OK, Barrett, I'm taking you up on your suggestion:

quote:

Diane,
#5 caught my eye: "5. (So why beat up on it all the time? But that's another
thread..)
This sounds like a good idea for the Bullypit, or the Open Forum if you prefer-it gets
more hits.
I'm hoping you'll start something like "Why do we push?"
Just an idea.
We'll see what happens. I might start a thread in Open Forum too, I'll wait and see
what happens here. Probably Open Forum is tired of me and the petition thread, so
I'll give it people there a bit of a rest.
I'll start by crediting Lorex Rex, DO, for being either the originator or at least the
first person I ever heard use the term "Mobilipulation". I like it, so I've adopted it.
(I've copied the post in Ginger's Orthopaedics thread over to here, and resequenced
the numbers a little):
I found myself inexplicably irritated by the zombie-like ritualized insistance I've
noted among my peers, i.e., that which I have come to refer to as "Mobilipulator"
techniques are so widely assumed to be effective and exclusively bowed down to as
the be-all and end-all of spinal treatment.
The emphasis on this buried part of the body (spinal column) ranges from it being
the source of all dysfunction (historical chiro) to it being the 'promised land' of all
correction of dysfunction (chiro, PT, osteo). Same thing, really, I think..
I started thinking about the homunculi and how they really don't contain much
representation of the spine, either motor or sensory. It would seem, therefore, to
be a part beyond cortical control. So I thought what that might mean. And this is
the sequence of thought that resulted:
1. Spines were around long before brains became fluffy. Our fish ancestors took
them and became vertebrates. Fish are not noted for braininess. Fish use/used
spines for their total sum of locomotion. (Fins are just stabilizers, not movers.)
2. Spines form from sclerotomes; the vertebral bones and muscles that relate the
bones to one another all form at the same time, from the same substance, cranial
to caudal, and require little or no hard drive (brain) to run.
3. The muscles that work the back are termed "epaxial" in embryologic terms, to
make a distinction between them and all the other muscles in the body, including all
the ones that came along later and covered up the epaxial ones, called "hypaxial."
(E.g., lats, traps, rhomboids, psoas, limb muscles, abs, etc.) Epaxials are triggered
by different genes than hypaxial muscular development.
4. The epaxial musclature is the only musculature that is "run" by motor rami of
dorsal spinal nerves. Absolutely everything else muscular runs from ventral rami.
5. There is no need really, for a sensory or motor homunculus for the spine. It is so

primitive that it can be run by a very old and probably very basal part of the
system. Or it might even be close to autonomous in its function, certainly selfreferent.
(So why beat up on it all the time? But that's another thread..)
6. Surely it's the overlying layers, through which the dorsal cutaneous sensory rami
have to pierce, that cause problems. That pesky lat. that runs from the brachial
plexus. That pesky trap that runs from the accessory. They cover up everything.
They are easier to neuromodulate, and likely their motor homunculi are included
with that of the neck, and arm, both of which are bigger than the back homuncular
representation.
7. When the lats and traps are relaxed, lengthened through eccentric training or
through the few minutes that it takes with neuromodulation, the core "back" or
"neck" or "spinal column" (now decompressed) regains function (including stability)
very easily and effortlessly, with no requirement for forced introduced motion of any
sort.
8. Oh yeah, sorry, I don't have any studies backing this up, it's straightforward
observation only, based on logic and a smattering of knowlege gleaned from
readings of embryology and evolution and anatomy.
-------------------Diane
Diane,
Nice stuff. In fact I understand most spinal movement is generated by spinal and
bulbar reflexes and for all practical puposes is "preprgramed" into various patterns.
Cortical involvement is associated with modification or recombinations of these
patterns. Patterns is the key concept. I agree with your premise that if movement
between each and every vertebrae was of hierarchal importance, our higher CNS
centers would reflect that. Apparently it just doesn't work that way.
Gil
Diane's thoughts raise a question in my mind. If the spine and the muscles directly
effecting the spine are developed from different stuff, are controlled by different
nerves, and are "run" by different neuorological regions, how well is the spine and
the rest of the body "connected"?
Observation makes me think that they can communicate well. Simple Contact
seems based on the principle that they can, but often don't, i.e. higher cortical
regions suppressing the spines more primitive responses.
mike t
Mike,
quote:

It's so...basic that finding specific research seems daunting.

