Biomechanics and the virgin Mary in a piece of toast

Position statement
My profession has become ever more insistent (since its takeover by fundamentalist orthopaedic specialists) that its members see the world of patient problems as biomechanical in nature and keep treatment concepts "corrective" of "faults" such as "weakness," "asymmetry,""imbalance" and "poor posture."

Biomechanics
These exist. People are physical, and biomechanics are basically what peoples' bodies do to hold themselves up against gravity and move around. They are patterns of movement, nothing more. They are measurable, sort of, and a science does exist around them, but clinically there is not much point in measuring them - they can change radically, depending on how people feel, whether someone is experiencing pain or not.

I definitely look at biomechanics. We all do. They are useful as feedback to our own therapist visual cortex to gauge if our treatment is being effective or if we should change course.

But biomechanics are like cloud patterns. They will shift anyway, should not be made into more than what they are - sudden changes should not be assumed to be "proof" (explicit or implicit) that "I, therapist," am therefore great.

Patterns on toast
These also do exist, although there is no science as far as I know. They are a natural function of burning a piece of bread. They should not be made into more than what they are - burnt spots. Neither should biomechanics.

Pareidolia
This is the name of a well-recognized perceptual fantasy: people read faces or pictures into patterns on toast or in clouds or whatever, see something that isn't there and which has no bearing whatsoever on the nature of the material they are gazing upon.

Finding "fault"
This is a common human trait. Sometimes "fault" actually exists. Lots of times it does not, and "fault"-finding is mere perceptual fantasy, like pareidolia, i.e., visually projecting onto an external object something that has nothing to do with anything but one's own personal (usually incorrect and off-target) mentation.

Finding things in biomechanics, then labelling them as "weakness" or "imbalance" or "poor posture" is value-judgy. Considering value judgments worthy of categorically diagnosing and treating is to somehow believe that value judgments can be objectified - they are not objectifiable, scientifically, IMO, because value judgments are not objective to begin with. Nevertheless they persist as a collective pareidolia, and people keep trying to couple them with biomechanics, keep cranking out papers full of implicit and explicit linkages. Excuse me - I think there is something wrong with that.

This is me, finding fault.

Prior plausibility
This is something that scientific investigation requires in order to even be scientific. There is no prior plausibility in linking biomechanics (expression of motor output or expression) to fault-finding; correlation is NOT causation, it isn't scientific, instead it leads to conceptual hallucinating all over the place. Conceptual hallucination often results in something known as pseudoscience.

Ritual
This is common human behaviour done to restore order to a universe that seems to go cockeyed viewed from a subjective standpoint. It's magical behaviour in that:

• there is no discernible connection in natural law between cause and effect, only in the mind of the conductor
• it helps the ritualist feel better; when conducted excessively, this attempt-to-feel-better behaviour is known as OCD (obsessive compulsive disorder).

When done regularly in a group setting, this is known as "religion" (e.g., Roman Catholic)

What does this have to do with PT?
There are different camps within PT. Using the religion metaphor, there are:

• Hard-tissue fundamentalists - these are the orthopaedic specialists who are convinced that orthopaedic manual therapy is the most smiled-upon. They have taken over the profession, pretty much. People practically bow as the high ortho priests pass by. There are systems in place wherein you can work your way up a hierarchy and earn a black belt in ortho manual therapy. Each stage requires one to drink ever-stronger Koolaid. There are tests to pass. Orthos are identifiable by their strict adherence to biomechanical concepts conflated with value-judgments about joint movement, elaborate rituals devoted to improving joint movement/mobility/function which they suppose will lead to heaven - er, I mean, better movement/less pain. In the last couple decades there has been an influx of dry needling as an added ritual. If cracking it or jiggling it doesn't work, poke it. There are many sects/gurus/professions with this stance outside PT.
  
