Stikkordarkiv: diagnostisk spesifisitet

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Svært interessant og bra skrevet blogg innlegg.

http://thesportsphysio.wordpress.com/2014/06/16/there-is-no-skill-in-manual-therapy-2/

For example, I learnt you can’t break down scar tissue, ‘release’ a muscle or a fascial adhesion (Chaudhry 2008, Chaudhry 2007, Schleip 2003, Threlkeld 1992)

I learnt that by stretching a muscle in a certain fashion, in a certain way, for a certain amount of time doesnt effect it’s structure (Solomonow 2007, Weppler 2010, Katalinic 2011)

I learnt that you don’t need to mobilise or manipulate a joint in a specific direction, based on a specific assessment of pain and joint feel (Chiradejnant 2003, Aquino 2009, Schomacher 2009, Nyberg 2013)

I learnt that palpation of muscles, joints, trigger points are all unreliable and can lead to questionable diagnosis that often direct treatment down wrong and ineffective pathways, I have done a blog on this particular topic recently with all the supporting evidence here.

I leant that when all the methods and techniques of manual therapy are examined through the process of systematic reviews and meta analysis most of the research is poor and even the good research shows that it doesn’t do much (Menke 2014,Kumar 2014, Artus 2010, Kent 2005)

 

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The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects

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Nevner at kontekst og pasientens forventning om behandling har alt så si for effekten av behandling. Denne studien gjelder manipulering av ryggraden, men kan forventes å gjelde absolutt all behandling som gjøre på menneskekroppen hvor man tar på huden.

http://www.biomedcentral.com/1471-2474/9/19

The current study replicates prior findings of c- fiber mediated hypoalgesia in the lower extremity following SMT and this occurred regardless of expectation. A significant increase in pain perception occurred following SMT in the low back of participants receiving negative expectation suggesting a potential influence of expectation on SMT induced hypoalgesia in the body area to which the expectation is directed.

A growing body of evidence supports spinal manipulative therapy (SMT) as an effective treatment for low back pain [1–6]. Furthermore, the evidence is particularly strong when patients are classified into subgroups by patterns suggesting the likelihood of a favorable response [2,3,6]. Despite the positive findings of clinical trials, the mechanisms through which SMT acts are not established.

Hypoalgesia has been associated with SMT and has a postulated involvement in the clinical effectiveness [7–16]. For example, Vicenzino et al [14] observed greater pain free grip and pain pressure threshold in the forearm following SMT to the cervical spine. A prior study by our group found hypoalgesia of c- fiber mediated pain as measured by lessening of temporal summation in the lower extremity following SMT to the lumbar spine [7]. Temporal summation results from multiple painful stimuli of the same intensity applied at a frequency of less than 3 seconds and has been observed in both healthy subjects [17–19] and those experiencing chronic pain [20,21]. Activation of the dorsal horn of the spinal cord has been directly observed with temporal summation in animal studies [22–25]. Subsequently, we interpreted our prior findings of hypoalgesia of temporal summation following SMT in healthy participants as indicative of a pain inhibiting effect occurring at the dorsal horn.

A criticism of prior studies of SMT is a lack of consideration for the influence of non- specific effects such as placebo and expectation [26–28]. The failure to account for non- specific effects may be significant as expectation has demonstrated a robust influence in the general pain literature [29–40]. Specific to manual therapy, Kalauokalani et al [39] report on a secondary analysis of subjects with low back pain who were randomly assigned to receive either acupuncture or massage treatments. Subjects with higher expectations for the effectiveness of their assigned treatments demonstrated greater improvement in function. In our prior study, we attributed hypoalgesia of c- fiber mediated pain in response to SMT to a local spinal cord effect. However, a limitation of our prior study was the failure to account for the potential influence of non- specific effects. Therefore, the purpose of this study was to determine how subjects’ expectation about the effect of SMT would influence hypoalgesia. Similar to prior studies [7–15], we expected a hypoalgesic effect in response to SMT, however we hypothesized this effect would be greater in subjects receiving positive expectation regarding the SMT procedure as compared to those receiving neutral or negative expectation.