That's always been my problem too. In fact I'm sure it's why nobody ever found a
sharpener for an Occam's razor for manual therapy. So it just grew, and grew, and
grew, helped by all the fertilizer from all the various vested interests in the spine,
and the worship thereof.. But man, we've got to start somewhere.. we've got to get
rid of all this underbrush so we can get out of this forest instead of wasting time
cataloguing all the trees.
quote:

If the spine and the muscles directly effecting the spine are developed from
different stuff, are controlled by different nerves, and are "run" by different
neuorological regions, how well is the spine and the rest of the body "connected"?
About as well as anything is, probably. Evolution doesn't seem to throw anything
out, it just uses existing bits for new purposes, by adding a neural layer to the
brain, or an outpouching of some bulge somewhere on the cortex, or running
another "wire" somewhere, as in recurrant nerves here and there in the periphery. I
think the brain is interesting, because it's not a monolith at all, it's a community of
parts, modules, that have to communicate and cooperate to get anything physical
or physiological done.
Jon, I'm glad I'm not the only one interested in epaxial versus hypaxial and how the
organism unfolds. Gil, I think we both see spinal functioning about the same. Pretty
low wattage compared to something as highly innervated and needing such a lot of
cortex as say, skin.
I think a lot of the fixation we've all had on the spine, and the waste of time we've
all spent trying to make it behave better while ignoring all the layers we have to get
through on our way into its function, we can blame on the knowlege base that
existed at the turn of the last century, the tail wind created by orthopaedic and
chiro schools of thought. At least osteopathic thinking was global; even while its hat
was tipped to the spine the school of thought was very inclusive of all physiological
processes.
-------------------Diane
From The Fatal Heuristic waaay down on the list on my site:
Heuristic comes from the Greek "heuriskein," meaning "to discover." A heuristic is
a problem solving technique that leads to conclusions that are based on appearance
rather than careful investigation. They are short cuts that allow us to proceed
rapidly from observation to action and we use them all the time.
My contention in this essay and elsewhere is that the supposed connection between
strength and posture, an enduring myth still being taught in the PT programs, has
led us into decades of irrelevant, inappropriate and ineffective training for painful
problems. (Does that sound a little harsh?)
Has a similar thing happened with our focus on the position of the connective tissue
when we should have been looking elsewhere? Does the classic symbol of a braced,
crooked tree trunk for the discipline of orthopedics exemplify this? Did we
mistakenly give the treatment of these problems over to the ortho community when
it should have been given to the neurologically inclined?
Barrtet
When taking these short cuts to attempt to come up with new theories you need
to take a close look at not only the individual ideas but how they are linked at what
premises they are based. Any missing link can turn a theory into conjecture or
worse destroy it.
For example, Dianes theory seam to rely on the premise that the size of
humuncular representation relates to the amount of pain a structure creates. I
dont know of any evidence that supports this and the excruciating pain that can
accompany visceral problems seams to refute this.
Basic science research relies on ceteris paribus. Variables are controlled to reduce

their effect on the study. When these variables or others not considered are entered
into the mix the result can be unpredictable. This is precisely why theories based on
basic science and personal experience still need to be confirmed by well designed
outcome studies. You could easily be missing a logical link in your theory or have
missed out on an important variable. All the evidence in the world may mean
nothing if a couple of key pieces in the puzzle are missing.
Did we mistakenly give the treatment of these problems over to the ortho
community when it should have been given to the neurologically inclined?
I wouldnt say that necessarily. I would say that many in the ortho community have
been doing neuro treatments without having a clue that they were doing so. I
would venture that 90%+ of what we do is neuromodulatory and that we have very
little if any effect on actual pathology.
Dont see what this thread has to do with manipulation or mobilization. Am I
missing the meaning of mobilipulation?
Doug
That thing that Doug said about ortho people doing neuro work without knowing it
is something I agree with entirely.
Where does it say I wasn't leaving room for both?
Surely you don't imagine that I'm unaware of primary orthopedic problems. But
what I've been seeing for over thirty years is that unless the nervous irritation
reaches epic proportions it is ignored. It's time for that to shift, and, of course, no
one is suggesting that the connective tissue of the spine be totally abandoned as a
possible peripheral driver of nociception.
Given its qualities and properties however, how is external pressure from our hands
supposed to make any real difference?
quote:

Dianes theory seam to rely on the premise that the size of humuncular
representation relates to the amount of pain a structure creates. I dont know of
any evidence that supports this and the excruciating pain that can accompany
visceral problems seams to refute this.
That's not what I'm saying Doug. I'm saying the spine gets blamed for stuff it isn't
causing. It doesn't cause the pain that is felt in its apparent physicality by a gall
bladder attack, etc... in lots of ways it is a screen upon which all sorts of things real
and imagined, are projected, like pain from somewhere else (real enough), like lack
of mobility/stability (mostly imagined IMHO.) I would even go out on a limb and
hang by a twig, battered by Katrina sized winds, and say that its very lack of
homuncular representation, the primitiveness of its motor system, leaves it
vulnerable to projection by other more "sophisticated" motor systems in the brain,
or at the very least sensory confusion. I think its very primitiveness evolutionarily
speaking means that apart from genetic/congenital problems, true bony scoliosis
etc, trauma resulting in fractures, osteoporosis of a parathyroid sort, ... barring true
pathology, the spine is really more a victim than a culprit, in terms of nocioception
origin. Certainly I disagree with looking to it first for every neuromusculoskeletal
problemo or glitch under the sun. We will have to agree to disagree on that.
quote:

I would say that many in the ortho community have been doing neuro treatments
without having a clue that they were doing so. I would venture that 90%+ of what

we do is neuromodulatory and that we have very little if any effect on actual

pathology.
I agree with you completely on this point, although I would raise the percent to
close to 100.
Re the ortho community:
I would say also 100% of what we do in any clinical field, especially paeds, is
neuromodulatory.
When the orthopods invented SLR, they were looking at gaining strength and ROM,
after knee and hip replacements. When patients are told to wiggle their ankles
around in bed post surgery, they are thinking of calf length and DVT prevention
thrown in for good luck. None of these techniques are wrong or inaccurate, but the
focus is narrow. These are definite neuromodulatory in effect, and the benefits are
placed in the sole belief that strength of muscle gets the patient mobile and
chucked out of hospital.
I think that is what confuses the issue amongst PTs.
Mobilipulation is based on the theory that movement = pain reduction. True so far.
Moving a spinal segment at a specific level can reduce pain, whether by a 1-4 mob
or a zippy 5. I agree with Diane that the spine is seen as a culprit, not a victim, and
all sorts of reasons emerge about its complexity, and how much movement occurs
in the thoracic as opposed to the lumbar, etc etc. If someone comes in for 15
minutes of mobilipulation and exercises, and feels instantly better, why is that? Can
anyone say precisely why patients return time and time again for this approach,
when it seems to be only temporary? Does it not occur that we are missing
something?
Exactly what that is...I ain't sure yet.
Nari
missing piece of the puzzle would certainly explain why there are so many different
methods being taught for mobilizing this or that aspect of the musculoskeletal
system, and all of them seem to "work" and make the patient feel better,
ultimately. Kind of like the blind men and the elephant fable.
Today, at an inservice, we learned an unfamiliar (to me) form of strain-counterstain
that was nothing like Jones work, but seemed vaguely similar to Barrett's only more
regimented. The presenter gave no explanation for WHY it works, only that it does
from clinical experience.
Someone brought up the subject of taping. I don't know much about the theory
behind kineosiotape, for example, but I have long suspected it works through
stretch-activated ion channels in the skin, proprioceptive feedback if you will.
Same goes for ASTYM, where tools are used to make long sweeping strokes over
the skin. It is supposed to break down fibrosis, but it is more likely having a
neuromodulatory effect like the stroking we were taught to do in school to facilitate
muscles. When I brought up this possible neurological effect at the course, the
instructor said they had never thought of it that way being purely orthopedically
minded. And the research being done is still looking at it through an orthopedic
lens.
I could go on and on, and maybe Jon would call me an assimilator (as I have called
myself), but I think Doug has a very good point. When in Rome, do as the Romans
do. If these "new" ideas or missing links or whatever, are ever going to get into
mainstream PT thinking, real research needs to be done because that is the
language the schools understand. One can spread the word through forums and
courses, etc (I still think Diane should teach one), but it is mere whispering
compared with the abundance of research singing the praises of current and long-

held orthopedic practices and beliefs.

