Ongaro and Kaptchuk 1

I am currently reading this paper: Symptom perception, placebo effects, and the Bayesian brain - so juicy. I stumbled upon a blogpost by Tim Cocks at Noijam that mentioned it.

I have decided to give it a "full treatment" - a full, line-by-line treatment. This is because I would love to understand Bayesian thinking better, I'm a beginner, pain has always been a way into understanding life in a body better, and this paper promises to do all that.
Plus, on Facebook, there are two bright minds who want to debate the paper.

As usual, this blog will be my private (well, probably not private, but I can pretend it is) workspace - a place for me to work on my own thinking about it, reflect on the conversation as it unfolds on Facebook, ruminating, pondering, storing all the links and analyzing WhatItAllMeans, to me.

As usual, I will be looking at all of it from the perspective of a manual therapist and neuromatrician who works with peoples' nervous systems directly to help them overcome pain problems.

This is the first of many blogposts I will write about this paper as I try to grok all of it.

Background
I had a moment of clarity yesterday (few of these moments, so it felt sharp!)
I sent out a thought.
Here is the thought I had:

"Here's a thought (spurred by a conversation with Hsieh Hsing Wu *):  

1. Kinesthesia is to proprioception as pain is to nociception.

2. Pain is awareness of (danger signaling perceived as if coming from) the body, top-down. Nociception is sensory input, bottom-up.  

3.Kinesthesia is awareness of (movement of) the body, top-down. Proprioception is sensory input, bottom-up.  

4. It is not appropriate to mix up any of these."

I based it (and will base subsequent thoughts) on these items, which clarified many things for me:
1. Anil Seth's TedTalk on predictive processing: Your brain hallucinates your conscious reality
2. Anil Seth's TedTalk, truncated.
3. A wonderful article in New Scientist that I refer to endlessly:  Understanding Body Ownership and Agency. 

Proprioception is likely more about ownership, whereas kinesthesia is more about agency.
Manual therapy is something I now regard as "exafference" (from the Liepelt and Brooks article) an environmental influence on the system) that creates compelling enough perturbation that the system can change its own predictions. 
........................
References

1. Ongaro, Giulio, Kaptchuk, Ted J., 2018, Symptom perception, placebo effects, and the Bayesian brain. PAIN, Aug 6, 2018. (To read the full paper, click on "Article as pdf")

2. Cocks. T, 2018, The ‘Bayesian brain’ for beginners, by way of placebo. Noijam blogpost Oct 9, 2018

3. Your brain hallucinates your conscious reality Ted Talk, Anil Seth, video, 17 minutes, April 2017

4. Your Brain Hallucinates to Create Your Reality. Ted Talk, Anil Seth, truncated to 3 minutes, June 4, 2018, TED Facebook

5. Roman Liepelt, Jack Brooks, 2017,  Understanding Body Ownership and Agency.  New Scientist May 1, 2017

*Hsieh Hsing Wu is a physio in Taiwan who I met 14, 15 years ago in online forums. He lived in Australia at the time I met him. He attended my DNM class in Taipei this past May, and is interested in becoming a DNM workshop instructor there.

So many papers and other good stuff lately!

I lack motivation, which is why I haven't been blogging much this past year. But I do notice many things as I drift by them in my mental inner tube, and just now, I decided I had enough energy to list the sort of stuff I see daily - an avalanche of great stuff, semi-organized.


In the peripheral nervous system:

1. Concept of acute neuropathic pain. The role of nervi nervorum in the distinction between acute nociceptive and neuropathic pain.  This one comes from Brazil, 2016. It eluded me until now, possibly because it had not been translated into English before, but is now. Really interesting, everything you ever wanted to know about nociceptive neurons in the periphery. Well, a lot at least.
And how they can be bothered on the inside of nerves.
My whole manual therapy worldview rests on this idea - that if nociceptive neurons inside nerves get riled up for any reason, e.g., mechanical deformation of the nerve OR the vessels that feed and drain it, the nerve itself will get plenty cranky, sensitize, and make a signal large enough to eventually overcome normal descending inhibition, whereupon the spinal cord will obligingly amplify said signal, compounding it with central sensitization through several mechanisms.

