Panel Discussion: A fiery debate on clinical decision making, evidence, and best practice
This discussion started on 8/11/13, with some very critical statements in response to a comment made regarding treatment based on "movement impairment." What followed turned into a very intelligent argument regarding what level of evidence is sufficient, the practicality of completely "evidence-based" practice, and a considerable amount of discussion regarding movement impairment as a basis for treatment plan development/exercise selection.
Thank you to Jason Silvernail (https://www.facebook.com/jasonsilvernail) for spending the time to engage in the debate, Robert Gazso (https://www.facebook.com/robert.gazso.7) for his interjections, Steve Middleton (https://www.facebook.com/mddltn) whose post we hijacked, and of course the "Body Movement Masters" group (https://www.facebook.com/groups/bodymovement/578320568878470/?notif_t=group_comment_reply) for hosting the discussion.
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
Jason Silvernail Altered biomechanics is largely speculation and fraught with reliability and validity problems. http://ptthinktank.com/online-courses/online-courses/2012/03/18/si-joint-mechanics-in-manual-therapy-relevance-please/comment-page-1/
13 Comments Preston Collins, SPT 03/18/2012, 5:49 pmReplyI would like to respond as a current… -
ptthinktank.com
Jason Silvernail Speaking of speculation, so are the latest assessment seminars full of determinations of "inhibited this and facilitated that" that are just recycling of old physical medicine ideas from years ago. No plausibility, no reliability studies, no randomized trials, just a truckload of seminar money and hyped up bullcrap. Not to put to fine a point on it.
August 1 at 7:47am
Robert Gazso Hey Jason – I agree with a lot of what you are saying but also think that if you can't fully disregard everything that we do not have research on yet. I had a young girl I worked with two mornings ago who was seeing me for the fourth time. She has come a long was since we started. She was hit while riding her motorcycle head on by a van (drunk driver) 4 years prior. Impact was to her L shoulder and L knee. I ask her what is causing her pain and she say just standing there she has pain at the level of a 1 in the knee and 6 at the shoulder. She shows me that she has 60 degrees in shoulder flexion and 45 in abduction (DP). I notice that when I get her on the table she has more ROM. I ask her about her pain and she says she does not have any while laying down. I have her again stand and she again has pain. I used a modified SFMA and with palpation determine lack of stability in
L Gmax was a primary area of painless dysfunction. Muscle testing shows Gmax inhibited. I locate the related compensating muscle and release using ART. A few min later I have her stand again. Already we are seeing 5-10 degrees of increased flexion and abduction. Long story short by the end of the 1st session she had better ROM than she had in 2 years (almost full ROM) and no pain in standing. After her I had a session with someone with knee pain - post arthroscopic. Pain going up and down stairs and when squatting. Pain gone by end of session in these movement patterns. I was mostly using anatomy trains and Vleeming slings to determine where to work and frequently not working at the site of pain. Should I disregard practice based evidence?
Saturday at 11:49am · Edited · Like · 1
Brent Brookbush You seem awfully pissed off Jason Silvernail… If you are not considering the quality of movement and how that affects muscle activity and length, arthrokinematics, and neural control… what are you doing in treatment? What modalities do you use? You obviousely don't release or activate, based on your argument above, I am guessing stretching would also be out, and since you don't care for biomechanics I am guessing you don't do mobilizations either… oh wait… are you the new type of physical therapists who uses the extremely high-tech "stim, ice and rest" method?
Saturday at 11:28am · Like · 2
Jason Silvernail Robert- no but you shouldn't substitute anecdote for a rational theory and evidence, either. People who advocate for some of these methods seem to want to paint this silly black and white dichotomy - either its '100% research or else' or 'any story I tell about my patient's recovery is fine since that's practice-based evidence.' Your practice based evidence is that you treat people with hands on therapy and movement and they improve in your anecdotal experience. You have no idea if that has anything whatsoever to do with the SFMA, 'Vleeming slings' or 'inhibited muscles.' There are several plausible explanations for your anecdotal results and assuming that the theoretical model you are using is the most likely one is at best naive and at worst intellectually lazy.
Even the *briefest* foray into the literature about nonspecific effects and cognitive biases should make us pause at every anecdote we tell. If she has shoulder pain there is good evidence for physical therapy there without the need to summon ideas about inhibited this and releasing that and all that other rigamarole. I'm less interested in what we collectively do and more interested that we can defend it in a rational way. At least the people advocating these kinds of assessments should be doing their due diligence and rationally stating that the reliability is unstudied and likely poor, the mechanisms are poorly understood, but that this approach seems to work clinically. But we don't have that, do we? We have fairy stories about x muscle inhibiting and "shutting off" abc muscles and all that foolish nonsense that isn't even explained using accurate basic science. While the people promoting it are raking in the seminar cash.
I teach manual therapy and practice in the Maitland method. I am honest with people when I teach about the issues with reliability, specificity, and necessity of the individual assessments. I am frank about the uncertainty in our understandings of mechanisms and that many of the concepts used (like manual movement/pain assessments) are for teaching clinical processes not exactly defining reality of joint movement and pain explanations. While also noting that people who are treated with this process improve when they are studied in randomized clinical trials. People may get better because of the specific things that I treat with manual therapy but I don't know that for sure. My practice-based evidence says people get better anecdotally when I treat them and in a similar fashion to the published RCTs on the methods that I use. There are many competing explanations for my results and the results in the clinical trials but no one, including me, is sure about exactly how it is all working. I certainly can't see the theoretical models of my treatment system as validated by my success in clinic, as that simply doesn't follow. http://www.evidenceinmotion.com/online-courses/online-courses/about/blog/2008/05/ebp-deep-models/
EBP, Deep Models, and Scientific Reasoning - Evidence in Motion
I want to talk about EBP in a different perspective in this post. I hope it will generate some good discussion about the role of evidence, theory, and research in driving our practice and our therapy culture. My apologies in advance for the long post, but I hope you’ll find it worth reading, thin…
Saturday at 11:49am
Jason Silvernail Brent Brookbush - of course it's easier to characterize me negatively than deal with the substance of my critique.Thanks for that though it reveals a lot. I addressed your questions above in my response to Robert. People need to dial down their claims in the absence of evidence - that's basic critical thinking.
Saturday at 11:52am
Brent Brookbush Lets talk substance… you say there is no research to support biomechanics… seriously? So Richardson and Hodges… what do they research, what about McGill, what about texts like Neumann, what about the research by Sahrmann, new studies coming out of USC via the National Academy of Sports Medicine, or how about journals like "Spine",… you want me to continue…
Just because you have not read the study does not mean it does not exist… and you started the negative characterization. I have dedicated the last 10 years of my life to a better education model in Human Movement Science Education. I deliver evidence based content on the topic you say does not exist.