Sarah
Hi Sarah,
Glad you made it over here.
I agree with you, and with Doug, about research being important. Here is the point
Doug made:
quote:

Basic science research relies on ceteris paribus. Variables are controlled to reduce
their effect on the study. When these variables or others not considered are entered
into the mix the result can be unpredictable. This is precisely why theories based on
basic science and personal experience still need to be confirmed by well designed
outcome studies. You could easily be missing a logical link in your theory or have
missed out on an important variable. All the evidence in the world may mean
nothing if a couple of key pieces in the puzzle are missing.
I humbly submit that I think there are some missing logical pieces in mobilipulation
theory frankly, and I've listed them, or most of the ones I can think of.
Correct me if I'm wrong, but the way I learned it was that theories can't be
"proven", hypotheses that don't support the theory are to be disproven ('negating
the null hypothesis') allowing the theory to stand.
Regarding the theory of mobilpiluation (that the spine is important and its good
function depends on mobilipulating it), I propose a null hypothesis in two parts that
would need tested and disproven before I'll believe the theory and put all my efforts
into supporting it instead of discounting it; (the wording will require some work, I
realize..)
1. that it is impossible to treat a live patient in back pain with mobilipulation
without contaminating the results with neuromodulation;
2. that any and all forms of neuromodulation for back pain are equally effective
regardless of what depth of tissue is targeted, including skin.
To me, it looks like tests that are done to see if vertebrae move with mobilization
etc, are done on cadavers, without a functioning nervous system, so really, I don't
see how it's possible to honestly extrapolate findings from cadaver studies to live
people with intact anatomy, who are in pain, to support a purely manipulative
theory of vertebral treatment.
What if 'back pain'/nocioception wasn't coming from the spine, had never come
from the spine? What if nocioception had been coming from other structures like
dorsal cutaneous roots all along? Nothing to do with spinal nerve roots at the spine.
That's my point. I don't think these factors have ever been considered, not in
anything I've ever read, let alone eliminated as confounding factors. Maybe people
take for granted that they've been considered and eliminated as possibilities, but I
don't think so. The theory has oozed out into a belief system that "pain" comes
from joints or their lack of function somehow.
I don't think any study has ever been designed to test mobilipulation theory against
neuromodulation theory. Hence I stand by the title of the thread.
-------------------Diane
In an eternity of managing (or trying to) post-surgical laminectomies and
discectomies and fusions, I noted several things about the results:

Assuming the nerve root was compromised by bulging whatevers (transducers??),

the surgeon might do a snip and tuck and scrape (clean up annular bits, maybe
section the lamina, and clean up the nerve root (rhysolysis)). The premorbid pain
would often disappear. That is, the severe pain, with dermatomal numbness; but
after five days the patient still had pain. It was different pain, like an aching.
Sometimes it disappeared, according to the few followups that occured, weeks later.
Roughly,in about 40%, the original pain returned. A culprit disc wasn't found to be
impinging; so for some, more surgery, sometimes the level above or below;
particularly if there was degeneration generally. For others, various forms of
physiotherapy, and I think this was fairly successful at relieving pain.
Of course the possibility of surgery in itself causing an AIGS (abnormal impulse
generating site)is always to be considered....
So what is the cause of the nociception and origin of the pain in the first place?
Degeneration of the spine and pain are not well related; discs can bulge happily
without any symptoms; facet joints...won't go there, not enough is known about
these little critters...
So Diane's theory of nociception possibly not coming from the spine, but from
elsewhere, is interesting. What if that were true? What an uproar. However, quite
hard to demonstrate, I think.
The only really useful testing done on cadavers is to demonstrate the lovely
tensioning and realxing of the nerve roots on movement. Previously, attention was
paid only to muscle states, which did not get anyone anywhere really..
Nari
What seems interesting to me are a few things:
Through research, Childs et. al. has proven when and to what degree manipulation
works in a certain population. (yeah, I know, the majority of you hear want to
scream disagreement with manipulation and all that, but put it aside)
You've got Powers and I can't remember the guy doing stuff at the foot level - but a
strong biomechanical approach to decreasing symptoms and preventing further
complications.
There's Geoff, continuously mobilizing the spine (although there doesn't seem to be
any published materials in peer-reviewed journals) - but he has a strong
conviction/claim that what he does works.
Then, there are the quality of movement assessment folks - Sahrmann, lumbar
stabilization folks, Powers to a degree - and their literature is slowly coming into
peer-reviewed journals.
And... nari and Lorimer with the importance of education (Lorimer is the one
getting his work into literature)
And then, Diane and Barrett with their hands on approach that has a basis from
things read, but doesn't have anything being shared via peer-reviewed journals.
So, if one just sits back and thinks... isn't it quite interesting how so many different
approaches are able to supposedly provide results? In my mind, the differences are
huge. I question whether the approach is the key OR if we the provider is the key
(maybe we need to be studied)... Does it matter what approach is taken? Are