• Soft tissue-ists: these are everyone else, mostly the stretch/strengthen/exercise crowd but their numbers include all manual therapists who don't do manipulation of a high-velocity kind. They might have different rituals but they still all see Mary-in-toast: they still all think various mesodermal derivative the source of all evil (pain), that the altar is whatever gym ball or equipment they put their patient on, or machine they hook them up to, and that their hard work to strengthen/lengthen/massage/release it (magically, from the outside of someone else's body, and continuing the "fault-find" in toast patterns) is the way to proceed (make an appropriate sacrifice/make a living).

Then there is me. What makes me different?
I checked out the two main sects of PT, but liked neither of them. Became an atheist PT and manual therapist/atheist/heretic/apostate beside being an ordinary atheist, even while continuing to practice hands-on therapy, which I reframed as human primate social grooming, in order to

• make it more palatable to myself
• make it more "scientific" to myself, more in line with evolutionary biology
• make it more compatible with neuroscience/pain science

Did fewer rituals, less and less of the time. Mostly wandered around in the desert. Found the oasis - neuroscience and pain science. These tell me that biomechanical patterns aren't important (which suited my own confirmation bias) and freed up even more hard drive to examine what the humanantigravitysuits standing in front of me every day really needed from me in the way of understanding and treatment.

Not much, as it turned out. No rituals, really. Just a bit of engagement, handling, education, reflection, support, encouragement, help, reinforcement, suggestions for pain management.

Taking stock

A convergence of sorts has occurred in the new year: today a friend sent me a link to this excellent essay, written by Frank Wildman, on the sad, rather shabby, rather scientifically disjointed state of PT. He was thinking of U.S. PT, I think, and he had his Feldenkrais goggles firmly duct taped to his head while writing, but I'll forgive him for that, because he makes many many good points. I like the way he compares the state of PT to the state of general science before Darwin came along with the unifying theory of evolution. This essay still seems topical, even though it is 22 years old: Learning: The Missing Link in Physical Therapy.

Lately, a New York Times article by Gina Kolata, Treat Me, But No Tricks Please, provided the reading public with a glimpse into the hall of distorting mirrors that is current, American at least, PT. This story has raised comment on a few PT forums/blogs:
1. NY Times: Physical Therapy Useless?
2. Yes, Gina you can tell if your physical therapist is "voodoo less"

There isn't a whole lot to come back with, though.. Frank is still right, I'm afraid.

This short video, "Myofascia," was constructed by a PT student, determined to be a PT who embraces rationality. It's very succinct and immediately was shared by several Facebookers. Facebook really is a networking site, because through it I met a fellow who wanted to counter the video and share that he is helping to organize an entire conference about fascia. He seems like a very nice guy. We struck up a conversation, shared who we are and what we're about. I won't divulge anything about him, as that would be improper, but I'll put here what I told him about me:

"Your enthusiasm for the topic (fascia) is palpable! [/manual_therapy_joke].

Congratulations on helping organize a conference! That's no small task!

I'm a manual therapist too, born and raised in Canada, of physiotherapy descent. ...

Anyway, I moved (grew up in Sask), now have colder weather but WAY more sun, which at my age I need. My interests include deconstruction of faulty treatment concepts, passion for the neuroanatomy, physiological function, understanding, and care and feeding of the human nervous system, and writing. I helped start the Pain Science Division of the CPA. Currently I am on the exec. and run the coast to coast online directory for PSD members/PTs who want to be in it, and for patients who want to find a pain therapist. In my private PT life I have taken what I know about manual therapy, and what I know about neuroscience, and have called the result, "dermoneuromodulation." It's basically skin stretching but with an entirely neurological treatment construct, no mesodermal derivatives involved whatsoever. I've done a pilot research project on this, along with Angela Busch at U. of S, not yet written up. I've done an initial cutaneous nerve dissection (at UBC), took lots of pictures, wrote it up but have failed to have it accepted so far. I'll be talking about dnm, and about Neuromatrix model of pain, at a congress for manual therapists in Brazil in May. Then (hopefully, don't know yet) in St John's at CPA Congress. My life goal is to help develop vast crowds of rationally thinking, compassionate PTs/manual therapists who care deeply about pain and choose to help their patients overcome it in ways and with treatment constructs that are scientifically bullet-proof. Down with woo, IOW. To help that happen my next ambition is to get ensconced in an anatomy lab somewhere and map out the entire cutaneous nervous system so that therapists of the 21st century can realize and visualize and develop treatment constructs around what they are actually touching, and what's actually responding, in the person/body they are handling. I call this an 'interactor' model rather than an 'operator' model. Many therapists learn to do this, but implicitly rather than explicitly. I want self-aware consciousness AND scientific impeccability AND simultaneous, seamless treatment construct. Not too much to ask, is it?..

