To PT or not PT: Part 2

In To PT or not PT: Part 1, Cory developed his theory from the perspective of "inside-out" neuromodulation. He finishes his discussion of placebo:

"The "as if body loop" provides a way in which the neural representations are present "as if" a body change has happened. The placebo, must be considered an appropriate action, because it creates a neural representation that is "as if" that action did in fact take place. As far as the neural representations are concerned, it did. This is why it "cancels and terminates" pain."

He introduces the phenomenon of "learned helplessness"; in treatment of humans, he argues that our explanations are contextual, and therefore very important - this transitions nicely into the perspective of "outside-in" neuromodulation, starting with Kandel, and synaptic plasticity.

1. "they found that synaptic connections can be strengthened and weakened based different patterns of activity. The analogs of classical conditioning and sensitization strengthened a synaptic connection, while habituation weakened it."

2.  (Quoting Kandel): "This suggested that synaptic plasticity is built into the very nature of the chemical synapse, its molecular architecture."

3. "This is important for us clinically. The mere presence of a signal going through a synapse strengthens its connection." (Also this on chemical substrates and DNA changes in memory formation/long term change, long term potentiation)


4. Motor control as context dependent, comparable sign as immediate feedback

5. Mechanical deformation of nerve tissue

6. Exteroception

7. Interoception

The thread trailed away, as so many do, without fanfare or summarization. Yet it contains a solid skeleton for further development.
It is the only one to date, anywhere, that I am aware, to tie in:
1. what is going on in the nervous system of a patient, in terms of awareness and responsivity, from skin cell to sense of self, with;
2. what is being done to that patient/patient's nervous system by a therapist, simultaneously aware of everything in point 1.

"Contextual Architect" - Cory Blickenstaff

Recently Cory wrote a letter to the editor of the Journal of Manual and Manipulative Therapy, which I've decided to quote in full (and hope I'm not breaching any copyright by doing so):

"Therapist as ‘contextual architect’ 

I would like to thank Bialosky et al. for their excellent article clarifying and discussing how and why to maximize placebo in manual therapy(1) practice. I would like to consider here the implications that placebo, conditioning, and expectation have on our roles and responsibilities as manual therapists. 

As pain is the primary complaint of many patients seen by the manual therapist, the potentially ubiquitous involvement of placebo in the ways we might approach these problems makes understanding such issues of vital importance. 

The authors operationally define placebo as the context of interactions between patient, therapist, environment, and intervention. A useful way to conceptualize these modes of interaction in the therapeutic encounter would be to consider three conceptual spaces: the subjective spaces of each the patient and the therapist, and the third shared ‘inter-subjective’ space (consisting of the environment and the intervention in the model of Bialosky et al.). Let’s examine how each space contributes to the ‘context of interaction’. 

The subjective space is private. Quintner et al. argue that the lived experience of pain is an example of an aporia, (2) a space to which an observer is denied access.(3) We lack a usable language to have access to the subjective experience of another (4) (such as the pain experience) and must therefore rely on indirect interpretation as exemplified by tools such as the visual analog scale, self-report disability scales and on our own interpretations of the interaction. All of these must be drawn from the shared inter-subjective space. 

The shared inter-subjective space represents the place where we can and do impact the other person through shared environments (including the intervention). When we interact with another, we become both the observed and the observer,(2) as we impact their subjective space and vice versa. 

Relevant to the inter-subjective space in therapy is the idea of soft paternalism that states that we cannot help but influence those with whom we interact. In other words, you can ignore the impact you have on context, but it will not ignore you, nor will it ignore your patient. This is a point the authors successfully drive home in their review, and Jacobs and Silvernail defended with the introduction of the ‘interactor’ approach in a previous response letter.(5) We should therefore strive to affect the interaction in specific and predictable ways, aiming for certain outcomes while respecting the rights of the individual involved.(6) As the authors point out, the evidence of impact of care gives us some insight into predictable outcomes of various forms of interaction. As we are attempting to build a specific context of interaction in the inter-subjective space to bring about predictable outcomes, we as manual therapists reside in the role of contextual architect. 

Our responsibility as contextual architects is to be purposeful in our influence in a responsible manner as prescribed in our code of ethics,(7) using predictable methods (when available) and plausible explanations consistent with best evidence with the patient’s individual goals and best interest as the guide.

Cory Blickenstaff PT, MS, OCS Forward Motion Physical Therapy Vancouver, WA, USA

References 

1 Bialosky JE, Bishop MD, George SZ, Robinson ME. Placebo response to manual therapy: something out of nothing? J Man Manip Ther 2011;19:11–19.

2 Quintner JL, Cohen ML, Buchanan D, Katz JD, Williamson OD. Pain medicine and its models: helping or hindering? Pain Med 2008;9:824–34.

3 Williamson OK, Buchanan DA, Quintner JL, Cohen ML. Pain beyond monism and dualism. Pain 2005;116:169–70. 

4 Scannell K. Writing for our lives: physician narratives and medical practice. Ann Intern Med 2002;137:779–81. 

5 Jacobs DF, Silvernail JL. Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther 2011;19(2): 120–21. 

6 Thaler RH, Sunstein CR. Libertarian paternalism. Am Econ Rev 2003;93:175–9. 

7 American Physical Therapy Association. Code of Ethics [docu- ment on the Internet]. Alexandria, VA: American Physical Therapy Association. Available from: http://www.apta.org/ uploadedFiles/APTAorg/About_Us/Policies/HOD/Ethics/Code ofEthics.pdf#search5%22Code%20of%20Ethics%22."

I made a picture of this awhile ago, that I call the 'therapeutic domain'. It's a not-yet-completely-satisfactory imaging of the interactor model of physical/manual therapy, taking into account the reciprocity of sensing that goes on between therapist and patient, which hopefully helps the brain of the patient resolve its pain production. 

I really like the term "contextual architect" - it provides room for creativity, and challenges all the other conceptualizations of manual therapy in existence that operate in "guilds" - i.e., here's the way it's done, do it this way, with these bricks, or you can't belong in this guild (how medieval is that?)

Way to go Cory - way to carve out more conceptual space for all those of us who are permanently dissatisfied with the current, inherited, mesodermalist climate that permeates most of manual therapy. Way to go, Journal of Manual and Manipulative Therapy, for holding open a door to new avenues of thought. 

JMMT is available online, but not accessible by me. Cory's letter appears in Vol 19, No 4, 2011. 

Cory's new blog: Forward Motion

Cory Blickenstaff, who has joined Matthias Weinberger and I on the Neurotonics PT team blog, has just launched his own blog and website, Forward Motion. I've included a permanent link on the right, in the PT blog menu. It's a very attractive, easy-to-read site, with spiffy dropdown menus. Good work Cory. I look forward to reading all your thoughts.