Integrated Human Movement Education System
b2cfitness.com
Human Movement Education and Articles
Saturday at 12:22pm
Brent Brookbush Last points (just read your longer post) Jason Silvernail - If you are practicing 100% evidence based you are at least 15 years behind the curve. I am a big proponent of evidence-based practice, but it takes a long time to go from innovation to popular to researched to body of research to meta-analysis comparing several high quality studies.
And who said there was anything wrong with scientific theory and a systematic approach that includes practice outcomes. I am not talking about simple conjecture "I think that worked" - but a theory as well developed as lets say "movement impairment" is tough to ignore if when implemented you have positive outcomes with patients/clients better than 90% of the time.
Even sliding filament theory is just that a theory… and until we build an electron microscope capable of penetrating a living cell it will stay that way… are you going to deny that because we do not have the evidence?
Saturday at 12:32pm
Jason Silvernail Yes Brent, you're right. That's what I said. There's "no research to support biomechanics" - whatever that means. Quite some light your little straw man is throwing off there. Well done.
To the substance you're talking about. My concerns about reliability and validity of assessments and the mechanisms of action of our treatments are clearly stated and those concerns stand and have nothing to do with kinesiology. Richardson and Hodges are researchers I'm very familiar with and the early research about Transversus abdominis and the importance of specific muscle training was largely disproved by Dr McGill's lab which you mentioned in the same breath. McGill and his lab have done wonderful work on the biomechanics of the spine. Now if only all that biomechanics knowledge translated into treatments with good effect sizes or a good explanatory model we'd really have something, wouldn't we? Texts like Dr Neumann's contain great kinesiology information that has a pretty tenuous relationship to pain problems. Sahrmann's work is largely theoretical, has very little supportive evidence, and has all the pitfalls of validity and reliabilty I've mentioned before. Naming an organization like NASM isn't providing evidence for the discussion. I read journals all the time and I can cite you systematic reviews and other evidence that this hyper-detailed biomechanics approach is primarily speculative and has little relation to common clinical pain problems.
Saturday at 12:34pm
Brent Brookbush So I am starting to see what the root of this debate is… We are really discussing what is sufficient evidence? I have no doubt that you could list a ton of research, after all, if you are truly for 100% evidence-based practice you would have to, but you have to leave room for other approaches.
I am not creating a "straw-man" argument, there is plenty of research on biomechanics, however, I am pointing to a problem with 100% evidence based practice? No room for innovation, and frankly so few definitive answers that we would be left wholly unable to treat various issues… some research simply does not exist. So how do we move forward, how do we fill in the gaps, why has someone like Sahrmann had so much success? If you want to stick to only what we already now, how are you going to get better?
I still have no idea what your issue is with theory, but to make sure we are on the same page I am going to post the definition of "scientific theory" belowhttp://www.ask.com/online-courses/online-courses/wiki/Scientific_theory?o=2801&qsrc=999
Even the Maitland approach has theoretical components.
Scientific theory - Ask.com Encyclopedia
Ask.com is the #1 question answering service that delivers the best answers from the web and real people - all in one place.
Saturday at 12:43pm
Jason Silvernail After that last post I think you are "not" seeing what the root of this debate is about. I am not discussing sufficient evidence and not discussing doing only things that have randomized trial support. I am talking about being cautious and honest about the limits of our knowledge and not making claims we can't support with plausible evidence. Every approach has theoretical components of course but we need to maintain skepticism about how valid those theories are as we move forward. It's really a question of just not speaking beyond the science and having some humility about how much we really understand. I am ok with uncertainty, I am not ok with assuming our theoretical models are accurate because people improve under our care. That's as true of my methods as for anyone else's.
What success has Dr Sahrmann had, Brent? I will say I have seen her admit some uncertainty and she put some effort into creating a plausible theory and testing her methods for reliability and validity and she's to be commended for that. Where are the trials though? There's really not much evidence for her approach and I would think she would admit that if asked ( I haven't asked her so I don't know). I would think she would match any claims she made with the evidence - and in the case of pathokinesiology and her assessment system, its pretty weak.
At the end of the day, people like complexity and the idea that going to some seminar about how to assess the 'anterior oblique subsystem' or whatever makes them experts. But we don't have much evidence about the validity and reliability of those assessments and those theoretical models. And history very clearly shows us that most of these models turn out to be incorrect so our default position should be skepticism and caution, not the smug certainty that many people selling seminars and books push out through their advertising in general. Not aiming that at anyone in particular, just a general observation.
Saturday at 12:54pm
Jason Silvernail I think people can have a huge range of different approaches but we should be requiring they be honest about how defensible they are. I don't require that people do what I do because I'm not sure my way is the best or even all that great - because I've read the evidence. I do require that people be able to defend what they do with a sound theory and a plausible explanation however. Most of these hyper-detailed assessment methods stand on extremely shaky ground. Its a foundation largely built from seminar cash not science.
Saturday at 12:57pm
Brent Brookbush You certainly like to throw a jab… I will try to ignore the diminution of my recent article on the Anterior Oblique Subsystem… If you think an educators life is a glamorous one, you are mistakin'. I think there is a fair amount of evidence to back of Sahrmann's work especially when you consider it in reference to the history of the research in the area (to keep it simple lets say Janda to McGill). And I think she had huge succes in the sense that others followed her methods because they were more successful than what they were taught in school or there own methods… for all we know it is Janda and Sahrmanns model that finally got PT's to start looking at the scapula and not just the rotator cuff for impingement issues (same line of thinking anyway) Theory simply gives a direction for future research and a way of using a set of information to make decisions about treatment. Because of the my theories and the theories of those who came before me I have been able to construct an assessment and treatment model that leads to very specific modality, technique, and exercise selection. Because that theory exists I can than take in each new research study, one at a time if need be, and refine my approach. To go from research to treatment is actually a far more daunting process. Can you imagine having to do an entire research review for every patient that walked in… And I looked at your facebook page… You are a DPT for the Military… How much research exists for treatment after gunshot wound or shrapnel wound?
Saturday at 1:01pm
Brent Brookbush Every time I am with Jason Silvernail, you throw another jab… lay off the seminar for cash argument, and lay off those of us who are trying to educate better. If it was not for seminars PT's would have very little treatment options. I don't know about you but the treatment I am learning in school is so far behind, so embarrassingly unsophisticated, and so few techniques I would have been embarrassed to walk out as a PT if not for my previous background, work, and well… ridiculous nerdiness.
I do 100% agree with you on the honesty issue… But I think a few things need to happen first:
1. We all have to come to grips with the fact that we will never be 100% research based
2. In reference to the above: Access to research must be free or ridiculously cheap. You cannot preach evidence based practice and charge $35 and article or $3500 for a membership to a database.
3. There is a difference between "scientific theory and conjecture," and credit should be given to theory until that theory is refined or debunked by research.
4. We need to do a better job as a community of tracking our outcomes. Just validity that a PT is effective at treating a certain pt population could lead to qualitative research that may refine practice.
