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Old 31-08-2010, 06:55 PM   #1
Chris Peterson
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Hi everyone,
My name is Chris Peterson, I have been a PT for 17 years. I am looking for ways to integrate what I understand of pain sciences without falling into complete nihilism, where anything is okay. I have a background and certification in manual therapy from the International Academy of Orthopedic Medicine and went back to the University of Kansas a few years back to update my knowledge and get a DPT.
I think I had a better post earlier but I lost it when I was trying to preview. So I'll work on some of those thoughts again later.
My influences have been International Academy of Orthopedic Medicine, Shirley Sahrmann's Movement System Impairments, Kevin Wilk, David Butler, Michael Shacklock, Explain Pain, among others.
Thanks
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Old 31-08-2010, 07:04 PM   #2
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Hi Chris,
Welcome!
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Old 31-08-2010, 07:40 PM   #3
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Hi Chris,

I went to undergrad. in Kansas City at Rockhurst. Isn't KU's PT school in KC?

I miss that town.

Welcome to SS. You have an interesting mix of influences that I'm very well-acquainted with. I look forward to hearing more of your thoughts.
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Old 31-08-2010, 08:21 PM   #4
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Thanks for the welcome,
I went to Rockhurst and graduated in 1993 with a BS in PT. KU is also in Kansas City, but on the Kansas side.
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Old 31-08-2010, 09:04 PM   #5
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Quote:
Originally Posted by chri5 View Post
I think I had a better post earlier but I lost it when I was trying to preview. So I'll work on some of those thoughts again later.
Welcome Chris. I look forward to you expanding on your thoughts.
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Old 31-08-2010, 11:59 PM   #6
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One of my lost threads involves controversial therapies. I am impressed with the open discussion about different manual and non-manual therapies for chronic pain. When I was completing my DPT at KU, I took a class on evidence based medicine from Winnie Dunn, OT. One of the tools from the class was criteria for deciding if a treatment technique was controversial and either new or suspect. The criteria were from articles about childhood development therapy and so we were able to talk about the criteria before getting into some of our own beloved treatment modalities. The articles are not available on pubmed but the citations are:
McWilliam RA. Controversial Practices: The need for a Reacculturation of Early Intervention Fields. Topics in Early Childhood Special Education; Fall 1999;19(3):177-188
Nickel RE. Controversial Therapies for Young Children with Developmental Disabilities. Inf Young Children 1996; 8(4):29-40.
To summarize, the two authors propose a list of factors which help identify controversial therapies. This can be used to help educate parents (or in our case patients) and to avoid falling into traps. I use the criteria to help avoid blind alleys and thought they might be useful for SomaSimple.
McWilliams (watch for more than one criteria)
1. Claims of Cures for disability which theoretically cannot be cured
2. Practitioner Specialization (ouch!): practice requires specialists to undergo even more specialized training
3. Questionable Research: experimental and qualitative
4. Intensity: more is better
5. Legal Action: often debated in court
Nickel
1. Overly simplified scientific theories
2. Therapies purported to be effective for a variety of conditions
3. Treatment claims that most respond dramatically to treatment
4. Treatments only supported by case series or anecdotal data
5. Treatments with little to no attention to specific objectives or goals
6. Therapies with little or no side effects and therefore no reason for controlled studies.
I have found these criteria very helpful litmus tests and hope they can be of some help with discussions on this board. That being said I have myself gone down many blind alleys and appreciate that often a sham therapy done with very good intent and belief is effective. Sometimes I feel less effective for knowing more.

Thanks,
Now with that being said I can use my overly specialized initials.
Chris Peterson, PT, DPT, OCS, COMT
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Old 01-09-2010, 01:02 AM   #7
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Chris,

Welcome.

I'm wondering what you think of the "science based" approach and how you've come to view what Sahrmann teaches.
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Old 01-09-2010, 04:12 AM   #8
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Hi Barrett,Those are two really big questions. As to the science based approach, I feel like I don't have much choice, if evidence starts to show that a treatment is effective or ineffective; I have to modify my approach. I can say that this is easier said than done as many of my actions become routine, I need to work to maintain an action-reflection state of mind. That is one thing I have appreciated from seeing this site over the last two weeks. The difficult part tends to be undermining my hidden assumptions but also not throwing out the baby with the bathwater. Although the science based approach is much harder I have a need for integrity to know that I am doing the best possible.As far as what I think of Shirley Sahrmann's work, I monitor my patient outcomes with FOTO, based on the SF-12. The use of Sahrmann's paradigm has increased my patients perception of their function more than any other single model. Using Nickel's and McWilliams litmus test, I feel like Sahrmann's work is not controversial, although I have noted strands in conversations here which I need to explore. I have gone to your Simple Contact course and I believe I remember your (Barrett's) bias against perfect posture. I can't say I disagree. After attending Shirley Sahrmann's courses, I would say that she seems to have shifted emphasis off of posture and shortened muscles as well. They are still part of the screen but the emphasis seems to be on finding movements and positions which provoke symptoms and then teaching mechanisms to perform the movement without symptoms, often submaximal, short of endrange, and few repetitions often during the day with changes of provoking positions. As often as possible, she teaches to make the exercise look like what they do during the day, so that they can incorporate into their routine. This fits rather neatly into locus of control, neural mobilization, specificity of training, and painfree movement advocated by my current understanding of current pain research. I am sure I have made a mess of that but I will think more on it.
Always hard to know what is justification for what I have always done and what is legitimate.
Thanks,
Chris

Last edited by Chris Peterson; 01-09-2010 at 01:34 PM. Reason: Not showing paragraphs - I don't know why
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Old 01-09-2010, 11:48 AM   #9
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Chris,

Try some paragraphs, please.