2. Entrapment of middle cluneal nerves as an unknown cause of low back pain. The author is Japanese - Yoichi Aota. My Japanese colleagues have met him in person. 

In the central nervous system:

1. Thalamus: A long-overlooked brain region may be key to complex thought
This one is not about pain per se, but about how the thalamus's job is much more than just relay. 

2. Cerebellum: The Cerebellum, Autism, and How The Human Brain Gets Organized - New Research.    This is a half-hour video with Peggy Mason and Aaron Freeman at U Chicago, who shed all sorts of light on this structure and its contribution to developing brains.

3. Pain as maladaptive plasticity, by DevraJoy Sheldon. I had the pleasure of meeting Dera Joy at the last San Diego Pain Summit. What a great blogpost!
Excerpt:

"Moseley et al 2009 noted that when individuals with CRPS crossed their upper extremities, the unaffected extremity became cooler than the involved limb. It wasn’t the limb, but the hemispace that was relevant. This is very much like a stroke with hemispatial neglect (an inattention to the environment on the involved side.) And what do we do with individuals who experience neglect, even extreme forms of it including anosognosia (denying the limb is theirs)? We help them attend to the limb and environment. We involve the limb in care and therapy. We apply stimulus to the limb to help the brain “tune in” to it and we encourage attention to the hemispace in which the limb resides. We do this to drive neuroplastic change."

She's right, that's exactly what we do.

4. The autonomic system: Professionalism-Autonomic Disorders: David S. Goldstein, MD, PhD He Could Have Been a Cartoonist. He Became an Expert in Autonomic Disorders Instead. Sounds like this may be the researcher to whom we owe a debt for elucidating dysautonomias. Note to self: look up all his work!

5. The ‘Bayesian brain’ for beginners, by way of placebo. A super good paper is linked into this blogpost.  Here it is: Symptom perception, placebo effects, and the Bayesian brain. Click on "Article as pdf" to get full text.

Studying the two together:

Skin nonlinearities and their effect on user perception for rotational skin stretch. This is REALLY exciting for me - someone has built a skin twizzler machine.  Now maybe someone can design a (really GOOD) research project to study DNM! 

Studying the therapeutic relationship:

A framework for establishing connections in physiotherapy practice. This new paper is by Maxi Miciak et al in Alberta. (* Don't miss her at the next San Diego Pain Summit where she'll be a speaker alongside Damasio!) I love how she geeks out the various components of therapeuttic relationship into an actual diagram.

Remember, for accessing beyond a paywall, scihub is our friend. 

Shin and Yoshi

In September I had visitors from Japan, two nice young men, one of whom translated my book into Japanese and the other who is a physio - together they plan to start teaching DNM in Japan and maybe elsewhere too - I couldn't be more relieved to hear that. It will save wear and tear on me to not have to travel so much, and at some point, I'll be able to just stop. 

Shin Iwayoshi, the translator and massage therapist, and I in front of a fountain in front of the courthouse in the small prairie city I live in. 

Yoshiro Morimoto, the physio, and I. 

Exciting times. 

About CKS (crabby knee syndrome)

I have a story about my right knee.

Picture the following scenario: I am a 67 year-old, overweight, under-fit female, in a foreign city (Barcelona), in the ladies room of a teaching venue. The 3 stalls are little rooms, with complete privacy, ordinary doors, not the kind we are used to here which are just partitions. I quite like this foreign version of toilet privacy, but it's a bit off topic so I'll head back to the point: when you gotta go you gotta go.
I use one of the little rooms, and completely forget that the little room is up a step that is about 4 inches high. I presume the plumbing had to be accommodated or something, but before I wander off topic yet again, let me just say I didn't notice myself stepping up to go into the stall (jet-lagged probably), and my brain did not account for the height-of-floor-difference coming back out again.