Effect of Instructional Set on Expected Pain in the Low Back. Change in expected pain in the low back following instructional set. Positive values indicate expectation of less pain. A statistical interaction occurred with participants receiving a positive expectation instructional set reporting expectations for less pain with quantitative sensory testing (QST) following spinal manipulative therapy (SMT) and those receiving a negative expectation instructional set reporting expectations for greater pain. Error bars represent 1 standard error of the mean (SEM). * indicates significant change at p ≤ 0.05.

Change in Pain Perception in the Low Back and Lower Extremity by Expectation Instructional Set. Change in pain perception in the low back and lower extremity following spinal manipulative therapy (SMT). Positive numbers indicate hypoalgesia, while negative numbers indicate hyperalgesia. A significant interaction was present in the low back suggesting that post SMT pain perception was dependent upon the group to which the participant was randomly assigned. Follow up pairwise comparison indicated a significant increase in pain perception in subjects receiving a negative expectation instructional set. No interaction was observed in the lower extremity of participants; however, a significant main effect occurred suggesting hypoalgesia regardless of group assignment. Error bars represent 1 standard error of the mean (SEM). * indicates a statistically significant change in pain perception in the low back following SMT at p ≤ 0.05.

This study provides preliminary evidence for the influence of a non- specific effect (expectation) on the hypoalgesia associated with a single session of SMT in normal subjects. We replicated our previous findings of hypoalgesia in the lower extremity associated with SMT to the low back. Additionally, the resultant hypoalgesia in the lower extremity was independent of an expectation instructional set directed at the low back. Conversely, participants receiving a negative expectation instructional set demonstrated hyperalgesia in the low back following SMT which was not observed in those receiving a positive or neutral instructional set.

 

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The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model

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Nevner det meste rundt behandling av muskel og skjelett problemer, både usikkerheter, manglende diagnostisk spesifisitet, dårlig forhold mellom forklaringsmodelle og realitet, og foreslår nevrosentriske forklaringsmodeller. Viser til at spesifikk behandling ikke har bedre effekt enn uspesifikk behandling. Og til at den mekaniske teknikken setter igang en kaskade av nevrologiske effekter som resulterer i en behandlingeffekt.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/

Abstract

Prior studies suggest manual therapy (MT) as effective in the treatment of musculoskeletal pain; however, the mechanisms through which MT exerts its effects are not established. In this paper we present a comprehensive model to direct future studies in MT. This model provides visualization of potential individual mechanisms of MT that the current literature suggests as pertinent and provides a framework for the consideration of the potential interaction between these individual mechanisms. Specifically, this model suggests that a mechanical force from MT initiates a cascade of neurophysiological responses from the peripheral and central nervous system which are then responsible for the clinical outcomes. This model provides clear direction so that future studies may provide appropriate methodology to account for multiple potential pertinent mechanisms.

Mechanical Stimulus 

First, only transient biomechanical effects are supported by studies which quantify motion (Colloca et al., 2006;Gal et al., 1997;Coppieters & Butler, 2007;Coppieters & Alshami, 2007) but not a lasting positional change (Tullberg et al., 1998;Hsieh et al., 2002). Second, biomechanical assessment is not reliable. Palpation for position and movement faults has demonstrated poor reliability (Seffinger et al., 2004;Troyanovich et al., 1998) suggesting an inability to accurately determine a specific area requiring MT.  Third, MT techniques lack precision as nerve biased techniques are not specific to a single nerve (Kleinrensink et al., 2000) and joint biased technique forces are dissipated over a large area (Herzog et al., 2001;Ross et al., 2004).

Finally, studies have reported improvements in signs and symptoms away from the site of application such as treating cervical pain with MT directed to the thoracic spine (Cleland et al., 2005;Cleland et al., 2007) and lateral epicondylitis with MT directed to the cervical spine (Vicenzino et al., 1996).