certain approaches or belief systems the key to success? If a person is considered

as a system that responds to inputs such that outputs are changed, well, how can
so many various inputs give the desired output?
Bgbbbjh
woke up thinking about something Doug said about the relation between
homuncular representation and the importance of an organ, and how this was
evidently not the case with many internal organs vital for function but not "seen" in
the brain. This sounded like a pretty good argument, and it may still be.
But in response, it occurs to me that many of these organs (kidney, heart, liver,
pancreas to name a few) commonly grow quite ill yet give no indication to their
owners. By the time the medical people find the problem with special tests the
disease process is often advanced. This is not the case with an abnormal
neurodynamic.
-------------------Barrett L. Dorko P.T.
SJ, exactly. The inputs we provide are variable, they all "work" which means none
of them really are heirachically more important than any other.. so I repeat, why
beat up on the spine all the time?
The goal in treatment is to hang in there with the patient, providing them with
some form of input,(kinesthetic, verbal, educative, mobilipulative,
neuromodulatory) until that patient's brain changes in terms of what it will consider
appropriate output in response to nocioceptive drivers.
The patient's brain is the thing that effects its own "change". The only thing that
can change itself. From the outside, we can do nothing but facilitate or catalyze.
That I would humbly submit is the real point of what we do, and a good enough
goal, with adequate science backing it.
Barrett, good point about the organs versus abnormal neurodynamics. The organ
system is almost like another creature embyologically. It is very self-maintaining
and runs on its own enteric nervous system, with not much patching into the brain.
We (our somatic selves) need it more than it needs us.
-------------------Diane
I don't know who beats up on the spine all the time, well, except for Geoff
But, at this point in time there is no right or wrong in the approaches taken, sort of.
In order to make decisions on which choice(s) optimizes the results most efficiently,
effectively and long-term, well, that is where research is valuable. Until there is
more research in the area of neuromodulation and the outcomes, I can't forsee a
change from what Barrett considers a "meme." Is it a meme when technically the
manipulative/mobilizative approach isn't challenged? If there isn't anything out
there in peer-reviewed journals reaching the appropriate reading population about
an approach/technique and the definitive outcomes, well, in my mind, all that's
going to happen is discussions like this with potentially no change in a provider's
preference in treatment choice/options. Granted, though, I'm not ignorant to the
degree to believe that just because something is published indicates that providers
WILL change to practice in accordance to the literature. I mean, look at what Childs
et al did - they are taking steps toward indicating when and to what degree

manipulation will give results (it isn't with every patient) which is a great step in the
direction of helping providers choose the interventions to provide to patients....
there are a lot of you here that for whatever reason won't let those statistics and
numbers speak for themselves because it goes against your very strong belief
system. And I do generally hear what those against manipulation say... some of
what is posted seems plausible... but I hate to say it, but it really does come down
to numbers and statistics to actually see that the outcomes are really there. And
chances are, there would probably be a lot of "right" in both groups. I honestly
can't believe that the manipulators are wrong nor do I believe that the
neuromodulators are wrong.
Mmmm
I was going to admonish Diane for using outdated theories about manipulation but
SJs post made me think that there are a lot of people who still cling to these for
some reason. Why do we have this desire to separate neuromodulators from
manipulators? Both sides look like they want to do this. This baffles me largely
because my working theory on mobilization and manipulation has been neuro since
before I started practicing. Almost all evidence that I know is consistent with this
view and very little that contradicts it. Research by people like Wright, Herzog,
McGill and others all support it. I dont know of any evidence that supports a direct
mechanical effect of mobilization/manipulation that links it to pain relief. Im not
saying that there isnt a mechanical effect, just isnt much evidence supporting it.
Now I dont agree with Diane that all neuromodulatory techniques are created
equal. I find clinically that mobilization, manipulation, acupuncture, muscle energy
and so on all work slightly differently and each are better for different situations.
Also lets not forget that most of the manual therapy studies that show longer term
benefit also include an exercise (read movement) component (maybe the best
neuromodulator). I think the work by Childs, Fritz and them supports this. At least I
hope it does. I hate to think that our techniques are only really effective on this
population. I think that the common theme with everyone who is showing effects is
some form of neuromodulation.
Not only can organs, bone and muscle have large problems without pain but so can
the nervous system. Brain tumors can be asymptomatic as well as spinal tumors.
Spinal tumors and other deformities can produce large changes in spinal
neurodynamics with little change in function. The rate of deformity progression may
be a key factor.
I doubt that a cortical system that has evolved to produce higher precision sensory
information and precision motor control is going to project pain in a manner that
undermines this. It is evident that we dont know the source of pain in most
instances of low back pain. Some structures have been shown to be involved in
some instances: Disc, SIJ, facet joint, nerve. Others have been shown to have the
ability to produce pain but their involvement in low back pain has yet to be
determined: muscle, ligaments. (this may be outdated).
Certainly I disagree with looking to it first for every neuromusculoskeletal
problemo or glitch under the sun. We will have to agree to disagree on that. I dont
know where you got that from. Ive never said that.
I dont know where this beating up on the spine comes from either. The spinal
mobilizations I use are rarely painful and I almost never manipulate into pain.
Doug
Manipulator and therefore a Neuromodulator
was going to admonish Diane for using outdated theories about manipulation but
SJs post made me think that there are a lot of people who still cling to these for

