"In theory there is no difference between theory and practice. In practice there is."
Yogi Berra
People frequently ask me why I practice differently from other therapists they have experienced. Most seem appreciative of the approach. Others struggle to go where they think I want them to go. Expecting someone to tell them everything that is wrong with them and set about fixing it, they are taken aback when I begin with acceptance and follow their lead toward correction. The truth is, they know more about finding their way out of pain than I do. I just need to help them find that path. I decided long ago that since I rarely met anyone's expectations of therapy that I would have to try instead to exceed them. That is easier said than done.
In this thread on SomaSimple, a fellow moderator had this to say about our profession:
"Perhaps as a profession, we've been following the wrong directions so long that we've had to convince ourselves that where we ended up is where we wanted to go. I imagine it would be hard to convince someone that all the hard work used to get somewhere may have been wasted (or at least not used efficiently)."
I think he is exactly right. When one finds oneself somewhere they don't really want to be, they should change course. So, I guess my simplest answer to the question of why my practice is different is that I have corrected course many times.
A few years ago James Willis, MD, gave an address on the importance of science in medicine that I think everyone should read. In The Sea Monster and the Whirlpool, he discusses the difficulty and imperative of steering a course between pseudoscience (see my last post) and scientific fundamentalism. In physiotherapy these days, these two extremes are exemplified by the enthusiasm for alternative methods and the excitement about clinical prediction rules for manipulation. This is not all bad, of course, and one must carefully separate the wheat from the chaff. The main imperative for many, however, seems protection of traditional methods of practice. This makes no sense when the science is leading us in a different direction.
I spend every day encountering patients in pain, trying to figure out how to help them find greater comfort and how to function better in their every day lives. Thankfully, there has been a tremendous amount of work in neuroscience that has revolutionized our understanding of pain. It has charted a course for my profession that we simply must follow if we hope to help those in need of our care. It is time for new theories. And from new theories, new practice.
That is why I practice differently.
Friday, August 29, 2008
Thursday, July 24, 2008
Where's My Qi Gone???
The ancient art of Qi Gong has become all the rage in Halifax. It comes complete with extraordinary claims and even a modicum of evidence. I want to be very clear that I think it is a wonderful form of movement therapy and can benefit many. Its focus on movement and breathing addresses two of the fundamental issues so important for people experiencing persistent pain. And it is here that the ancient art intersects with modern science.
There is a growing body of research literature that demonstrates the efficacy of acupuncture and other related modalities - at least in some circumstances. However, one must be careful not to leap to an acceptance of the theories behind these methods. Traditional approaches claim that energy or qi (chi) flows along channels called meridians and that blockages can cause illness or dysfunction of various sorts. In spite of claims to effectiveness, there is no support for this theoretical model. Meridians have never been identified by scientific method and far more plausible mechanisms, such as endorphin release and neuromodulation, are offered by neurophysiological investigations. One need not depend on outdated theory and magical thinking to understand empirical observations.
Dr. Harriet Hall helps shed light on such matters in discussing what she calls Tooth Fairy Science:
"You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists."
For instance, Qi Gong or acupuncture or many other similar treatments may produce measurable outcomes (even good ones), but that does not establish the existence of some vital energy that can be manipulated by a practitioner claiming to have special powers. No one has bothered to establish whether qi and meridians even exist.
Here is the protocol for treatment outlined in a pilot study for Qi Gong for people with fibromyalgia (THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 12, Number 9, 2006, pp. 851–856)
"EQT treatment by this specific healer consisted of administering acupressure, qi emission, qi balancing, and magnetic cupping on each individual. The following is a briefdescription of the main steps in the specific EQT of this healer, and the presumed functions of these various steps in the treatment process:
(a) The fully clothed patient lies down on her back on the examination table; the healer lightly touches the abdominal area to sense the blockage of qi flow in the major organs, allegedly moving the qi around, and driving the stagnant qi out via the bottom of the patient’s feet.
(b) The healer examines the key acupoints (not necessarily the tender points) to sense the extent of the blockages at each point and in the internal organs. He uses his palm(s) movements to generate the flow of qi in each blocked area, driving the stagnant qi out through the patient’s feet (Yongchuan acupoint).
(c) The patient turns around facing down on the examination bed and raises the back of her shirt;
(d) The healer examines major organs from the patient’s back with his palm to locate any deficiency in function and qi balance.