Subsequently, we suggest, that as illustrated by the model, a mechanical force is necessary to initiate a chain of neurophysiological responses which produce the outcomes associated with MT. 

Neurophysiological Mechanism 

Studies have measured associated responses of hypoalgesia and sympathetic activity following MT to suggest a mechanism of action mediated by the periaquaductal gray (Wright, 1995) and lessening of temporal summation following MT to suggest a mechanism mediated by the dorsal horn of the spinal cord (George et al., 2006) The model makes use of directly measurable associated responses to imply specific neurophysiological mechanisms when direct observations are not possible. The model categorizes neurophysiological mechanisms as those likely originating from a peripheral mechanism, spinal cord mechanisms, and/or supraspinal mechanisms.

Peripheral mechanism 

Musculoskeletal injuries induce an inflammatory response in the periphery which initiates the healing process and influences pain processing. Inflammatory mediators and peripheral nociceptors interact in response to injury and MT may directly affect this process. For example, (Teodorczyk-Injeyan et al., 2006) observed a significant reduction of blood and serum level cytokines in individuals receiving joint biased MT which was not observed in those receiving sham MT or in a control group. Additionally, changes of blood levels of β-endorphin, anandamide, N-palmitoylethanolamide, serotonin, (Degenhardt et al., 2007) and endogenous cannabinoids (McPartland et al., 2005) have been observed following MT. Finally, soft tissue biased MT has been shown to alter acute inflammation in response to exercise (Smith et al., 1994) and substance P levels in individuals with fibromyalgia (Field et al., 2002). Collectively, these studies suggest a potential mechanism of action of MT on musculoskeletal pain mediated by the peripheral nervous system for which mechanistic studies may wish to account. 

Spinal mechanisms 

MT may exert an effect on the spinal cord. For example, MT has been suggested to act as a counter irritant to modulate pain (Boal & Gillette, 2004) and joint biased MT is speculated to “bombard the central nervous system with sensory input from the muscle proprioceptors (Pickar & Wheeler, 2001).”Subsequently, a spinal cord mediated mechanism of MT must be considered and is accounted for in the model. Direct evidence for such an effect comes from a study (Malisza et al., 2003b) in which joint biased MT was applied to the lower extremity of rats following capsaicin injection. A spinal cord response was quantified by functional MRI during light touch to the hind paw. A trend was noted towards decreased activation of the dorsal horn of the spinal cord following the MT. The model uses associated neuromuscular responses following MT to provide indirect evidence for a spinal cord mediated mechanism. For example, MT is associated with hypoalgesia (George et al., 2006;Mohammadian et al., 2004;Vicenzino et al., 2001), afferent discharge (Colloca et al., 2000;Colloca et al., 2003), motoneuron pool activity (Bulbulian et al., 2002;Dishman & Burke, 2003), and changes in muscle activity (Herzog et al., 1999;Symons et al., 2000) all of which may indirectly implicate a spinal cord mediated effect.