some reason. Why do we have this desire to separate neuromodulators from

manipulators? Both sides look like they want to do this. This baffles me largely
because my working theory on mobilization and manipulation has been neuro since
before I started practicing. Almost all evidence that I know is consistent with this
view and very little that contradicts it. Research by people like Wright, Herzog,
McGill and others all support it. I dont know of any evidence that supports a direct
mechanical effect of mobilization/manipulation that links it to pain relief. Im not
saying that there isnt a mechanical effect, just isnt much evidence supporting it.
Now I dont agree with Diane that all neuromodulatory techniques are created
equal. I find clinically that mobilization, manipulation, acupuncture, muscle energy
and so on all work slightly differently and each are better for different situations.
Also lets not forget that most of the manual therapy studies that show longer term
benefit also include an exercise (read movement) component (maybe the best
neuromodulator). I think the work by Childs, Fritz and them supports this. At least I
hope it does. I hate to think that our techniques are only really effective on this
population. I think that the common theme with everyone who is showing effects is
some form of neuromodulation.
Not only can organs, bone and muscle have large problems without pain but so can
the nervous system. Brain tumors can be asymptomatic as well as spinal tumors.
Spinal tumors and other deformities can produce large changes in spinal
neurodynamics with little change in function. The rate of deformity progression may
be a key factor.
I doubt that a cortical system that has evolved to produce higher precision sensory
information and precision motor control is going to project pain in a manner that
undermines this. It is evident that we dont know the source of pain in most
instances of low back pain. Some structures have been shown to be involved in
some instances: Disc, SIJ, facet joint, nerve. Others have been shown to have the
ability to produce pain but their involvement in low back pain has yet to be
determined: muscle, ligaments. (this may be outdated).
Certainly I disagree with looking to it first for every neuromusculoskeletal
problemo or glitch under the sun. We will have to agree to disagree on that. I dont
know where you got that from. Ive never said that.
I dont know where this beating up on the spine comes from either. The spinal
mobilizations I use are rarely painful and I almost never manipulate into pain.
Doug
Manipulator and therefore a Neuromodulator
SJ, nobody is wrong exactly, but something is.. I say it's the sense of proportion,
the weight given mobilipulation over neuromodulation. I say one (mobilipulation) is
a subset of the other (neuromodulation). I say that neuromodulation is the group
known as "animal" and mobilipulation is merely "cow." Cash cow to be precise.
I say that mobilipulation is given weight way out of proportion (which turns it into a
sort of ritualized religious thing, especially among chiros) within the applied science
of physiotherapy, and has attracted more attention, more research dollars, way
more mental space than it deserves, not because it is any more useful or right or
good for people (I strongly protest!) than any other form of intervention/
neuromodulation, but because it is historical and traditional. It's definitely a
memeplex that needs pruning. Good for Childs for pruning it, if that's what happens
from his work.