5. We have to educate better. Evidence-based education and lesson plan development actually exists… however, our educators (including college professors) do not need to know a thing about it. The delivery of education is most often very poor both colleges and seminars alike… this can only lead to lower retention, comprehension, application, and in the long-term outcomes for patients.
Saturday at 1:13pm
Robert Gazso Hi Jason - You said “but you shouldn't substitute anecdote for a rational theory and evidence." I can tell you that I don't substitute anecdote for rational theory and evidence but also don't fully disregard it. I do realize that there are shortcommings to including practice based evidence. There are also shortcommings to only using 100% EBP. I think you would agree that research is lacking in many areas. How often do we see poor study design?
Saturday at 1:21pm
Jason Silvernail Brent those aren't jabs, its just plain speaking. We are definitely conflict-averse in our culture and its far easier to complain about 'tone' or whatever than address the issues. You've done a pretty good job of taking the discussion well.
We are going to have to agree to disagree on the 'evidence' for Dr Sahrmann's work - perhaps we are going back to the point you made about what is sufficient evidence and I definitely agree that is the issue in this case. When you mention Janda you aren't really bolstering your position much - there's even less evidence to support the crossed syndromes than there is some of Sahrmann's work. When you mention that people followed her based on their anecdotal experience of success then that helps reinforce the points I've been making about the issues with anecdotal evidence, popularity in the absence of evidence and problems in clinical reasoning that plague most of musculoskeletal medicine. I'm not asking for people to be 100% research based, I'm asking them to defend what they do with a coherent theory and not rely on outdated and falsified ideas of pain and function while teaching a hyper-detailed assesment method with no plausible validity or reliability. I don't think that's too much to ask. If it is then I guess I'll just keep asking. I have no intention of "laying off" people who charge money for seminars if the seminar quality isn't rigorous. I actually didn't notice the anterior oblique subsystem was your seminar, this group appears to be little more than a stream of seminar advertisements and I just noted it as I scrolled. I can see how that would come across as mean spirited and I didn't intend that.
I think knowing 'in general' what the evidence says for the common conditions I treat isn't a daunting process but an expectation of a doctorally educated health care provider. How to apply that to each patient and work with them is the art of clinical practice and that's what I like about my job. Well, one of the things.
Saturday at 1:27pm
Brent Brookbush Janda was just the beginning, I think of Sahrmann as one of the individuals refining that work, if you look at my view impairment it takes it yet another step… I am simply pointing to 70 years of progress in a field.
I think your jabs are not plain speaking, they are unempathetic and mean. There are people trying to change things for the better and to simply demonize them as money hungry salesman is unfair. I don't add my political views of war to this discussion, because it has no bearing on the argument and regardless of what I think about it, it does not color my view of you as a professional. Educators have to make a living to, and just because I charge for my courses does not make me any less dedicated to improving practice, in this case improving the quality of human movement education. Trust if I could get a large grant from the Bill and Linda Gates foundation as the "Kahn Academy" did I would keep a huge portion of my platform free for all.
Last, although I would like to agree with your last statement I think it is unrealistic. A research review takes an enormous amount of time and a ton of resources. Look at the Cochrane Library, it is not brimming over with relevant reviews, or reviews for every case we are going to see. When you just consider setting up business, treating, notes, dealing with insurance companies, scheduling patients… and then you add what could easily be a full time job of writing reviews on top of it… it is just not plausible… I will say this though. Everyone should read research regularly, I hope for the success of institutions like the Cochrane Library so that reviews are available to us (rather than having to do them ourselves), high quality research should affect your practice immediately and should never be dismissed, but you have to consider it in reference to all of the relevant information you have compiled before hand.
Saturday at 1:35pm
Jason Silvernail I think we are unnecessarily attached to a lot of old theories that we need to let go of if we are going to move forward here as a profession and better serve our patients. Many of these famous folks did great work with what they had at the time and may or may not be happy with the way the way they are often lionized today. Sackett wrote some good material on this issue: http://www.bmj.com/online-courses/online-courses/content/320/7244/1283.1
You are free to interpret my comments about seminars as mean and unsympathetic but that's your choice, not my intention or motivation. I can't be responsible for how you choose to react to that. Educators have to make a living but they have a responsibility to convey good information and many of them do not do that. I believe you are unnecessarily personalizing my general seminar comments in a way that I don't think is helpful but of course its your choice how you want to handle that issue.
The sins of expertness and a proposal for redemption | BMJ
Footnotes If you would like to submit a personal view please send no more than 850 words to the Editor, BMJ, BMA House, Tavistock Square, London WC1H 9JR or e-mail editor@bmj.com
Saturday at 1:42pm
Brent Brookbush Okay, I can see that. I would actually agree, most seminars are poor. Promoting the ideas of one individual without consideration of research, theory, practice, outcomes, etc… I also agree that I am taking it personal (can you blame me, it's what I do). If you promise to keep hope alive that there a few great educators out there, I will agree that most need to let go of old theories and take themselves out of the equation.
I will read this article, thanks for the post.
Saturday at 1:46pm
Jason Silvernail There are tons of great educators out there Brent. For all I know you might be one of them. But what can I say, like in everything else out there, I'm skeptical.
Saturday at 1:47pm
Brent Brookbush Fair enough…
Brent Brookbush Just wanted to post that summary from our offline conversation Jason Silvernail: Please refine if need be:
Agreements:
1. Evidence is important
2. Theory is important but may be changed or debunked by more recent research
3. Practice should not be based on what you feel
4. There are other approaches to treatment
Grey Area:
1. Should theory and evidence be weighted equally
2. What influence should your personal outcomes have
3. Is "movement impairment" the best approach
Saturday at 1:51pm
Jason Silvernail I think an important point from my point of view is that we should have a thought process of skepticism and caution and not of certainty. And we should be aware of the common cognitive errors and biases we all have, that are harder to spot when talking about something we feel strongly about.
Saturday at 1:55pm
Robert Gazso “I think we are unnecessarily attached to a lot of old theories that we need to let go of if we are going to move forward here.” I agree Jayson. I also agree that there is a lot of “bullcrap” out there and thanks for pointing this out. That being said there are also many great courses out there. Using the information I have gained in my biomechanics courses I have taken has been tremendously helpful.
Saturday at 2:05pm
Robert Gazso “And we should be aware of the common cognitive errors and biases we all have, that are harder to spot when talking about something we feel strongly about.” Well stated.
Saturday at 2:11pm
Brent Brookbush Great comments Jason Silvernail, I would just prefer a more positive approach… I don't look to information with utter skepticism, instead I look for congruence (congruence between theory, research, observation, practice and outcomes) - I am actually working an article on this topic. My goal is always to integrate and refine - to search for how things fit into an optimal approach. I know this is roughly the same idea, but speaking to bias - IMHO skepticism may lead to dismissal where integration is more likely to lead to innovation.
