Some Common Delusions of Physical Therapists

Orientation of vertebrae
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I would like to give a nod to Barrett Dorko and his article: The Matrix and Me, where he lists some common illusions of therapists (I assume physical therapists). Dorko is provocative writer and I recommend taking a look at his work.

From his article:

Traditional Therapeutic Illusions

In my experience most therapists (this occasionally includes me) practice clinically as if certain things were true despite the fact that researchers have learned that they are not. Here’s a short list of what I call “therapeutic illusions”:

Strength and posture are related

Pain and posture are commonly related

Strength and pain are related

You can stretch connective tissue with your hands

You can reliably palpate vertebral joint movement”

I have no idea what “palpate verbal joint movement” means nor do I think about “connective tissue” when I work. But I agree with Dorko on the first two illusions . Do you agree that the beliefs above are illusions?

Are pain symptoms and posture unrelated?
Are strength and pain unrelated?
Are they completely unrelated or just occasionally unrelated?
Or occasionally related?

I believe what Dorko is talking about above is the medical model idea that pain is the result of dysfunction or structural problems in the spine, nerves, joints or elsewhere. That is, if a person has chronic back pain, there MUST be a pinched nerve, degenerated disk, herniated disks (etc.) that is causing the pain. This type of thinking can lead to drastic interventions such as invasive surgery to “fix” the spine. But is the thinking correct and does the research bear this out? (I believe the answer is “No.” But it has been several years since I have read research in that area.)

Does your own experience as a Feldenkrais practitioner match what Dorko is saying?

Let me know your thoughts.

(A special thanks to Robbie Ofir for mentioning Dorko on the FeldyForum several months ago. I learned about him there. Dorko has some interesting essays that are well worth a read: Dorko’s Desk. )

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8 thoughts on “Some Common Delusions of Physical Therapists

  1. Geoffrey Coe

    First off – have a look at a dictionary. Are PTs –delusions are not the same as illusions. So what are we – a profession with a mental health disorder or in need of reality testing? Make up your mind – there is a difference

    Second Feldenkrais practioners have this a long held pastime of and it goes back to the guru himself: PT bashing. In the training I attended a large number of us were PTs. For the first three years of the training we listened to a diatribe of how hopeless PT is, how goal oriented we were, short sighted, involved in quick fixes, didn’t understand how the brain works. Everything from being totally incompetent to servants of the antichrist. In the final year of the training however, a lot of us had bought into this and then there was this massive effort to dress us up as competent practitioners again. The strategy is clear. You have to define yourselves as Feldenkrais practitioners separating yourselves from the heathen. However the effect is that you are locked into an unproductive exercise in forever marginalising yourselves.

    Third: these illusions. physical therapy is a science-based and doesn’t operate from a set of dogmatic principles as outlined. We as practitioners do not hold to these “illusions” as beliefs. We look to evidence in the scientific literature. Take an example:

    Strength and posture are related. Well the evidence is that there is a positive relationship in some studies and not in others. So one has to think of the context that you are applying this dogma to. Posture is a multifactorial entity and looking at one body function such as strength is not going to give you the whole story. So therefore as a profession you will not find PTs whole-heartedly believe or disbelieve such principles

    Rather than going through these “illusions” of whether your readers believe or disbelieve these “illusions” I challenge you to provide sound evidence for or against these statements. That is how PTs make a decisions.

  2. Ryan Nagy

    Geoffrey – Most of your comment is nothing more than mind reading and the making over generalized claims based on no data. You know nothing I of what I am thinking nor why. And what relationship it might have to your experiences of 20 years ago is mindless speculation. You have given me a very clear idea of how YOU make decisions. You simply create a story that fits your particular emotional and intellectual needs.

    As far as evidence, if you are a science-based practitioner, as you suggest, why can you not quote your own evidence against what I am saying? Would that get in the way of your story telling?

    Here are a few research articles to get you going.

    http://content.nejm.org/cgi/content/short/361/6/557
    Trying to correct a structural problem (i.e. pain and posture are related) by “fixing” the vertabra via surgery has been shown to be no more effective than a “sham” treatment.

    http://content.nejm.org/cgi/content/abstract/347/2/81
    “In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure.”

