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Visceral Manipulation Embraced by the APTA

Many years ago, when I was a naïve and gullible teenager, I read about a home treatment for constipation that involved rolling a bowling ball around on the abdomen. I was intrigued, thought it sounded reasonable, and might even have tried it myself if I had been constipated or had had a bowling ball to experiment with. Many decades later, with the advantages of a medical education and experience in science-based medicine and critical thinking, I encountered a treatment that reminded me of the bowling ball: visceral manipulation (VM), a practice developed by a French osteopath and physical therapist, Jean-Pierre Barral. This time I was far more skeptical. VM may be more sophisticated than a bowling ball, but its effectiveness and safety are equally dubious.

Visceral manipulation (VM) will probably be unfamiliar to most of my readers, but its promoters say it has been adopted by osteopathic physicians, “allopathic” physicians, doctors of chiropractic, doctors of Oriental medicine, naturopathic physicians, physical therapists, occupational therapists, massage therapists and other licensed body workers. Its origin follows the path of many other alternative health systems. Like chiropractic, ear acupuncture, iridology, EMDR, and others, it was developed by one individual based on his personal observations and experiences without any kind of proper testing. Like the others, it started with a single patient: in Ignaz von Peczely’s case an owl with a spot on its iris, in D.D. Palmer’s case a janitor whose hearing allegedly improved after something was done to his back, in Barral’s case a patient who said he had felt relief from his back pain after going to an “old man who pushed something in his abdomen.” From a single case they extrapolated to a general belief about disease causation and a whole diagnostic and/or treatment system.

How is VM Done?

A video shows Barral demonstrating his skills.  He “listens with his hands” to detect tension (elsewhere the perception is designated as a thermal phenomenon). His diagnostic process begins by “listening with the hands” on the top of the patient’s head to determine the lateralization or general area of the problem. Then his hands “listen” to the areas of concern to further localize the problem.  In this demonstration he detects something in the stomach which he says could be from decreased acidity or emotional tension. Then he listens to the skull repeatedly with both hands, does something simultaneously to the neck and abdomen, and finally he is satisfied that his hands are telling him that he has corrected the problem.

The Underlying Rationale

From the Barral Institute website:

Therapists using Visceral Manipulation assess the dynamic functional actions as well as the somatic structures that perform individual activities. They also evaluate the quality of the somatic structures and their functions in relation to an overall harmonious pattern, with motion serving as the gauge for determining quality.

 The visceral system relies on the interconnected synchronicity between the motions of all the organs and other structures of the body. At optimal health, this harmonious relationship remains stable despite the body’s endless varieties of motion. But when one organ cannot move in harmony with its surrounding viscera due to abnormal tone, adhesions or displacement, it works against the body’s other organs, as well as muscular, membranous, fascial and osseous structures. This disharmony creates fixed, abnormal points of tension that the body is forced to move around. In turn, that chronic irritation paves the way for disease and dysfunction throughout many systems of the body – musculoskeletal, vascular, nervous, urinary, respiratory and digestive to name a few.

Barral says the organs remember physical and emotional traumas, and each organ is connected to specific emotions (!). He says “structural relationships” (peripheral, spinal, cranial) can self-correct after VM. He says that each internal organ rotates on a physiological axis. He says organ problems profoundly affect the spine.

Each organ has a regular intrinsic oscillatory motion that follows lines of embryologic migration. This motion resembles, but is distinct from, the craniosacral rhythm [a delusion accepted only by craniosacral practitioners]… If the kidneys are moving out of phase, with one moving inferiorly while the other moves superiorly, this side bends the spine every 3.9 seconds. This small motion is like water drop torture for the spine, resulting in a repetitive motion injury.

Strains in the connective tissue of the viscera can result from surgical scars, adhesions, illness, posture or injury. Tension patterns form through the fascial network deep within the body, creating a cascade of effects far from their sources for which the body will have to compensate. This creates fixed, abnormal points of tension that the body must move around, and this chronic irritation gives way to functional and structural problems.

Where’s the Evidence?

This is fantasy, not science. Adhesions do exist and certainly can cause problems, especially after surgery, but Barral claims they are widespread. For instance, he says they form around the heart in whiplash neck injuries. There is no evidence that they are responsible for symptoms of all the conditions Barral claims or are even present in those conditions, or that disrupting them improves health. And there is no evidence that Barral is actually disrupting adhesions and no reason to think that gentle manipulations like his could possibly do so.

The Barral Institute website  claims that “Comparative Studies found Visceral Manipulation Beneficial for Various Disorders” including a long list of everything from whiplash to PTSD, from menopause to urinary reflux; but I have been unable to locate any such studies.

I won’t even attempt any evaluation of the literature, because there’s nothing worth evaluating. The extensive bibliography provided on the website is not helpful. It provides links to popular articles by Barral, to published studies that are not pertinent to VM, and to a few uncontrolled pilot studies and case reports where the clinical significance of the reported changes is uncertain or where any observed improvement can’t be attributed to VM itself. The bibliography reveals that VM has suspicious bedfellows: it is related to energy medicine, craniosacral therapy, zero balancing, Upledger’s bizzare ideas, neurodevelopmental therapies, and other dubious concepts.

Is It Safe?

I think we can reasonably assume that any abdominal manipulation sufficient to disrupt adhesions would risk tissue damage and internal bleeding, but VM is not likely to do that. As practiced, VM amounts to relaxation, suggestion, and gentle massage; so it is not likely to cause physical harm unless it replaces other, effective treatments. It’s more likely to cause harm to the wallet and to critical thinking.

The APTA Goes Astray

The American Physical Therapy Association is trying to establish evidence-based clinical practice guidelines.   The Women’s Health Section  features a prominent link to CME courses on visceral manipulation offered by the Barral Institute.

J.W. Matheson, a physical therapist in private practice and a long-time APTA member, wrote the organization to protest their promotion of pseudoscience. He provided supporting documents and said,

Visceral Manipulation is a pseudo-scientific practice that belongs outside of the field of physical therapy.  The practice of visceral manipulation is not consistent with the vision and mission statements of the APTA.

Carrie Schwoerer, the Director of Education, replied with an astonishing letter. Here are some of her more alarming statements:

Our course offerings are based on the model of evidence informed practice, which Sackett defined as balancing clinical research with clinical experience and patient values. Some of our course offerings… were… based on extensive review of the literature and are clearly advertised as evidence based.

Other aspects of physical therapy practice reflect the clinical experience of the physical therapist providing care and the values, which the patient views as critical to their healing process… some of these techniques have not been validated by the more rigorous clinical research protocol because we have yet to develop measurement tools that could undergo appropriate testing… Adhering to clinical research as the only valid evidence is a disservice to patients who have responded time and again in case studies to so-called “pseudoscientific” interventions and threatens to undermine future innovation in the field.

The Board of Directors… embrace the instruction of visceral mobilization under the tenets of clinical experience and patient values. We disagree that this is pseudoscientific in nature but also recognize that clinical trials do not support its use and therefore do not advertise as evidence based. If individuals are not comfortable with the level of evidence supporting this coursework, there is no obligation to take it for any of the SoWH certificates or to sit for the WCS.

In other words, “We don’t need no stinkin’ science! We support any treatment that can provide positive anecdotes. We believe the plural of anecdote is data. Instead of offering guidance, we’ll let our members sink or swim: we’ll make them responsible for knowing ahead of time how much evidence supports a treatment and deciding whether they believe it is sufficient to merit a personal decision to study it.”

This is beneath contempt. I don’t think I need to elaborate. Another formerly respected organization has drunk the CAM Kool-Aid.

Posted in: Energy Medicine, Science and Medicine

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111 thoughts on “Visceral Manipulation Embraced by the APTA

  1. DrRobert says:

    This must be frustrating for PTs who want to lead a science-based career. Obviously they can still be science-based, but to have the professional organization adapt quackery… well that just sucks. I respect PTs, but they still have a bit of quackery (well, at least treatment modalities that are completely ineffective) that needs to be shaken out of their practice. It doesn’t do anyone any good to be adding in stuff like this.

    Massage therapists in our area advertise on TV that they can fix surgical adhesions. Sigh.

    I posted this in another thread, but this seems very appropriate:

    Chiropractors have invented a new disease: “ileocecal valve syndrome.” It’s apparently responsible for everything from dark circles under the eyes, PMS, anxiety, tiredness, or even back pain. They claim that they can manipulate the vertebrae and “fix” your ileocecal valve.

    http://drvittoriarepetto.wordpress.com/2009/05/23/what-is-an-ileo-cecal-valve-and-how-is-it-related-to-your-digestive-health/

    Quack, quack, quack.

  2. Janet Camp says:

    I have always attributed my full recovery from rotator cuff surgery to the physical therapy–which I always assumed was completely science-based. I will be more skeptical in the future. Are there ANY professional organizations left who HAVEN’T drunk the Kool Aid of “integrating” dubious practices into their fields? Their rationale for doing so is deeply disturbing in relation to the failure of the educational system (especially higher education) to weed these critical thinking errors out.

  3. David Weinberg says:

    Dr. Hall,

    I think there may be something to this manipulation stuff. I had a visceral reaction just reading about it!

  4. kathy says:

    Yet another quack system … is there ever going to be any limit? The number grows more every year. Without science to limit what may or may not be preached or practiced, the only limits left are the imagination of every kook and his/her concience … if any.

    And is insurance obliged to pay for each and every one of these ever-more-weird treatments? Will there ever be a line drawn? On what basis can we say: this is acceptable, but that is not? Scientific testing, and even basic chemistry and physics, are no longer allowed to determine how we decide. Politics and political correctness will be the deciders.

    Of course the insured are the real payers for everyone’s favourite woo … certainly the insurance company will make sure that they are not financially down at the end of the fin. year. Costs as always will be passed on to the clients.

  5. Scott says:

    So sCAM is up to what, now? The Ninety-Seven True Causes of All Disease? (Precise number comes from the same place as 98% of all statistics.) All exclusive to one another, of course, yet nobody seems to notice that. Holding two contradictory thoughts at the same time seems positively plebian in comparison.

  6. Zetetic says:

    This practice also has some parallels with the assessing and balancing of energies claimed by Therapeutic Touch and Healing Touch proponents. Then – It’s combined with some massage woo!

    However, I dimly recall something I was instructed to do at an army hospital in the 1960s with quadriplegics that was somewhat effective . To stimulate bowel movements, we manually massaged the patient’s abdomen. I think it was referred to as “triggering”.

  7. David Gorski says:

    Ack! I frequently use a line about chiropractors that usually gets a laugh and, as far as I know, I originated, specifically, “Chiropractors are physical therapists with delusions of grandeur.” Inherent in that line is the assumption that physical therapy is science-based, while much of chiropractic is not. After this, I might have to rethink my line. I don’t want to (it’s a great line and physical therapists can do amazing things), but if the APTA keeps this up, I’ll have no choice.

  8. jmilan says:

    I teach at a PTA program and reading this is just incredible frustrating. It is complete nonsense and I would like to think that the majority of the profession is not susceptible to these inane concepts, but apparently it goes all the way to the top. I place significant effort in teaching my students the skill of critical thinking and to understand the value that science offers the profession. I hope that our educational programs at both the PT and PTA level can effectively incorporate these skills to produce professionals that can reason through the mess that is out there.

  9. David Gorski says:

    One other thing: The only way visceral manipulation “works” is when surgeons operate and directly “manipulate” a patient’s anatomy. :-)

  10. arufa says:

    First of, by no way do I condone any support by any part of my profession or professional organization of crap like this. Visceral manipulation is non-scientific and very far from the core principles of the PT profession and the APTA.

    However, to paint the APTA and the PT profession as embracing CAM because of one link and one comment from a tiny, sliver of the professional organization is misleading. The Women’s Health Section of the APTA is very small and it is very insignificant. The APTA is broken down into many parts and there is some autonomy given to these sections (women’s health section being one of the smallest). The APTA has a very clear mission of promoting scientific and evidence based practice. This very small example, although disturbing, is hardly a representation of what the APTA stands for.

    With that said, in the PT profession (as with all medical professions) we need to be vigilant about keeping our house clean of this type of non-sense. I will practicing my vigilance with a nice letter to the president of the APTA and the head of the Women’s health section to express my concern about this subject.

  11. arufa says:

    First of, by no way do I condone any support by any part of my profession or professional organization of crap like this. Visceral manipulation is non-scientific and very far from the core principles of the PT profession and the APTA.

