Yet another level

In manual therapy one is taught that one can push bits of body around, and that this makes them feel better to the person whose bits one is pushing.

I call this the "operator model" of manual therapy.

One quickly learns (or should) that manual therapy is much less about the bits one thinks one is pushing, much more about one's speed and force, mostly minimalizing thereof, waiting for the opening, waiting for the person's physicality to let one in.

I call this the "interactor model" of manual therapy.

However, it's quite possible to remain stuck in the operator model for good.
As one proceeds through life one begins to realize that it is impossible to prove to oneself or anyone, through any method, specifically scientific but also logical or philosophical, that what one "thinks" one is doing has any bearing on reality. I.e., you cannot prove, even to yourself, that the SI joint, actually is what you are "feeling" with your fingers, as you perform what has been taught to you as a "test" of its "function." Yes, you can feel stuff... stuff is moving, or not moving, but what one feels moving or not under one's fingers, from on top of skin, has absolutely NO bearing on whether or not a buried SI joint is literally moving. There are many layers and structures all moving on each other between skin and joint, even inside "skin" (cutis/subcutis) itself.

It's merely a convenient assumption. It's a belief. There is absolutely no way to show that it is or isn't moving, or that people can or can't palpate it clinically.

In this case, what do you do? You realize (with a sickening feeling) that you've managed to paint yourself into a conceptual corner. There is no way out, except:

1. ... tromp out over wet paint, spreading dirt and paint.

This is the equivalent of insisting that it's possible, it must be, you've always thought so, your patients' results have always verified your magic-hand ability to ferret out movement/non-movement in the SI (except for when they didn't), therefore the premise must be right. Right? (Those patients who don't fit, well, there are always a few patients who don't fit, outliers, right? We can ignore them, can't we?) Wrong.
Trying to set up tests to "prove" you are right/how right you are is a version of what Harriet Hall calls, tooth fairy science.

2. ... admit defeat, stop thinking about escape, sit in the corner, deal with your feelings, and wait for the paint to dry, however long that may take.

This is the equivalent of waking up yet another rational level on the manual therapy mesodermal mesmerization coma scale, reconfiguring/allowing reconfiguration of your own mentation to accept the facts as they are, including that you were a victim of your own conceptual hallucination, perceptual fantasy, that you were dreaming your own bad-logic dream. But it's OK, you're more awake now, and can move your mind differently, more reasonably. You can now reinterpret your work more correctly as interactive with somebody else's neuromatrix, and whatever it is you think you felt in the past, can go ahead and just be whatever it is/isn't, a mystery of function/dysfunction, not having to have any anatomical identity whatsoever. It will change anyway, just like patterns in clouds change. Continuously. That's a good thing, especially when the patterns are associated with something feeling 'wrong'.


Especially freeing is to know you don't have to prove anything, because there is nothing to prove. Instead from now on you can sit back and disprove, which is a heck of a lot more fun.

Biomechanics and the virgin Mary in a piece of toast

Position statement
My profession has become ever more insistent (since its takeover by fundamentalist orthopaedic specialists) that its members see the world of patient problems as biomechanical in nature and keep treatment concepts "corrective" of "faults" such as "weakness," "asymmetry,""imbalance" and "poor posture."

Biomechanics
These exist. People are physical, and biomechanics are basically what peoples' bodies do to hold themselves up against gravity and move around. They are patterns of movement, nothing more. They are measurable, sort of, and a science does exist around them, but clinically there is not much point in measuring them - they can change radically, depending on how people feel, whether someone is experiencing pain or not.

I definitely look at biomechanics. We all do. They are useful as feedback to our own therapist visual cortex to gauge if our treatment is being effective or if we should change course.

But biomechanics are like cloud patterns. They will shift anyway, should not be made into more than what they are - sudden changes should not be assumed to be "proof" (explicit or implicit) that "I, therapist," am therefore great.

Patterns on toast
These also do exist, although there is no science as far as I know. They are a natural function of burning a piece of bread. They should not be made into more than what they are - burnt spots. Neither should biomechanics.

