appear that he had let the cool reception daunt him. He's after turning his idea into $, that much was clear..

[Diane]

A bit of a twist:
Here is a thread from a chiro forum, by a chiro who is trying to move away from mesoderm. He appears to have stirred himself awake from the mesodermal coma and is really trying to distance himself from the bone gang, and into some neuro logic. If you check out his site you can see he's really trying.

I found it interesting that the righteous "anti-quack" chiros, the mesodermal fundamentalists, jumped on him immediately. To them anything sensory motor is suspect. Anything motor is permissible (like muscular innervation) but there is this total block on any ingoing, unless it's ingoing from mesoderm, like joint receptors or GTOs.. They'll have nothing to do with ectoderm that is skin/brain, just like the PT mesodermalists. (It makes me wonder if it's to do with setting up of treatment boundaries? But so unconsciously that they end up with cognitive hemineglect.)

I think this is an interesting turn of events. This guy was one of the most vociferous defenders of chiropratic on that board, and now he claims to be letting go of it, reinventing himself and his conceptual framework. Good for him...

[Randy Dixon]

Hmmnn. Correct me if I'm wrong, but does not the good doctor contradict himself in his own post? I mean, the last sentence sounds good, but he just wrote a whole post rationalizing why he didn't do exactly that. Shouldn't the concepts come before the research? Is this not a backwards way to do science? Is it just me?-Diane

I would have answered "it's just you" but apparently, on this forum, it is more like "it is just me". Before we attempt to discover WHY something works we have to discover IF something works. You make the claim that, like virtually every other PT intervention, that ATM2 works because of skin contact, yet we have no proof and no real evidence that your theory is valid. Sure, it could be, but until you have evidence that your skin contact theory is actually works, trying to figure out the why it does so is putting the cart before the horse. I know this is the reverse of how you see it.

The doctor didn't contradict himself at all, once we know that something does X, we then figure out why it does X, then we figure out how we can apply that to research and practice. Then we began the process over again. What you are doing is starting in the middle step, based on the work of others, and ending it at the application step. You believe you know why what you are doing works, but you actually don't know why and you don't know if, not with any degree of scientific certainty, only with your own observation. This is a level of evidence you would never accept in someone else's argument.

[Diane]

Randy,
Hello? What about skin? It's the "confounding factor" IMO, that shoots a bunch of holes into the hull of mesodermal theorizing ... everyone leaves it out except ectodermal theorists. C'mon, you can't deny it's there, can you? Not forever.. Endlessly comparing one outcome to another ≠ development of a deep model.

Which is why I think we need to start over with a better theory.

The way it works (from what I've read) is you start with a good theory (i.e., one that has not arbitrarily excluded ectoderm), and work in from there. You then set up hypotheses and try to knock them out by testing. If all the hyotheses stand the test the theory is proven sound. You can set up null hypotheses and try to knock those out too. If they fall down, the theory stands.

What good is testing "applications" if they are based on a theory that can't hold water, and doesn't concur with the reality that other sciences agree on? Like biology, evodevo?

[Randy Dixon]

I think you make a good point about any technique that is applied to tissue under the skin must go through the skin. This may be, but is not necessarily, important. I think it is important, but it does not mean that it is the only thing that is important, so discounting everything else isn't useful or accurate. In fact, this demonstrates exactly what I suggested, if you demonstrate the effects of skin manipulation, in a scientifically useable fashion, then you can begin to differentiate what is ecto- and what is meso-. Until you demonstrate that, then you are just arguing your untested theory against others.

We need to test applications because they are what drives theory, theories don't just pop up, they are the result of observation then testing then application and repeat. This is how the basic science that support your theory evolved. I believe I understand your point, and if we look at devices like the ATM2 as the culmination of research then I agree with it, but that is not how I see it. I'm not discounting what you do, only saying that your dismissal and apparent disdain for other approaches isn't warranted.

[nari]

Randy,

Just a point or two - say you have a patient with pain around the neck and shoulders, and you decide (this is hypothetical, you may NOT decide to do this) to mobilise the cervical spine and do some soft tissue work of some kind.
When these methods result in improved function and reduced pain, can you say why? If so, you might consider the fact that the ectoderm is very much involved and may have a role in resolution or part-resolution of pain; and if not, what process initiated the improvement? Is that actually known, or surmised?
Just a thought...

Nari

[Diane]

Randy, I have as the years have gone by eliminated treating mesoderm and treat only skin. So I think I've effectively rulled out mesoderm as having anything to do with anything, since my patients seem to not only get better at about the same rate as anyone else's but seek this out. Treating skin seems to do it all; increases range of joints, lengthens/softens muscles, decreases pain. Why would I bother treating mesoderm when this works fine? I am confident I've been "scientific" in this evolution, i.e., I have used Occam's razor to eliminate the mesodermal constructs from my life as a therapist. Perhaps I've let the "troop" down by not producing a study of some kind, however anyone who wants to test the process can easily do so, same way I did and draw similar conclusions. After all, the skin is right there, begging for novel input.

And I don't think I agree with your idea that the testing precedes the theory. I think the other way round is more sensible. The theory should evolve as new info becomes available. Mesodermal theories have not. They deserve to be tossed.

[Vanscott]

Not sure of the correct thread to post this in ... and not sure if it's worthy of its own thread, so:

I've been reading alot on here about Neurodynamics and also came across some info on the ATM2 device (active therapeutic movements). I noticed that Diane mentioned in an old post that a probable mechanism of action was the different types of skin stretches incurred when one tightens the straps on the device at different areas. A type of mechanically applied DNM.

Could another possible mechanism be that the unit provides a non weight bearing posture and subsequent slackening of the nerve roots thus allowing for painfree neurodynamic movements? (not sure what their specifically called ... 'nerve glides'?)

Scott

[Diane]

Vanscott, do you have a link to the thread of which you speak?

[Vanscott]

Not sure how to post a link ... but it's this thread from way back in 06:

SomaSimple Discussion Lists > WWW The Wild Wise World > The Wind Rose More on Cognitive Hemi-Neglect

[Diane]

OK, thanks Vanscott.
Here is a link to the thread in question. You could have posted directly to that thread, and I might just move these posts there to keep this thrad on track.

To link to something, highlight and copy the url beforehand, then highlight the text you want to link to inside your post. Then click on the little icon of the earth, with a chain link across it. A new window will come down - paste your url in there, and hit "OK". Then you end up with a tidy hyperlink.

Could another possible mechanism be that the unit provides a non weight bearing posture and subsequent slackening of the nerve roots thus allowing for painfree neurodynamic movements?

About the big ironing board to which the patient is attached with straps, in the video it looks to me that they are weightbearing at all times, so I don't really understand your question.

[Vanscott]

hehehe ... ironing board

I guess, to me, it looks like the the pelvic straps could be cinched up tight enough to essentially hold the weight of the body. If one side is cinched up more than the other, it stands to reason that a small tilt would be induced in the lumbopelvic region. I was reading about slackening of nerve roots on the NDS website and, for some reason, this device sprang to mind as I remembered coming across it months ago. I began to wonder if this could also be a plausible explanation for the claimed effects of the ATM.

They claim neuroplasticity through pain free movements. Could neurodynamics with relaxed nerve roots also be an explanation?

[Diane]

They also claim that they are affecting "part of the brain called the CNS."
Um, the brain IS the CNS.
I don't know if they know anything about what they are talking about.

[Vanscott]

Originally Posted by Diane

They also claim that they are affecting "part of the brain called the CNS."
Um, the brain IS the CNS.
I don't know if they know anything about what they are talking about.

Touche