    I could grab another 6 or online rather quickly. But it might be simpler and easier to do it yourself.

    Unless, of course, you are not looking to disconfirm what you already believe?

    1. Ryan Nagy

      Geoffrey – I need to amend my comment above. You wrote:

      “Feldenkrais practitioners are not educated in reading the literature. – it isn’t part of the education.”

      In retrospect, you are correct. The method seems to attract many PT, PhD’s etc, but the current educational model does not include training in reading scientific or medical literature. I’m not 100% certain that it is a limitation in learning to DO the work, but it may be a limitation in the overall ability of some to generalize their skills and improve their knowledge and understanding.

      Moshe Feldenkrais was a scientist who had a great deal of research experience. He was capable of using research and philosophical literature from a variety of fields. In my estimation few of his students do that now – even some who like to call themselves “trainers.” I had an online conversation recently, in which a feldenkrais trainer, who calls himself a “PhD” essentially resorted to ad hominen attacks against me as a person (questioning my motivations, intelligence etc.) simply because he did not have a leg to stand on, and know nothing about research design, statistics or – it appears – common sense.

      Thanks for your comments – Ryan

  3. Geoffrey Coe

    Well that did touch a nerve didn’t it.

    You are quite right. I didn’t provide any references to back up my comments. However I am not making the claim about physical therapists suffering from illusions. You are by quoting this material. It is incumbent on you to come up the evidence to make these sweeping generalisations about these statements.

    My “mind reading” is actually an observation I made over a number of years: many Feldenkrais practitioners feel compelled to justify their approach by endlessly slagging off at other professionals. This is a common behaviour that much of the leadership in the Feldenkrais community partake in and something that the great leader himself liked to rant on about, so I think that it is behaviour that was modelled by him. I put it to you that much of the Feldenkrais community is on the whole hostile to physical therapists and that this listing of these “therapeutic illusions” is just another example of that hostility.

    You wanted me to comment on the studies you quoted. Both studies you quote are about orthopaedic surgery. Physical therapists don’t perform orthopaedic surgery. So the studies are a bit irrelevant if you are trying to make a case for physical therapists “illusions”.

    The first study you quote is about a vertebral a pathological fracture. What the study tells you is that the vertebroplasty used in the study failed to work better than a placebo. However you can’t generalise the study to other structural problems and create some dogma that ALL surgery to correct ANY structural problem is doomed to failure. If this study is a of adequate quality I don’t know or if it is or not, is adequately powered and has been replicated in other centres then it informs orthopaedic surgeons not to offer the treatment but look for a better solution.

    I could make exactly the same comment about the other study.

    Physical therapy is amongst other things an applied science. As a consumer of the scientific literature that relates to physical therapy I know how to appraise a study or a systematic review and to decide whether to use it to inform my practice.

    you wanted an example – ok:

    http://www.amjphysmedrehab.com/pt/re/ajpmr/home.htm

    This randomised controlled study was for a group of people living with Ankylosing spondylitis. The experimental group received specific strengthening and stretching exercises and this report is a long term follow-up. The study is of adequate quality to consider the findings in that the assessors and participants were blinded, used valid and reliable measurements, and there was baseline comparability. There was an adequate follow-up. Not perfect though by any means: no intention-to-treat analysis and a rather small group of participants.

    The results clearly indicate the benefits of the programme. Next time I see a patient with A/S who appears at risk of developing posture (or already has the posture) that is likely to be detrimental would definitely offer such a programme. In this case this is a good example of where strengthening improves both structure and function.

    Would I offer it the programme to another condition eg someone with benign chronic back pain – no!. Would I generalise this to a statement such as strength and posture are related? With some caution maybe. But I would want to see such a relationship established across a wide variety of conditions.

    Feldenkrais practitioners are not educated in reading the literature. – it isn’t part of the education. In contrast PTs are educated. Evidence-based practice in integral to a modern physical therapist’s training.