Saturday at 2:26pm
Jason Silvernail IMHO skepticism is a positive process of questioning not a reflexive negative feeling about things. I think integration without sufficient skepticism leads to idea hoarding and not the kind of winnowing of no-longer-useful ideas that moves science forward. I don't think skepticism is negative it's basically what Steven Novella said about science "It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results"
Saturday at 2:32pm
Brent Brookbush I think where "The search for congruence" differs is it is skepticism relative to all other bits of information - I actually think we are saying the same thing here. I think skepticism without perspective is most often reflexively negative, but if you are skeptical and consider the information you are critiquing with in the scope and in reference to everything else you know on the topic than it leads to the systematic approach and refinement of practice that you allude to above.
Saturday at 2:39pm
Jason Silvernail I wouldn't disagree with that at all Brent.
Saturday at 2:52pm
Roderick Henderson I'm late joining the discussion but I've come to view skepticism in a very different light, much like Jason. I think it's a humble acknowledgement that the null hypothesis is very difficult to overcome without rigorous testing. I doubt many of us would consider much of what we read in the orthopedic literature as "rigorous testing". It's hard work of course, but right now I see much more that is unknown than known in the fields of movement science. Moreover, I'm not convinced (skeptical) that understanding more about biomechanics does much to move the needle. Most problems we encounter in the clinic are a maelstrom of sensory (including biomechanics), cognitive, and homeostatic processes. I'm not opposed to learning more about biomechanics. It's fun and intuitive. Unfortunately the issues we encounter in the clinic aren't intuitive unless we consider the broader spectrum of dysfunction. I see this glaringly omitted in much of the work that has been done over the last 20-30 years. That includes the works of "big names" in our profession. Have you read much research on hormone replacement therapy (HRT) or prostate screening? Both good examples of constant reexamination of science and clinical practice coupled with the willingness to consume a handful of humble pie now and then. Another fun discussion to read BTW.
Saturday at 3:46pm
Brent Brookbush On a slightly funny note Roderick Henderson, Jason Silvernail, Nick Chertock and Robert Gazso - Do you think Steve Middleton knows we hijacked his post to go on a rant about research… I wonder what he is going to think when he sees this thread
Saturday at 3:50pm
Roderick Henderson It all fits Brent. Since having a prostate exam I've come to be more vigilant when any provider gets near my sacrum.
Saturday at 3:59pm
Brent Brookbush The fact that you used the word "fit" and "prostate" exam in one post does not fit with my sensibilities at all - and I will take my sacral mobs posterior to anterior thank you very much
Saturday at 4:13pm
Robert Gazso Jason – you said “so are the latest assessment seminars full of determinations of "inhibited this and facilitated that" that are just recycling of old physical medicine ideas from years ago. No plausibility, no reliability studies, no randomized trials” Going back 7 years ago I was experiencing headaches that would last all day. I was in pretty bad condition. I made up my mind that I was going to find a solution to this issue. I found a practitioner that used a technique that involved using muscle testing to find inhibited and facilitated muscles. The result of this was that after 6 sessions my headaches went away. This was life changing for me. I ended up studying this technique and many others. I've taken 40-50 classes in the last 3 years. Some were not very good and others were. I continue to use the technique since it gets me some of the best results.
11 hours ago
Brent Brookbush Hey Robert Gazso, I am assuming you are talking about David Weinstock's - NeuroKinetic Therapy Approach? Great guy, good stuff.
10 hours ago
Robert Gazso Yes.
8 hours ago
Jason Silvernail Robert-
I know someone who went to see a seminar instructor with no training in healthcare whatsoever and after several months of treatment with an implausible method based on pseudoscience he found out he had cancer and a lot of problems related to missed and delayed diagnosis. Now that we've exchanged anecdotes where do we go from here?
I'm glad your headaches are better.
7 hours ago via mobile
Robert Gazso Jason - the situation you speak of is a problem and very unfortunate.
5 hours ago
Roderick Henderson I think if we were to exchange clinical anecdotes, we could all sound pretty impressive. It's fun and makes us feel better about what we do. On the flipside, they don't move the needle very much in terms of clinical reasoning. In fact, they may ground us further in the bog of our own confirmation biases.
5 hours ago
Robert Gazso Concerning the first woman I spoke of - She had said to me that she was really glad that after this surgery she was given the option whether or not to do PT. It is interesting to hear that she elected not to have the PT (there are certainly some amazing PTs out there – It is just unfortunate to hear this).
5 hours ago
Brent Brookbush I think we need to be careful and make sure we delineate between differential diagnose with the intention of discovering if the pathology is treatable through movement therapy or should result in a referal to a physician, and movement assessment which dictates treatment selection with in the realm of movement therapy. This discussion has been largely about the later, and I doubt anyone would deny the importance of differential diagnosis.
5 hours ago
Jonathan Fass The idea of the SIJ as a common point of pain *is* flawed, which is why I agree with Jason. The concept isn't rooted in current best-practice approaches, and this course appears to propagate a Cartesian model of pain that is currently under question and scrutiny, with validated reason. Jason was correct to call this into question and rightful for doing so. If we are so attached to our models of explanation that we defend these models in the face of greater understanding and evidence that contradicts these models, how are we progressing?
Brent Brookbush I disagree… I get fantastic results from SIJ work, Maitland has a course dedicated to the subject, "Spine" has several research studies pertaining to the SIJ, as well as tons of other journals, Janda discussed the SIJ as a "keystone" joint complex in his models, you are going against the grain on this one, and the word "is" is certainly not evidence - but that is not the point… it was his tone Jonathan Fass and whether this post was the appropriate place for it.
Steve Middleton Brent: Thanks for your concern about my post being hijacked. I have been watching from the background waiting to see where things go:
Jason: There seems to be 2 main groups in regards to Evidence Based Practice: those who love it and those who hate it. The problem seems to be that it is an all or none endeavor for individuals. EBP has 3 components: research, clinical experience/rationale and the patient's values. The major proponents of EBP tend to only focus on the research component. I've seen research on several different treatments where the results were phenomenal however I did not find the treatments affective clinically. Should I continue to use the techniques because the research says they work?
Also, I do have a 'system' of my own. I have spent almost 15 years developing it clinically from a combination of research and clinical experience. I have taught the techniques for the past 5 years. I see the results clinically with my patients but, more importantly, I see immediate changes in PTs/OTs/ LMTs/ATs at my seminars. These trained clinicians should be above the placebo affect. I would say people like Brent, Gray Cook, David Weinstock and others have success with their treatments otherwise 1) they wouldn't still be teaching the courses and 2) people wouldn't still be paying thousands of dollars to learn from them. The problem I feel is they haven't published a peer-reviewed study on their techniques. Yet, the techniques themselves meet the highest level of research: inter-examiner reliability.
Jonathan: Again, I saw my practice change drastically once I started treating the SI joints. I have an ongoing clinically trial right now and about 98% of the patients that have come into our clinic this year have had SIJD; sometimes it is symptomatic, other times it is creating compensatory movements elsewhere. I have treated the SI joint individuals with chronic low back pain who were pain free after 1 treatment. I have treated several patients who had 'plantar fasciitis' which was really an Si or S2 radiculopathy. The SI is the center or core of the body: most tests reference the center of gravity at the S2 level. Martial artists have taught for thousands of years to watch the abdomino-pelvic movements to predict your opponents moves.