Long story short, I made a predictive motor error. Or at least my brain did. I thought the floor was all one height, and when it suddenly wasn't, I landed pretty hard when finally the floor came up to meet my descending foot. My foot that descended surprisingly farther than anticipated. With all my considerable overweight jolting down an extra 4 inches to stop more abruptly with a lot more gravitational force than I had expected. Four inches in which apparently a lot of acceleration can occur, within mere nanoseconds.

I didn't fall over or anything.. I carried on.
The knee felt weird though. Not right. Like it wasn't quite me. Stiff and unnatural. Like there wasn't any room for "me" in it. Like a mechanical thing more than an alive thing. The interoception felt cloudy, and the proprioception seemed to be missing. My brain didn't trust it anymore.  It didn't really hurt at first, but I could feel machinery running in the background of my awareness as though my brain was trying to figure out where it had gone wrong. And the knee acted slow and stiff. But I hobbled around for the next 5 days, teaching, sightseeing on foot (slowly). The best thing to do with stuff like this is ignore symptoms and keep moving, right? Treat whatever it is as though it were normal, make normal demands on it, don't baby it, just keep going. And that is exactly what I did.

Pain set in during the long flight home, but I just kept going. I had to go to Taiwan, then Winnipeg. Then Minnesota, just last week. Four months have elapsed since the bathroom floor predictive error encounter.
It has been variable, with entire days pretty much nociception free, but it would wake me up at night, pain shooting through my knee. I would have to wake up fully to change position. I did not let this worry me. I would just go back to sleep, easily enough.
Some days it really hurt, so I would baby it with some stretchy tape and keep on going.
It was always worse after sitting for a long time.
Like on airplanes.
And a number of different people helped me by treating it, which always made it feel better, for a little while at least. 

It did not slow me down at all, really, except when descending stairs. Then I knew I still had a knee pain problem. I live on the fourth floor. Three flights of stairs. About 60 steps in total. Going up was easier than coming down. Yes, there is an elevator. Yes, I took it, but I tried to make myself do stairs as much as I usually do, which is about half the time going up, and all the time going down. So, I worked it under load.

.........

The backstory: I had a terrible time getting paid for the work I did in Barcelona.
Finally, after a lot of back and forth and several attempts (according to the party that had hired me) to wire the payment through, I got paid through good old Paypal, at my suggestion.
I was in Minnesota when the money from Barcelona finally came through; I emptied the Paypal wallet into my account, mentally heaved a sigh of relief that that particular psychosocial worrisome bothersome irritation was over with, crossed off my list of things to be dealt with.

......

Here's the weird part, the gist of this whole story, the juice in the blogpost: Almost immediately with the experience of relief of this formerly noxious situation, I felt a reduction in pain, like someone flushed a toilet in there, and "me" gushing back into my own knee, able to "re-inhabit" it physically, much much better. Such a peculiar feeling.
Slept through the entire night that night, didn't wake up once.
So.
Cool.
The psychosocial aspect of pain perception.

....

I'm back home now, and 8 or 9 days later, I can feel my knee getting better with each day. (FINALLY!)(After 4 months!)
I can do stairs normally now, descending straight down without needing to have a hand on the handrail. I even noticed, today, I led with my left leg! Unconsciously! I could not do that for the entire 4 months the right knee was being a pain. There are still little twinges in it, but I can fully flex it now, just as far as the other knee, and the twinges feel a lot more superficial, medial knee, saphenous nerve, not throughout the entire joint as though it were made entirely of wood and discomfort. Now it's time to work on squatting.

So much more space inside it for "me."
I love endogenous opioids, so much. Especially when they hit at the precise representations in the various somatosensory cortices where they've been dried up for however long an accompanying situation has been grinding along, unresolved. Another neurotag bites the dust! 

DNM 2.0

Totally exhausted, but in a good way, after being in Minneapolis for a week attending a 6-day long seminar that Jason conceptualized and organized, such that all the people out there in the world who are explaining their manual approaches using the stretchy framework of dermoneuromodulating could have a chance to build a new community.