Supraspinal mechanisms 

Finally, the pain literature suggests the influence of specific supraspinal structures in response to pain. Structures such as the anterior cingular cortex (ACC), amygdala, periaqueductal gray (PAG), and rostral ventromedial medulla (RVM) are considered instrumental in the pain experience.(Peyron et al., 2000;Vogt et al., 1996;Derbyshire et al., 1997;Iadarola et al., 1998;Hsieh et al., 1995;Oshiro et al., 2007;Moulton et al., 2005;Staud et al., 2007;Bee & Dickenson, 2007;Guo et al., 2006). Subsequently, the model considers potential supraspinal mechanisms of MT. Direct support for a supraspinal mechanism of action of MT comes from (Malisza et al., 2003a) who applied joint biased MT to the lower extremity of rats following capsaicin injection. Functional MRI of the supraspinal region quantified the response of the hind paw to light touch following the injection. A trend was noted towards decreased activation of the supraspinal regions responsible for central pain processing. The model accounts for direct measures of supraspinal activity along with associated responses such as autonomic responses (Moulson & Watson, 2006;Sterling et al., 2001;Vicenzino et al., 1998) (Delaney et al., 2002;Zhang et al., 2006), and opiod responses (Vernon et al., 1986) (Kaada & Torsteinbo, 1989) to indirectly imply a supraspinal mechanism. Additionally, variables such as placebo, expectation, and psychosocial factors may be pertinent in the mechanisms of MT (Ernst, 2000;Kaptchuk, 2002). For example expectation for the effectiveness of MT is associated with functional outcomes (Kalauokalani et al., 2001) and a recent systematic review of the literature has noted that joint biased MT is associated with improved psychological outcomes (Williams et al., 2007). For this paper we categorize such factors as neurophysiological effects related to supraspinal descending inhibition due to associated changes in the opioid system (Sauro & Greenberg, 2005), dopamine production (Fuente-Fernandez et al., 2006), and central nervous system (Petrovic et al., 2002;Wager et al., 2004;Matre et al., 2006) which have been observed in studies unrelated to MT.

Figure 3 Pathway considering both a spinal cord and supraspinal mediated effect from Bialosky et al (2008)

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Evidence for surgery in degenerative lumbar spine disorders

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Nevner forskjellige kirurgiske inngrep og den svake effekten på korsryggsmerter.

Selbe Studien her: http://www.ncbi.nlm.nih.gov/pubmed/24315148

http://www.anatomy-physiotherapy.com/component/content/article/33-articles/systems/musculoskeletal/spine/lumbar/572-evidence-for-surgery-in-degenerative-lumbar-spine-disorders

Low Back Pain (LBP) has a high lifetime prevalence rate. This article reviews the available evidence on the effectiveness of surgical interventions for some conditions resulting in low back pain (LBP) or spine-related irradiating leg pain. The most important findings are presented below:

– The current evidence does not support surgery as effective treatment compared to high-intensity conservative interventions for the treatment of discogenic LBP without disc herniation or spinal stenosis.
– In patients with disc herniations surgery can lead to short-term benefits of leg pain, to a lesser extent for LBP. However, no difference between surgery and conservative treatment is present at the 1-year follow-up
– In spondylolisthesis (type II and III) surgery appears to lead to better clinical improvements compared to conservative treatment. Fusion appears to be superior to decompression techniques.
– In patients with degenerative spinal stenosis surgery resulting in better outcomes, both in leg pain and disability, compared to conservative interventions. However the evidence is not consistent and the quality of the studies was not all of high quality. > From: Jacobs et al., Beste Pract Res Clin Rheumatol 27 (2013) 673-84. All rights reserved to Elsevier Ltd.

 

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Ten Steps to Understanding Manual and Movement Therapies for Pain

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Alt om smerte, kort fortalt, fra: http://www.somasimple.com/forums/showthread.php?t=4942
Nothing Simple – Ten Steps to Understanding Manual and Movement Therapies for Pain

1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus.

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.

3. A pain experience may be induced or amplified by both actual and potential threats.

4. A pain experience may involve a composite of sensory, motor, autonomic, endocrine, immune, cognitive, affective and behavioural components. Context and meaning are paramount in determining the eventual output response.

5. The brain maps peripheral and central neural processing into each of these components at multiple levels. Therapeutic input at a single level may be sufficient to resolve a threat response.

6. Manual and movement therapies may affect peripheral and central neural processes at various stages:
– transduction of nociception at peripheral sensory receptors
– transmission of nociception in the peripheral nervous system
– transmission of nociception in the central nervous system
– processing and modulation in the brain

7. Therapies that are most likely to be successful are those that address unhelpful cognitions and fear concerning the meaning of pain, introduce movement in a non-threatening internal and external context, and/or convince the brain that the threat has been resolved.

8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.