I run a page here, Neuroscience and Pain Science for Manual Physical Therapists, if you'd like to check it out some time. I also help admin a skeptical PT site/discussion forum called SomaSimple. You are welcome to come, join, discuss there too! We welcome everyone who wants to learn to think more clearly about what we do or who might have light to shed.

Diane"

Controversy in British Pain Society: PT president ousted

Protests as physio ousted as British Pain Society president.

BPS = British Pain Society

BMJ= British Medical Journal

NICE = National Institute for Clinical Excellence

Here is NICE outraged by ousting of BPS President in the BMJ, dated July 23.

"We write to express our outrage at the British Pain Society’s vote to force their President, Professor Paul Watson, out of office because some members disagreed with a recommendation in NICE’s recent guideline on low back pain which he helped develop.

The BPS’s sustained campaign against this highly respected pain management and rehabilitation expert is professional victimisation of the very worst kind. That it has now culminated in the BPS forcing an exemplary expert out of office, is shameful.

All NICE guidelines are developed by independent clinical and patient experts who give up their time and expertise, over a two year period, to produce robust, evidence-based guidance. It is totally unacceptable for guideline developers to be singled out in this way and have their professional integrity called into question, simply because some groups don’t like a robust, evidence-based recommendation that has been developed by a group of independent experts.

The guideline developers’ only aim is to help improve the care and treatment of people with specific conditions by highlighting gold standard approaches based on the available evidence. The BPS is clearly admitting that they do not accept evidence-based medicine. Moreover, the Society’s actions fly in the face of the comment made in a recent High Court judgement. At a judicial review of NICE’s chronic fatigue syndrome guideline in March this year, at which the judge dismissed the claims in their entirety, he particularly highlighted the importance of health experts to be able to express their opinions without fear of retribution.

The BPS has acted dishonourably in making their own President a scapegoat for the fact that some of its members refuse to accept that there is not the scientific evidence to support their interventions. It is a sad day for freedom of experts to express views, for evidence-based medicine, and for the ideals of the medical profession.

Yours faithfully,

Sir Michael Rawlins, Professor Peter Littlejohns"

It's worth reading through all the letters in the BMJ link. Rarely are PTs involved in public politics and turf battles at levels such as this. The story involves a PT and it involves pain, so I find it all very interesting. There appears to have been somewhat of a coup by an organized group of doctors concerned over supposedly evidence-based guidelines which might have affected their own livelihoods, or at least what they consider to be their turf...

I find it all a bit bewildering at the moment, as I only learned about it this morning. But I'm curious and plan to read through it all again.

First day of "vacation"

I'm officially not at work now, as of yesterday at 4:45 PM. And I officially do not have to return until January 5th, in the afternoon. (L-o-n-g-.........-e-x-h-a-l-e.)

Part of me feels, oddly, very upset by the prospect of all this idleness. Clearly I seem to have, overall, lost touch with my inner irresponsible child parts.

It will be a first real break (longer than three weeks) from work in over 14 years. It will be the first time I will have been out from under the Dark Grey December Sky Lid of the temperate rain forest in 18 years. The part that feels upset is undergoing a taste of Freedom Vertigo, is all. It's a minor cognitive tilt-a-whirl that I'm sure will pass, once I get to Maui and experience immersion in high photon density. Maybe even before then.