    However, to paint the APTA and the PT profession as embracing CAM because of one link and one comment from a tiny, sliver of the professional organization is misleading. The Women’s Health Section of the APTA is very small and it is very insignificant. The APTA is broken down into many parts and there is some autonomy given to these sections (women’s health section being one of the smallest). The APTA has a very clear mission of promoting scientific and evidence based practice. This very small example, although disturbing, is hardly a representation of what the APTA stands for.

    With that said, in the PT profession (as with all medical professions) we need to be vigilant about keeping our house clean of this type of non-sense. I will practicing my vigilance with a nice letter to the president of the APTA and the head of the Women’s health section to express my concern about this subject.

  12. j30 says:

    As a physical therapist and an APTA member, I would like to make clear that the endorsement made by the specialty section of the APTA does not reflect the values and goals of the profession or the APTA at large.

    I’m about 6 years out of school, but even then, evidence-based medicine was a central part of our curriculum. Even more research classes have been added to the programs around the country.

    As noted above, I do recommend that patients check into a practitioner before they begin treatment, as they should with any health care provider. Unfortunately, there is a very small percentage of our profession which has swallowed the kool aid on various pseudosciences. I don’t have actual statistics, but my best guess is that 80-90% of PT’s are much closer to the evidence-based end of the spectrum. We do need to rely somewhat on our personal experience, but experience should inform evidence, not vice versa.

    I hope the APTA takes this opportunity to step up and clearly make it known that we are a profession that places evidence above anecdotes.

    As a side note, I’m wondering if the APTA actually endorses the statements made by Carrie Schwoerer. Each section within the APTA is a separate specialty, with its own governing body and individuals capable of making statements that are out of accordance with professional values.

    I applaud Dr. Hall on calling our national organization out on their endorsement. I hope this becomes a jumping-off point for a productive discussion regarding how we can better self-monitor our profession.

  13. DrRobert says:

    @arufa – what is your opinion of myofascial release? I found two reviews, one on MF and the other on rolfing, which seems to be MF x 10 treatments. Both reviews were negative.

  14. cervantes says:

    FYI, I have entirely lacked an ileocecal valve for 20 years, having undergone a right hemicolectomy. I have no dark circles, tiredness, low back pain, or anxiety. Have never consulted a chiropractor either. Just sayin’. (Would like to have the colon back anyway, but what can you do?)

  15. arufa says:

    DrRobert,

    First we need to define what myofascial release is, which is difficult. If you are talking about myofascial release as describe by John Barnes and his followers then I would say it is complete and utter non-sense. PTs will often talk about myofascial release and what they really are talking about is just massage or soft tissue mobilization. I think there may be some utility to soft tissue mobilization but why it works or even if it works is still questionable. I think if you are going to use it, it should be done sparingly and for a short duration.

    Check out this debate about the topic: http://www.somasimple.com/forums/showthread.php?t=1841

  16. MathesonJW says:

    I am an avid reader of the blog and appreciate Dr. Hall taking the time to highlight the pseudoscientific practice of visceral manipulation. From some of the emails I have received this afternoon, I wish the title of the post would have ended with “Section of Women’s Health (SOWH) of the APTA” versus the “APTA.” Some comments (j30, arufa) have addressed this above.

    The APTA (www.apta.org ) is my professional association along with 80,000 other physical therapists, physical therapist assistants and physical therapy students. This represents roughly 40% of the PTs in the US. The mission and vision of the APTA clearly supports and recommends evidence based practice. As others have commented above, the APTA consists of 18 sections (http://www.apta.org/Sections/ ), each which have their own bylaws and board of directors. The SOWH is a younger section and indeed one of the smaller sections. Please don’t confuse the actions of a single section with those of the APTA in general. What I confronted on the SOWH website would not be posted on the research section website, the orthopedic section website (www.orthopt.org), etc. In addition, the APTA itself is very careful what it posts on the consumer site at http://www.moveforwardpt.com. So, this is exactly why I felt it necessary to confront the SOWH board. Unfortunately, their response was depressing, as it shows that the SOWH board just doesn’t get it.

    Many of us within the APTA practice science-based medicine and are the first to challenge a section’s support or a member’s support of such pseudoscientific practices as visceral manipulation, craniosacral therapy, etc. We don’t want to see these unwarranted practice variations within our profession or our clinic practices. For the most part, these pseudoscientific techniques are not taught in physical therapy academic programs, rather they are taught in weekend courses across the country. From my observations, PTs are drawn toward these pseudoscientific techniques in exactly the same way patients, physicians and other medical providers are drawn to the various forms CAM. They become personally and emotionally attached to these interventions despite the lack of evidence or even the lack of plausibility (as Dr. Hall illustrates nicely) for the intervention. They refuse to accept, and then become afraid to accept, that what they practice is silly at best and harmful at worst.

  17. stanmrak says:

    The argument here seems to be that unless science has proven something is true, it can’t possibly be.
    Using that logic, the earth could not have revolved around the sun until Galileo proved it (or was it Copernicus?).

    Sorry… science doesn’t have all the answers, even in 2012.

  18. daedalus2u says:

    Stanmrak, this isn’t about science, it is about doing random made up crap on patients without telling them that it is random made up crap with no theory or clinical trials backing it up. And charging them for it.

  19. lordshipmayhem says:

    He “hears with his hands”. And all these years I’ve been using my ears.

  20. Harriet Hall says:

    @stanmrak,

    “The argument here seems to be that unless science has proven something is true, it can’t possibly be.”

    Not at all. You are misreading or misunderstanding. The argument here is that when something is improbable and there is no evidence to support it and there is a good psychological explanation for how people have fooled themselves into believing in it, we can reach the provisional conclusion, with a high degree of probability, that it is not true.

    Science hasn’t proven the moon is made of green cheese. I suppose it could “possibly” be. I think it is highly unlikely.

    “Science doesn’t have all the answers”

    No one said it did. But science does have a lot of good questions, and the scientific method has a better track record in answering those questions than any other system.

  21. Harriet Hall says:

    @arufa,
    “to paint the APTA and the PT profession as embracing CAM because of one link and one comment from a tiny, sliver of the professional organization is misleading.”

    She could be in a minority, but she has been put in a position to speak for the organization. I will gladly change my opinion if there is a strong protest from members, if the leaders of the organization speak out against the comments in the letter, if they remove the offending link from their website, and if they strongly re-affirm their understanding of science and their adherence to good scientific evidence.

    Not holding my breath, but willing to be pleasantly surprised.

  22. arufa says:

    Dr. Hall

    She is in a position to speak for a very small section of the organization, not the organization. It would be like saying the mayor of my hometown of Fort Covington, NY (population about 2,000) can speak for the entire state of NY because he is part of the government (yes this is a bit of an exaggeration).

    Either way, I agree with you that the leaders of the organization needs to speak out and make it clear that this is not the policy of the organization. Lets hope that happens.

    I would not expect a strong protest from members because, again, the Women’s Health Section is inconsequential and very few members will even know that it is an issue.

    I have emails into several people high up in the APTA and will let you know if I get a response.

  23. DrRobert says:

    @stanmrak, that is nonsense. Medicine cannot exist in a society where whackos can just “invent” things and declare that we must accept them as true until they are proven false. Alternative medicine has operated in this way for far too long. Legitimate medicine can not and will not.

  24. Harriet Hall says:

    @arufa,

    A mayor is not hired by the state and does not issue official correspondence on state letterhead. I contend that she was hired by the organization and if she is issuing statements identified with any part of the organization and is misrepresenting the organization’s policy, the organization should put a stop to it. I hope your e-mails get a favorable response. The APTA’s efforts to develop evidence-based policies are laudable in general, which makes this slip-up just that more regrettable.

  25. Jason Silvernail says:

    As a Physical Therapist, I am extremely disappointed in the response of the Women’s Health Section to JW Matheson’s letter.

    This is not the first time that Physical Therapists have publicly fought questionable claims and practices among their colleagues. In 2008, myself and several other PTs were threatened with a lawsuit for our discussion of the “John Barnes Myofascial Release” method. In our US legal system, it is a “pay to play” system, so those with lawyers and money win over those with neither. Since neither I nor my fellow bloggers had the estimated $30,000 to contest the case in court, we were forced to retract the material. You can see some of that on the Evidence in Motion blog here: http://blog.myphysicaltherapyspace.com/2008/08/myofascial-rele.html
    I’m told the original material was picked up and reposted elsewhere on the web but of course I don’t have any control over that and I don’t have an extra $30,000 lying around so I can’t link to it here – you’ll have to find it on your own if you are interested. Penn Jillette once said that about the worst thing you can say about something in a free society is that you are afraid to talk about it – in my case I can’t financially afford to talk about John Barnes’ Myofascial Release. Hopefully we won’t see a similar legal response here.

    Physical Therapists in general and the APTA in particular have been on the forefront of the Evidenced Based Practice movement and in my profession we have high standards in education, practice, and research. Like any group, there are always a few who fail to meet those standards and in my opinion the inclusion of Visceral Manipulation by the Section on Women’s Health does not meet those standards. I know that the Section on Women’s Health has much to offer the public through training and board certification of PTs in science-based techniques and practices, and I can only hope that most of their members are as appalled by this as we are. Physical therapists have been leading the charge to provide effective and science-based hands-on manual therapy for musculoskeletal conditions, including published randomized trials that Dr Hall and Dr Homola have written about on this blog. These randomized trials have shown important effect sizes for relief of musculoskeletal pain of the shoulder, hip, knee, back, neck, and foot. Visceral manipulation, Reiki, chiropractic subluxation, energy healing, and myofascial release have no relationship to those successful trials of manual therapy provided by physical therapists in a science-based model.

    Thank you JW Matheson and Harriet Hall for bringing this issue to light and giving the APTA and the Physical Therapy community the chance to make the right decision regarding this material and this unfortunate response to reasoned criticism. Clearly the letter writer has the mantle of APTA behind her, and Dr Hall and others are right to call both her and APTA to account here. Hopefully we will hear from someone official in APTA soon.

    Jason Silvernail DPT, DSc
    Board-Certified in Orthopedic Physical Therapy
    Fellowship-Trained in Manual Therapy

  26. arufa says:

    @ Dr. Hall

    Just to clarify the person who you quoted in the article was not hired and is not employed by the APTA. She was elected to the position (she is not paid) by the members of (not the entire APTA) the Women’s Health Section. So just like the governor of a state has limited power over what a local mayor says, the APTA has limited power over what this person says. But again, I will gladly join you in scolding the entire organization of the APTA, if they do not make a statement which distances themselves from the comments made by this representative of the Women’s Health Section.

  27. WilliamLawrenceUtridge says:

    For all the PT’s defending their organization – it’s your organization. If you don’t like that it’s embracing quackery, as members don’t you have the right to defend science and oppose things like this? Rather than posting comments on this blog, it might be worth writing a letter to the APTA. Just a thought.

  28. Jon Newman says:

    @arufa,

    “However, to paint the APTA and the PT profession as embracing CAM because of one link and one comment from a tiny, sliver of the professional organization is misleading. The Women’s Health Section of the APTA is very small and it is very insignificant. The APTA is broken down into many parts and there is some autonomy given to these sections (women’s health section being one of the smallest). The APTA has a very clear mission of promoting scientific and evidence based practice. This very small example, although disturbing, is hardly a representation of what the APTA stands for.”

    Consider our upcoming Combined Sections Meeting in Chicago this year. The Geriatrics section, a much larger section of the APTA than the Women’s Health section, is sponsoring a course titled “The Science and Practice of Integrative Therapies in Physical Therapy: A Movement Whose Time Has Come.” The description of this pre-conference course is

    “This 1-day course is designed to describe the science and practice of integrative (complementary) therapies in rehabilitation and the evidence for efficacy in therapy, prevention, and wellness. Physical therapists using integrative therapies will report on evidence and their patient experiences using such therapies as yoga, tai chi, Pilates, myofascial release, and Body Talk.”

    One of its course objectives is

    “Present evidence behind the science of energy-based integrative therapies.”

    The APTA is providing a venue and giving credit to its members for taking this course. Also, my state chapter allows advertising of CAM classes in its publications, and on its website, and gives continuing education credit for taking those courses. To my mind, these are actions which ARE representative of what the APTA stands for. So while they may have a very clear mission of promoting scientific and evidence based practice, they also seem to not be averse to collecting advertising money from CAM providers and giving PTs credit for attending the courses.