9. Tissue length, form or symmetry are poor predictors of pain. The forces applied during common manual treatments for pain generally lack the necessary magnitude and specificity to achieve enduring changes in tissue length, form or symmetry. Where such mechanical effects are possible, the clinical relevance to pain is yet to be established. The predominant effects of manual therapy may be more plausibly regarded as the result of reflexive neurophysiological responses.

10. Conditioning for the purposes of fitness and function or to promote general circulation or exercise-induced analgesia can be performed concurrently but points 6 and 9 above should remain salient.

Bibliography

Books:
Pain: The Science of Suffering – Patrick Wall
The Challenge of Pain – Patrick Wall, Ronald Melzack
Explain Pain – David Butler, Lorimer Moseley
The Sensitive Nervous System – David Butler
Phantoms in the Brain – V. S. Ramachandran
Topical Issues in Pain Vol’s 1-5 – Louis Giffiord (ed)
The Feeling of What Happens – Antonio Damasio
Clinical Neurodynamics – Michael Shacklock
Eyal Lederman – The Science and Practice of Manual Therapy

Research articles:
Melzack R. Pain and the neuromatrix in the brain. J Dental Ed. 2001;65:1378-82.
Craig AD. Pain mechanisms: Labeled lines versus convergence in central processing. Ann Rev Neurosci. 2003;26:130.
Craig AD. How do you feel? Interoception: the sense of the physiological condition of the body. Nature Rev Neurosci. 2002;3:655-66.
Henderson LA, Gandevia SC, Macefield VG. Somatotopic organization of the processing of muscle and cutaneous pain in the left and right insula cortex: A single-trial fMRI study. Pain. 2007;128:20-30.
Olausson H, Lamarre Y, Backlund H, Morin C, Wallin BG, Starck G, Ekholm S, Strigo I, Worsley K, Vallbo AB, Bushnell MC. Unmyelinated tactile afferents signal touch and project to insular cortex. Nature Neurosci. 2002;5:900–904.
Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Ther. 2003;8:130-40.
Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 2003;4:184-89.
Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007;133(1-3):64-71.
Moseley, GL, Nicholas, MK and Hodges, PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20:324-30.
Crombez G, Vlaeyen JWS, Heuts PH et al. Pain-related fear is more disabling than pain itself. Evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80:329-40.
Zusman M. Forebrain-mediated sensitization of central pain pathways: ‘non-specific’ pain and a new image for manual therapy. Manual Ther. 2002;7:80-88.
Dorko B. The analgesia of movement: Ideomotor activity and manual care. J Osteopathic Med. 2003;6:93-95.
Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72:893-902.
Lederman E. The myth of core stability. Retrieved at: http://www.ppaonline.co.uk/

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Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests.

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Om at de tradisjonelle diagnosekriteriene som brukes i fysioterapi ikke holder mål i klinisk sammenheng.

http://www.ncbi.nlm.nih.gov/pubmed/17720798

Currently, almost without exception, there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.

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Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear

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Mer om at operasjoner ikke er bedre enn placebo ved mediskproblemer.

http://www.nejm.org/doi/full/10.1056/NEJMoa1305189

In this trial involving patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after a sham surgical procedure.

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Upper Limb Neural Tension and Seated Slump Tests: The False Positive Rate among Healthy Young Adults without Cervical or Lumbar Symptoms

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Nevner at nevrodynamiske tester også har «false positive» resultater, som man må være oppmerksom på. Ca.33% av alle uten problemer vil likevel få positive resultater på nervestrekk-tester. Så som alle andre diagnoser vi prøver å sette på menneskekroppen, er heller ikke nevrodynamikk spesielt spesifikk, pålitelig eller objektiv.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582423/

The purpose of this investigation was to determine the false positive rate of the seated slump test (SST) and the upper limb tension test (ULNTT) in a sample of healthy adults without spine or peripheral symptoms. The false positive rate was found to be high for both the SST (33.3%) and the ULNTT (86.9%), which raises question about the diagnostic validity of these tests as previously described using full-range knee and elbow testing. Based on the results of this investigation, it appears that there is a significant degree of inherent neural sensitivity among healthy adults without a history of spinal or peripheral symptoms when full-range testing is performed. To increase the diagnostic accuracy of these tests, we have proposed possible cut-off scores for these tests. Based on the 75th percentile, we suggest that a positive test only be identified when peripheral symptoms are reproduced before 22° of knee extension in the SST and 60° of elbow extension in the ULNTT.