I'm thinking I'll get some time to contemplate what I'd like to be when I grow up (a job that is never really over), how to safely disengage from the life I've constructed here and move on, hopefully to a more sunny location, and some kind of reasonable time frame to conduct this transition, make it gentle on everyone including me.

Does the economy worry me? A little.. so it's a good thing that I have never really worried a whole lot about stuff over which I have no control, like the value of money. When the opportunity to move smoothly presents itself, I will do so in a heartbeat, even if I lose money in the process.

If I were really concerned about money, I'd never spend any, and I'd not have become a PT in the first place, because you never get rich doing human primate social grooming. At best, you make a comfortable living doing honest work that's meaningful in the moment, involves helping others, and does no harm. I can do that anywhere. It's one of the things that attracted me to PT in the first place. Who needs more than that out of life? Really?

Speaking of doing no harm, I received yet another missive from my good friend and correspondent, "anonymous," who regaled me yet again on the blogpost I wrote concerning Sandy Nette and her lawsuit. See Alberta woman with chiropractic stroke sues bigtime. Sorry anonymous, I am not going to publish your comment. Surely you can read, and have already read this part:

"Since I put this blogpost up I've received a couple comments from one or two readers, both named "anonymous." I did not allow their comments to appear. They are glaringly pro-neck-manipulation, and I think the pro-neck-manipulators have already had far too much leeway in the realm of swaying public opinion to give them any sort of platform, however buried, obscure and humble this blog may be.

It's because of:
1. chiro training in a rationalized (as opposed to rational), deliberately propagated, bizarre belief system, combined with
2. a cultivated and honed persuasive attitude,
3. which appears aimed at propagating reckless enactment of a type of human physical social grooming (high-neck-manipulation) which is irrelevant and unnecessary in the first place,
4. against all common sense AND scientific investigation,
5. for the sole purpose of making $,

... that this woman became tetraplegic.

I have too much respect for the human nervous system to ever condone manipulation of its high-neck housing; therefore, "anonymous," I consider my prevention of your promotion of it on my blog, a positive choice - an action (however tiny) against letting myself and this blog be a vector for further perpetuation of your particular memeplex. And I happen to think it's an accumulation of tiny actions that count in life."

I suspect that my dear friend anonymous constructed his straw man argument in Word and is simply surfing his way around with the help of google, and like a crazed harpy (even though probably male), is dropping his load everywhere he can. I'm sure I've already read the exact same prose many other times, in many places.. anyway, no need for me to allow it here. I get to set editorial policy in my own blog, anon. Tough darts, but that's how it's gonna be. Try popping this delightful bubblewrap instead.

See? I just guided someone from a harmful activity over into an enjoyable and harmless one. That's part of what I help people figure out how to do in my work.

Another part is helping people figure out how to do what they want to do without having to endure pain while doing it. The last but not least part is teaching people about pain, and engaging with their physical nervous system to relieve it while they and their nervous system simultaneously learn how not to have it. Do I treat necks? Yes, of course I do. Do they improve? Yes of course they do. Do I pop them? Never. See?

Really, I do love my work. But also, really, I do need this trip to a Land of Photons, and I need it now. I want a big blue-dome sky over me and gorgeous glinting light ricocheting around, vigorously bouncing off surfaces of everything instead of feebly allowing itself to be sucked straight into them. I want vibrant color all round, color that here would seem garish but there will seem blanched in the vibrancy of ambient blue-sky light. I want to see light bending off water and water that looks blueblueblue, not this dark green black stuff that we call "the ocean" here where I live, that up close reminds me of wrinkled, liquid trash bags rippling slightly in the breeze, weakly fwapping at the shoreline, sucking away sand, depositing dead cold darkgreenbrown slimey seaweed. I want sharp contrast, not fuzzy edges. I want black shadow, not a dull grey haze. I want light that hurts my eyes, burrows directly into my brain, forces me to wear shades to protect my peepers from sheer sizzle. I want to be dazzled by direct light, not fooled by artificial street lights tossed haphazardly upward from puddles on the street, not placeboed by a sun lamp with which, frankly speaking, the honeymoon was over long ago. Let there be light. Real light. Honest. Sun. Light. Puhleeze.