DNM has stretched from standing for dermo, neuro, modulating, to also include everything from "deconstructing/demolishing nonsensical methodologies," to "deep 'n meaningful."

Too many highlights to list everything from every topic or every person, but overall:

1.  I appreciated the inclusion and emphasis on cognition and psychosocial aspects, like Robert Rex's inclusion of narrative medicine, and Erik Ouellet's emphasis on cognitive biases and perceptual fantasies/illusions.

2. I absolutely loved the examination and treatment directed toward cranial nerves, by Julie Porter and Jeff Rockwell. This was a bio part I've been missing all my life, and I think, a missing part for most of us probably. We have plans to bring together a new book, written by Julie and Jeff, with some art provided by me. It will be a separate book for now. (Maybe later, as in someday in the far distant future, a new inclusive edition of the original DNM book will emerge in which EVERY nerve will be included, and the head and body will finally be reunited in manual therapy examination and deployment. But that will have to be a long way away. Meanwhile Julie and Jeff deserve the first round of royalties from all their hard work placing all these cranial and superficial nerves into DNM context, so a separate book will come first.)

3. Brian Rutledge, a Feldenkrais practitioner, spoke for about 10 minutes in a very metacognitive fashion about how he sees cognitive/bio integration.

4. Jason Erikson always thinks in a way that is social first, psycho next, and bio eventually. He spoke about how to integrate change in culture as manual therapists, the manual therapy culture that currently exists, promoted the idea of joining organizations that improve social acceptability of our work, make it more visible. Some of the participants were moved to speak about social inclusion/exclusion, their experiences of having personally felt the impact of discrimination, how they deal or have dealt with it. The feelings were big and traveled through the room, as they usually do when the topic is about the experience of personal injury or harm. I had several thoughts initiated by this, outlined further along in this blogpost.

5. One event stands out in particular: One of the participants had a longstanding inability to flex forward to touch her toes. In fact she couldn't reach much past her knees. Julie asked her to hum while flexing, and she did. Suddenly, while humming, she reached way past her knees all the way to the floor.
It was stunning.
Julie did a little victory dance, and the participant was astonished. Having successfully reached the floor while humming, she did it several more times to make sure it wasn't a one-off, that she would be able to repeat it from then on.
It was the most fabulous example of a distraction technique I have ever seen.
The participant "believed" she could not forward flex her trunk in a standing position. Her brain was kept busy by humming (novel input and output) while bending. Her predictive motor control was interfered with. Her belief that she couldn't flex her back was disconfirmed. Her next job was to integrate all the new information and realize she had successfully crossed a chasm of sorts, a chasm that had existed only inside her own competing neurotags.

6. Such wonderful partying. This is what my own social life consists of, mostly, as I am generally a hermit where I currently live, and because I'm a big-time introvert it suits me just fine these days. But I do love me a good round of being with other people, in a suitable context, where there is deeper meaning and purpose, enjoying rounds. :)

7. It really did feel as though Jason created a context within which DNM is about to go to the next level. I couldn't be more content about that.

..........

I love that DNM is a stretchy enough conceptual container that just about every form of manual therapy (but only the interactive kinds, not the coercive kinds) can find a home in it. It is essentially about:
1. embracing human primate social grooming at its most fundamental, i.e., be kind, purposeful, slow, responsive, intelligent, with physical touch;
2. incorporating widespread biopsychosocial principles which boil down to listening first and talking after (minimally, without nocebo);
3. deliberately dis-including all conceptualizing about any tissue but skin and or nerve;
4. promoting nervous system awareness and handling.

I sit back and think, wow, here we are/here manual therapy is, at the bottom of society's ladder, really, without a lot of respect or acknowledgement for our efforts, which in the end doesn't really matter anyway, because human primate social grooming doesn't require much more nod to society other than a basic license to touch people and it sort of returns the favour. Yet, YET, here we are in all our multiple professional designations, called to them for whatever reason, trying to figure ourselves out and fit in somehow, the non-pharmaceutical, non-surgical alternatives to helping people with pain problems. We are in a similar clinical boat as the psychologists that way, except that we also have the advantage of being licensed to touch people.