    This isn’t a new problem and isn’t unique to the APTA. I don’t have a specific solution in mind but I’m glad the problem is getting some exposure. Perhaps a solution will be forthcoming.

    Jon Newman, PT

  29. jmilan says:

    @WilliamLawrence Utridge

    We do realize it is our profession and by reading the threads, it seems that there will be people (myself included) writing to the APTA. However, it is also our job to inform the public of what is an acceptable standard of practice by the majority of PTs/PTAs. Considering that this issue came up in this blog, it seems like a very appropriate place to discuss this here with other medical professionals and any others that may have had questions raised because of the post. Certainly there are issues to fix, I do not think anyone would deny that. Dialogue is an important first step in change.

  30. WilliamLawrenceUtridge says:

    Jmilan, have you considered an online petition and/or blog posting on a site that is dedicated to PT treatments and practitioners? You could backlink to this page and include a longer, more PT-centric discussion of the issues that could promote an overall dialogue with far, far more professional members who can more easily make their voices and opinions heard. An intersting post for the public might be an illustration, from someone familiar with the PT literature, regarding the evidence-based differences between VM and actual scientific interventions.

    This blog probably gets a lot of hits, but they’re not a targetted audience. The proportion who are PTs would be pretty small. The proportion who read these comments even smaller. The number of APTA members with regulatory, oversight or other positions of power who delve into the comments would almost certainly be miniscule. But a blog read by PTs in general with a link to an online petition circulated through professional mailing lists – that would stand a greater chance of having an impact.

    Plus, it justifies me not doing anything but sitting on my arse bitching in comments ’cause I’ve got an excuse – I’m not a PT :) And I do love to criticize…

  31. arufa says:

    Jon,

    Good points!

    My guess is that professional organizations and publications allow this stuff to occur more based on money than philosophy. It may also be difficult for large organizations to agree on what is ok to allow and what is not. I wonder how other professional organizations deal with this?

    What bother me most about this blog posting was the rational provided by the Women’s Section Education Director. I would much rather have seen them say, we do not necessarily support or agree with the teaching however we make good money off these courses. That rational would make more sense to me than the one provided.

  32. Costner says:

    I always wondered what technique Mr. Miyagi used on Daniel LaRusso when he hurt his leg in the karate tournament.

    Now I know… it is called visceral manipulation. Learn something every day.

  33. ErikMeira says:

    I have been involved with APTA programming for several years and I may be able to shed a little light on some of these issues. Quick disclaimer: I IN NO WAY REPRESENT THE APTA AND THESE ARE MY OPINIONS ONLY. I have submitted my own email tirade to the APTA regarding this post – Bottom-line: The reply by the SoWH was deplorable and unacceptable by ANY entity affiliated with the APTA.

    First, the APTA is desperately trying to support science-based practice in our profession. JW Matheson and I were granted the opportunity to present a preconference course on the application of science in physical therapy practice titled “Challenging the Myths in Physical Therapy”. The course was sadly cancelled just before the conference due to poor enrollment. Not the APTA’s fault – they would have lost money on the course and obviously it would have had a very limited impact since enrollment was so small. Why do they have a course on “integrated therapies”? As Jon Newman noted, because it sells. At Combined Sections Meeting, the individual sections judge the merits of the courses that they sponsor (not the APTA) and stand to make a lot of money to boost their budgets for the year. Sadly, many of these “integrated” courses sell really well. I know, it’s disgusting.

    The other side of this coin is advertising. I have personally been involved in several challenges to state chapters of the APTA for openly advertising these kinds of courses. I have begged for a certification process for courses to be deemed evidence-based or not. All of this gets stopped due to fears of legal action. It is feared that these continuing education groups will sue the state chapter for restraint of trade by “unfairly” discriminating against and not supporting their courses. They claim that they are “evidence-based” by citing some obscure, unrelated, or completely misinterpreted studies. These state chapters literally have no money to fight these accusations and, even if they did, they have a very difficult time deciding where exactly to draw the line. Again, disgusting but as Jason mentioned, there is a precedence for these lawsuits. That said, some successful fights have been waged recently and quite humorously: http://www.quackometer.net/blog/2011/11/the-burzynski-clinic-threatens-my-family.html

    The Oregon chapter of the APTA is trying to force the issue a little by having me open their annual conference with a “science talk” that is unopposed by other programming. This makes it a little less optional for attendees. It may also end with torches and pitchforks as I am hung from a rope by the more “fringe” attendees…

    As for the PT-centric debate. A couple colleagues and I are discussing developing a journal club podcast and blog that will discuss these issues more in depth. The plan is to launch sometime in March. There will be more information posted via my current podcast website (http://ptpodcast.com) where you can also find my recent interview with JW Matheson himself as we talk science application in our profession (shameless plug – I apologize).

  34. Jon Newman says:

    Hi Eric,

    Your post did shed some light on the background of how courses are chosen for such a conference. Still, I’d like to hold the APTAs feet to the fire a little more than you. Determining the demarcation between science and pseudoscience isn’t always easy but if it is your mission to be science-based and you’re in a position of leadership and have the authority to not only require CE credits but also what counts as credit, then some responsibility should be taken in promoting the science-based vision.

    For my part, I want to tell the APTA to “get back on that damn ship”.

  35. Diane Jacobs says:

    Greetings from a PT in Canada,

    Thank you for your post Dr. HH. Many of us labour in the dark fighting this stuff in our own profession – it’s good to see a post from ‘outside’ pointing at something like this.
    I really hope APTA sorts this one out, as CPA and APTA work fairly closely together. If one lowers the bar, the other might feel free.. I really want to see the bar raised up, not lowered, for the whole profession, so that the face it shows to the world isn’t smudged.
    Here is a Facebook thread about your post, Dr. Hall, on a page I’m responsible for, Neuroscience and Pain Science for Manual Physical Therapists. https://www.facebook.com/permalink.php?story_fbid=274234605972907&id=114879238784

    I want to include a link to something I wrote awhile ago, trying to make sense of all the strange conceptualizations that arise in manual therapy, which I arbitrarily lumped together under “operator” models, to differentiate them from another model, which I named “interactor” model. https://docs.google.com/document/d/1ruRBlTM-7eJq2EbJCsdfrRf3Pgg0SsShvKIkEoyKP-c/edit?hl=en_US

    It was inspired by something Mark Crislip said here long ago: “Monkeys, and other animals, groom each other often with a marked reduction in stress. Touch is good, and one doesn’t need to wrap it up in pseudoscientific nonsense for it to be beneficial.”

    Please EricMeira, if it’s of any use to you whatsoever, please steal it.
    Diane Jacobs PT

  36. ErikMeira says:

    Jon-
    I wholeheartedly agree, all science-based PTs do. As someone who has watched his own scientific courses get passed over for crap, I have spent plenty of time fuming about this. As someone who has received “Too much science/research in the presentation” MANY times on a course review, I have spent a lot of time worrying about my profession. The role of the professional association is to provide the best environment to support scientific practice and intelligent discourse. It is the role of the professional to f***ing support it!!! By the way, allowing VC to advertise or teaching “integrated therapies” at a conference is doing a poor job of providing the best environment, in my opinion (and I think yours as well).

    Diane-
    Nice piece on manual therapy. Manual therapy is a “gateway drug” to woo for all of the reasons that you mention. Your “operator model” is spot on. I just worry that as researchers dig deeper and deeper into manual therapy, and all the proposed theories keep getting systematically discredited, we may find out that we have been lying to ourselves all along. Things like, “It works, but the mechanism is elusive,” and “Pick your favorite manipulation that works for you and use it,” start to sound a lot like acupuncture – “Who cares where you stick the needles, it works somehow!” I have heard very scientifically minded manual therapists start to embrace that it may just be a manifestation of the placebo effect. If that’s so, why does manual therapy get a pass, but acupuncture doesn’t? Where do we draw the line?

  37. Jon Newman says:

    Thanks Erik,

    You summed up my position better than I originally expressed it. And sorry about misspelling your name in my previous post.

    Yes there are many market related issues to help explain the spread of CAM in PT (among other places) with both therapists and their patients involved.

    I think the policies and procedures regarding continuing education are the low hanging fruit here. I don’t expect it will be a perfect solution but I’m also not looking to commit the perfect solution fallacy here.

  38. Diane Jacobs says:

    Eric: > “I just worry that as researchers dig deeper and deeper into manual therapy, and all the proposed theories keep getting systematically discredited, we may find out that we have been lying to ourselves all along.

    Yes, I think we have been. Lying to ourselves. All along.
    PT is like a leaking ship with big holes in its sails, and no rudder, that has been blown in the wrong direction for a very long time by forces beyond its own control. Tissue-based explanations for pain, and practices that were built on them, from other “professions” and their traditional tissue-based notions, are like rocks under the water. (Barral is an osteopath as I recall.)
    People come to see us because they have pain. Pain (non-medical, persisting) is “100% produced by the brain in response to a threat” as pointed out today by @PainPhysio, Richmond Stace in the UK. http://www.specialistpainphysio.com/pain-some-things-you-may-not-have-realised/
    Therapists are supposed to be people who know how to put patients first, not tissues first or tissue based ideas about treatment first. Then we’re supposed to know how to create a therapeutic context for them, including treat their physicality with a bit of manual contact, so that they can learn how do things like move easier, with less pain.

    > “Things like, “It works, but the mechanism is elusive,” and “Pick your favorite manipulation that works for you and use it,” start to sound a lot like acupuncture – “Who cares where you stick the needles, it works somehow!”

    Yes, it really does sound like that. I’ve been here at SBM before when the topic of placebo has arisen.

    > “I have heard very scientifically minded manual therapists start to embrace that it may just be a manifestation of the placebo effect. If that’s so, why does manual therapy get a pass, but acupuncture doesn’t? Where do we draw the line?”

    I do not know the answer to that. To me, acupuncture is just a (very) pointy kind of manual therapy, useful mostly for therapists who don’t actually like to touch people long enough to feel their autonomic and somatic motor output change for the better as a result of providing it with practiced, sensitive, warm, kind, sensory input. I don’t know what it’s like in the US, but in Canada the elite of the PT profession usually try joint manips first and if that doesn’t work, dry needling second (no different from acupuncture IMO, other than they don’t have to learn a bunch of exotic concepts), and if none of that works, they’ll resort to TENS and theraband, etc. My opinion is that none of that is particularly nervous system friendly, overall. But it’s more “evidence-based” because there are thicker piles of published papers that support them.
    My fantasy is that one day someone will see the point of providing contactful therapeutic human primate social grooming that is woo-free: studies will have been published that leave nothing in place BUT that, because all the operator model woo is gone, completely demolished and cleaned up by Occam’s Wrecking Ball, Chainsaw, Firehose, and Backhoe.

    Meanwhile, all we have to work with are papers from Nature Neuroscience, different pain journals, etc., that discuss sensory processing in the vertebrate nervous system, perception and cognition/evaluation, and how these two combine to affect descending modulation.

    Best of luck. It’s hard to steer a ship that has no rudder, or sails, and has big holes in the hull. We’re all trying as best we can even though we realize sinking has commenced. Apparently.
    Diane, professional PT Human Primate Social Groomer

  39. ErikMeira says:

    Jon-
    Come find me at CSM. Grab me after my lecture on Saturday or, if you are leaving early, leave a message for me at the Sports Section booth – they know where to find me.

    Diane-
    I tend to think that a lot of the manual therapy stuff is a sinking ship (others have said this as well), but not the PT profession as a whole. I work in a sports medicine facility really closely with orthopedic surgeons so I tend to deal with more concrete kinds of issues – you know – surgeon says to patient “you torn ligament, me fix ligament” then I say “me see weak quad after surgeon fix ligament, me strengthen quad”. The other non-surgical stuff that I do falls more into educate, activate, motivate. So I’m not a great person to comment on what most PTs do here in the US. I will say, however, that when a patient comes to me after working with another PT, I am sometimes a little baffled by the previous approach. Like “why did they do nothing but massage the crap out of someone’s Achilles tendinosis when there is so much high quality literature on eccentric training?” Hell I can treat that with a 15-min eval followed by 45 minutes of education, a home exercise program, and a two-week follow up (with a motivated and focused patient). What was all that 3x/wk rubbing nonsense? Didn’t they READ the literature? Oh yeah, I forgot. They learned from a multi-installment “evidence-based” con ed series whose evidence was all case studies and the “expert knowledge” of the presenter…

  40. Diane Jacobs says:

    Erik, I invite you to visit SomaSimple ( http://www.somasimple.com/forums/index.php ) where you’ll find support for your efforts to drive woo out of PT. It’s been up since 2004. It’s international, multilingual. The English-speaking part is skeptic-friendly and woo-unfriendly. (I think the parts in other languages are too.)