I think the big take home from all of this is that as long as your patient is getting better in a timely fashion and you can 1) justify and 2) reproduce your results, that is all that matters.
Brent Brookbush Steve Middleton thank you for mentioning me in the same sentence as Gray Cook, and David Weinstock… much appreciated. There is a ton of great research out there, which I reference throughout my course materials, but my goal is to educate better. The idea of adding a clinical trial on top of trying to improve Human Movement Science Education creates a band width issue for me personally. I do have several peer-reviewed publications coming out in regard to innovations in Human Movement Science education, but I am not particularly experienced in research… Besides, why would my research be any more relevant the research I am citing?
I think the problem with all-or-none thinking in reference to EBP is it implies that we have answered all questions, and examined all approaches with high-quality research. Obviously this is not the case. I use an integrated approach that considers Theory, Research, Assessment, Practice, and Outcomes to delineate the best possible approach to a given issue - as you mentioned… this is what evidence-based practice is.
It sounds like we have very similar approaches Steve… I hope you will view my blog , and check out what I am trying to do to ensure everyone has the resources to learn human movement better. I even have an article on my view of SIJ movement and impairment. Maybe as my education platform grows we can add your research and articles to the materials offered to students.
BrentBrookbush.com
brentbrookbush.com
Jonathan Fass But now we're right back where we started: clinical approaches that are being used to justify physiological explanations that are outdated and have been shown to be inaccurate. Acupuncture has been shown to be "effective" in certain situations for certain issues…and it is almost certainly a placebo effect, and I believe that the evidence shows this. Does this mean that suddenly the use of acupuncture is rendered ineffective? No…but what does clinical findings have to do with the explanations behind them? I use ART in many treatments. I *believe* that I get good-excellent results (although I cannot state this as fact as it is entirely clouded by confirmation bias and the inaccuracy of my recollection as evidenced through cognitive research findings in our memory and recall). I *believe* that this works well, although I have no evidence that it actually works an better/faster than any other technique. However, even if all of this is true, should I believe that if the approach works, that the theory that it is based on - myofascial restrictions and mechanics - is therefore correct? Absolutely not, and in fact that theory is almost certainly wrong, in part if not entirely incorrect. So why waste my time and hours spreading questionable information based on clinical results that I cannot validate as being significant and which, even if they are valid, still say nothing about the validity of the theoretical underpinnings of that approach. This is a failure to recognize the very likely endogenous causes that may truly be at play here. Intellectual honesty demands that we consider this and to not overstate our abilities or our ability to identify a cause for both the experience of pain or the effect of our clinical results.
One of my favorite studies looked at arthroscopic surgery for OA. As you are all certainly aware, this basic "knee scope" is a widely practiced and highly effective treatment for identified knee pain and OA. And they found that it was actually *no better than sham scopes.* think about that for a moment: we have plausible and workable theory, identifiable removable of insulted tissues and excellent recovery that can be objectively recorded…but in a triple-blind RCT study with placebo control, we find out that we may in fact be performing a grand theatrical placebo treatment.
Do you *really* believe that your ability to identify "leg-length discrepancies" (questioned by systematic literature," to be able to palpate accurately the position of the SI joints (questioned by systematic literature) or otherwise identify SI joint dysfunction through cluster testing (which does not actually claim to do this, mind you: all you know is that a series of tests are reproducing symptoms, making the use if certain treatments more likely to improve those symptoms) is more accurate and more scientifically valid than arthroscopic surgery for identified tissue damage? Do you *really* believe this? It's time that manual therapies started being intellectually honest with our extraordinarily limited abilities to accurately identify/diagnose clinically, and instead recognize that our approaches may indeed be entirely and highly effective despite our limited ability to entirely understand why. Appeals to mechanical explanations do nothing to improve our outcomes, only to satisfy our own egos in thinks that we understand cause-effect. I couldn't care less if I'm somehow affecting the position of the intervertebral disc (highly dubious) or if I'm working on a completely different level of psychosomatic response to pain interpretation and outputs. If it works, it works. Why appeal to things that we know to be suspicious, if not entirely false?
Yesterday
Michael Jocson Jonathan, what if we all just admit that we really don't know what's going on? And then would it be so wrong after this admission if one submits their own possible interpretation for the results they are experiencing so as to be a spark for further research by others? And of course, this would be with the underlying understanding that we still do not really know completely but at least we have some sort of reference point to work from?
Yesterday
Jonathan Fass That is exactly the process that *should* occur imo, Michael Jocson. The problem occurs when we mistake an explanation as a plausible theory with evidence to support it when no such thing exists. If we present uncertainty with certainty, then we put an end to discovery. We *must* be intellectually honest with *any* explanations that we out forth, and to be not only willing but excited by the prospect of that explanation being false: only then does true learning and advance occur
Yesterday
Brent Brookbush Jonathan Fass you don't know these claims to be entirely false, just as the studies you mentioned above cannot prove certainty… but the reason why we use intellectual reasoning is simple… so that we may be systematic in our approach, leading to better outcomes with experience.
Michael Jocson Thank you. This has been an awesome thread….
Jonathan Fass Bret: we know that the Cartesian model of pain is flawed and does not represent our current understanding of pain in the body. We know that biomechanical models of injury have a poor reliability for predicting injury and pain. We know that our best investigations into injury evidence that our current common understanding and treatment models are highly contingent on numerous validated influencers that renders any conversation limited to single-solution answers to be entirely and grossly misleading. If we present these issues as anything but such, we are either deceiving ourselves or our patients. This does not further discovery, it limits it. It says "we hold knowledge that we do not actually possess" and that makes further investigation a folly. This is wanton appeal to ignorance and has no place in a science-based field. Statements were made here without justifiable and defensible evidence to validate the claims, and that can never be acceptable
Steve Middleton Michael:
I totally agree with you that we, regardless of our education or clinical designator, have no idea what we are treating. If you look at the different 'systems' you will find:
The Anatomy Trains identified by Thomas Myers identify lines of fascial tightening/shortening that affects the human movement system and overlies the
Acupuncture meridians. These are areas that have been treated in Traditional Chinese medicine for thousands of years. They may be treated by acupuncture or gua sha but these lines overly the
Nerve lines. Most of the stretches for the fascial lines mimic the Limb Tension Tests. However, these lines also overlap
The lines of lymphatic drainage. I am not as familiar with these lines but have had attendees in several courses point out both the similarities and the overlaps.
So, I agree that we have no idea what we are treating. Again, for ethics, for documentation and for patient perspective, it all comes back to our ability (based on the research we have read AND our clinical experience) to rationalize why we did a particular treatment.