(e) The healer moves his own qi to the organs and verifies that the organ is functioning normally with balanced energy. He drives the stagnant qi out, and supplies healthy qi energy to the major organs.
(f) After the qi adjustment, small magnetic cupping is often used to directly take the excessive stagnant qi out from a specific organ (through acupoints)."
I'm leaving it to you readers to spot the Tooth Fairy here. Let me know if you see her. I'll be back with more later.
There is a growing body of research literature that demonstrates the efficacy of acupuncture and other related modalities - at least in some circumstances. However, one must be careful not to leap to an acceptance of the theories behind these methods. Traditional approaches claim that energy or qi (chi) flows along channels called meridians and that blockages can cause illness or dysfunction of various sorts. In spite of claims to effectiveness, there is no support for this theoretical model. Meridians have never been identified by scientific method and far more plausible mechanisms, such as endorphin release and neuromodulation, are offered by neurophysiological investigations. One need not depend on outdated theory and magical thinking to understand empirical observations.
Dr. Harriet Hall helps shed light on such matters in discussing what she calls Tooth Fairy Science:
"You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists."
For instance, Qi Gong or acupuncture or many other similar treatments may produce measurable outcomes (even good ones), but that does not establish the existence of some vital energy that can be manipulated by a practitioner claiming to have special powers. No one has bothered to establish whether qi and meridians even exist.
Here is the protocol for treatment outlined in a pilot study for Qi Gong for people with fibromyalgia (THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 12, Number 9, 2006, pp. 851–856)
"EQT treatment by this specific healer consisted of administering acupressure, qi emission, qi balancing, and magnetic cupping on each individual. The following is a briefdescription of the main steps in the specific EQT of this healer, and the presumed functions of these various steps in the treatment process:
(a) The fully clothed patient lies down on her back on the examination table; the healer lightly touches the abdominal area to sense the blockage of qi flow in the major organs, allegedly moving the qi around, and driving the stagnant qi out via the bottom of the patient’s feet.
(b) The healer examines the key acupoints (not necessarily the tender points) to sense the extent of the blockages at each point and in the internal organs. He uses his palm(s) movements to generate the flow of qi in each blocked area, driving the stagnant qi out through the patient’s feet (Yongchuan acupoint).
(c) The patient turns around facing down on the examination bed and raises the back of her shirt;
(d) The healer examines major organs from the patient’s back with his palm to locate any deficiency in function and qi balance.
(e) The healer moves his own qi to the organs and verifies that the organ is functioning normally with balanced energy. He drives the stagnant qi out, and supplies healthy qi energy to the major organs.
(f) After the qi adjustment, small magnetic cupping is often used to directly take the excessive stagnant qi out from a specific organ (through acupoints)."
I'm leaving it to you readers to spot the Tooth Fairy here. Let me know if you see her. I'll be back with more later.
Saturday, June 28, 2008
Sparked
John Ratey's new book Spark combines a look a two of my greatest interests - exercise and brain science. Ratey promises to "supercharge your mental circuits to brain stress, sharpen your thinking, lift your mood, boost your memory, and much more." How could anyone resist? He presents a compelling case for the positive effects of aerobic exercise on brain chemistry. While I agree with much of what he writes, there are some complicated issues that he does not address. I have written Dr. Ratey about these questions, but have yet to receive his reply. To state my position most clearly, I think he would do well to distinguish more explicitly between exercise and recreational activity. Find more on that in previous posts on Good Medicine.
Basically it comes down to this issue at the heart of his book: Ratey states that "the paradox is our that our wonderful ability to adapt and grow doesn't happen without stress - we can't have the good without the bad." He also offers that everybody's threshold for stress is different and admits that "there is no specific point at which scientists can say stress shifts from building up to tearing down." These are extremely important points and I think they are glossed over too quickly and easily in the final analysis of his recommendations. I agree that people need to move more than they do and that enjoyable activity has tremendous psychological and social benefits driven, at least in part, by the chemical changes in one's brain. However, causing the body to adapt requires hard work balanced with adequate recovery. Ratey gives lip service to resistance training and recovery, but neither is given the attention it deserves and requires. If everyone is unique, then generic admonitions to be more active certainly will not do. Again, like any medicine, exercise must be prescribed in a manner that suits a particular individual and accomodates the desired response. He states the importance of individuality in the book, but the rest of his writing contradicts it.