    Everyone else is welcome to visit as well. We do our best to be fine filters of info., to share it, and make sure nothing woo-esque escapes our eye. We’ve been fans of SBM for a long time.

    Diane

  41. Josh Berndt says:

    Thanks to Dr. Hall, JW, Erik, and others for addressing this junk. Your work is appreciated! Hopefully the letters to the APTA will lead to a change. As a PT and a member of the APTA, it is quite frustrating to see this stuff creep into our profession.

    On a side note, I have always felt a disconnect between practitioners and our professional organizations. I’d be interested to find out your opinions on how to change that.

  42. elmer says:

    I guess I’ll just keep spamming this quote by Jan Dommerholt (although I did correct the typos this time):
    “Although there appears to be consensus that physical therapy is an integral component of pain management centers, few physical therapists have received adequate training in clinical pain mechanisms and pain management strategies, which is somewhat remarkable considering that the chronic pain prevalence is estimated to range from 10% to 55%. The International Association for the Study of Pain (IASP) has developed a specific pain curriculum for occupational and physical therapy education (http://www.iasp-pain.org/ot-pt_toc.html), yet there is no evidence that hits or similar curricula are commonly taught in physical therapy academic programs. It should then come as no surprise that many physical therapists lack knowledge on pain management and may not be all that interested in working with persons with chronic pain.
    According to Wolff and colleagues, 96% of orthopedic physical therapists prefer to work with patients who are not likely to have chronic pain. A search of the membership directory of the Orthopedic Section of the American Physical Therapy Association (APTA) suggests that its Pain Management Special Interest Group has less than 400 physical therapy members out of a total APTA membership of about 64,000, which equates to approximately 0.6 percent (from “members only” section of http://www.orthopt.org, accessed October 30, 2004). A similar search of the membership directory of the American Academy of Pain management suggests that there are less than 100 identifiable physical therapy members out of a total of approximately 6,000 members (less than 1.7 percent)(http://www.aapainmanage.org/search/MemberSearch.php, accessed October 30, 2004). The apparent lack of professional interest and insufficient education and knowledge in pain mechanisms and pain management strategies can create multiple challenges for physical therapists to become effective pain management clinicians.”

    The article’s a bit old, obviously, and that link for the pain curriculum is bad. This appears to be the current link (which I’ll take a look at now that I’ve posted it): http://www.iasp-pain.org/AM/TemplateRedirect.cfm?template=/CM/ContentDisplay.cfm&ContentID=7616

    As I’ve said, my experiences with physical therapists have been mostly bad. Most of them seem to use mindless weightlifting for everything, which in my case aggravated my condition.

    So, sure, the example Dr. Hall picked out is particularly bad, but I hope PTs reading won’t be inspired by this blog to take a scorched-earth approach to anything that isn’t within the formal curriculum, or even to approaches that seem reasonable even if there isn’t much experimental evidence.

  43. ErikMeira says:

    @elmer – I understand where you are coming from and again, I am not a PT who works with chronic pain (there are many different specialties in PT and not all of us deal in chronic pain). As Diane Jacobs mentioned, groups like SomaSimple are supporting very scientifically sound approaches to PT management of pain. It is not a “scorched earth” approach to anything outside the formal curriculum (all specialist training is post-graduate, just like the docs), just to diagnoses and treatments that do not stand up to scientific scrutiny. From my limited understanding, chronic pain is best handled through a comprehensive medical team that addresses the physical, psychological, and emotional components – a PT by themselves is not capable of addressing all of these things (contrary to the beliefs of some PTs). I fear that your experience involved a PT who was working on an island and did not have the proper background (it wasn’t me was it?). As often happens, the medical system failed you and that is unfortunate.

    @Josh Berndt – Quite simple explanation. PT schools are doing a much better job teaching a science-based curriculum. However, professional associations are often run by more “seasoned” (old) therapists who may rely more on experience than good science. I believe that this is getting better and will continue to improve over time as we speak out through volunteering and voting. For example, the APTA is very well run at the top, but can get a little fuzzy farther down the chain (this post on VM being a great example). The danger is when younger, better trained therapists, get brainwashed (for lack of a better word) by the older therapists with whom they work. To fix it, we need to continue to reinforce the science training (like my upcoming OPTA talk – own horn is now tooted) and tell younger therapists that it is okay to be skeptical when a mentor fails to use scientific reasoning. Attacking misguided professionals just makes them defensive (and sometimes litigious) no matter how good it makes us feel.

    @Harriet Hall – Sorry for commandeering the comment board…

  44. Josh Berndt says:

    Erik, I agree with your explanation, but I am not as informed as you appear to be, so I didn’t want to come out and say it. I feel the PT profession as a whole has changed significantly over the last 30 yrs, for the better! Now we just have to keep the ball rolling. Again kudos to those questioning the science, or lack thereof, behind fringe techniques such as (VM, CST, MFR) and challenging the endoresment of these classes at APTA events. As a CI, my number one goal is to make skeptics of my students so they start asking the “why” questions during their day. Over the years the answers have changed from because my teacher told me it works..to because the literature supports it!

    elmer, on a side note. Share your beliefs and expectations for therapy with your PT (I don’t like weight lifting, I feel it will make it worse) next time prior to a treatment plan is developed. If they are iformed, they will design a plan that fits with your expectations and you will see better results!

  45. PT for EBP says:

    I am a PT who is all for innovation in the field, HOWEVER, If an MD were to cook up a new drug in his basement and begin trying it on patients, he’d have his license revoked and likely be sent to jail. PT as a profession needs to check and balance itself against these types of misuses of our patient’s trust.

    I’m a new Grad and proud that my academic program strongly supports the use of evidence based practice. I too will be sending a letter to my local PT organization against this type of endorsement.

    I truly appreciate this website and all of the contributors.

  46. Gredo says:

    As a PT I feel that all “techniques” that we employ should eventually be scrutinized and supported by available evidence. However, most treatment techniques are borne out of observation and trial and error. Should Brian Mulligan have first designed a set of theories to base his treatments and then designed controlled trials before sharing his ideas? It had been years of him honing his skills, practicing, and sharing his findings before studies actually looked at what he was doing. If you read commentary at somasimple, Mulligan missed the PT interactions with the pt and the afferent rich skin stimulation as most likely being the primary reason for his techniques success. Ive learned much at SS, but I feel that they are made up of a core group of bloggers that sit in a circle and pat each other on the back and wait for new prey to enter their realm. New prey being any practitioner of most every technique, save “simple contact”, which from my last check, SC has no studies validating either its effectiveness nor the theory governing its use. They are a very, very, very bright and articulate group that fully know that there arent any studies that validate any woo-woo techniques and wait for the unsuspecting to enter and be torn apart…a repeated event that is comically very predictable from start to fleeing end.

    My question is, how is it recommended that a “technique” be shared and at what point of use should it be tested. Would we as PTs been better off if Mulligan, Sahrmann, Mckenzie, etc. had fully tested their theories before sharing their ideas?? In a thread at somasimple looking at a craniosacral study, it appears that a well designed study is nearly impossible. I realize that eventually a technique needs to be validated, but how should it all start if not by an idea that is shared?

  47. Diane Jacobs says:

    Gredo, two words, well-discussed in this blog: “Prior”, and “plausibility”.

  48. ErikMeira says:

    @Gredo- To answer your question, “Would we as PTs been better off if Mulligan, Sahrmann, McKenzie, etc. had fully tested their theories before sharing their ideas??” YES YES A THOUSAND TIMES YES!!! Because if they are later proven to be wrong, their theories are now spread through the profession like a virus (not specifically the people mentioned, by the way). Don’t believe that this is a problem? Ask the PT who still uses hot packs/massage/ultrasound to treat back pain why he does what he does.

    The way that an idea is initially shared in medical science is through case studies which will lay one’s ideas on the alter of science to be poked, prodded, and tweaked by the research community. In order for an idea (not yet a theory, by the way) to be accepted to be studied by the scientific community it must fit two requirements: 1. Plausibility (whether or not the base concepts of the idea have already been shown to be invalid) and 2. Falsifiability (whether or not the idea is SCIENTIFICALLY TESTABLE).

    If the idea fails either of these requirements, it is NOT SCIENTIFIC. Why? Because we CAN’T TEST IT! As you mention regarding craniosacral, “…it appears that a well designed study is nearly impossible.” That means that whatever craniosacral is, it is NOT SCIENCE. It may “work”, hell, it may even be 100% true (can’t disprove it), but if you cannot test it, then the one thing that it is NOT, is science. Technically, by the classic definition (not just my opinion), that makes it pseudoscience.

    The talk I am giving for OPTA annual meeting is titled “Science, Pseudoscience, and Protoscience” because I feel that this is the root of the disconnect for many PTs who embrace these things. They are not evil or stupid, they just forgot the answer to the question, “What is science?”

  49. Gredo says:

    @ErikMeira: Great answer…Thank you. To be clear then, for something that is designated pseudoscience as craniosacral is if, as a therapist, one were to employ a pseudoscience to address “X” dysfunction and were to relieve a pt of their dysfunction, is that wrong? From my take of SS (which I may be wrongly interpreting), if for example, I were to use Barnes Myofascial release or Iams PRRT (which neither I employ) and state that it has its response due to stimulation of skin afferents and pt interactions, does that classify it as plausible? At what point then would it be testable. As such, is this how Simple Contact heralded at SS has its designation as being science if that is its classification?

  50. ErikMeira says:

    @Gredo- Aha! The root of the problem! Developers and proponents of some of those specific (sometimes trademarked) techniques are using explanations that are simply not plausible. The great folks at SomaSimple have postulated the Simple Contact idea to provide a plausible explanation for the effects of these “hands on” treatments. It is a much MORE scientific position because you now have plausibility. Where I get a little uncomfortable with Simple Contact is the falsifiability part. How do you control for placebo? In other words, how do you fake putting your hands on someone? There are some very creative attempts at doing this, but the results are not yet satisfying to me.

    If the patient gets better, even if just due to the placebo effect, “…is that wrong?” Dr. Gorski did a great job addressing this in an earlier post:
    http://www.sciencebasedmedicine.org/index.php/the-rebranding-of-cam/

    There are some ethical considerations: Are you lying to the patient about how something works which violates informed consent? Will you diminish the effect if you tell the truth about what you know? More ethical proponents of Simple Contact explain their more plausible idea to their patients with the disclaimer of “This is the most plausible explanation, but we still don’t know exactly what is going on.” I feel more comfortable with that, than the more popular CAM explanations. MORE comfortable, mind you. Not entirely comfortable. I tend not to use it at all.

    All treatments have a placebo effect of some sort, even something as straight-forward as surgery. “Placebo enhancing” interactions are well documented. Spend time with your patients in an unrushed environment. Have a clean professional appearance. Have compassion. Be confident and honest about what you know and don’t know. Truly care about your patients. Provide reassuring physical contact through palpation, validated special testing, and a confident touch (Keep it clean people!). Take their concerns seriously and address those concerns honestly and thoroughly. (I’m about to break into “Kumbayah” in a second.) DO ALL OF THIS WITH EVERY PATIENT WHILE APPLYING SCIENTIFICALLY SOUND INTERVENTIONS and you will find the most consistent, optimal outcomes.

  51. Gredo misunderstands something. Simple Contact is just a term used to describe a method of non-threatening communication that enhances another’s awareness of their own ongoing processes. I picked it out of a book about awareness many years ago and it has served as a way of approaching our patients, with and/or without touching them. It is NOT a technique. It is simply a phrase. After all, I had to give what I did a name. That’s a cultural imperative.

    Having read the Skeptical Inquirer (and related publications) since ’79, written endlessly about science-based thinking and championed the work of the columnists here throughout the country I feel I can defend what I say and do within the realms of reason and logic.

    I do not anticipate that Simple Contact will ever become a “technique” taught to others as so many have been. These lead to dogma and multiple courses to enhance “skill” and certification. I advocate none of that and never have.