Jonathan Fass Anatomy Trains: This is an expert opinion that invokes a physiological explanation that is at odds with evidence (see "Three-Dimensional Mathematical Model for Deformation") - "Our calculations reveal that the dense tissues of plantar fascia and fascia lata require very large forces—far outside the human physiologic range—to produce even 1% compression and 1% shear. However, softer tissues, such as superficial nasal fascia, deform under strong forces that may be at the upper bounds of physiologic limits. Although some manual therapists anecdotally report palpable tissue release in dense fasciae, such observations are probably not caused by deformations produced by compression or shear. Rather, these palpable effects are more likely the result of reflexive changes in the tissue—or changes in twisting or extension forces in the tissue." Undoubtedly Mr. Meyers is an excellent clinician, but his opinion does not equal fact, especially when there is higher quality evidence that contradicts assumed physiological explanations without physiological plausibility (see also "The fall manual and physical therapies: Exemplified by lower back pain" for an overview of the issues surrounding physical explanations for pain, in addition to current literature in neuromatrix pain research). This an "Appeal to Expert" fallacy.
Acupuncture: Acupuncture is almost certainly placebo. Presenting acupuncture as "meridians (that) are areas that have been treated in Traditional Chinese medicine for thousands of years" is misleading and largely false. (See "Acupuncture Is Theatrical Placebo") - "Although it is commonly claimed that acupuncture has been around for thousands of years, it has not always been popular, even in China. For almost 1000 years, it was in decline, and in 1822, Emperor Dao Guang issued an imperial edict stating that acupuncture and moxibustion should be banned forever from the Imperial Medical Academy.
Acupuncture continued as a minor fringe activity in the 1950s. After the Chinese Civil War, the Chinese Communist Party ridiculed Traditional Chinese Medicine, including acupuncture, as superstitious. Chairman Mao Zedong later revived Traditional Chinese Medicine as part of the Great Proletarian Cultural Revolution of 1966.2 The revival was a convenient response to the dearth of medically trained people in postwar China and a useful way to increase Chinese nationalism. It is said that Chairman Mao himself preferred Western medicine. His personal physician quotes him as saying “Even though I believe we should promote Chinese medicine, I personally do not believe in it. I do not take Chinese medicine.” Besides being largely misleading, the appeal to something being correct because of its antiquity is an "Appeal to history" fallacy. Leaching, burning patients to remove possessions and surgically producing holes in the skull were all medical treatments favored for hundreds of years: does this make them good treatments?
Nerve Lines: Our understanding of Nerve Tension techniques is questionable and clinical experience may be over-estimated. (see "Neural Mobilization: A Systematic Review of Randomized Controlled Trials with an Analysis of Therapeutic Efficacy") - "Nine of the 11 studies reviewed demonstrated moderate methodological quality; the two remaining studies yielded limited methodological quality. Studies exhibited weaknesses in random allocation, intention to treat, concealed allocation, and blinding; consequently, our ability to review and assess the therapeutic efficacy of neural mobilization for treatment of altered neurodynamics through evaluation of appropriate randomized controlled trials was substantially limited.
Methodological weaknesses can lead to over- or underestimations of actual outcomes. For example, blinding can significantly eliminate bias and confounding, and is essential in maintaining the robustness of an RCT." An appeal to a technique that may not actually result in any effect, or if there is an effect it may not actually result in better outcomes or outcomes based on supposed physiological explanations does not lend credibility to your example.
Lines of Lymphatic Drainage: Lymphatic vessels run along anatomical pathways with nerve and blood vessel bundles, but this is entirely a correlation that does not imply any actual interaction in what is being discussed. This is an error of assumptive correlational importance where no such importance is likely to exist and offers little in terms of effective argument. Unless there is an important finding concerning this, it is irrelevant. This is similar to the idea that impingement of the nerve results in illness (originally part of chiropractic) or that an impingement of vessels results in illness (originally part of osteopathic); both are outdated and largely erroneous concepts without evidence in terms of the scope and impact of the ideas…and yet we still see individuals in both fields defend these concepts because techniques based on these flawed concepts "work," therefore they believe that the idea is sound. This is entirely false.
The correlations that have been presented do not lead us to further knowledge or understanding, they take us further away. By putting forth these ideas, we make it more difficult to practice with sound reasoning and a scientific basis for our approaches. There is a difference between discussing ideas vs. dismissing valid criticisms of these ideas because of a groupthink protection of indefensible views.
Robert Gazso Jonathan - What is your take on Active Release Techniques?
Jonathan Fass Robert Gazso, this was from a thread on my page discussing a claim that "someone truly EBP is always two years behind the cutting edge." This was my response, which I used the example of ART:
Dave, that's *not* what this means, at least not to me. I can't speak for others, but I can say that the *only* approach consistent with the hierarchy of knowledge and skepticism is that we do not accept something as a given fact until we have valid evidence to state this. It does *not* mean that we must wait until we have a meta-analysis of RCTs to begin practicing something *if* we believe that there could be benefit and *if* we believe that the risk to this practice is low. For example, I *think* that I see good-great results with ART when I apply it. I will *not* say that, therefore, ART gets good-great results, only that it appears that it benefits my patients. I do not know that they could not do just as well from another approach, nor do I know that if there is an effect from the techniques that it isn't placebo or patient expectations. In fact, I *do* have good reason to believe that the ART explanation - myofascial manipulation - is almost certainly *not* the case. I use it because I find it to be clinically reliable, but I do not go further with those statements, nor do I scoff at the lack of evidence for it. I am simply honest with my knowledge of the approach (and specifically, my lack of knowledge), and I would be happy to dismiss it if/when it was shown to be unreliable or ineffective because I do *not* believe that my experience > systematic evidence if that evidence disagrees with my experience
Laree Draper Hey, Jon, would you say much of the problem we've been talking about is simply word choices? I had that feeling working on Lorimer Moseley's DVD, too -- people are often saying the same thing, but a bit behind the research in their explanations.
Jonathan Fass I think that it's word choices that lead to a thought process, yes. Dr. Moseley (btw, I'm about half-way through that lecture and it's gold ) offers an excellent example: the "newer" exploration into pain and the neuromatrix theory (I say "new" since that theory has been around for over ten years now…so much for "EBP being two years behind." How about ten years ahead, IRL?) is at significant odds with the above SI Joint lecture in terms of the theoretical causative claims being made here. Now, if you've been led to believe through misleading claims of evidence strength where none exists and understanding of this phenomenon that we don't have, how do you respond to *accurate* statements about the validity of SIJ dysfunction and biomechanical causes of pain? Oh…I guess we know exactly how: we refuse to accept superior evidence or adjust our thought process - leaving us practicing an outdated conceptual framework - and then we ban the only individual on the thread that actually had anything of value to contribute in terms of improving learning and ultimately practice. This is the problem, in my eyes.
Laree Draper Hey, Jon, would you say much of the problem we've been talking about is simply word choices? I had that feeling working on Lorimer Moseley's DVD, too -- people are often saying the same thing, but a bit behind the research in their explanations.
