THIS IS AN EDITORIAL THAT I WROTE FOR THE JOURNAL OF BODYWORK & MOVEMENT THERAPIES, IN MAY 2014... ANY COMMENTS WOULD BE WELCOME AS THE TOPIC IS UNIVERSAL IN MANUAL THERAPIES....AND NEEDS ADDRESSING: Editorial Can we describe what we do? BY Leon Chaitow, ND DO (Editor-in-Chief) In an editorial in the Fascia Science & Clinical Applications Section of this journal, in Volume 17, Issue 1, Paul Standley PhD, writing as a research scientist, asked for greater clarity in the way manual methods of treatment are described ( Standley, 2013). He observed that most manual methods involve combinations of stretch, compression, shear and torque forces, and that: “despite being called different names, many of these techniques used around the world really create the same (or nearly the same) effects on tissues and cells.” He continued: “Practitioners of manual medicine techniques currently use individualized glossaries of maneuvers that ultimately may describe similar or identical treatment modalities. To enhance the construction of an evidence base to describe clinical efficacy our goal should be the establishment of a unified set of terms.” [SEE IMAGE OF STANDLEYS ROSETTA STONE OF MANUAL THERAPIES THAT ACCOMPANIED HIS PLEA FOR GREATER CLARITY REGARDING WHAT WE ACTUALLY DO CLINICALLY] It should be noted that Dr Standleys plea for accurate descriptions was not based on idle curiosity. In a number of studies he and his colleagues have attempted to model manual methods such as Counterstrain and Myofascial Release, in laboratory conditions, in order to evaluate possible cellular responses to alterations of load (Meltzer and Standley, 2007, Meltzer et al., 2010, Standley and Meltzer, 2008). And quite obviously, in order to replicate in laboratory conditions, what happens clinically – accurate descriptions of what is being modelled is essential. Is this possible – or is this a request too far? [NOTE:THE ACCOMPANYING IMAGE OF STRAINED AND UNSTRAINED FIBROBLAST CELLS IS FROM STANDLEY & MELTZERS S RESEARCH - SHOWING THE EFFECTS ON THESE CELLS VARIOUSLY OF 8 HOURS OF REPETITIVE STRAIN AND 90 SECONDS OF MIMICKED COUNTERSTRAIN ......SEE THE 2008 CITATION BELOW] Variables It should be noted that apart from “stretch, compression, shear and torque” (and shouldnt ‘bending’ be another form of load?) a huge variety of variables accompany manual and instrument assisted load-applications, and that descriptions required to meet Dr. Standleys request for accuracy and clarity, would need to include information as to what tissues were being addressed, as well as the degree of surface contact – together with: • The degree and direction(s) of force application? • Whether force was direct (engaging resistance barriers, as in Muscle Energy Technique), or Indirect (disengaging as in Counterstrain)? • The velocity of load application? • The amplitude (range) of load application? • Whether load application was sustained, gliding, rhythmic or variable? • The length of time that was involved? • Whether the forces were generated manually (and if so whether this was by means of hand, thumb, elbow or other contact), or mechanically (and is so what type)? • How many repetitions were involved, and at what intervals? • Information as to temperature variables? •Whether the therapeutic objectives were to tone, modify circulation, lengthen, stimulate, sedate, mobilise, or other (possibly reflexive) effects? It seems therefore that detail of a single manual method might need to incorporate a dozen or more descriptors. And since, in many manual treatment settings a range of methods are involved in a single session – precise replication, based on such descriptions, would at times be extremely difficult, if not impossible, to realise. And that is even if accuracy could be achieved in the actual descriptions offered? Example A random search of a recent (April 2014) issue of Manual Therapy offers a typical example of the Sisyphean task that Dr. Standley has requested. Saban et al. (2014) report on a study involving combinations of ‘deep’ massage and neural mobilization (involving different forms of self-stretching), in treatment of heel pain. Consider these extracts of descriptions of the therapeutic interventions following identification of relevant areas requiring attention: “Deep massage therapy consisted of 10 minutes of forceful soft tissue massage mobilization techniques, described by Cyriax (1984), directed to the incompliant and painful areas of the posterior calf muscle group. The technique was applied across the muscle fibers both medially and laterally, with sufficient sweep and depth ( Cyriax, 1984) until obtaining a pain response to the pressure. The therapist could choose to work with thumbs or other body parts i.e. elbow to enable sufficient force top reach deeper muscle areas.” (Saban et al 2014) In addition protocols were described for several self-stretching methods – all of which contained the potential for variability in load application – despite clear guidelines. The request by Dr. Standley, for precise descriptors, so that manual approaches might be replicated in laboratory settings, can be seen to require far more detail than is offered in the protocol. For example: • “Deep massage therapy”: How deep? How rapid? How forceful? • “Applied across the muscle fibers both medially and laterally, with sufficient sweep and depth”: How many times? In what sequence? At what speed and rate? And how is ‘sufficient’ determined? NOTE: It should be clear that there is no suggestion in these comments that the protocols used in the reported study were anything other than appropriate. The issue lies not in the clinical methods, but in their inherent variability – moment-to-moment, case-to-case – partly controlled by the therapist, and partly influenced by the tissues being addressed. Also please note that this particular study was chosen at random – similar observations could be made relative to many studies published, in almost any major journal reporting on manual and movement therapies (massage, physiotherapy, osteopathy, chiropractic and others). Standley requested a virtual “Rosetta stone” of manual therapeutic methodology. This might not be an impossible task, but it would certainly require focused attention from many for a considerable time. Are we prepared for such a task? References J. Cyriax Textbook of Orthopedic Medicine (eleventh ed.), vol. 2 Balliere Tindall, London (1984), pp. p9–10 K.R. Meltzer, P.R. Standley Modeled repetitive motion strain indirect osteopathic manipulative techniques regulation human fibroblast proliferation interleukin secretion J. Am. Osteopath. Assoc., 107 (12) (2007), pp. 527–536 K.R. Meltzer, T.V. Cao, J.F. Schad, et al. In vitro modeling of repetitive motion injury and myofascial release J. Bodyw. Mov. Ther, 14 (2) (2010), pp. 162–171 B. Saban, D. Deutscher, T. Ziv Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: a pilot randomized clinical trial Man. Ther., 19 (2014), pp. 102–108 P. Standley My personal journey that led to the crossroads of interdisciplinary manual medicine research: serendipitous opportunities afforded a basic scientist J. Bodyw. Mov. Ther., 17 (2013), pp. 79–82 P.R. Standley, K. Meltzer In vitro modeling of repetitive motion strain and manual medicine treatments: potential roles for pro- and anti-inflammatory cytokines J. Bodyw. Mov. Ther., 12 (3) (2008 Jul), pp. 201–203 FOR MORE ON JBMT GO TO: leonchaitow/journal-jbmt/
Posted on: Thu, 23 Oct 2014 06:45:54 +0000
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