Yes, Sahrmann became Feldenkrais. Did she ever mention him?

How many years ago did you take my course? Under whose sponsorship?
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Old 01-09-2010, 01:39 PM   #10
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I have no idea why there are no paragraphs. In the edit box, they are there. Anyway, I seem to be losing the battles with my text editor but will win this war.
Barrett,
I went to your seminar about 2004 or 2005 under Cross Country Seminars, if I remember correctly. It helped me step more toward neuroplasticity but I needed more structure than the technique of Simple Contact. I tried it but may have had a nocebo effect. That being said, I have kept the idea of the wisdom of the body and allowing people to move wherever feels good. It is funny that they need permission sometimes.
I hope this shows paragraphs.
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Old 01-09-2010, 07:33 PM   #11
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From McWilliams
Quote:
3. Questionable Research: experimental and qualitative
This is rather vague, don't you think, Chris? Research is a funny thing- it can look really good in terms of the numerics, but if doesn't relate to a sound theory, or if it is has "tooth fairy science" qualities, then it's actually pretty worthless, if not deceiving.

Quote:
2. Practitioner Specialization (ouch!): practice requires specialists to undergo even more specialized training
Most of the gurus have a process of specialization with their own credential at the end of it. For others, like Sahrmann, the "specialization" is implied once you've taken all the levels of her courses. You then become a Sahrmann acolyte and continue to receive course updates from her listserv (I know, I had to unsubscribe a few years back).

Quote:
4. Intensity: more is better
I'm not sure how McWilliams fleshes this out, but certainly with the Sahrmann approach, in a sense "more" is better, if you mean more precise (within the instaneous axis of rotation) or more biomechanically sound. In fact, my frustration and my patients' frustration with the Sarhmann approach was that it so damn hard to do right.

From Nickel:

Quote:
1. Overly simplified scientific theories
What about overly complicated, non-parsimonious theories, like the dominant pathokinesiological (or is it kinesiopathological) theory espoused by Sarhmann? In my experience, overly complicated explanations tend to come from over-simplification of the phenomenon that's trying to be described, e.g. quantum physics to describe myofascial restrictions. Both the premise and conclusion are unnecessarily complex.

Quote:
6. Therapies with little or no side effects and therefore no reason for controlled studies.
I don't know of any real serious side-effects with any PT interventions with the exception of high-velocity thrust techniques. Certainly Sahrmann's approach, where manual contact is only used to cue "correct" movement by alleviation of symptoms is at least not going to make anyone worse. (Actually, it may well do so, but not due to "side effects" as their typically used in a medical context).

These criteria seem to come out of a more traditional biomedical/biomolecular model where the therapies are primarily pharmaceutical. Since the biomedical approach doesn't work in physical therapy for most of our patients, then it doesn't really fit within this model, in my opinion.

So, I was able to identify two criteria within each of the lists proposed by McWilliams and Nickel that may jeopardize Dr. Sarhmann's claims as an effective treatment approach, despite the fact that these criteria may not even be relevant to physical therapist practice in the first place.