Pareidolia
This is the name of a well-recognized perceptual fantasy: people read faces or pictures into patterns on toast or in clouds or whatever, see something that isn't there and which has no bearing whatsoever on the nature of the material they are gazing upon.

Finding "fault"
This is a common human trait. Sometimes "fault" actually exists. Lots of times it does not, and "fault"-finding is mere perceptual fantasy, like pareidolia, i.e., visually projecting onto an external object something that has nothing to do with anything but one's own personal (usually incorrect and off-target) mentation.

Finding things in biomechanics, then labelling them as "weakness" or "imbalance" or "poor posture" is value-judgy. Considering value judgments worthy of categorically diagnosing and treating is to somehow believe that value judgments can be objectified - they are not objectifiable, scientifically, IMO, because value judgments are not objective to begin with. Nevertheless they persist as a collective pareidolia, and people keep trying to couple them with biomechanics, keep cranking out papers full of implicit and explicit linkages. Excuse me - I think there is something wrong with that.

This is me, finding fault.

Prior plausibility
This is something that scientific investigation requires in order to even be scientific. There is no prior plausibility in linking biomechanics (expression of motor output or expression) to fault-finding; correlation is NOT causation, it isn't scientific, instead it leads to conceptual hallucinating all over the place. Conceptual hallucination often results in something known as pseudoscience.

Ritual
This is common human behaviour done to restore order to a universe that seems to go cockeyed viewed from a subjective standpoint. It's magical behaviour in that:

• there is no discernible connection in natural law between cause and effect, only in the mind of the conductor
• it helps the ritualist feel better; when conducted excessively, this attempt-to-feel-better behaviour is known as OCD (obsessive compulsive disorder).

When done regularly in a group setting, this is known as "religion" (e.g., Roman Catholic)

What does this have to do with PT?
There are different camps within PT. Using the religion metaphor, there are:

• Hard-tissue fundamentalists - these are the orthopaedic specialists who are convinced that orthopaedic manual therapy is the most smiled-upon. They have taken over the profession, pretty much. People practically bow as the high ortho priests pass by. There are systems in place wherein you can work your way up a hierarchy and earn a black belt in ortho manual therapy. Each stage requires one to drink ever-stronger Koolaid. There are tests to pass. Orthos are identifiable by their strict adherence to biomechanical concepts conflated with value-judgments about joint movement, elaborate rituals devoted to improving joint movement/mobility/function which they suppose will lead to heaven - er, I mean, better movement/less pain. In the last couple decades there has been an influx of dry needling as an added ritual. If cracking it or jiggling it doesn't work, poke it. There are many sects/gurus/professions with this stance outside PT.
  
• Soft tissue-ists: these are everyone else, mostly the stretch/strengthen/exercise crowd but their numbers include all manual therapists who don't do manipulation of a high-velocity kind. They might have different rituals but they still all see Mary-in-toast: they still all think various mesodermal derivative the source of all evil (pain), that the altar is whatever gym ball or equipment they put their patient on, or machine they hook them up to, and that their hard work to strengthen/lengthen/massage/release it (magically, from the outside of someone else's body, and continuing the "fault-find" in toast patterns) is the way to proceed (make an appropriate sacrifice/make a living).

Then there is me. What makes me different?
I checked out the two main sects of PT, but liked neither of them. Became an atheist PT and manual therapist/atheist/heretic/apostate beside being an ordinary atheist, even while continuing to practice hands-on therapy, which I reframed as human primate social grooming, in order to

• make it more palatable to myself
• make it more "scientific" to myself, more in line with evolutionary biology
• make it more compatible with neuroscience/pain science

Did fewer rituals, less and less of the time. Mostly wandered around in the desert. Found the oasis - neuroscience and pain science. These tell me that biomechanical patterns aren't important (which suited my own confirmation bias) and freed up even more hard drive to examine what the humanantigravitysuits standing in front of me every day really needed from me in the way of understanding and treatment.

Not much, as it turned out. No rituals, really. Just a bit of engagement, handling, education, reflection, support, encouragement, help, reinforcement, suggestions for pain management.