Thursday, September 06, 2012

Deep versus shallow models of manual therapy

A long time ago, shortly after I moved online and joined discussion groups (way back in 2001), I encountered Barrett Dorko, who was the first PT I had ever met who differentiated between what he called deep models of manual therapy versus shallow models. It made sense to me. 

Deep models seem to line up well with knowledge of science in general, understanding of neuroscience in particular, and logical deconstruction of the pretence that we, manual therapists, can actually have any direct physical impact on somebody else's (i.e., a patient's) tissues that would result in a therapeutic outcome. 
I could relate. In my mind, deep models equate with what I call "ectodermal" models - "interactor" models. It's where I've always wanted to see PT go - more emphasis on "therapy" - less on "physical". 

Shallow models line up with everything I detested (and still detest) about manual therapy - a tissue is chosen as a target, then an entire world-view built around it, including a whole set of ritual interventions directed toward said tissue target. 
Tissue targets range from the most deep (spinal joints) to the most superficial (fascia, head sutures); muscles, ligaments, tendons - pick some part - any part - of the movement conglomerate, or passive elements that are there to keep it from falling apart! - then have at it. 
Build an entire religion around "correcting" it. 
A large vocabulary is invented, based on pareidolic assessments of biomechanics which are asymmetric and therefore "faulty". These observations are welded to pain manifestations. Therapist "corrects" the "faulty" biomechanical appearance of a person's posture, or position, or movement, and voilá, if the pain diminishes, it has "proven" the therapist's religious-like world view about what was "wrong" in the first place. It's like driving forward while looking in a rear view mirror. 
These are the shallow models.  These line up with what I call "mesodermal" or "operator" models. 

I recently devised a flowchart of sorts, exposed it to my peers, got good feedback, revised it a few times, and posted it to Facebook, where it went out into the world a little way. Here it is again. (Click on it to make it big.)

In my opinion, the problem stems back to language, and particularly to the human brain's difficulty with recognizing that as soon as nouns are applied to treatment, the life gets sucked out of treatment as encounter between two human beings. Life is sucked out of the verb of the encounter, out of the encounter as verb. As process. As something that has a beginning, and a middle, and an end. Like a story. Like a story built by two people, interacting, not by one person who thinks they know everything about everything and treats the other like an object

More information:

1. Beyond the technique- from Operator to Interactor BlogTalk radio podcast interview with Diane Jacobs and Jason Silvernail

2. "Touch is good" - HumanPrimateSocialGrooming manual

3. Manual therapy and its treatment models (google doc)

4. Diane F Jacobs*, PT and Jason L Silvernail, DPT, DSc, FAAOMPT; Therapist as operator or interactor? Moving beyond the technique.  J Man Manip Ther. 2011 May; 19(2): 120–121. (*FYI: This is my only pubmed publication - any other "Jacobs DFs" out there are not me)

5. New Treatment Encounter (I-VI)

6. DNM in a Nutshell

7. Boiling down the problem


Taya Countryman LMP said...

I really like your article although you used some big words that I don't usually use and unfortunately being a massage therapist without a science background the chart as hard to look at. So am I correct that we need to meet the patient's body where it is, use a variety of pressure and treatments to decrease their symptoms instead of just diving into what we "think" they need? Please correct any faulty thinking.

Diane Jacobs said...

Hi Taya, thank you for your interest. Mostly this post is about examining our own belief systems, really, really closely, and when it comes to treating patients, always putting their nervous system's responses first, ahead of whatever manual treatment "technique" we may have learned last weekend.

Anonymous said...

Love you blog. Have tried to subscribe to it, but I can't pick up the feed with Google reader either by dumping it in directly, or by using the feed button on your blog.

"The feed requested can not be found"

Is RSS turned off on your blog or something?

Diane Jacobs said...

Hi anon,
I have tried to figure out how to turn on whatever needs turned on in order to allow people to subscribe to this blog, but alas, I'm just not geeky enough to figure out the trick, and don't have access to a 10-year old who could help. So sorry. It's all my bad.