I'm seeing yet another ravine in the chasm.
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Old 02-09-2010, 01:23 PM   #12
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Hi John,
Thanks for your thoughts, as I read through your comments it helps to expose some of the mental models that I use as subconscious routines which need fleshed out. That is really the whole reason, I took the leap to post. I have never posted to a message board before, which is probably painfully obvious.
Quote:These criteria seem to come out of a more traditional biomedical/biomolecular model where the therapies are primarily pharmaceutical. Since the biomedical approach doesn't work in physical therapy for most of our patients, then it doesn't really fit within this model, in my opinion.
The criteria come out of childhood special education needs. They are simply two authors opinions, but I they have been helpful to me in physical therapy. I have found them useful myself. My real intention of posting them was to get this kind of feedback. I thought you used them quite effectively to talk about Sarhrmann's approach and find issues which need fleshed out.
I don't know that I am qualified to argue intelligently about why Sahrmann does certain things, but I can talk about my own mental models in why I use the parts I use.
[INDENT]Quote: 3. Questionable Research: experimental and qualitative
This is rather vague, don't you think, Chris? Research is a funny thing- it can look really good in terms of the numerics, but if doesn't relate to a sound theory, or if it is has "tooth fairy science" qualities, then it's actually pretty worthless, if not deceiving.
/INDENT]
Reply: I think this is a very hard criteria when dealing with chronic pain. I do note that to this point there have not been any good, controlled studies supporting Sarhmann's technique's effectiveness of which I am aware. I think this criterion supports a questioning attitude towards this approach.
[INDENT]Quote: 4. Intensity: more is better
I'm not sure how McWilliams fleshes this out, but certainly with the Sahrmann approach, in a sense "more" is better, if you mean more precise (within the instaneous axis of rotation) or more biomechanically sound. In fact, my frustration and my patients' frustration with the Sarhmann approach was that it so damn hard to do right.
/INDENT]
Reply: In this criterion, the author is looking at therapies which require a lot of one on one treatment for a very long time. Sahrmann looks for only a few visits with patient self management, so I feel her approach is clear in this criterion
In regards to specialization, I felt like the authors were pointing to special letters, and secret information which is shared only after completing the first courses. I need to give Sahrmann credit that everything she teaches is in her textbook, even if it is difficult to follow that text.
I think Nickel's criteria are more limited by biomedical thinking. I hadn't considered it in that context and will need to think on that.
I am still interpreting this thread to be about my thinking in the use of certain influences. I really do appreciate everyone's time.
[INDENT]I do have to confess that i have no idea what is meant by, "I'm seeing yet another ravine in the chasm." It feels like an exclamation point, I'll just assume it is part of an ongoing discussion which I haven't found yet. /INDENT]
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Old 02-09-2010, 03:26 PM   #13
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Chris, you're doing alright with your attempts in this format.
I appreciate your response with regards to #4.
Quote:
In this criterion, the author is looking at therapies which require a lot of one on one treatment for a very long time. Sahrmann looks for only a few visits with patient self management, so I feel her approach is clear in this criterion

In regards to specialization, I felt like the authors were pointing to special letters, and secret information which is shared only after completing the first courses. I need to give Sahrmann credit that everything she teaches is in her textbook, even if it is difficult to follow that text.

I think Nickel's criteria are more limited by biomedical thinking. I hadn't considered it in that context and will need to think on that.
Sahmann's approach is biomechanically and motor-control-wise quite complex for patients (and PTs) - that is where it sort of fails the "more is better" principle. Especially since the basis for the approach (muscular imbalances and postures) is so poor. In other words: there is no support to consider "abnormal biomechanics".
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Old 07-09-2010, 11:51 PM   #14
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Default Nickel's and Williams criteria for controversial therapies

I have done some reflection over the holiday weekend, I re-read the articles by Nickel and McWilliams which I wish I could post legally. Nickel's criteria does in fact seem to reflect a straight bio-medical perspective and was written my an MD. I no longer recommend using them for non-biomedical issues such as pain. McWilliam's criteria suffers mostly from my translation. After spending some time with the consensus statement on manual and movement therapies for pain, I think I can rephrase them to make more sense.
I wrote:
McWilliams (watch for more than one criteria)
1. Claims of Cures for disability which theoretically cannot be cured
2. Practitioner Specialization (ouch!): practice requires specialists to undergo even more specialized training
3. Questionable Research: experimental and qualitative
4. Intensity: more is better
5. Legal Action: often debated in court
I should have wrote:
1. Claims of Cures: "If a specific practice claims to cure a disability which theoretically cannot be cured, it is controversial." The author notes an example of craniosacral therapy purporting to claim cerebral palsy. The way I phrased it implied that disability cannot be cured.
2. Practitioner Specialization: "If the practice requires people who are already specialists to undergo even more specialized training...The stipulation that only certain disciples can practice a certain discipline." I think this actually supports simple explanations and simple treatments.
3. Questionable Research: I think Science Based Medicine is what the author is describing.
4. Intensity: The author specifically notes high cost and frequent professional treatments.
5. Court Action: has been debated in court.
McWilliams himself argues that the list should be controversial. What is missing? What is overemphasized? He then lists many controversial educational, medical, surgiccal, rehabilitative and other practices which he feels meet the criteria.
I was hoping to spark a discussion about the list, expand it and then use it to start to sort through my own treament modalities. I will try another post later about my current understanding of science based therapy. I don't mean to sound like I have many answers. Hopefully that will make later posts make more sense.
Chris
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Old 07-09-2010, 11:56 PM   #15
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I was hoping that someone could point me in a direction of which posts to explore for those of us without full access yet in regards to this consensus statement: [INDENT]8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.
/INDENT]Thank you,
Chris
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Old 08-09-2010, 12:09 AM   #16
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Quote:
Originally Posted by Chris Peterson View Post
I was hoping that someone could point me in a direction of which posts to explore for those of us without full access yet in regards to this consensus statement: [INDENT]8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.
/INDENT]Thank you,
Chris
Hi Chris,

I'm just a participant here but I used to moderate when this consensus was developed. We also created a special thread for this sort of discussion and in order to make things easier to track, you could repost your reasonable question in that thread.

For those that don't know what Chris is referencing--here is the Consensus the moderators at that time developed after some lengthy discussions.
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