  52. Gredo says:

    @ErikMeira: Thank you again. I am better informed. Not looking for a fight with proponents of Simple Contact. Just have not understood the defense of it over other methods like myofascial release. It appeared to me when reading at SS that it was simply a matter of redefining the probable cause of effect into a more plausible reason.
    So, if in an enlightening moment, Barnes says to himself “they were right at SS…its not the fascia…its pt interactions, placing the body in non-threatening positions and stimulation of the skin afferents so that the body can correct itself.” Technically that would start them into the realm of being scientific wouldnt it? And if all other pseudoscientific techniques were to use similar logic to get their techniques embraced by the evidence based community, wouldnt they too be afforded the same treatment as SS has afforded Dermoneuromodulation and simple contact?

    If I understand Barrett and Dianna correctly, they are stating that their “techniques” are really not a “technique” and is therefore immune to the scrutiny that is held before other techniques? Is that all it takes…a proclamation by the developer and it is no longer to be seen as duck even though it quacks and walks like one?

    ” I do not anticipate that Simple Contact will ever become a “technique” taught to others as so many have been. These lead to dogma and multiple courses to enhance “skill” and certification. I advocate none of that and never have.”

    Dermoneuromodulation was put together very well in a pdf file describing specifically what a therapist needs to do to address dysfunction in various parts of the body. It describes how to interact with the pt and it looks very much like myofascial release combined with positional release. However, if I understand all that was written in this thread, it is science via its creator’s definition of plausible effect. Again…is it really that simple?? Just for the authors of all the other psedoscientific techniques to reassign what they believe the treatment effect to be into something acceptable by academics and researchers? I guess to go a step further, if they were to offer it for free online and not require multiple courses to enhance skill it would therefore be seen even more so as science?

  53. John says:

    I’ll preface my comment by saying that I abhor the inroads that pseudoscientific methods have made into my profession of Physical Therapy, and I’m very disappointed how the Section on Women’s Health has addressed this issue. I’ve made my feelings known to the APTA in writing.

    Also, several of my respected colleagues above have already made both strong defenses and criticisms of the PT profession and the APTA in particular as it deals with the unfortunate influence of pseudoscience in the field, and I have nothing further to add to that.

    However, Dr. Gorski made a comment early in this thread identifying that the only time visceral manipulation works is when it’s performed by a surgeon during an operation on a patient’s anatomy, which prompted me to view this issue from a broader perspective.

    While certainly the medical profession has made astounding advances in surgical techniques, which have been advanced by scientific discoveries, medicine also has a very dubious record with regards to many of the invasive procedures they perform on patients with persistent pain. The example of spinal surgery for lumbar disc herniation is one notorious example where a classic study found that the best predictor of whether a patient would undergo this procedure was their ZIP code (Birkmeyer & Weinstein, 1999). And despite the high rates of failure, lumbar fusion surgeries increased 77% between 1996 and 2001 (Deyo, et al. 2004;350:722-726). In the same study, the use of MRI for spinal problems increased about 4-fold between 1994-2004 among the Medicare population, and prescription of opioid analgesics doubled during the same decade.

    I’ve practiced PT for over 17 years, and I’ve received many referrals from medical professionals (MD’s, DO’s, DDS’s, DMD’s) for “woo” therapies like craniosacral and myofascial release, not to mention all the referrals that specified poorly supported interventions like ultrasound, hot packs and massage.

    Therefore, while I appreciate the comment above by elmer identifying the low representation of PTs in various pain organizations and our lack of pain education, I don’t think the medical profession is doing a whole lot better in this area. What’s more, they are likely causing a lot more harm and cost to society by performing very expensive procedures and ordering excessive diagnostic tests that do little to help the patient, and often make the patient worse. Far too often, PTs are expected to “clean up the mess” as best we can once a patient has been through the noceboic gauntlet that is modern medical treatment for persistent spinal pain. Patients are desperate and due to our lack of education in pain neuroscience, so are PTs. Some end up grasping at pseudoscientific “straws” to help desperate patients. It’s not right and it’s not helpful, but it’s occurring within a medical milieu of profound ignorance of persistent pain.

    Just last month Mezei et al published their disconcerting findings of the state of pain education in North American medical schools (J Pain,2011;12(12):199-1208). Their conclusion: “…pain education for North American medical students is limited, variable, and often fragmentary.” Major topics recommended by the International Association for the Study of Pain (IASP) were often neglected in many medical schools. The authors’ final recommendation was that an overhaul of medical school pain education curricula would be necessary to make the needed “sea change” in the delivery of pain care in North America.

    As a profession with strong traditional ties to the medical profession, many of us are anxiously awaiting this sea change in the approach to pain care by our medical colleagues. Too few of us are engaged in the battle against pseudoscience within our profession- this is true, but if the medical profession would get on board with a more dedicated, organized and science-based approach to treating pain, I think we would see far fewer patients resorting to seeking out “woo” treatments for their pain in the first place.

  54. Diane Jacobs says:

    @Gredo

    Once you get the hang of using Occam’s Razor on your own thinking, and practice doing so, it gets to be a habit. If the teaching of simple contact or dermoneuromodulation is anything, it is the attempt to teach people how to apply Occam’s Razor to manual handling.

    As I’ve said before, there simply aren’t as many “ways” of “doing” manual therapy as all the purveyors of multi-level courses would have us believe (and pay for). It really is as simple as ErikMeira pointed out in his most recent post:
    > “All treatments have a placebo effect of some sort, even something as straight-forward as surgery. “Placebo enhancing” interactions are well documented. Spend time with your patients in an unrushed environment. Have a clean professional appearance. Have compassion. Be confident and honest about what you know and don’t know. Truly care about your patients. Provide reassuring physical contact through palpation, validated special testing, and a confident touch (Keep it clean people!). Take their concerns seriously and address those concerns honestly and thoroughly. (I’m about to break into “Kumbayah” in a second.) DO ALL OF THIS WITH EVERY PATIENT WHILE APPLYING SCIENTIFICALLY SOUND INTERVENTIONS and you will find the most consistent, optimal outcomes.”

    Most of us (regardless of what scientifically sound ground we may think we are on), still have yet to deal with the confound that we can’t really EVER touch anything of anyone else’s', except:
    1. their skin (and by extension of the simple fact that there are only three neurons between your helpful hands),
    2. all the the somatosensory processing areas of a patient’s awake brain.

    All else is fantasy in the collective manual therapy mind (conceptualizations based on having studied anatomy or having been taught someone’s favorite reasoning process). Most manual therapists end up interacting with their fantasies, apophenia they have paid good money to buy; they do not focus on the lightening fast nervous system (peripheral or central), the responsiveness of the patient at the other end of our compassion and hands.

    Human primate social grooming, Gredo, that’s what manual therapy is. From a bed-rock science point of view it is all it is. Sorry, but no matter how exotic the conceptualization (viscera) or well-accepted it may be (orthopaedics), that’s really all manual therapy boils down to, and that’s all we have to work with – what you can get your hands on, and what sense the patient’s wide-awake, not anesthetized, fully supported within a context, brain’s “salience detection system” can make of it, short term. Regardless of where we sit on our own manual therapy community’s acceptability scale, desperate for control, we all seem to do everything we can to not have to deal directly with (or learn about!) what usually bothers patients most – usually non-medical persisting pain.

    Well, some of us have concluded pain is important, and have discussed how to put THAT at the forefront, instead of monkeying around with (mostly extraneous) ideas about tissue for the rest of our lives. Teaching the patient what a good working brain does, in the first place, and providing them a big picture idea of how threat detection inside it works, can help them relax a bit better on the inside than if the practitioner were to say, show them scary images of mangled mesodermal derivative, then pretends they can fix it from the outside. Even if what Barrett, or I, “do”, on the outside, would not appear to be much different from what all sorts of other human social groomers are “doing”, the teaching prior and homework after and thought process/conversations during, are miles apart. Mainly by removal of erroneousness, not by putting more in place.

    I really do not know how such a difference in thought process and approach amongst human primate social groomers could be scientifically measured or more favourable outcomes determined to show the validity of one kind of thinking ahead of the other. The way I see it, sticking only with anatomy/tissue-based models of manual therapy falls under “operator model” mentality: pain science/neuroscience-based approaches, relatively new, but taking into account the last 2 or 3 decades of neurobiological/physiological sciences (not forgetting about any of the anatomy learned in the past, but no longer blaming only it, for pain problems), fall under “interactor model” mentality.

    My apologies for being long-winded.
    Diane, human primate social groomer

  55. Jon Newman says:

    Hi Erik,

    Falsifiability, on my reading, is unfortunately not a gold standard that can distinguish between science and pseudoscience. I learned that it was at some point but now I’m learning that it isn’t. For some further reading on that particular issue consider a search for an easy to read essay by Carol E. Cleland titled “Historical science, experimental science, and the scientific method” or for a more thorough treatment see

    2002. C. Cleland. Methodological and Epistemic Differences between Historical Science and Experimental Science. Philosophy of Science 69:474-496.

  56. Diane Jacobs says:

    Erk.
    I screwed up the italics. I dd not intend *that* much emphasis. Sorry.
    A preview function would be nice..

  57. ErikMeira says:

    @Diane Jacobs- Well put and I think answers Gredo’s questions (@Gredo- if still unclear please say so). Don’t worry about the italics. I don’t know how to use them on this editor so I obnoxiously WRITE IN ALL CAPS for emphasis.

    @Jon Newman- I am familiar with that article and Michael Shermer’s (I love that guy – http://www.scientificamerican.com/article.cfm?id=what-is-pseudoscience) recent article in Scientific American challenging falsifiability as a tenet of science (his argument being as a way of describing string theory as legitimate science). I use the term falsifiability for it’s simplicity in argument. I would say, in my opinion, by CE Cleland’s definition, medical science as a whole is more experimental than historical. That said, I feel that it is irrelevant to this discussion – as is Shermer’s argument. They are not wrong or invalid or unsound, just not applicable to this discussion. Let me clarify what I mean when I say “falsifiable” as concisely as I can (I kind of suck at brevity) and I think you will find that you and I are pretty close in our view.

    In science (experimental, historical, whatever) there is a specific goal (accuracy of ideas) and a specific framework for achieving that goal. The framework is the scientific method. What that is is a way to systematically evaluate or test an idea through a proof of some kind, whether it be an experiment, trial, mathematical inquiry, whatever (I know this is already understood, but bear with me). The way it works is by starting with an unknown. Then you must work vigorously and systematically to build the most inclusive list of PLAUSIBLE explanations available (think of a differential dx in medicine). What you will quickly see is that ideally these ideas, while 100% scientifically plausible, cannot both be exclusively accurate.

    So you investigate looking for a “smoking gun” as I believe CE Clelend puts it (essentially what we would call “evidence”). The smoking gun is a finding that forces you to cross one of your explanations off of your list. The investigation has effectively made one of the ideas no longer plausible. You continue to investigate to whittle down the list. When you are left with only a handful of VERY SIMILAR ideas you now have an actual “theory”. This is true in paleontology, astrophysics, theoretical physics (string theory etc), or any other science.

    [Quick aside, in my opinion, in medical science, if one of your remaining plausible ideas regarding a phenomenon (treatment) is that it may be NOTHING MORE than a placebo then you have not even reached the level of theory. I will not stress or argue this point further as I feel it is more an issue of semantics in this context.]

    Now that science has a theory, THEY AREN’T DONE. The process continues until they are left with one, solitary idea. Don’t believe this? Why are theoretical physicists (one of CE Clelend’s non-experimental sciences) so insanely uncomfortable that there is not a unified theory (Einstein’s relativity not fitting with particle physics)? So uncomfortable that they built the Large Hadron Collider to force an answer and move their science forward (or create a black hole and kill us all).

    Falsifiability is a term originally proposed by Karl Popper almost 100 years ago when it was demonstrated conclusively that gravity will bend light supporting Einstein’s theory of general relativity. The point that was being made by Popper is that what made Einstein’s ideas scientific is that you could test it (if it was false, the star in question would not have appeared to have moved by the precise amount predicted by Einstein). The semantics of the concept are more for fun philosophical discussions in my opinion.

    Bring it back to our discussion. “Simple Contact” is great. Very plausible. I will even say that, when talking manual therapy, we may be left with only two plausible explanations, “simple contact” on the one hand and “it’s all placebo” on the other. Through exploring simple contact we may even find the scientific explanation of the physical manifestation of placebo itself (admittedly my bias if I were a betting man). The acceptance of “We may never know” is simply not scientific (even if accurate). Science keeps digging.