    Is it a problem that Feldenkrais Practitioners are not trained in science? Well it depends what you want to achieve and what you are claiming to do. But then making gross generalisations to prop up your dogmas such as “Strength and posture are not related” Well people who live in glass houses shouldn’t throw stones.

    1. Ryan Nagy

      Likewise! And to be fair, Feldenkrais Pracs, like any other group have their own illusions. I just need to find a way to write them up without being shot…

      cheers – Ryan

    2. Ryan Nagy

      Geoffrey – Your reply is not much different from your last one. You offer one or two anecdotes, much like I did. I’m certainly not going to do a full literature review – are you?

      The difference between my post and your response is that you are making it – and taking it – personally. I put some topics up for consideration. You seem to be so intimidated by the idea of discussion that you have to attack something that is not even there.

      Is it really true that “Feldenkrais practitioners feel compelled to justify their approach.”? Perhaps. Or they may simply be expressing real differences in orientation and belief.

      Likewise, this comment: “Feldenkrais community is on the whole hostile to physical therapists.” Is that true or is it simply your opinion? There may be a certain hostility – by some – to the practice of physical therapy, to the theories (or lack there of) of certain practices but that cant’ be generalized to an entire community. And the points are about certain practices in physical therapy, not physical therapists themselves. There are many PT’s who maintain active Feldenkrais practices, including several trainers who were, at one point PT’s. I would hope that they are not hostile to themselves or to PT’s in general, but I suppose you would have to ask them to find out.

      You wrote: “Both studies you quote are about orthopaedic surgery. Physical therapists don’t perform orthopaedic surgery. So the studies are a bit irrelevant if you are trying to make a case for physical therapists “illusions.”

      Thanks for pointing that out. I can only agree. However, the larger frame of reference is the medical model and medical training itself. Or perhaps better said, simplistic causal thinking, that has infected many disciplines including the social sciences.

      “However you can’t generalise the study to other structural problems and create some dogma that ALL surgery to correct ANY structural problem is doomed to failure.”
      Your right. Logically I cannot do that. The real question is where did you come up with the idea that I was? And why would you try to force that type of interpretation on the original post?

      “Physical therapy is amongst other things an applied science. As a consumer of the scientific literature that relates to physical therapy I know how to appraise a study or a systematic review and to decide whether to use it to inform my practice.”
      That may be true. However, I have seen no indication of that based on what you have written here.

      “Feldenkrais practitioners are not educated in reading the literature. – it isn’t part of the education. In contrast PTs are educated. Evidence-based practice in integral to a modern physical therapist’s training.Is it a problem that Feldenkrais Practitioners are not trained in science? Well it depends what you want to achieve and what you are claiming to do. But then making gross generalisations to prop up your dogmas such as “Strength and posture are not related” Well people who live in glass houses shouldn’t throw stones.”

      I have a Master’s in research psychology, nearly 10 years of lab experience, I have created and taught Research Methods classes and have done work towards a PhD. There are dozens of PhD’s and medical doctors and active researchers and research programs in the Feldenkrais community.

      But again – you and I are not really having a conversation, are we?I put up a post asking for feedback and discussion and you start talking about “dogma” and “gross generalizations”…? What exactly is it you are defending yourself against? It’s certainly not anything that I wrote in the original post.

  4. Ryan Nagy

    oops – I just noticed that my browser only showed me the first few lines of your comments. I will take a deeper read and reply later. I appreciate the feedback. – Ryan

  5. Jerry Larson

    To “palpate vertebral joint movement”-NOT “verbal joint movement”!–
    I’m not a PT, but palpate means to touch and feel, like a bone or a muscle.
    For instance, you can palpate your own or someone else’s hyoid bone, just the end of it, on the lateral side of the neck. You normally wouldn’t feel it or know about it, but if you know where you’re looking, you can feel, press in it a little bit perhaps, and find it by touch. (Careful, it’s kind of tender). Or you can palpate the radial artery in the wrist, i.e. feel the pulse there, and you can palpate arteries in various places, like the brachial artery in the antecubital fossa.