Jonathan Fass I think that it's word choices that lead to a thought process, yes. Dr. Moseley (btw, I'm about half-way through that lecture and it's gold ) offers an excellent example: the "newer" exploration into pain and the neuromatrix theory (I say "new" since that theory has been around for over ten years now…so much for "EBP being two years behind." How about ten years ahead, IRL?) is at significant odds with the above SI Joint lecture in terms of the theoretical causative claims being made here. Now, if you've been led to believe through misleading claims of evidence strength where none exists and understanding of this phenomenon that we don't have, how do you respond to *accurate* statements about the validity of SIJ dysfunction and biomechanical causes of pain? Oh…I guess we know exactly how: we refuse to accept superior evidence or adjust our thought process - leaving us practicing an outdated conceptual framework - and then we ban the only individual on the thread that actually had anything of value to contribute in terms of improving learning and ultimately practice. This is the problem, in my eyes.
Nick Chertock Ad hominems: I listen to them I just don't use them myself.
There's no Constitutional protection in a FB group. Rules of democracy don't apply. There are no stated rules in the group at all.
My 'cause' if we want to use that word, was that I felt the group would be better without Jason than with after doing a bit of research and asking around. And his mocking post on 7/31 made it an easy call for me because if that's his first contribution I can use that evidence to conclude that I should expect more of the same since I share a lot of Perry's stuff. I like Perry Nickelston's podcast, I like his blogposts, I like his social media comments. Yes he is passionate and perhaps the claims are impossible to substantiate but I really want to hear what he and others using NKT and SFMA and Rocktape and Lasers are doing. If Jason staying means Perry leaving that's an easy choice. One guy puts it all out there and takes the risk that what he's saying may be unproveable and the other exists mainly to poke holes and rain on parades.
A separate group for open debates makes sense. This group is about sharing and promotion of ideas and publications and seminars and certifications and having discussions and if you want to call it an echo chamber you'll need more evidence than just me removing Jason, because there's been not one other instance of ever having to moderate the group prior to that. I've never deleted a comment unless it was spammy, including any comments from Jason himself.
Initially I started the group with about 30 people who I considered to be highly regarded in the field. I wanted to host discussions and promote their events and eventually partner with some in business, as a way to connect clients with providers. Then the group grew organically, mainly from people requesting to join (I have no idea how they find out about it) or people adding their friends. Before approving, I look at who our mutual friends are, whether they appear to be a practitioner or a trainer or therapist or maybe even a sport coach with an extreme interest in training movement. Sometimes I come into contact with folks and I invite them to join. I don't see this as building an echo chamber. More of a friendly community that may not always agree with each other.
I agree with Laree Draper that a group consisting of just seminar announcements is really a bulletin board. I don't want that for this group-I'd like to see more interactivity- and I try to get conversations going when I have time. But I would accept it being a large bulletin board over being a place only a small handful of skeptics wants to be, that's how it would go down, it would just turn into the Soma Simple forum.
8 hours ago · Like
Lars Avemarie Personlig Tränare "Acupuncture meridians. These are areas that have been treated in Traditional Chinese medicine for thousands of years."
Appart from being a fallacious argument, called appeal to tradition fallacy (argumentum ad antiquitam). Are we really still talking about acupuncture?
"Applying stricter inclusion criteria, however, showed that none of the 35 reviews supported acupuncture, predominantly because there were too few patients in the randomised, double blind studies. Six reviews with more than 200 patients in randomised, double blind studies had good evidence of no benefit. Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication"
“The 35 systematic reviews of acupuncture published since 1995 represent what should be the highest level of evidence available. Unfortunately, most of the reviews were based on a few small trials of inadequate design and statistical power. Many reviews included studies with designs known to be associated with bias and overestimation of treatment effects, notably trials that were not randomised, not blind, or neither randomised nor blind. Pooled analysis of trials with flawed design does not resolve, but rather accentuates, these problems.”
Ref:. Derry CJ, Derry S, McQuay HJ, Moore RA. Systematic review of systematic reviews of acupuncture published 1996-2005. Clin Med. 2006 Jul-Aug;6(4):381-6.
"It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture and hundreds of systematic reviews, arguments continue unabated"
Ref:.
Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg. 2013 Jun;116(6):1360-3.
"We found a small analgesic effect of acupuncture that seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."
Ref:.
Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009 Jan 27;338:a3115.
"Clinical trials have failed to demonstrate that there is a reliable difference between true and sham acupuncture as defined by traditional acupuncture theories. Scientific rationales for acupuncture are needed to define valid controls"
Ref:.
Moffet HH. Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. J Altern Complement Med. 2009 Mar;15(3):213-6.
And it does not matter where on the body/meridians you insert the needles
Moffet HH. Traditional acupuncture theories yield null outcomes: a systematic review of clinical trials. J Clin Epidemiol. 2008 Aug;61(:741-7. Epub 2008 Jun 6.
or how depth the needles are inserted
Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009 Jan 27;338:a3115.
Lars Avemarie Personlig Tränare Brent Brookbush - "Lets talk substance… you say there is no research to support biomechanics… seriously?"
Yes, there are not consensus on supporting a biomencanical model of pain
"Summary points:
• Postural and structural asymmetries cannot
predict back pain and are unlikely to be its
cause.
• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain.
• A PSB model is not suitable for understanding
the causes of back pain."
"A clinical alternative to the postural–structural–biomechanical (PSB) model is a Process Approach model. The aim in this approach is to identify the processes underlying the patient’s condition and provide the stimulation/signals/management/
care that will support/assist/facilitate change. This
approach has been extensively discussed in Lederman (2005) and will be discussed in a future article.
Summary and conclusion points
• PSB asymmetries and imperfections are normal
variations—not a pathology.
• Neuromuscular and motor control variations are
also normal.
• The body has surplus capacity to tolerate such
variation without loss to normal function or development of symptomatic conditions.
• Pathomechanics do not determine symptomatology.
• There is no relationship between the pre-existing
PSB factors and back pain.
• Correcting all PSB factors is not clinically attainable and is unlikely to change the future course of
a lower back condition.
• This conclusion may well apply to many common
musculoskeletal conditions elsewhere in the body
(e.g., neck pain)."
Ref:. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011.
7 hours ago · Like · 1
Brett Jones Outside of the "political" issues in the thread there is some great info in this thread
Lars Avemarie Personlig Tränare There even is no similar (isomorphic) relationship between pain and tissue damage, or pain and nociception
Ref:.
Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May 8;353(9164):1607-9.
…See More
7 hours ago · Like · 1
Lars Avemarie Personlig Tränare And if we go deeper down the rabbit hole
Pain is influenced by sight and colors
Lars Avemarie Personlig Tränare "We tend to endorse the complexity of the brain and its fundamental role in what we experience. Unless, of course, we are talking about pain"
"The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain , n…See More
Laree Draper I'll bet it would be easier for people to jump on board if they knew where to start. Is the study of research taught in places like PT and chiropractic schools, massage therapy, personal training or coaching education? Or are those of you at the forefront self-taught because you have a passion for it?