    My final point (“about time wind-bag”) is back to my example of acupuncture (so thoroughly attacked on SBM and rightfully so in my opinion). If you remove the mystical explanations and replace them with a more plausible explanation (even simple contact could be extended to acupuncture as Diane had mentioned), does that make it science? Is plausibility without “falsifiability” (as described above, maybe you prefer “investigatable”?) alone enough? In my opinion no, but I will support the continued investigation.

  58. Jon Newman says:

    Just a few quick notes from me based on previous comments.

    SomaSimple is a discussion board with a variety of people promoting their theories, ideas, etc., some of whom are moderators and many that are not. It’s a discussion board with a diverse set of views and the only consensus among the moderators there that I’m aware of can be found in this thread.

    http://www.somasimple.com/forums/showthread.php?t=4944

    But focusing on SomaSimple and two of the theories that have been promoted there is a distraction, in my opinion, from the issue at hand which is the role our professional organization has in promoting science in continuing education. My expectations of what responsibilities I think the APTA ought to strive for and what they think is appropriate may simply be different. Caveat emptor, as far as I can tell, has been the policy thus far. Unfortunately, it’s the patients, not just the therapists who reap the consequences of such a policy.

    I think the claims made (e.g. the ability to detect pathology, the ability to fix the detected pathology with their method/technique) by CE providers are areas that may allow people within the structure of the APTA to discriminate which courses are worthy of CE. I may be wrong or at least incomplete.

    Also, as mentioned in earlier comments, changing the culture is much harder than changing a policy.

  59. ErikMeira says:

    @Jon Newman- SomaSimple is awesome and I would completely agree with the “10 steps”. The moderators are doing a great thing and, when I lecture on science in PT, I tell everyone who uses manual therapy to go to the site. As you said, let’s not focus there. I agree with you on almost every count.

    The main thing that I am trying to get across is how muddy the waters get when you try to create a line of demarcation for con ed. Is scientific plausibility enough? Sure, if presented objectively but who does that (even I don’t)? Scientific plausibility is a continuum from “not likely at all” to “almost definite” (no absolutes) so where do you draw the line? The black and white position that I just presented creates such a line, but who would be happy with it? This is the problem we have had trying to create a policy in the past. Every modification we give to that hardline position that I described creates enough of a crack to let a whole lot of things come pouring in. I challenge the moderators of SomaSimple (obviously very smart, scientific, and have their heads on straight) to create such a policy (even the “10 steps”). Then see how easily one can make a little tweak to something like MFR to make it fit on a technicality and all of a sudden you need to let them present or face a lawsuit for restraint of trade. Think this won’t happen? http://en.wikipedia.org/wiki/Wilk_v._American_Medical_Association

    As I mentioned in my first comment, I am VERY active in the APTA and have banged my head against the wall of policy change. Scientific PTs have been fighting that fight for years and we can’t legally close all of the loopholes. And here is where I disagree with you: In my experience, it is MUCH harder to change a policy than to change the culture.

    Don’t misunderstand me here. I am talking about regulating non-conference, good-old-fashioned weekend courses here (which are controlled at the state level). It is embarrassing to have “integrated” courses at an APTA conference. They are much more likely at CSM due to the autonomy of the individual sections. Some sections have one person who decides what to put on, some have committees (I am on such a committee for Sports). Don’t like what you see? Vote out the section leadership. Want to see a policy on APTA conference content? Vote in people who will create that. Just remember that they may later get voted out UNLESS YOU CHANGE THE CULTURE (remember I can’t do italics).

    People, support good programming! See a science-based course or known science-based presenter on the program? Go to it and sit your butt in a chair EVEN IF YOU HAVE SEEN THE CONTENT BEFORE AND COULD PROBABLY PRESENT IT YOURSELF. Join a section (as I am the Membership Team Coordinator of SPTS might I suggest the Sports Section?). Insist that those running for your section’s leadership openly run on a platform of science and vote them in. You people want change? Then speak up where it counts!

  60. ErikMeira says:

    @John (not Jon Newman)- Sorry no one responded, I just read your comment. You put it very well and one of my favorite skeptics (Michael Shermer) had a very similar op-ed that he wrote for the AMA that you might enjoy. I suggest all medical professionals should read it once a year.
    http://virtualmentor.ama-assn.org/2011/06/oped1-1106.html

  61. Gredo says:

    Erik and Dianna: Thank you very much for your time and courtesy. I understand better what you are both trying to communicate.

  62. John Ware says:

    Thanks for noticing, Erik. I’m also an avid reader of SBM, but I don’t think the contributors here are critical enough of the significant limitations of the biomedical model for treating pain problems.

    I don’t begrudge at all Dr. Hall and others highlighting the ridiculous pseudoscientific CAM approaches being foisted upon the public, after all, the name of the blog is “Science-Based Medicine”. However, when we honestly appraise the critical financial state of modern health care systems and the current failure of these systems to effectively treat persistent pain problems, then the proliferation of these pseudoscientific approaches to treating often desperate patients makes much more sense.

    I would like to see a broader frame of reference with respect to biomedicine’s failure in treating chronic pain so that readers get a better sense of the intransigence of pseudoscience in health care delivery.

  63. I’m right with John’s last post.

    I have said for years that we could do a much better job, and we could do it greater efficiency if we UNDERSTOOD more – not if we pushed harder, faster or with exquisite “skill” (whatever that it).

    Soma Simple provides a platform for that understanding. When someone writes me with another agenda I always say, “Bring it.”

  64. MathesonJW says:

    The Bottom Line is that individuals, chapters, and sections of the APTA are allowing pseudoscience into their educational programming. This needs to stop happening.

    Both Voltaire and Benjamin Parker said, “With great power comes great responsibility.” As physical therapists continue to move forward as legitimate autonomous providers of musculoskeletal medicine, we must, as a profession, drop the pseudoscience Woo. It just doesn’t belong in the practice of physical therapy. It makes us look silly and ignorant. It’s embarrassing. It also down plays the tremendous amount of scientific work we have done in the past two decades.

    In my opinion, the APTA doesn’t adequately address the ethics of physical therapists treating patients with pseudoscience techniques such as Visceral Manipulation, Craniosacral Therapy, Applied Kinesiology, and Body Talk. None of these practices are worthy of scientific merit. In fact, I would argue the practice of such pseudoscience is unethical.

    The APTA Code of Ethics for the Physical Therapist (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/HOD/Ethics/CodeofEthics.pdf) states that:

    “Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors. (Core Value: Excellence)

    6A. Physical therapists shall achieve and maintain professional competence.
    6B. Physical therapists shall take responsibility for their professional development based on critical self-assessment and reflection on changes in physical therapist practice, education, health care delivery, and technology.
    6C. Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice.
    6D. Physical therapists shall cultivate practice environments that support professional development, lifelong learning, and excellence.

    So now three questions:

    1. As a PT considering some of these “integrative” or “alternative” treatment interventions, don’t I have an obligation to patients and an obligation to honesty and integrity, which in turn is either explicitly or implicitly linked to science?

    2. Isn’t it unethical for physical therapists to first offer implausible treatments (like visceral manipulation, craniosacral therapy, etc) and second, to fail to inform patients of the implausible nature of such treatments?

    3. Isn’t it unethical to mislead patients about the reasons that implausible treatments make some people feel better? Even if the reason the patient is being misled is because the PT is regurgitating back some faulty reasoning the instructor teaching the course said?

    In 2012 if the PT profession, as a majority, answers these three questions with a resounding “Yes!”, then why do we still see the APTA allowing the promotion of pseudoscience within its sections? The PT profession is better than this.

  65. Adam Rufa says:

    Great conversation all. I agree with JW Matheson’s comments above however as ErikMeria pointed out, it may be a very difficult task to develop a fair policy which adequately excludes woo. I also think that in some cases it can be difficult to determine where the line is between woo and acceptable ambiguity. In the case of VM, it is obvious that it is woo but what about courses which teach examination based on palpation (like SI joint). There is a good amount of evidence showing that palpation is unreliable and not a valid method to examine the SI joint (better plausibility than VM). Should we exclude those courses as well?

  66. Diane Jacobs says:

    @Adam,
    There is a good amount of evidence showing that palpation is unreliable and not a valid method to examine the SI joint (better plausibility than VM).

    Really? Better according to whom?
    That’s part of the problem. Sometimes woo is hard to spot when it’s been around a long time. But really, I would argue, none of it should be acceptable as plausible, including traditional ortho woo. When the manual therapy evidence-base repeatedly points out the non-validity of something everyone’s believed for a couple hundred years or longer, people should no longer accept it or teach it as if it were real.

    JWMatheson, I also agree with you.

  67. Adam Rufa says:

    Diane,

    I don’t disagree with you and maybe SI joint palpation was not the best example to use. I meant to put a question mark after (“better plausibility than VM?). My point is, the original idea that bio-mechanical factors are important in orthopedic manual therapy seems (at least to me) more plausible than VM, based on the scientific principle of the stress model. I agree, the problem is that much of the bio-mechanical model has not held up when studied. Therefore, it may be no better than VM.

    However, when does something cross the line into woo?

    It is easy to identify those models on the fringe, but how do we weed out those which are straddling the line?

  68. ErikMeira says:

    @Adam Rufa- You are asking the same question that I was. Plausibility is a starting point as I described above. You then must test it. In science, your default position is that a statement is NOT true. Until you prove otherwise, you continue to believe that it is NOT true (this is referred to as the “null” position).

    Use the SI example. If one approaches the question of SI joint palpation with “It has to work, but how?” then that person will struggle intellectually with those findings you mention. They will keep trying to prove their position that they have been taught must be true. If the default position is, “This doesn’t work,” then the scientific method can work its magic. It puts the burden of proof on the proponents, not the skeptics.

    This is the danger of plausibility alone, it will trick people into accepting something prematurely (“that makes sense so it MUST work”), and then it is really difficult to undo when it is discredited.

  69. Josh Berndt says:

    JW, I agree again and answer yes to all 3 questions. I think 6C is extremely important, but some PTs don’t have the ability to critically evaluate the science or evidence independently. They often trust others to do the thinking for them and then follow them around. It’s my opinion that this has lead us to where we are. This is why the schools have to continue to educate students on critical evaluation of “evidence” I am confident the PT profession will do this, but it may take longer than all of us would like.

    Erik, the subtle difference you outlined is Extremely Important. The only frustration with the burden of proof placed on proponents, is, it is a timely and costly process. Take nonspecific back pain for example, maybe taking a daily walk around the block and reassurance this will resolve is the best treatment for a population with back pain, who will pay for a study on that since nobody stands to make money, except nike, maybe! In the meantime others swoop in to fill in gaps with crap, make fortunes, and confuse our patients and practitioners!

  70. Diane Jacobs says:

    > “In the meantime others swoop in to fill in gaps with crap, make fortunes, and confuse our patients and practitioners!”

    Or costly imaging that conflates some minor tissue irregularity with a big pain problem, reinforcing tissue-based thinking about pain, or worse, orthopaedic surgery to “fix” something that, although it may have been a bit funny on imaging, wasn’t the “cause” of the “pain”, doesn’t work for the “pain” at all, was never really been vetted in the first place, ever, and leaves the patient not only still in “pain” but mechanically in worse shape than before.

    But back to manual therapies, and to the thing about the SIJ:

    Occam’s Razor is cheap to use. Why not use it?

    Let’s compare the “belief” that SIJs “move” in the ortho manual therapy world (which prides itself on being less wooey overall, even imagines itself to be on safe ground); let’s compare that, to the “belief” held by the craniosacralists who swear up and down they can not only feel sutures moving but that they can move them, make them better or something.

    I really don’t see a lot of difference, actually. In both cases, head sutures and the SIJs, we’ve been told since forever by various anatomists that they just don’t move. (We’ve also been told discs can’t slip, but there are still anatomical models sold to therapists and physiatrists that show big red plastic blobs on spines to depict a disc that has!)

    Back to sutures and SIJs, I see treatment concepts built on kinesthetic apophenia in BOTH cases. Tell me why one kind of apophenia should be more “plausible” than the other. (Apophenia = finding patterns in random noise and irrelevant stimuli.)

    I don’t want to put Adam on the spot all by himself, but it’s still all about plausibility, and I’d love to learn why this stress model would excuse one kind of kinesthetic apophenia (ortho testing of [supposed] motion or lack thereof, at SIJ, then choosing a technique, then retesting), but not the other (cranial therapists, sitting there feeling for increases of amplitude in what they imagine to be skull motion, testing and treating simultaneously).

    Too my mind, both are ultimately unacceptably wooish.