All people.
Every person who asks.
This is a huge advantage.

We get to cherry-pick and be as evidence-informed as we could possibly want to be because we know how to read, think, and use scihub to look up all the latest information and scientific literature. We get to freely make up new conjecture, simultaneously weeding out anything ridiculous because now we know we can't just make shit up - we have to be from the start at least scientifically plausible and, if not completely bias-free, at least bias-reduced, because we know about fallacies and all the cognitive biases that exist and can appreciate how science itself is in a similar boat, and that science exists to prune back airy assumptions. We can trust it, and trust ourselves to be better off than we were before we were science-literate. We can deploy science-based consideration of every idea that pops into our head, and weed out all the mutually exclusive ones. We can be Occam's Razor all we want. We can place our work on a platform that is more solid, therefore.
We still get to be as jazzy as we like - but we aren't on crumbling ground conceptually or perceptually anymore.
And pain science and neuroscience are proving to be our best way forward into the future.

Just think: this might be the freest least-confining and simultaneously most challenging field of endeavor any human could possibly choose: we each have a human brain to use - the human brain, thought of as the most complex object in the known universe.
And what do we do with ourselves? We access and work with human brains all day long.
Is that not awesome? The most complex objects in the known universe taking on the most complex objects in the known universe as our daily work.

And here we are, asking those people inside those brains to change their pain perceptions by providing them with a bit of novel stimulus, getting them to disconfirm their beliefs about their pain by a little or a lot.

Picking back up on the thread of the inclusivity of DNM, as I sat back and observed a bit of acknowledged social pain ricocheting round the room for a little while, I reflected on how much stretchier I have become in my own life - in the past I might have squirmed and judged. Some thoughts that might have arisen may have been along the lines of, wait a minute, I'm not here for this - what does this have with learning how to use my hands - this is taking up too much oxygen and is not the focus we should be having - that guy does not know how to keep the room contained, etc.
I might have become impatient and annoyed and blamey.
I watched myself watching and listening and was pleased to note I felt or thought none of those things whatsoever, and instead just waited for the tension to conclude on its own, which of course it did.
I had some political thoughts too.
As a Canadian watching people interacting so close to the bone in an American context close-up, I marveled at how in Canada this would probably never happen. I extrapolated on that thought, comparing the US to all the other more hidebound countries - basically, all the other countries - where tradition dictates everything and freedom to invent new ways to be human don't really exist, although we love to pretend we're just as hip as US people who are constantly inventing new language and new things like internet and new music.
It occurred to me that after the US dumped the monarchy it built a pressure cooker for its citizens, politically, and although it is probably hard to live in it, it has innovated very cool stuff. Furthermore, without all the huge effort people in the US make in terms of social interaction, there would be no social progress anywhere else in the world, or there might be but it would be a lot slower to evolve. For example, as a queer woman (and I have my own definition of that, but totally identify with queerness in general and consider myself part of the queer community) I wouldn't likely have enjoyed my life as much as I have, so far, or come to know myself as well as I've managed to, and in Canada I would never have had access to anything social outside my white-bread rural upbringing and the rather conservative social conditions that accompany it (of which I am acutely aware, having gone back to live in it again, at least for now, but could never succumb to ever again).
So, thank you US people for all the discomfort you endure, having the courage to be vulnerable, speak your truth even though it takes a lot of nerve to do so, living in your social pressure cooker of a country, raising the boiling point so the cognitive and social interaction food can cook faster and be more delicious for everyone including all those who see it then duplicate it (social progress for all formerly dis-included people or groups) in our own respective, probably slower-moving, slow-cooking countries. 
And I sincerely hope that you will manage to deal with the orange menace appropriately when your time comes to vote.