Brett Jones Pain changes "everything"
Lars Avemarie Personlig Tränare "Acupuncture meridians. These are areas that have been treated in Traditional Chinese medicine for thousands of years."
Appart from being a fallacious argument, called appeal to tradition fallacy (argumentum ad antiquitam). Are we really still talking about acupuncture?
"Applying stricter inclusion criteria, however, showed that none of the 35 reviews supported acupuncture, predominantly because there were too few patients in the randomised, double blind studies. Six reviews with more than 200 patients in randomised, double blind studies had good evidence of no benefit. Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication"
“The 35 systematic reviews of acupuncture published since 1995 represent what should be the highest level of evidence available. Unfortunately, most of the reviews were based on a few small trials of inadequate design and statistical power. Many reviews included studies with designs known to be associated with bias and overestimation of treatment effects, notably trials that were not randomised, not blind, or neither randomised nor blind. Pooled analysis of trials with flawed design does not resolve, but rather accentuates, these problems.”
Ref:. Derry CJ, Derry S, McQuay HJ, Moore RA. Systematic review of systematic reviews of acupuncture published 1996-2005. Clin Med. 2006 Jul-Aug;6(4):381-6.
"It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture and hundreds of systematic reviews, arguments continue unabated"
Ref:.
Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg. 2013 Jun;116(6):1360-3.
"We found a small analgesic effect of acupuncture that seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear."
Ref:.
Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009 Jan 27;338:a3115.
"Clinical trials have failed to demonstrate that there is a reliable difference between true and sham acupuncture as defined by traditional acupuncture theories. Scientific rationales for acupuncture are needed to define valid controls"
Ref:.
Moffet HH. Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials. J Altern Complement Med. 2009 Mar;15(3):213-6.
And it does not matter where on the body/meridians you insert the needles
Moffet HH. Traditional acupuncture theories yield null outcomes: a systematic review of clinical trials. J Clin Epidemiol. 2008 Aug;61(:741-7. Epub 2008 Jun 6.
or how depth the needles are inserted
Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ. 2009 Jan 27;338:a3115.
Lars Avemarie Personlig Tränare Brent Brookbush - "Lets talk substance… you say there is no research to support biomechanics… seriously?"
Yes, there are not consensus on supporting a biomencanical model of pain
"Summary points:
• Postural and structural asymmetries cannot
predict back pain and are unlikely to be its
cause.
• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain.
• A PSB model is not suitable for understanding
the causes of back pain."
"A clinical alternative to the postural–structural–biomechanical (PSB) model is a Process Approach model. The aim in this approach is to identify the processes underlying the patient’s condition and provide the stimulation/signals/management/
care that will support/assist/facilitate change. This
approach has been extensively discussed in Lederman (2005) and will be discussed in a future article.
Summary and conclusion points
• PSB asymmetries and imperfections are normal
variations—not a pathology.
• Neuromuscular and motor control variations are
also normal.
• The body has surplus capacity to tolerate such
variation without loss to normal function or development of symptomatic conditions.
• Pathomechanics do not determine symptomatology.
• There is no relationship between the pre-existing
PSB factors and back pain.
• Correcting all PSB factors is not clinically attainable and is unlikely to change the future course of
a lower back condition.
• This conclusion may well apply to many common
musculoskeletal conditions elsewhere in the body
(e.g., neck pain)."
Ref:. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011.
Jonathan Fass …and everything changes pain, Brett Jones
Jonathan Fass Laree: Any undergraduate science major will touch into research, usually with at least an entry-level statistics class. Graduate programs (Masters, clinical doctorates) will have a certain component of research and research design, varying on the school, program and degree. PhDs and other "terminal" degrees are focused on research design and development and are therefore the most detailed in its teaching. I think that with most things, however, a student can always take that understanding further as interest and clinical needs require. My assumption is that for those of us here using research as our primary source of evidence, we probably have a certain extent of both classroom formal education and then further reading outside of a classroom setting (EBP essentially demands this because you must remain active in your field of literature in order to maintain current best-practice)
Lars Avemarie Personlig Tränare Brent Brookbush - "I would have been pissed if some jerk bashed my article for no apparent reason"
How about there is lack of evidence? Is that a reason?
"I disagree… I get fantastic results from SIJ work"
But that does not prove anything, and is purley anecdotal, and anecdotal evidence is flawed in so many ways.
"Maitland has a course dedicated to the subject,
You can also take a course in voodoo healing? but that proves nothing.
"Spine" has several research studies pertaining to the SIJ, as well as tons of other journals"
Please provide references to these studies? I am always looking for new learning opportunities
Brent Brookbush Hey Lars Avemarie Personlig Tränare, Jonathan Fass, Laree Draper, Brett Jones, Steve Middleton, Nick Chertock, and Robert Gaszo
I have pondered this discussion quite a bit since being in the middle of the discussion a few days ago, and we all failed to do one very important thing - define evidence-based practice. Several have commented that Steve's article is not evidence-based, but that hardly makes sense, the article is well cited with none-other than research studies. Earlier in the discussion Janda's work was bashed, but Janda's distortion patterns are again based on EMG research Sahrmann has several published research studies supporting her work, Maitland Workshops include manuals with long bibliographies of research supporting their practices and texts for further reading, can we really say that Richardson and Hodges work is not evidence-based because there is no outcome study - they are well respected researchers in the field… right? Most of us build treatment strategies from similar research studies, that is research that does not specifically validate a practice, but rather research that implies certain attributes of the human movement system and the potential effect of various modalities. I would argue that everything I do is evidence-based, and well supported by research (I do use predictive models of human movement impairment as the basis for treatment), but I would be the first to admit that facets of my programming are not validated by the aggrandized meta-analysis, long-term outcome analysis, nor are they limited to practices implied by clinical predication model and the often archaic APTA preferred practice patterns.
We all need to be a little more humble, myself included, there is more than one way to practice, andjust because you have not seen the study does not mean the evidence does not exist. Don't believe someone else when they say there is no research to support, go into a database and start putting in search terms regarding the various aspects of someones assertion, I am willing to bet you will find more research than you can handle. If you search "Validation of Human Movement Impairment Models" you are likely to get nothing, but if you put in "gluteus medius" "activity" "exercise" you will get several studies. The same could be done for any of the other approaches used.
I am actually thankful that different Human Movement Professionals (since I was asked earlier this includes PT's, ATC's, LMT's, DC's, and CPT's) practice differently. The two professionals I refer out to do not treat the way I do… That's why I refer out to them. If I cannot get the outcome I am looking for I want a different set of views, principles, techniques and biases to be applied to the case. If they treated as I did and I am unsuccessful where would my client/patient go next? No one is 100% effective, 100% of the time.
Thanks again for a wonderful discussion and learning experience.