  71. ErikMeira says:

    Damn good analogy, Diane. Not picking on Adam at all, as he never said that he uses that approach – he just brought it up. But his point (that many well respected PT use and teach that stuff) demonstrates the problem that we have trying to make policy changes. Really smart people are easily confused by plausibility and therefore can’t agree, even at the highest levels, even on a science-based medicine blog!

    Many have built their entire careers on concepts that at one time were scientifically plausible. When they are discredited, they refuse to accept it and keep teaching it anyway. Those of us in the know have a hard time stopping them because of the respect these people have within the profession. Besides, “How could it not work? It makes sense. Isn’t that enough?”

  72. Diane Jacobs says:

    Yes. I think that’s called Argument from Authority (fallacious).

  73. Adam Rufa says:

    Wow, I feel like Sarah Palin with all these gotcah questions (j/k). And thanks for the definition of apophenia.

    By no means am I suggesting that the model of SI joint bio-mechanical evaluation treatment is valid. I think it is the poster child for why we need treatment philosophies to go through the scientific process before they are taught and used by the masses. Once they are “accepted” it is very hard to get rid of them.

    I regret bringing up the example of SIJ because it has inadvertently distracted from the point I was trying to get across.

    As Erik put very well “Really smart people are easily confused by plausibility and therefore can’t agree, even at the highest levels, even on a science-based medicine blog!” Disagreements regarding plausibility and interpretation of the literature are common among very intelligent and scientifically minded individuals.

    Based on that, it would seem like a difficult task (as Erik mentioned previously) for an organization to develop an objective policy which was both sensitive and specific. Or, maybe it is easy and I am just not clever enough to figure it out.

    Diane (or others)what standard would you suggest groups like the APTA use to accurately weed out woo while still providing a platform for new and emerging concepts which are going through the scientific process?

  74. Diane Jacobs says:

    @Adam,
    “what standard would you suggest groups like the APTA use to accurately weed out woo while still providing a platform for new and emerging concepts which are going through the scientific process?”

    I could go on for days about this, but I’ll try with a short list of what I consider to be common sense rules.

    1. Understand the difference between “EBM” and “SBM”: This blog is a good resource. Check out Harriet Hall, tooth fairy science. In my Occam Opinion, most of what science we have in PT is only at a tooth fairy level. Everyone is focused intently on outcomes but no one has asked, “Does the tooth fairy really exist?”

    2. Do a lot more reading about the implications of treating human beings as the evolved vertebrate multi-cellular organisms we are. Furthermore, as PTs we treat mainly conscious awake human organisms with evolved, kludged, non-monolithic, nervous systems. We should not treat patients as though they were stretchy animated corpses. We should not be primarily “meat” focused or “joint” focused the way we have been in the past.

    3. We should understand we are creating conceptual hallucinations to match our perceptual fantasies. It’s OK to do that, as a stream of hypotheses that arise in the moment, but we should KNOW we’re doing that, and know when to STOP doing that.

    4. The more we understand pain science (which unfortunately has its own hydras to battle), the more our language will evolve away from meat (mesodermally-derived) language/ treatment concepts and theories, toward something more “real” – that the nervous system in a patient is having a problem managing its inTRA-relationships. The “meat” of the person is usually an innocent puppet of said nervous system glitch. Here is a link to Lorimer Moseley’s blog, BodyInMind. He’s made his papers available. Read the first one, the most recent, “Teaching people about pain: why do we keep beating around the bush?” It’s short, and he lays out the problem really clearly.

    5. There are some mountains we’ll never be able to climb, as a profession, and that’s OK. But we can, should, and will become the most science-based human primate social groomers on the planet, who can be fluent in speaking about what we are doing.

    6. Trying to rule placebo out of what it is we do is a fool’s errand. It’s there in every awake person. It’s there like gravity. To try to rule it out, isolate it for science-production purposes would be like taking things out into outer space in order to “rule out” gravity to weigh them “objectively”. Placebo will always be part of treatment relationships, manual therapy or otherwise. Here are thoughts I wrote about that, lately: http://humanantigravitysuit.blogspot.com/2012/01/pain-and-fire.html

    7. I think we can figure out how to study our work, but the designs will not be based on medical science, probably.. they’ll have to be a lot more sophisticated and clever, more like ones in social science or psychological science.

    I’ll stop here because I need to go back to work.
    Diane, human primate social groomer

  75. Adam Rufa says:

    Diane,

    Great list but it seems a little like you are lecturing to me about your thoughts on PT and science (which is fine by the way) but I don’t see how that answered my question. I am well aware of your stances on the PT profession from your previous writings (and I agree with some of them) and have read just about all of Lorimer’s papers (and books)several times.

    I for one cannot figure out how to take your points 1-7 and put it into a workable policy which would assist the APTA in determining which courses to allow and which to boot out the door.

  76. Linda Rosa says:

    Unfortunately the literature on VM shows evidence of harm. Here’s a Reuter’s story reporting on a case history in the NEJM. The paper’s particulars reveal that the particular “massage” method was VM.

    “Doctor finds liver damage after massage
    “BOSTON, Dec 22, 1999 (Reuters) – Sometimes a deep body massage can be a little too deep. A 39-year-old woman was ill for six months after a massage therapist apparently rubbed too hard and damaged her liver, causing a painful accumulation of blood called a hematoma, Dr. James Trotter of the University of Colorado Health Sciences Centre reported in Thursday’s New England Journal of Medicine. Even after the damage was discovered, Trotter’s patient experienced nausea and low-grade fevers that caused her to lose 23 pounds (10.5 kg). Subsequently, she recovered fully.“Therapeutic body massage has become a popular treatment for a variety of disorders,” Trotter said, noting that while the rate and severity of side effects “is probably quite low” the practice can lead to occasional problems. Doctors “whose patients undergo massage therapy should be aware of these potential complications,” Trotter said. Trotter, J.F. “Hepatic Hematoma after Deep Tissue Massage,” N Engl J Med 1999; 341:2019-2020, Dec 23, 1999.

    I became aware of VM when it became a method used by Attachment Therapists on adopted children. Pressure on the abdomen (e.g. the therapist’s elbow is pushed into the abdomen of the restrained child) was supposed to release “repressed infantile anger” stored in the tissues of the child.

    In another case, VM was responsible for the death of 3yo Krystal Tibbets:
    http://www.childrenintherapy.org/victims/tibbets.html

    Here is a very disturbing film of VM being used to torture a child (the 6th clip down: CBS 48 Hours “Afraid of Our Children”):

    http://www.childrenintherapy.org/videos.html

  77. Diane Jacobs says:

    @Adam,
    Sorry, I got on a roll and started typing. Sorry if it sounded lecture-esque.
    A succinct policy statement on standards? [/ohboy]
    We thought about this, in the Pain Science Division (Canada). What we came up with was a statement about not supporting anything that wasn’t plausible or science-based, something like that. We thought that should suffice to keep out the really strong-smelling woo, put the onus on practitioners thereof, to convince us of their, um, “science”. I argued hard for “science-based” (not just evidence-based), mostly because of what I’ve read here at SBM (thank you, people at SBM!), and the sense I’ve been able to make out of human primate social grooming so far.

    The fact a Pain Science Division exists at all in PT is already quite a coup/first step forward for reality-based treatment IMO. See this link on our history: http://bodyinmind.org/canadian-physiotherapy-pain-science-division/

    When we started, spokespeople from the ortho division wanted us to be a subgroup under them. I argued hard that we needed to be a stand-alone group even nobody understood why at first. As a result, we are independent, are not obliged to think or speak “orthoese”, or deal with patients in terms of structural parts, can encourage and teach our members to talk neurophysiology with patients, so I think that’s hopeful. Our new chair has his black belt in ortho (understands and is fluent in it), plus a PhD, plus teaches pain neurophysiology, so I think we are safe for now.

    I expect the conditions you face in the US are different and maybe more daunting. Maybe not. Anyway, I hope you succeed in course-correction at the APTA level.

    Linda, thank you for those VM links!

  78. Gredo says:

    This was where I was looking to go with my comparison of what Jacobs and Dorko utilize in their care of their pts. The topic is VM and why it does not belong in our profession. A follow up to this is how do we weed out that which doesnt belong. I use Simple contact and DNM as a template because these two “methods” have been given passage through the test of what is considered as scientifically/evidenced based forms of treatment. Surely as these have been given the OK there must be a way of standardizing to vet other approaches. My questions and confusions arise regarding comparisons of DNM and Simple contact with other forms of treatment if those other forms were to justify their treatment similarly to how Jacobs and Dorko justify theirs and were to adhere to the processes of pt education, addressing fear avoidance, providing a safe environment, etc. In other words, what is the difference between say myofascial release and positional release if they held to their tenets of pt treatment and the explanation of treatment effect as described above by Jacobs, Meira and Dorko? Will someone answer this question please?

  79. Adam Rufa says:

    Thanks Diane for your thoughtful response. What you propose still leaves a lot of room for personal interpretation but I think it may be the best we can do. It seems in certain cases it is challenging to objectively figure out what is plausible and science based.

  80. Diane Jacobs says:

    @Gredo:
    > “My questions and confusions arise regarding comparisons of DNM and Simple contact with other forms of treatment if those other forms were to justify their treatment similarly to how Jacobs and Dorko justify theirs and were to adhere to the processes of pt education, addressing fear avoidance, providing a safe environment, etc. In other words, what is the difference between say myofascial release and positional release if they held to their tenets of pt treatment and the explanation of treatment effect as described above by Jacobs, Meira and Dorko? Will someone answer this question please?”

    Are you saying names of things don’t matter? If so, I heartily disagree.

    Half the battle is to get RID of all the conceptual packaging and the meat-theory based names and all the operator model associations connected to the verb of effectively relational human primate social grooming, effectively relational for each affective aspect of the nervous system, exteroceptive, interoceptive and proprioceptive. It has to hit the right notes to satisfy the cognitive evaluative aspects of a patient’s conscious awareness, to be able to enter the patient’s “umwelt” the right way. It has to be non-threatening. It has to be ready to answer questions on any/all levels of pain-science-base. (I like to imagine myself having to treat Ronald Melzack, developing a therapeutic relationship with him!)
    To be able to do that, to be able to move human primate social grooming forward, practitioners have to understand advances made in pain science him/herself, not just continue to blame “pain” on something bottom-up, vague and unsubstantiated as “trigger points” or “fascia” or anything concocted as being a misbehaving-meat part. Manual therapy has to be re-invented from scratch, the right way this time, with prior plausibility, way fewer (none if possible) conceptual rabbit holes, incorporating modern pain science, if it is to pull itself up out of the conceptual muck in which it is still buried, and which threatens to bury our organizations.

  81. Jon Newman says:

    As far as what an APTA/State Chapter policy might look like I made some comments in a previous post the suggested the evaluation process focus on the claims made by the CE provider. I was also exploring this issue in a thread at SS in 2009. See here

    http://www.somasimple.com/forums/showthread.php?t=6638

    I also chimed in on this issue in an Evidence in Motion blog in the past.

    I guess I was imagining a sort of peer review process similar to how papers get accepted for a journal but with different areas of emphasis.

    Possible ideas would be to classify different sorts of CE available such as CE whose emphasis is on jurisprudence, or CE whose provider is a scientist/clinician presenting research they’ve participated in, CE whose emphasis is on medical humanities, etc. The submission process could require the providers to identify claims being made during the course and theoretical constructs underpinning their work. The “claims made” aspect could be further categorized into claims of detecting pathology, claims of fixing pathology, claims of changing a subjective self-reports, etc.

    Some sort of grading system could be developed that takes all these into consideration. The APTA/State chapter could require a certain number of credits in a variety of the categories such as x in jurisprudence, y in basic research, z in medical humanities. Certain courses could be weeded out completely or they would have to change their content in a positive direction.

    At this point I’m just trying to come up with ideas of creating a system knowing that some team will be responsible and it will likely increase costs.

    Those are some initial back of the envelope thoughts. I’m also not deluding myself that this is a perfect solution but I’m hopeful that it’s a step toward a more accountable system.

  82. Gredo says:

    @Dianna: Fair enough…Thank you. So as DNM and Simple Contact meet the inclusion criteria to be defined as being science/evidence based, what is the difficulty in using your intervention methods (including pt interaction and PT education from start to end) as guidelines to systematically look at emerging/current methods to see if they similarly meet the science/evidence based inclusion criteria? In other words, you can succinctly define why DNM is evidence based step by step…couldn’t this be used as a template to construct the principles for evaluating an intervention?

