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.