Critique of traditional non-surgical, yet operative approaches

Some papers I’ve gathered up, on page 79 of 85 at this link: https://docs.google.com/document/d/1FJ9jWwUIcEr7kJ07DJMitYW3C0nLHJU_cJoO_U2Rx28/edit#

1. Wellens F;  The traditional mechanistic paradigm in the teaching and practice of manual therapy : Time for a reality check. www.physioaxis.ca © 2010

2. Zusman M. Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for MT. Man Ther. 2002 May;7(2):80-8.

3. Zusman M. Structure-oriented beliefs and disability due to back pain. Aust J Physiother. 1998;44(1):13-20.

4. Zusman M; The meaning of mechanically induced responses.  Australian Journal of Physiotherapy Volume 40, Issue 1, 1994, Pages 35–39 (FULL TEXT PDF)

5. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain.  J Bodyw Mov Ther. 2011 Apr;15(2):131-8.

6. Lederman E; The myth of core stability. J Bodyw Mov Ther. 2010 Jan;14(1):84-98

7. Hartman SE; Why do ineffective treatments seem helpful? A brief review. Chiropractic & Osteopathy 2009, 17:10 doi:10.1186/1746-1340-17-10 (OPEN ACCESS)

8. Pekka Kuittinen, Petri Sipola, Tapani Saari, Timo Juhani Aalto, Sanna Sinikallio,Sakari Savolainen, Heikki Kröger, Veli Turunen, Ville Leinonen and Olavi Airaksinen.  Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.  BMC Musculoskeletal Disorders Clinical diagnostics and imaging Volume 15 (OPEN ACCESS)

9. Sutton C, Nono L, Johnston RG, Thomson OP. The effects of experience on the inter-reliability of osteopaths to detect changes in posterior superior iliac spine levels using a hidden heel wedge.   J Bodyw Mov Ther. 2013 Apr;17(2):143-50

10. Pattyn E, Rajendran D. Anatomical landmark position – Can we trust what we see? Results from an online reliability and validity study of osteopaths. Manual Therapy Volume 19, Issue 2, April 2014, Pages 158–164

11. Video, 7:21 Andreo Spina; The easily fooled nervous system: How immediate changes in NS function are misinterpreted Apr. 9, 2015  (I include this because it’s important to stay humble, faced by the overwhelmingly self-corrective capacity of the nervous system in another person. In other words, we shouldn’t let ourselves take credit for successfully interacting with someone else’s nervous system, or as manual therapists, remain married to invasive or unnecessarily violent forms of treatment.)

12. Lorimer Moseley; Unraveling the Barriers to Reconceptualization of the Problem in Chronic Pain: The Actual and Perceived Ability of Patients and Health Professionals to Understand the Neurophysiology. The Journal of Pain, Vol 4, No 4 (May), 2003: pp 184-189. (FULL TEXT)

13. Troyanovich SJ, Harrison DD, Harrison DE. Motion palpation: it's time to accept the evidence. J.Manipulative Physiol Ther. 1998;21:568–571.

14. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128.

15. Schmid A, Brunner F, Wright A, Bachmann LM. Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilization. Man Ther. 2008 Oct;13(5):387-96

16. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ; The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8 (FULL TEXT)

17. Joel E Bialosky, Mark D Bishop, Steven Z George, and Michael E Robinson; Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb; 19(1): 11–19. (FULL TEXT)

18. Diane F Jacobs and Jason L Silvernail; Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. 2011 May; 19(2): 120–121. (FULL TEXT)

19. Bahram Jam; A new Paradigm in Manual Therapy: Abandoning Segmental Motion Palpation. July 15, 2016 (FULL TEXT) APTEI.ca

20. Adam Fehr’s thoughtful blogpost series about manual therapy (the orthopaedic sort) with lots of references:

1. Manual therapy: What we are NOT doing
2. Manual therapy: What we ARE doing

3. Manual therapy: Treating under contemporary manual framework

Ortho Division in Canada is taking a look at itself, finally.

Is it ever about time, too.

Seriously.

Apparently there was a big meeting recently, and this appeared on twitter:

Physiotherapists are not corn.

(Did I miss something? Did someone imply we were?)

It seems like a response to certain individuals on SoMe who are especially voluble about the way manual therapy continues to conduct its affairs in ways that have been mostly debunked. Alas, the ortho div. seems to want to bolster its fortress instead of coming out of it to join with the rest of us.