Update Nov.30
My friend "anonymous" has written to me again. This time, he said he agreed that avoiding neck manipulation was a good idea (which is a step forward), but said I was off the mark on chiro education. Come on Anon, get over yourself. Perhaps your chiro school was (relatively) wonderful, but I have it on quite good authority that there is no particular standard amongst U.S. chiro schools. So don't presume to speak on behalf of all chiro. Go read Chirotalk, where I get all my info about chiro from ex-chiros who are fighting their way back to sanity, who engage true believers in hilarious discussions. It was you who drank the chiro koolaid, not me - I see no reason to change my overall opinion of chiropractic.

Barry Beyerstein on Pseudoscience and other related matters

I've been neglecting both blogs I'm involved in, lately... One part of me feels like it's been spinning its wheels in the mental mud of descending seasonal affective disorder, while another part has become rather fascinated with active digestion and absorption of Berry Beyerstein's wonderful 50 page exposition, Distinguishing Science from Pseudoscience. I wrote several posts on SomaSimple on the topic, and compiled them into a single "digest" to try to keep life simple.

Important gleanings I took from this relatively short and cursory foray into the topic, are as follows:


1. BELIEF FIELDS and RESEARCH FIELDS:

From Mario Bunge: rather than dividing cognitive domains into sciences and non-sciences, we might divide them into "belief fields" and "research fields."

Belief fields include "religions, political ideologies, pseudosciences and pseudotechnologies, as well as any mystical system that believes that enlightenment can be gained through revealed truth rather than painstaking examination."

"The primary attribute of belief fields is that, for their devotees, evidence is personal and subjective. I.e., they advocate using emotional criteria to distinguish truth from falsehood. Belief fields hold private feelings and hunches to be reasonable grounds for certainty—or, as New Age writers put it, “You create your own reality.”"

Research fields "can include disciplines not typically thought of as scientific, as long as their practitioners are committed to gathering objective data to support their positions."

"evidence in research fields is interpersonal. That is, it can be compared by disputants, according to open and objective criteria. It is sometimes said that objectivity is merely inter-subjectivity. I.e., an “objective” consensus is reached by comparing various individuals’ perceptions with each other and against agreed-upon external standards."

2. THE ROCK BOTTOM SCIENCE "BASICS"

Contravene any of these and you are skating on thin ice too close to open water.
They are:
1. The inverse square law
2. Laws of Thermodynamics (e.g. the Law of Entropy)
3. Laws of Conservation of Energy, Momentum, etc.
4. Injunctions against reverse causality ("Time's Arrow")
5. One or more of C.D. Broad's "Basic Limiting Principles"
6. Data of modern Neuroscience, psychology, and psychophysiology

"Many pseudosciences claim extraordinary precision, power, or yields, well beyond those achievable by conventional scientists (and often by means of secret proprietary processes, formulas, or equipment)." Chiropractic springs to mind. PT often isn't very far behind however.. and many PTs seem to admire the marketing employed by chiropractors as if it were something to be aspired to instead of either ignored or pointing a finger at.

My favorite is number 6., ignoring the nervous system, a serious error my profession and the PT people in it make all the time, trying to pretend it isn't there, that it doesn't "sense", trying to work around it in order to make life simple for themselves, working from "models" (such as a joint biomechanical model) that refuses to take the nervous system into account at all - even the physical 72 kilometers of it weaving throughout the "body" referred to in "the literature" as "nerves"(!). This is so rampant that there are even PT university profs using the biomechanical model as their teaching platform who have the audacity to declare that pain doesn't exist and isn't our business as PTs. Ahem, I beg to differ, strenuously.

Broad's "Basic Limiting Principles" are listed here.