Wednesday, March 12, 2008

Always right?

This is from a certain ortho blog which shall remain nameless and linkless, because I'm not interested in supporting it by sending traffic its way. The author (who I met and had a discussion with online) starts out with some nice thoughts nicely couched, quotes Kipling, then by paragraph three gets to his point, which is to lump dermoneuromodulation (my approach) in with quack-based manual therapy treatments.

Here is the paragraph:
"Yet some in our profession would speak as if this weren't the if some are indeed always right or always wrong. Most notably, these ideologues tend to speak in absolutes with very little equivocation. They will actively recruit easily led individuals and defend the faith at any cost. Questioning is met with often harsh admonishment that you must be part of some central orthopedic conspiracy designed to bring them down. It's the behavior expected of someone who always got picked last for kickball. We've seen it in our daily practice from subluxation-based chiropractors, myofascial release providers, and recently dermoneuromodulation."

So, I get that he thinks I'm an "ideologue", speaking in "absolutes". In that I give the nervous system 100% of the credit for arranging:

a) all autonomous movement of, and

b) all actions (including physiological and pain-reducing) taken in response to perturbation of the conscious human organism in a manual therapy context,

... then I agree, yes I am. Guilty. There's no "faith" to defend at my end. None whatsoever.

I can't help it that this is the only reasonable position that science supports. I can't help it that an "ectodermal derivative"/nervous system-friendly manual approach will always trump any "mesodermal derivative"/ bone-shoving/ muscle-bending/ fascia-stretching/ joint-mobe-ing approach whenever pain and movement dysfunction are chief complaints. These complaints are, after all, what we are supposed to be treating. He still thinks he's treating anatomy, not physiology. It was Butler (author of The Sensitive Nervous System) who first said (in a discussion thread several years ago) "We don't treat anatomy - we treat physiology!" Matthias, the Neurotopian, calls it treating "functionally" as opposed to "structurally".

The blogger reads quite a bit into my conceptualization of what I call the ortho/chiro/meso-digm; I have not ever claimed it is a "conspiracy" - first, it's not that bright, and second, it's identifiable as a collective largely by its collective lack of understanding that science has moved on - really, really moved on!.. in the last 30 or so years when it comes to understanding pain and nervous system function. It's not my fault that manual therapy (with a few notable exceptions) hasn't caught up yet. The mass of PTs out there are still drenched in the same sets of assumptions we were all drenched in a hundred years ago. And they are still producing masses of papers based on those same out-dated assumptions. And they are so proud of this "science" that they won't listen to any voice that suggests to them, however kindly, that perhaps their assumptions are lacking in any way. Again, it's not my fault that the body is set up in such a way that certain specialized portions of it are built for signalling speed and other parts are built merely for structure. I want to work with the signalling part, thank you, not the structure. I want the system I treat to self-correct, because it's a lot less work for me and less confusing to it.

He is insinuating there is a "cult" at work, that there are members actively recruited. Or at least that's the conceptual slag he's providing his readers, in an effort to head them back into his own conceptual fold, perhaps. Or maybe he's truly paranoid.. There is no dermoneuromodulation cult as far as I know. If there is one, I'm it. The only follower and the only teacher.

As far as kickball goes, I never played it, so never was picked last for it. Or for anything else. Perhaps he was, since he seems to know something about the behavior.

Lumping dermoneuromodulation in with subluxation-based chiro and MFR providers is his idea of having the last word, I guess. It's a meaningless statement which only shows his defensiveness and how little he learned from our little encuentro.

He goes on to talk about "science" (by and for the orthodigm), ending with an admonition for his readers not to listen to anything else. A former teacher of mine described this sort of attitude as "Don't think or you'll weaken the team." I maintain that certain pervasive ideology needs to be weakened, deserves to be weakened, and that I have not only full right, but a scientific duty to the profession, to do precisely that, here in my humble blog and anywhere else I might go.

To be fair, I see a ray of hope here and there. Here is an abstract of a paper, Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation, by Annina Schmid et al., in Switzerland, published in Manual Therapy, that with great scientific delicacy exposes the chiro/ortho/mesodigm to some nervous system reality, carefully weaning them away from the idea that what they do with their hands somehow directly translates into improvement for the patient. It actually points out that there are a few papers out there that would suggest that just perhaps other perspectives on the matter may just possibly (but without any of those annoying 100% declarations of course).. exist. Perspectives that include a consideration that a patient's CNS might actually be a willing and participatory and cooperative change agent itself.


Segmental neurological modulation, neural hysteresis and biomechanical effects have been proposed as mechanisms underpinning the effects of manual therapy. An increasing number of studies hypothesise activation of the central nervous system resulting in a non-segmental hypoalgesic effect with concurrent activation of other neural pathways as a potential mechanism of action. Whether this model is consistent with the current literature is unknown.

This systematic review aims to assess the consistency of evidence supporting an involvement of supraspinal systems in mediating the effects of passive cervical joint mobilisation.

We searched randomised trials in three electronic databases from inception to November 2007, without language restriction, and checked reference lists of included studies. We assessed study validity and extracted salient features in duplicate.

Fifteen studies met our inclusion criteria. The overall quality was high. We found consistency for concurrent hypoalgesia, sympathetic nervous system excitation and changes in motor function. Pooling of data suggested that joint mobilisation improved outcomes by approximately 20% relative to controls. This specific pattern suggests that descending pathways might play a key role in manual therapy induced hypoalgesia.

Our review supports the existence of an alternative neurophysiological model, in which passive joint mobilisation stimulates areas within the central nervous system.

Keywords: Treatment outcome; Cervical pain; Neck; Manipulation spinal; Joint mobilisation techniques; Physical therapy" (speciality)

Once joint mobilization can be shown to not do a whole lot as such, then it should be more plausible for the joint mobers to see that it's the contact itself that stirs the brain and accounts for the changes. If they care to include work by Collins, Gandevia etc., in their reading. Which is unlikely to happen probably, unless those authors start to publish in Manual Therapy.

So, there you go ortho-boy. My best to you. As far as I'm concerned this ship left the dock ages ago.

Dec 15/08 Update: As of today, this individual and I have buried the hatchet. He agreed to remove the offending bits from his post, and for that I thank him. He has, of late, come to appreciate the role the nervous system plays in pain, turned a new leaf and apologized for his former attitude. He is forgiven. The tiff has ended.

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