-------------------Diane
Hi Doug,
I see you posted just before I did. I didn't say you said that, I am declaring the
belief system that PTs who study mobilipulation are left saddled with. I have no
particular quarrel with most of what you say on this topic, because I think you can
see the proportionality of it all, better than most.
About beating up on the spine, a poster on chirotalk came on quite some time ago
to talk about her husband, who had been in a great deal of merciless pain for three
years following a mobilipulation delivered by a chiro. Sounds a lot like cauda equina
syndrome. Right in the e-medicine write-up on that, mobilipulation is cited as one
causative factor. So while you might be a sage and safe mobilipulator, I doubt all
true believers are.
Barrett, your post from Sept 1 on heuristics speaks to me a great deal with regard
to mobilipulation and the hoopla around it.
-------------------Diane
2. that any and all forms of neuromodulation for back pain are equally effective
regardless of what depth of tissue is targeted, including skin.
This assumption is one that has caused a great deal of argument on this forum. The
studies are not there and apparently not too many people are interested in doing
the studies to demonstrate if the above is true. If it is true, outcome studies would
demonstrate it and Diane's arguments would be more convincing.
I agree with Doug in that I don't see many mobilizers or courses in mobilization
that don't consider neuromodulation, most of them that I have seen consider that it
is quite likely the primary mechanism.
Randy
How would one be able to distinguish between the effect of one form of
neuromodulation and another? Use of PET and fMRI is rather limited (!), and that
would be the only possible way to indicate that mobilising a segment is more (or
less) effective than Diane's skin techniques. Even then, the variables would be
difficult to sort out.
Empirically, Diane's statement #2 is probably correct. A proportion of patients will
get better with manual therapy in all its different guises. A control group receiving
only, say, a specific exercise regime might be useful...and a third group who do not
receive any PT. And there are plenty of them around. As long as the phrase
'standard physical therapy' is never used; I have no idea what standard PT is,
anyway. Is there any such thing?
Nari
Hi there,
Just want to follow up on a couple points.
First of all, Jon pointed out my statement about why beat up on the spine all the
time is vague and inflammatory. I think that is likely true, so I apologize for
creating discomfort, if I have... However certain forms of discomfort are growthful,
as Jon's many links on learning show.

I think his observation also serves to sum up exactly how I feel about
mobilipulation, or rather how my particular nervous system feels about it: that the
whole approach is, ummn.. vague and inflammatory.
Randy, Nari made a good point on behalf of the statement you selected to disagree
with.. that it's impossible to separate skin out from any form of neuromodulation.
Exactly. So like it or not, it will have to be considered one of these days, as a
confounding factor if nothing else.
To remove the skin from consideration in mobilipulation theory has been arbitrary,
thoughtless, and pseudoscience, not science.
Right here, at the skin layer, is where I've always had an argument with
mobilipulation as a treatment construct. It has never dealt fairly with or ever even
considered the actual nervous system in its entirety. The whole construct has
treated the human body as if it were a stretchy corpse with no feeling, no brain, no
nervous system except the one mobilipulation tries to 'get the bone off of' (one of
the oldest, crudest theories to justify mobilipulation), or which mechanoreceptor
mobilipulation thinks it might be targeting deep in the facet joints whilst blithely
ignoring all the ones in the skin.
Because skin is impossible to remove from the body without killing the patient, the
only way to study it from a mobilipulator perspective is as a potentially confounding
factor to the theory of mobilipulation (go ahead and pick one, any one you want.)
The only way to study skin at all, as mobilipulators, is in vivo; study the effects of
treatment that is skin deep only, in the hopes of finding no effect, so as to justify
having ruled it out as a non-confounding factor.
So everyone who reads this and says, "Show me the studies", is quite right. I'd love
to see some too. I don't have a clue how to conduct one or I would. Maybe
someone who knows how would be willing to teach me.
In a hypothetical world of non-prejudiced PT science, if studies like these were to
finally be conducted by keen researchers eager to prove there is no effect, that
effects produced by the nervous system through skin are nonexistant, (i.e., knock
down the hypothesis), watch out, there would be so many effects that the "theory"
or "theories" underpinning the whole mobilipulation industry, science and
commercial, would be forced to face and account for a plethora of confounding new
facts. Occam's razor would finally slice into mobilipulation. Mobilipulators would
have to do some awfully fancy scrambling to justify bothering to pop spines to get
effects. It would have to rethink itself. It has never had any problem reinventing
itself, but this time it would have to do so in harsh daylight; no obfuscation allowed.
Mobilipulation would no longer be able to ignore the multiple effects skin produces
by virtue of being the most sensitive and fastest signalling part of the sensory
nervous system. It could end up having a hard time justifying its existance at all.
-------------------Diane
Nari,
I agree it is difficult, and if you try to work from the deeper tissue levels upward it
doesn't work. But if ALL neuromodulation is equal then simply working at the skin
level would show similar results to the other, deeper levels that have to go through
the skin.

