Saturday, March 10, 2012

Dermoneuromodulation: Where it came from

Dermoneuromodulation represents my personal effort to make sense out of manual therapy in general. Manual therapy gradually evolved. 
Given the advances in neuroscience in the last couple decades, and concomitant advances in pain science (although slower), ideas upon which manual therapy bases itself are due for overhaul, in my opinion, by starting further back than mere production of ever more outcome studies. Todd Hargrove, a thoughtful blogger, nails it perfectly in his post, Souless bodies and bodiless souls (3); 
"..vitalism and structuralism are two sides of the same dualistic coin..Vitalism is an example of belief in a “bodiless soul.” Vital energy is considered to be an animating force that exists outside the physical realm and is not reducible to it. And structuralism is the metaphorical flip side of the coin – the tendency to treat the body as a physical object, as opposed to an intelligent agent with feelings, thoughts and intentions.
Scientific study of manual therapy
Manual therapy teaches a bunch of stuff about "proximate cause (1)." Manual therapists want to, and are taught to, take on the role of "operator(2)", not just humble interactor. 
the questions themselves 
We seem to think that manual therapy can't be studied scientifically unless it can be isolated and specific effects determined. Problems arise with study designs, and poor interrater reliability seems ubiquitous. Even when separate outcome studies are good, the results don't seem to be able to stand up to statistical analysis very well (16,17). Could it be we asked wrong questions in the first place? 

Rethinking the problem of pain
People who come for manual therapy come because they are experiencing pain (or some sort of discomfort with their body), usually. 
Melzack(5) puzzled over pain for decades and finally concluded it was not an input, it was an output (see neuromatrix diagram here). He at least got us (manual therapists) that far, by separating nociception (an input) from pain, a brain output - he de-Cartesian-ized pain - not an easy task; it meant moving in opposition to 400 years of medical science which claimed pain was a bottom-up phenomenon (and still does, as do most forms of manual therapy). Melzack realized pain was biopsychsocial in nature, something that had to do, perhaps, with being lost in one's own embeddedness into, and ideas about, externalized reality, or not sufficiently aware of one's own physicality, or both, not able to detach from either when desired. His model is brilliant, clinically useful, and best of all, non-dualistic: we treat conscious, living people after all, not anesthetized patients. We are forced to interact - we do not have the luxury of (merely) 'operating' (2). 
Another perspective on the same matter is offered by Quintner(6), who argues that far from being something that can be disassembled into bio-, psycho- or social components, pain is an aporia, which is to say... 
"...a space and presence that defies us access to its secrets. We suggest a project in which pain may be apprehended in the clinical encounter, through the engagement of two autonomous self-referential beings in the intersubjective or so-called third space, from which new therapeutic possibilities can arise."
I see parallels between manual therapy with its attendent problems, and what I found in a revealing blog post interview (about psychiatry) with Richard Marken, discussing Perceptual Control Theory (7): Instead of looking at a human being from "outside" that human being, and his or her own "behaviour" (including pain "behaviour") as a problem of input/output, we could try to look at the behaviour itself as a process of control, by the organism itself/himself/herself

So, rather than flailing about with manual therapy as my only tool, a tool, furthermore, honed and contaminated by centuries of Cartesian misunderstanding, I adapted myself to new information. Now I consider manual therapy to be just a tiny part of the process of interacting with people who have come in as patients with pain problems. Providing them with a boundaried therapeutic relationship is far more useful to them in the long term. The hands-on part may be both optional for some and optimal for others. But all  PT patients will benefit by understanding simple facts about the nervous system and pain science (4) (however awkwardly confused, bottom-up, Cartesian such information may still be), couched in a framework such that it lays no blame on them or any of their body parts/mesodermal derivatives for having it, and at the same time leaves them with the locus of internal control they need for extracting their own conscious awareness out of it once more.

Is a new awareness is dawning in manual therapy?
I think maybe there might be (8-15). 

2. Operator/Interactor model (Diane Jacobs)
3. "Soulless Bodies and Bodiless Souls" (Todd Hargrove)
4. New treatment encounter Part I (Diane Jacobs)
5. Melzack R; From the gate to the neuromatrixPain. 1999 Aug;Suppl 6:S121-6.

6. Pain Medicine and its Models: Helping or Hindering? (John Quintner et al)

Quintner, J. L., Cohen, M. L., Buchanan, D., Katz, J. D., & Williamson, O. D. (2008). Pain medicine and its models: Helping or hindering? Pain Medicine, 9(7), 824–834. doi:10.1111/j.1526-4637.2007.00391.x

7. Does Psychology Need a Revolution? An Interview with Richard Marken on the Radical Implications of Perceptual Control Theory. 

8. Bialosky JEBishop MDGeorge SZRobinson MEPlacebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb;19(1):11-9. (free access)

9. Bialosky JEBishop MDPrice DDRobinson MEGeorge SZThe mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model  Man Ther. 2009 Oct;14(5):531-8. Epub 2008 Nov 21. (Open access)

10. Bialosky JEGeorge SZBishop MDHow spinal manipulative therapy works: why ask why? J Orthop Sports Phys Ther. 2008 Jun;38(6):293-5. Epub 2008 May 27.

11. Lucas NMacaskill PIrwig LMoran RBogduk NReliability of Physical Examination for Diagnosis of Myofascial Trigger Points: A Systematic Review of the Literature  Clin J Pain. 2009 Jan;25(1):80-9.

12. Maher CGLatimer JAdams RAn investigation of the reliability and validity of posteroanterior spinal stiffness judgments made using a reference-based protocol. Phys Ther. 1998 Aug;78(8):829-37.

13. M. J. Hancock, C. G. Maher, J. Latimer, M. F. Spindler, J. H. McAuley, M. Laslett, and N. BogdukSystematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 October; 16(10): 1539–1550.
Published online 2007 June 14. doi:  10.1007/s00586-007-0391-1 PMCID: PMC2078309

15. M. Zusman, "The Modernisation of Manipulative Therapy," International Journal of Clinical Medicine, Vol. 2 No. 5, 2011, pp. 644-649. (open access)

16. Rubinstein SMvan Middelkoop MAssendelft WJde Boer MRvan Tulder MWSpinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008112.

17. Rubinstein SMvan Middelkoop MAssendelft WJde Boer MRvan Tulder MWSpinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine (Phila Pa 1976). 2011 Jun;36(13):E825-46. 

1. Dermoneuromodulation (diagram, gearing up)

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