Here, in my opinion, is the biggest mistake in the book: "The process of getting fit is all about building up your aerobic base." This statement simply is not true. Sure, it is important to get your blood pumping but think about where that blood is going. Ratey, importantly, adds the brain to the list of tissues that benefit from exercise; however, he mostly overlooks the muscles. In personal correspondence, he did acknowledge the importance of resistance training for brain changes and he gives it a brief nod for preventing osteoporosis in the book. He recognizes that "even if you do all the aerobic training in the world, your muscles and bones will still atrophy with age." But he seems to fail to see the implications of this. First, it is the primary reason why people become frail and lose functional ability, including performing all that activity he is so fond of. Second, there is growing evidence, though Ratey seems not to have read this research, of the connection between healthy muscles (ie. ones that are not wasting away) and healthy brains.
Good news: a little activity can do wonders for your brain. Spark could be a great motivator for someone requiring a little extra motivation to get moving and stay strong. Beware, however, the generic recommendations. Injury and pain are real problems that often significantly limit activity tolerance and negatively impact quality of life. In other words, don't just do it; do it right!
You can also listen to Dr. Ratey at Brain Science Podcasts, one of my favorite sites on the net. Check it out.
Basically it comes down to this issue at the heart of his book: Ratey states that "the paradox is our that our wonderful ability to adapt and grow doesn't happen without stress - we can't have the good without the bad." He also offers that everybody's threshold for stress is different and admits that "there is no specific point at which scientists can say stress shifts from building up to tearing down." These are extremely important points and I think they are glossed over too quickly and easily in the final analysis of his recommendations. I agree that people need to move more than they do and that enjoyable activity has tremendous psychological and social benefits driven, at least in part, by the chemical changes in one's brain. However, causing the body to adapt requires hard work balanced with adequate recovery. Ratey gives lip service to resistance training and recovery, but neither is given the attention it deserves and requires. If everyone is unique, then generic admonitions to be more active certainly will not do. Again, like any medicine, exercise must be prescribed in a manner that suits a particular individual and accomodates the desired response. He states the importance of individuality in the book, but the rest of his writing contradicts it.
Here, in my opinion, is the biggest mistake in the book: "The process of getting fit is all about building up your aerobic base." This statement simply is not true. Sure, it is important to get your blood pumping but think about where that blood is going. Ratey, importantly, adds the brain to the list of tissues that benefit from exercise; however, he mostly overlooks the muscles. In personal correspondence, he did acknowledge the importance of resistance training for brain changes and he gives it a brief nod for preventing osteoporosis in the book. He recognizes that "even if you do all the aerobic training in the world, your muscles and bones will still atrophy with age." But he seems to fail to see the implications of this. First, it is the primary reason why people become frail and lose functional ability, including performing all that activity he is so fond of. Second, there is growing evidence, though Ratey seems not to have read this research, of the connection between healthy muscles (ie. ones that are not wasting away) and healthy brains.
Good news: a little activity can do wonders for your brain. Spark could be a great motivator for someone requiring a little extra motivation to get moving and stay strong. Beware, however, the generic recommendations. Injury and pain are real problems that often significantly limit activity tolerance and negatively impact quality of life. In other words, don't just do it; do it right!
You can also listen to Dr. Ratey at Brain Science Podcasts, one of my favorite sites on the net. Check it out.
Wednesday, May 28, 2008
One too many dandelions...
I thought of this when a patient of mine wondered aloud about how many of us on our death beds would wish we had spent more time killing weeds. This was while she was being treated for back pain after spending the weekend making her yard look beautiful. Isn't it amazing how often our culture chooses beauty over comfort?
Then again, maybe I'm just rationalizing the state of my lawn and hoping my neighbors forgive my obvious lack of passion for green carpet.
I’d Kill More Dandelions
Nick Matheson, Age 35
If I had my life to live over,
I'd try to make fewer errors next time.
I would stress out. I would stiffen up.
I would be more sober than I have on this trip.
I would be more orderly. I would be neater.
I would take fewer chances, I would stay home more.
I would climb fewer mountains, swim fewer rivers, and watch fewer sunsets.
I would burn less gasoline. I would eat less ice cream and more broccoli.
I would have fewer actual troubles and more imaginary ones.
You see, I am one of those people who throws caution to the wind and hopes it won’t blow back in my face.