So superficial treatments are distinguishable and therefore testable.

I agree with Diane that it probably has to be considered as at least a confounding
factor, I'm not even arguing that she is wrong.
Diane,
Just curious, if a study was conducted that tested the skins effect on
neuromodulation and it was found not to be significant, at least in terms of
manipulation, would you change the way you treat?
It is obvious that the skin has some neuromodulating effects, how could it not, but
that is not necessarily significant to the effects of manipulation.
Randy,
quote:

if a study was conducted that tested the skins effect on neuromodulation and it was
found not to be significant, at least in terms of manipulation, would you change the
way you treat?
If I could be convinced... that a study was designed and carried out... that
eliminated the effect of live awake cooperative patient skin... making it clear that
effects of mobilipulation are separate and distinct and special and that the skin
exerts no messaging influence during a mobilipulation treatment, then I'd consider
changing my ways. But I seriously doubt that could ever happen.
I'm so convinced that
a) such a study could never support mobilipulation theory, and b)it is essentially
unnecessary to mobilipulate, that I would bet the farm on it. A good study testing
the effects of skin neuromodulation alone, proving it to be an unavoidable
confounding factor that obviates the clarity of any mobilipulation theory in
existance, would help put mobilipulation/any form of spinal snap/crackle/popping
completely in perspective.
quote:

It is obvious that the skin has some neuromodulating effects, how could it not, but
that is not necessarily significant to the effects of manipulation.
With all due respect Randy I think you missed the big point. Skin trumps vertebrae.
It's completely in the way. Having no input into it is unavoidable. Having no output
from the brain as a response to skin input is unavoidable. It's time it got the
respect it deserves as an active participant in any/all neuromodulatory approaches,
and the proposed in-the-face confounding factor that erodes any mobilipulation
theory that says
1. that neuromodulation is not a part of mobilipulation;
2. that mobilipulation's effects can somehow be considered separately from
neuromodulatory effects via skin and its mechanoreceptors;
3. that mobilipulation is somehow special and distinct and separate as a treatment
technique;
4. that it requires a whole mystique to support it because it's mysterious and elite
(the cult factor.)
quote:

if ALL neuromodulation is equal then simply working at the skin level would show
similar results to the other, deeper levels that have to go through the skin.

Bingo. This time you won the toaster. Although I'd change that statement to ..."the
other, deeper levels that practitioners think they have to get to, and think they
bypass skin to get there."
-------------------Diane
Jon,
How would a study of doing mobilipulation under anesthetic be of any use to those
who mobilipulate awake aware patients? Just curious.
-------------------Diane
Hi Diane,
In my particular example I meant that the patient would be rendered unconscious.
This way the groups cannot know if they have actually been manipulated or not. It
would significantly hamper the effect of engaging expectancy pathways and other
neuromodulatory routes leaving only mechanical changes as the main effect. If it
can be demonstrated that the mechanical effects are negligible then I think many of
the schools of thought would be compelled to change. Although I thought that also
with Childs' CPR validation study and I was apparently wrong or biomechanics
wouldn't continue to be the basis for selecting the techniques.
If it turns out that neuromodulation is the main effect then the hard part about
teasing out the role of expectancy, the role of touching, the act of healing, and all
that sort of business is left to someone more clever than me. Manipulation has the
advantage of having a great deal of social acceptance and belief to aid in its
helpfulness. I wonder if acceptance (and associated helpfulness) would wane if
people knew that there was no mechanical effect; that their spine was not actually
being fixed but rather they were engaged in a sophisticated game that takes
advantage of the ease with which our minds can be manipulated.
I look forward to the day we find out for sure but I'm not holding my breath
because that would entail finding out something many don't want the answer to.
jon
Jon,
Ahhhh.... I love your post, I see what you are tracking on. Hmmnn.. interesting.
Eliminating expectancy pathways indeed. Hey, why not do both? A study on skin
only and a study of MUA with expectancy pathways knocked out. Like pinchers from
two sides. Occam's razor disguised as a pair of scissors. I know I'd be very
interested in knowing the answers provided by such studies. I bet there are actually
lots of others who would be too. The ones who wouldn't be wanting to know would
be those who have something to lose.
Hi there drbuddy. What does your post mean?
-------------------Diane