    So “palpating vertebral joint movement” means touching someone’s vertebrae and being able to feel active or passive movement between two vertebrae.
    There’s a joint (actually more than one joint) between each two vertebrae.
    Now, I would think that the only part of a vertebra that you can really palpate is the spinous process, the part that sticks up in the back.

    You could try to do this either actively or passively. For instance, let’s take C6 and C7. If you put a finger on C6 and another on C7, and have the person flex and extend their neck, you can feel the movement, right? You can feel the tips of the spinous processes getting closer together and further apart. No question about it. How about actively? Say you have the person lying supine, and you put one finger under the neck touching C7, or T1 maybe, so you can feel whether it moves or not, and you rotate the head very slightly, can you feel the movement of C6 on C7, or C7 on T1? I don’t know. Maybe. The things you’re touching, the tips of the spinous processes, aren’t directly connected, but each one is part of a vertebra, and there joints are between the other parts of the vertebrae. So you might be able to feel that, but it wouldn’t be terribly easy; and if you’re talking about lumbar or thoracic vertebrae, or the high cervical vertebra that you can’t actually palpate at all, it’s probably impossible.
    So I wouldn’t be surprised to find out that PT’s or other somatic practitioners THINK they can palpate that, but in general they can’t. If so, then that would be an illusion, QED.

    Ryan,

    Accuse me of “mind reading” if you want, but I just want to say that in my training, there were a number of PT’s, and several of them did tell me that they felt they were being dissed, or bashed, or whatever, and I could see what they were talking about; the trainers did frequently make disparaging remarks about physical therapy, and also about medicine. We even had a visiting instructor one time who was a prominent Feldenkraiser AND a prominent PhD PT, and he complained about hearing his profession bashed all the time in the Feldenkrais world. I certainly heard myself, in the training, at the Guild conference, and on the Feldigest (precursor of the FeldyForum), much bashing of other somatic professions such as bodyworkers, and also much bashing of medicine, the scientific method, and science in general.
    It did seem, btw, that the PT’s had the worst hands in our training, but hopefully they learned, and grew out of that; and they certainly do have a lot of knowledge that many prax don’t.

    Now, I understand that there is plenty of room for valid criticism of Western scientific medicine, in particular of the reductionist approach many people have, and a kind of linear, mechanistic causality; and I understand that people go into alternative fields like Feldenkrais work because they’re dissatisfied with Western medicine. However, what I observed goes beyond that.
    I mean, I like Feldenkrais people. They’re smart, good-looking, interesting, committed, etc. But the Feldenkrais community is just nuts on the subject of its relations with other professions, with the scientific consensus, etc.
    You’re not allowed to compare Feldenkrais work to anything, and it seems like no one can say anything right if they’re not a Feldenkrais trainer.
    I think this has a lot to do with Moshe’s ego problems; in the process of deifying him, his acolytes have enshrined them.

    For instance, Moshe didn’t like the idea of diagnosis, and I can certainly see his point. Diagnoses can be wrong, and for what Feldenkraisers are doing, it’s better not to have a prejudicial idea of what someone can do, so it may well be better at times to ignore, or not even know about, the diagnosis.
    On the other hand, for most things in medicine, it totally makes sense to make a diagnosis on base your treatment on that. It would be crazy not to.
    Say someone has a fractured cervical vertebra with pseudoarthrosis (movement where there should be none!)– that personally probably needs surgery in order not to become paralyzed, and you have to figure out what that problem is before you go in and do surgery on it. Or if you have a spinal cord tumor, again, you need to know the mass is there so you can decide how to treat it. It’s just like fixing a leak in the plumbing, or fixing your car; figure out what the problem is so you can decide how best to fix it. People aren’t machines, and that kind of approach has its limitations, but it’s also enormously useful, and grounded in common sense. It might not be useful in Feldenkrais work, but there is no need to make an ideological issue out of it, or think people are stupid, misguided or evil, or insult them, just because they rely on the concept of diagnosis and treatment.

    The Feldenkrais Method can be, and needs to be, compatible with everything else we know, and everything we know how to do, not be the adversary of other professions.

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