Oh, I have had my moments when I thought I had it all figured out.
Everything seemed just right.
Risk appeared to have its reward
and truth was more certain than reality.
But if I had to do it again, I would forget now and live every day in the far off future, ready for any eventuality.
You see, I got kicked out of Boy Scouts and have never been prepared.
If I had to do it over again, I would stay home and do more yard work.
I'd watch more TV and read fewer books.
I’d spend less time worrying about my kids and more time worrying about the neighbors.
If I had my life to live over, I would start weeding earlier in the spring and keep mowing way later in the fall.
I would make sure the grass was greener on my side of the fence.
I would never miss a day of work. I would make more money and live in a bigger house. I would be fully insured.
I would avoid merry-go-rounds, but would run on treadmills.
I'd kill more dandelions.
Wednesday, April 30, 2008
Pain Without Pain
So back to the Pain List - Ten Steps to Understanding Manual and Movement Therapies for Pain.
"2. Nociception (warning signals from body tissues) is neither necessary nor sufficient to produce pain. In other words, pain can occur in the absence of tissue damage."
Perhaps even more surprising is that tissue damage, even when severe, may not result in pain. A few weeks ago I had the privilege of attending a seminar with Lorimer Moseley, one of the leading researchers in pain science and physiotherapy. His book Painful Yarns contains many great stories about the pain experience. In one, he recants the experience of a man who had the great misfortune of having a hammer go through his neck. Arriving in the Emergency Room, the man showed no sign of being in pain and even joked about the situation. Joked, that is, until he banged his knee on a table and doubled over in pain.
Moseley concludes that in order to experience pain, one's brain must
(a) conclude that tissue is in danger, and
(b) conclude that one should do something about it.
Mr. Hammerhead Shark, as he is named in the story, had concluded that he was safe and he took action to resolve the problem. Pain, therefore, was not necessary in spite of significant warning signals from the tissues.
On the other side of the coin, pain can, and frequently does, occur in the absence of tissue damage. Mr. Hammerhead experienced more pain with a bang to his knee that resulted in no damage. In many instances, pain occurs without any signalling from the tissues at all. We'll examine how in upcoming posts.
"2. Nociception (warning signals from body tissues) is neither necessary nor sufficient to produce pain. In other words, pain can occur in the absence of tissue damage."
Perhaps even more surprising is that tissue damage, even when severe, may not result in pain. A few weeks ago I had the privilege of attending a seminar with Lorimer Moseley, one of the leading researchers in pain science and physiotherapy. His book Painful Yarns contains many great stories about the pain experience. In one, he recants the experience of a man who had the great misfortune of having a hammer go through his neck. Arriving in the Emergency Room, the man showed no sign of being in pain and even joked about the situation. Joked, that is, until he banged his knee on a table and doubled over in pain.
Moseley concludes that in order to experience pain, one's brain must
(a) conclude that tissue is in danger, and
(b) conclude that one should do something about it.
Mr. Hammerhead Shark, as he is named in the story, had concluded that he was safe and he took action to resolve the problem. Pain, therefore, was not necessary in spite of significant warning signals from the tissues.
On the other side of the coin, pain can, and frequently does, occur in the absence of tissue damage. Mr. Hammerhead experienced more pain with a bang to his knee that resulted in no damage. In many instances, pain occurs without any signalling from the tissues at all. We'll examine how in upcoming posts.
Friday, March 21, 2008
Sicko
I finally watched Michael Moore's documentary Sicko last night. Although it would be wise to recognize the one-sided nature of Moore's depiction of the health care crisis in America, it is hard to argue with him on many of the issues raised in this film. Unless, of course, you were the beneficiary of greased palms from those seemingly interested in anything but your health.
For me and my wife Lori, the issue certainly hit home. After weathering a severe health care storm in our own family, we cannot imagine the added burden of dealing with a bureaucratic nightmare hellbent on protecting precious profits. We are extremely fortunate that our health care system and the support of family, friends, and even strangers, enabled us to focus solely on getting our daughter well. Without that support system a completely unforeseen illness would have left us bankrupt in more ways than one.
Our journey through Maryn's illness brought us into contact with many families experiencing similar trauma. The stories that reached us from the U.S. left us very grateful our daughter's life was not left hanging by a thread while we waited for insurance approval. I'm pretty sure her treatment didn't come cheap. Which, of course, raises another issue...