  83. Diane Jacobs says:

    @Gredo,
    >”In other words, you can succinctly define why DNM is evidence based step by step…couldn’t this be used as a template to construct the principles for evaluating an intervention?”

    I can step-by-step you through every step of why DNM (and simple contact) is SCIENCE-based… it’s not “evidence”-based yet, because my little preliminary cae-series outcome study (showing weak but significant support) remains to be published. But at least we’ll know at the get-go that there is no tooth fairy in sight. S/he will have been ruled out at the start.

    Jon, I hope you continue to keep a stack of blank envelopes for ideas just like those. :)

  84. ErikMeira says:

    Wow, I missed a day…
    @Gredo- In answer to “…what is the difference between say myofascial release and positional release if they held to their tenets of pt treatment and the explanation of treatment effect as described above by Jacobs, Meira and Dorko?” I say that there is no difference. In my opinion, scientific plausibility, no matter how logical it sounds, is not enough to reject the null position, as long as there is another equally scientifically plausible yet divergent explanation (placebo). I don’t support any of it. I tolerate “social grooming” more than MFR, but it still doesn’t satisfy me. Again, I’m not a pain specialist, I’m speaking from a purely scientific and therefore a hardline skeptic’s position. Also, to everyone, do not assume I am not compassionate here. I understand the dilemma.

    @Diane- I personally don’t need any more info on the hypothesis of how manual therapy might affect pain. Let me ask a more direct “yes/no” question. If what you are describing turns out to be nothing more than a scientific explanation of how “social grooming” uses ONLY the placebo effect (which it seems we all agree is possible), are you okay with that? I am not asking why that is okay. I understand the position of “It doesn’t matter. It is our most effective treatment under the current understanding.” Which brings me to…

    @Jon- Those are great ideas and I encourage you to continue to develop them! I have been involved with three state chapters who are trying to implement exactly what you describe – a multi-category system of grading courses. The problem we have found is that these groups keep squirming around the guidelines to be “technically evidence-based” (citing case series, clinical commentaries, underpowered clinical trials, etc). We have even tried requiring citations of “Level I” evidence. All they do is cite something that is Level I and then build a scientifically plausible thought experiment that is ultimately untestable (“supporting” it with case series, etc) leaving a bad taste in everyone’s mouth. Sure, their stuff “makes sense”, but it could all just be placebo. It takes an army of very patient reviewers to defend the system from these perpetual attacks, only to be usurped by members who ultimately want the course in question.

    I know, I know. I keep hearing that we need to focus on removing the embarrassingly bad stuff. Slippery-slope applies here. If we as a profession are okay with teaching concepts that may be nothing more than placebo (no matter how you justify it), we unfortunately have to tolerate the other crap as well. They are very good at finding that little crack in the dam and are persistent little bastards AS LONG AS THE DEMAND IS THERE.

    I’ve tried to force speakers to objectively address and acknowledge scientifically plausible counter arguments to their content. They continue to squirm and argue from authority or throw up a straw-man against the counterarguments making the hardline skeptic the bad guy…

  85. ErikMeira says:

    Also, in my experience, Arizona is the closest to regulating it, but it is by no means perfect.

  86. Diane Jacobs says:

    @Erik:
    > “@Diane- I personally don’t need any more info on the hypothesis of how manual therapy might affect pain. Let me ask a more direct “yes/no” question. If what you are describing turns out to be nothing more than a scientific explanation of how “social grooming” uses ONLY the placebo effect (which it seems we all agree is possible), are you okay with that? I am not asking why that is okay. I understand the position of “It doesn’t matter. It is our most effective treatment under the current understanding.” Which brings me to…”

    YES! I’m more than ok with that.

    Predictions (I know you didn’t ask for these but here they are anyway):
    1. ALL of rehab will be shown to be elicitive of non-specific effects, of placebo response, of confidence cures minus any and all conning, no more and no less, with or without manual handling. ALL of rehab’s success will turn out to have had WAY more to do with psychosocial aspects than anything bio.
    2. We will have to figure out how to get comfortable with, live with, and work with non-specifics, non-specificity, uncertainty, stick with the verbs of what we do (and do well), learn to do battle with and toss out meat-based nouns/false conceptualizations/conceptual hallucinations based on palpatory fantasies.

  87. ErikMeira says:

    @Diane- Thanks for clarifying! I appreciate your thoughtful dialogue and your honesty. Keep up the great work that you and the rest of the moderators are doing at SomaSimple.

    @Anyone else- The link to the APTA-AZ approval process:
    https://www.paymyassociation.com/displayemailforms.cfm?SessionId=171BF3B3-08C3-F0B1-8371B42821178121&emailformnbr=107088

    Sounds good doesn’t it? And I can tell you that they have a good panel (I’ve been through their process myself). Now look at the list of approved courses. Kinesiotaping, strain/counterstrain, MFR, etc (just examples, do not reply with a defense of one of these – Diane will eat you for lunch!). And this is a list of courses with “Category A” status ONLY. The other categories have much less scrutiny. Don’t give up on the policy change angle, just realize that it is really, really difficult and good people are already trying very hard.

  88. Diane Jacobs says:

    Alas, that link you posted, Erik, is a closed one.

    Anyway, keep up the good work. One war, many fronts.

  89. ErikMeira says:

    Sorry…
    http://aptaaz.org/

    Click on Continuing Education>Apply for CEU Approval

  90. Diane Jacobs says:

    About the work we are doing at SomaSimple, since you mention it, here is a link to a thread with information about the site’s founder, Bernard Delalande, and the suit he faced in France for standing up to dubious conceptualizations. http://www.somasimple.com/forums/showthread.php?t=12318
    The “method” owners took him to court, and although he didn’t lose, he didn’t win either – he was fined, and now SomaSimple’s existence needs some outside support. Before Bernard was fined he supported it himself.

    Suits have been threatened against US PTs too, by a well-known MFR group. Here is a thread about all that, from 2008. http://www.somasimple.com/forums/showthread.php?t=6054

    So far I think we’ve done quite well, and learning good discussion manners has helped a great deal in the last few years.

  91. Diane Jacobs says:

    Thank you Erik for the new link – I was able to access the right page and look at the process. It’s a start.
    I couldn’t find a list of approved courses however, just the sponsored ones.

    If I were on such a committee I’d not let the current explanations for Kinesiotaping, MFR etc, pass.
    Jones’ original explanations of targeted tissue in StrainCounterstrain would be subject to questioning as well. No one would want to get me started on the subject of dry needling. I’d probably create such a logjam I’d get kicked straight back off the committee for being obstructionist.
    I have questions about the fee – do people who pay the fee and fill in the boxes properly automatically get approved? Or does anyone ever get refused for talking BS?

  92. ErikMeira says:

    @Diane- A major source of operating revenue for many chapters comes from advertising courses. My guess here is that this is a means of having some kind of review while trying to recoup costs (pay us $ to review your course and get a our endorsement/free listings/discounts on additional advertising). The non-refundable aspect helps (they make $ whether it gets approved or not). I’m not defending it, that’s just the reality. Also, they will still sell their mailing list to non-approved con ed providers, but that will not get you the chapter “seal of approval”. Again, by no means perfect.

    Your comment about getting kicked off the committee for being obstructionist is exactly my point regarding policy.

  93. Jon Newman says:

    Hi Erik,

    I fully expect some people to be able to game the system and I keep mentioning I’m uninterested in a “perfect solution”, just a better one. I don’t have a deep appreciation, not being in the same position you are, for examples of “squirming around the guidelines” as you call it. And I don’t know if you mean guidelines as you linked to or guidelines as discussed thus far.

    A common theme in the CE submission process is asking for learning objectives which I think is secondary to asking for claims being made, theoretical underpinnings, etc. Once those things are in place, there should be a lot less “sure it makes sense” type submissions that don’t actually make sense. At least not without major assumptions or “then a miracle occurs” type step in the process.

    Anyway, woo courses would probably still find a place to exist but they would exist low on the scoring system. If a chapter required a high enough number of points/yr, someone would be more financially burdened trying to meet all their CE requirements by taking woo rather than taking a course with reality-based content.

  94. Jon Newman says:

    Something else I’m wondering about is how PT student course material gets vetted. Why aren’t there law suits left and right because things like faith healing, subluxation theory, etc. aren’t being taught? There must be some sort of standard that must be achieved to teach a course to students that doesn’t leave schools and professors particularly fearful of being sued for not teaching some other alternative. Of course I could be wrong. However, if not, then maybe the policies involved in that sort of decision making could come to bear on CE courses.

  95. ErikMeira says:

    @Jon Newman- Schools get accredited and must fulfill certain standards. There are still some areas of ambiguity and some schools find a way to support some shady stuff but, on the whole, they are mostly science-based. The school chooses who to hire so an upstanding academic institution with a strong science tradition will tend to hire good educational faculty. This is not ALWAYS the case by any means – you may have had a student or two in the past that will make you scratch your head.

    In con ed, the con ed company hires the speaker based on demand for the speaker, and they can mold their courses to fit into loopholes of “integrated” or “clinical experience” or “emerging fields” through the techniques that I described earlier. Unless you can provide clear cut parameters (get rid of allowing ANY “integrated”, “clinical experience”, or “emerging fields” i.e. UNTESTABLE), you get into restraint of trade issues – you are “unfairly” keeping these people from earning a living. Again, plausibility alone will not shut the door on these guys.

    It’s not that schools can’t do this, it’s that the CULTURE in a true academic institution will internally do a better job limiting it.

  96. Jon Newman says:

    The legalities are clearly beyond me but I think it’s simplistic to charge that anyone is unfairly keeping anyone from earning a living. I’ll let someone with legal credentials speak to that.

    The take home message I get from your post is that the culture of the APTA and its chapters is NOT that of a true academic institution. And I guess they aren’t an academic institution. Perhaps they shouldn’t even be in charge of setting the academic requirements of post-professionals.

  97. ErikMeira says:

    @Jon Newman- I won’t let you slide on that one. The APTA is the one who credentials the schools and, as you point out, they do fine with that. The academic institutions “play nice” and are trying to achieve the same lofty scientific goals. They also set the competencies for which their students must be prepared – the license exam.

    When you are talking con ed, the APTA and its chapters play the same role, they set the framework as best they can for the profession to be free to operate within the law (see the Wilk/AMA case that I referenced earlier). The “academic institutions” in this case would be the con ed companies themselves (NOT the APTA or the chapters). I think that we would agree that those are not known for holding themselves to the standards of large universities. The courses developed internally by the APTA and its chapters tends to be of a much better caliber – there are limitations as we noted above and that needs to improve.

    So why not have the APTA set competencies for continuing licensure? Wow, I wonder if anyone else thought of THAT before?
    http://www.apta.org/ContinuingCompetence/

    Again, the APTA is trying very hard but until the profession as a whole (i.e. “culture” – take THAT dead horse) stops being willing to entertain “new” and “untested” ideas without a PROPER scientific process (as opposed to “this really smart guy seems to have worked hard on his idea and it makes a lot of sense”), you will continue to see this crap pop up.

  98. Jon Newman says:

    Hi Erik,

    I’m not looking to have things slide so good for you for not letting what I said slide. But I don’t think I made my analogy clear enough. You mentioned that in a “true academic institution” it’s the culture that keeps that crap out, or at least keeps it to a minimum. So if an individual professor wanted to start teaching faith healing to the students, the institution would be able to say “no” without spending a lot of time fearing being sued for unfairly not letting this person earn a living. However, when a CE provider comes to ask approval for their pseudoscientific or ascientific course, then what? Better approve it, we might be sued? The APTA/chapter are the ones approving and disapproving the course–it shouldn’t matter what “the culture” of the CE provider or the therapists they cater to is.

    I have little doubt that there a nuances that I simply can’t understand because of my lack of participating in processes like this but I sense a disconnect.

    I should clarify that I don’t disagree about PTs desire for magical treatments or the CE providers willingness to fulfill those desires. I don’t think there is one thing to blame, as if that’s what this is about. I’m looking at where change can most easily be made and that seems to be at home in the APTA and its chapters. I have no reason to think the APTA can change CE providers from desiring to provide what PTs apparently want. I do think they are the only people in position to say “no” when it comes time to say “no”. I guess have a good rationale, hire good lawyers, and start a legal fund is the best they can do.

    I’ll post some limited thoughts on Wilk v. AMA later if it seems pertinent. Right now I don’t see the connection.

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