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"

More about oscillations- Part I: Where do brain oscillations come from?

In reference to Oscillatory Matters:
If the reader goes back through all the posts linked in the post I've linked to here, he or she will learn that György Buzsáki has studied the hippocampus and brain rhythms all his research life. I completed an entire transcript of the Buzsáki interview by Ginger Campbell of Brain Science Podcast and sent it to her to do with as she wishes. I'm sure she will find good use for it. My main objective in writing a transcript was to understand the material in greater depth.

I plan to bring a series of notes here, based on the interview. This is Part I - Where do brain oscillations come from?

His opening statement in the interview is:

"Synchrony is an important mechanism to bring elements of a system together in time - it's critical - then I think everybody agrees that it's a pretty important mechanism. The only thing we can add to it is that oscillations do a fantastic job of doing that and they do it almost for free."

That "almost for free" aspect is important given that the nervous system is an expensive system to maintain metabolically.

What are oscillations?
*Nature is full of cyclic phenomena - movement of heavenly bodies, the calendar, the life cycles in biology, respiration, heart beat, menstrual cycles.. these are all rhythmic phenomena.

*Many man made objects are also based on rhythms or oscillations, such as clocks, radios, TVs, computers, cell phones, even electrical line transmission

*What is the use of all this repetitive phenomena? Artifact (side effect of how things are put together), or essential parts of the mechanism?

*A one or five megahertz clock could be built using random timing, but it would be incredibly difficult.

Oscillations synchronize events

*Imagine a car designed to not move smoothly; it speeds up and slows down irregularly. The average speed of this car and a regular car may be identical. On a smooth terrain both would take about the same length of time to get to the goal. When the terrain is difficult the car would be harder to drive.

Types of oscillators

1. "Harmonic" oscillators: predictability

* e.g. pendulum clock with motion almost perfectly sinusoid
* e.g. orbit of the moon around the earth
* "predictability" is that one need only look at motion of the moon for a short period of time to extract the phase information then one can predict the phase of the moon tomorrow or a million years from now
* harmonic oscillators are very useful for predicting events in time
* there are many examples in the brain of harmonic oscillators, exploited for exactly this purpose


2. "Relaxation" or "pause" : easy perturbation

* discrete events repeat with long or less predictable intervals
* e.g. clapping of hands: a discrete event is followed by silent period which may vary in length
* e.g. a dripping faucet: drips (discrete events) repeat at certain intervals; if observation period is short, within two drops, one cannot predict the occurrence of next event
* no timing precision, but they can be perturbed easily - tap on the faucet will produce a premature drop, determined exactly by the timing of the perturbation

* very effective to synchronize in large numbers if they are identical:

Imagine hundreds or thousands of faucets, simultaneously perturbed: phase reset means to start them all with the same phase (tap on the tap): if they are identical this need be done only once - they will drip simultaneously thereafter, demonstrating synchrony and phase reset-ability.
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So where do oscillations come from? The short answer Buzsáki provides is that they seem to come from nature itself.

This next thought doesn't come from the interview, but I want to point out that even a glass of water sitting unperturbed will contain "oscillation" in the form of Brownian movement of the water molecules - and life contains a lot of water molecules.

This inherent atomic motion is unlikely to be completely stilled by being bound in a cell. In fact those who study motility in single-cell organisms have to separate out Brownian movement as a potential confounding factor.

What are neurons? They seem to be many things to many fields, but first of all they are long skinny single cells containing water, very easily perturbed, whose job seems primarily to be to signal - to chatter continuously. This entire interview, and the book Rhythms of the Brain, explains how this chatter appears to be organized into patterns.
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References:
1. Stephen Strogatz: known for his discovery of “small world” architecture. Sync: The emerging science of spontaneous order (2003) is for a general audience

2. Nancy Kopell: mathematician
We got Rhythm: Dynamical Systems of the Nervous System (pdf). N Am Math Soc 47: 6-16 (2000). (Buzsáki recommends her review of the analytical approaches to neuronal oscillators)