"...the OD provides a layered educational system that works for many people in terms of time commitment, cost and structure. It provides a solid framework with which to approach clinical interactions, starting at the tissues and working through whole body regional interdependence."

And that might just be the problem, right there folks. Too tissue-based, too peripheral. Like looking through a telescope backward, such a perspective does not let you see much. Learning about human functioning starting with tissue does not lead to much understanding of humans or of their pain problems.

How about starting with nervous systems first? What they do, besides run commands out to muscles? What they want and need? Is that really so impossible?

.........

I have many thoughts about this:

1. Not only that the entire edifice of ortho PT is built around issues supposedly existing in tissues, but also the huge emphasis on (accurately!) palpating joints/joint movement, which has been found to have little if any interrater reliability. Yet to get your black belt in ortho, you had to have your palpation accuracy given the nod by your instructor. (I remember Bahram Jam admitting that even with his three black belts he still couldn’t really feel anything.)

I went to ortho school many years ago: an instructor described how hard it was to feel joint movement in "dumpy middle-aged women with cellulite." I dropped out about 5 seconds later, because what was the point of learning all this tissue-based, biomechanical joint-based minutia if you could only treat thin people with it? If it did not address pain problems being suffered by moderately overweight people who constitute about half the population? Were we supposed to just leave them out? What nonsense. I knew I could help people with pain problems already, no matter their size.

2. The obvious nocebo inherent in blaming "tissue" for pain problems. Check out Adriaan Louw’s work for more on that. Also Peter O’Sullivan’s.

3. Lack of evidence for what constitutes "good" movement as opposed to "bad" movement.

4. Discomfort (as a recipient) with having one's joints moved instead of one's sensitized(!) nerves considered, then handled carefully.

5. Joints are the deepest thing in the musculoskeletal system. Why go there first? This seems exactly backward. This is a touching profession; we touch the outside of the body first, so why not think about physical contact from the outside in rather than inside out? The outside is actually the most sensitive! Furthermore, movement does not only happen at joint surfaces - it happens throughout all layers and structures and tissues.

.......

"Yes, we still learn about biomechanics (joints do move, after all) but also about the neurophysiology controlling joint and muscle function, movement screening, pattern recognition, pain science and exercise dosage. We are taught to clinically reason, to think in terms of the biopsychosocial model and to treat according to those influencers. It certainly isn’t all mobs and manips. The syllabus has come a long way."

Maybe you are evolving, Ortho Div., but it still looks to me like something that started out the way this did is still going to have all the same problems. Joints are still the centre of the universe in this system, seems to me.  And the whole thing, like the ortho biomedical model, is still resting on top of a Cartesian model of pain. Why oh why do you insist, Ortho Div., on putting the body before its operating system, the brain, and why do you insist on emphasizing motor neurology ahead of sensory neurology? Manual therapy might want to re-think itself in light of the fact that new sensory information is coming in from a well-meaning manual therapist and that brains might be able to use that info to self-correct output, both motor and sensory (ever heard of the Neuromatrix theory of pain by Ronald Melzack?). That would both take the load of responsibility off the therapist AND be more meaningful from a person-with-pain perspective. Please see my humble effort at distinguishing between operator mindsets compared to interactor mindsets.

"The update is now underway and the new manuals will be released in early 2019. Would it have been nice to have them sooner? Sure. But the OD is a large not-for-profit organization, founded and run by volunteers – it’s a big ship to mobilize and refurbish."

About refurbishing the ship, maybe the ship should never have been expected to sail on dry land in the first place. Maybe we need to build a vehicle with wheels. And if it's a cart, the horse should be in front of it, not behind.

Alas, putting the structural body before the sensory nervous system
 in manual therapy training
makes about this much sense. 

I have gone to some trouble and no small pains to develop a model for manual therapy that makes more sense. To me anyway. Here is a list of some 85 pages (at this point) of references to support my point. Oh, and wrote a book as well, linked to the top of the page.