As Canadians, we greatly value universal health care. We also recognize, however, that it is huge economic burden and one that is showing no signs of abating. There are no simple answers to resolving this issue, but we all should consider how to preserve those things worth fighting for.
For me and my wife Lori, the issue certainly hit home. After weathering a severe health care storm in our own family, we cannot imagine the added burden of dealing with a bureaucratic nightmare hellbent on protecting precious profits. We are extremely fortunate that our health care system and the support of family, friends, and even strangers, enabled us to focus solely on getting our daughter well. Without that support system a completely unforeseen illness would have left us bankrupt in more ways than one.
Our journey through Maryn's illness brought us into contact with many families experiencing similar trauma. The stories that reached us from the U.S. left us very grateful our daughter's life was not left hanging by a thread while we waited for insurance approval. I'm pretty sure her treatment didn't come cheap. Which, of course, raises another issue...
As Canadians, we greatly value universal health care. We also recognize, however, that it is huge economic burden and one that is showing no signs of abating. There are no simple answers to resolving this issue, but we all should consider how to preserve those things worth fighting for.
Saturday, March 15, 2008
The Pain Experience
Wow. Keeping up with a blog is much harder thean I could have ever imagined. It's becoming a painful experience itself. Time to revisit the overview of pain science and clinical application I wrote about a few weeks ago.
Today, we'll review number 1 of the Ten Steps to Understanding Manual and Movement Therapies for Pain. Much credit for this summary belongs to Luke Rickards, an Australian osteopath and researcher, and many of the other moderators at SomaSimple, a site dedicated to the application of scientific principles to the treatment of pain.
"1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus."
Most people think of pain as a sensation - sensory input coming from a particular body part signalling that something is wrong. We are "hard-wired" to respond to danger signals in order to protect ourselves. That is why we have a pain system. However, pain is much more than sensory input being transmitted along a single pathway. Modern pain science describes pain more as an output generated by the brain, rather than an input from the body. It is always a bit hard to wrap your mind around something that seems to contradict your immediate experience. Then again, that is what science is for, right?
I think pain is most accurately understood as an experience, an experience comprised of sensation, but also the way one interprets and responds to that sensory information. It is easy to fall into the trap of linear or even circular thinking here, but understanding the importance of processing and behavior is essential to moving beyond pain. Understanding pain accurately helps reduce sensitivity and facilitates adaptive motor responses.
In Pain: The Science of Suffering, Patick Wall, asked the question: "What are the appropriate motor responses to the arrival of pain and injury signals?" In other words, "what movement do I need to do to feel better?" To me, this is, or ought to be, the central question of physiotherapy. Contrary to those who insist we treat biomechanics or function not pain, patients generally seek our care because they hurt and want to feel better. Understanding pain is the central issue for both therapist and patient. As we explore its meaning, we will begin to see how the right kind of movement can set us free.
Today, we'll review number 1 of the Ten Steps to Understanding Manual and Movement Therapies for Pain. Much credit for this summary belongs to Luke Rickards, an Australian osteopath and researcher, and many of the other moderators at SomaSimple, a site dedicated to the application of scientific principles to the treatment of pain.
"1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus."
Most people think of pain as a sensation - sensory input coming from a particular body part signalling that something is wrong. We are "hard-wired" to respond to danger signals in order to protect ourselves. That is why we have a pain system. However, pain is much more than sensory input being transmitted along a single pathway. Modern pain science describes pain more as an output generated by the brain, rather than an input from the body. It is always a bit hard to wrap your mind around something that seems to contradict your immediate experience. Then again, that is what science is for, right?
I think pain is most accurately understood as an experience, an experience comprised of sensation, but also the way one interprets and responds to that sensory information. It is easy to fall into the trap of linear or even circular thinking here, but understanding the importance of processing and behavior is essential to moving beyond pain. Understanding pain accurately helps reduce sensitivity and facilitates adaptive motor responses.
In Pain: The Science of Suffering, Patick Wall, asked the question: "What are the appropriate motor responses to the arrival of pain and injury signals?" In other words, "what movement do I need to do to feel better?" To me, this is, or ought to be, the central question of physiotherapy. Contrary to those who insist we treat biomechanics or function not pain, patients generally seek our care because they hurt and want to feel better. Understanding pain is the central issue for both therapist and patient. As we explore its meaning, we will begin to see how the right kind of movement can set us free.
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