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Scratch collapse test for evaluation of carpal and cubital tunnel syndrome.

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Viser hvilken klinisk relevanse scratch collapse test har for å finne hvor nerver er i klem.

http://www.ncbi.nlm.nih.gov/pubmed/18984333

For the new test, the patient resisted bilateral shoulder external rotation with elbows flexed. The area of suspected nerve compression was lightly «scratched,» and then resisted shoulder external rotation was immediately repeated. Momentary loss of shoulder external rotation resistance on the affected side was considered a positive test.

For carpal tunnel syndrome, sensitivities were 64%, 32%, and 44% for the scratch collapse test, Tinel’s test, and wrist flexion/compression test, respectively. For cubital tunnel syndrome, sensitivities were 69%, 54%, and 46% for the scratch collapse test, Tinel test, and elbow flexion/compression test, respectively. The scratch collapse test had the highest negative predictive value (73%) for carpal tunnel syndrome. Tinel’s test had the highest negative predictive value (98%) for cubital tunnel syndrome.

The scratch collapse test had significantly higher sensitivity than Tinel’s test and the flexion/nerve compression test for carpal tunnel and cubital tunnel syndromes. Accuracy for this test was 82% for carpal tunnel syndrome and 89% for cubital tunnel syndrome.

Mer utfyllende studie om Scratch Collapse her: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880669/

Though the exact mechanism of the scratch collapse test is unknown, we believe it may represent a gross physical manifestation of the “cutaneous silent period.” This EMG-demonstrated phenomenon is observed following noxious stimuli. A brief pause of voluntary muscle contraction is demonstrated following stimulation of a cutaneous nerve [24]. The scratch collapse yields a similar reflex response. We propose that as the nervi-nervorum at the site of neuritis are stimulated, an ipsilateral central inhibition is transiently activated. It is not surprising that this response would be most robust at the focus of the neuritis.

The scratch collapse examination shares several features with the cutaneous silent period. Both phenomena occur after a noxious stimulus, are very resistant to habituation, are able to override voluntary muscle contraction, and result in a deferment in resistance in a pattern that corresponds to the withdrawal of the extremity into a position of protection (e.g., in this case, internally rotating the arms in against the body) [9, 11, 13, 16, 17]. From an evolutionary standpoint, such a reflex would be important in survival.

The test offers an advantage over these other tests in that it appears to precisely localize the site of nerve compression.

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Om alt som er galt med fysio

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Her er et fantastisk innlegg fra en fysioterapeut. Dette er så spot-on at han ble kalt inn på teppet av ledelsen på sitt undiversitet og forsøkt kneblet. De mente han burde ha ventet med å skrive slikt til han hadde minst 5 år mer erfaring. Noe som bare viser hvordan autoriteter mangler evne til fleksibilitet, og at såkalte evidensbaserte behandlingsformer ikke greier å tilpasse seg ny forskning. Fysioterapi henger 50 år etter. Jeg har samlet alle referansene for lettere tilgang.

http://blog.theravid.com/patient-care/redefining-evidence-ebp-in-experience-cut/

How does one justify the use of ultrasound when the biophysical (Baker et al 2001) and clinical (Robertson et al 2001) effects have been so thoroughly disproven?

Why are we still taught that we are molders of connective tissue, when the forces required to create plastic deformation of connective tissue ranges between 50 and 250 pounds of force (Threlkeld 1992)?

When are we going to accept the fact that our palpatory exams lack reliability (French et al 2000) (Lucas et al 2009)

and validity (Najm et al 2003) (Landel et al 2008) (Preece et al 2008)?

When will we stop telling students, colleagues, and patients that pain is related to their posture, muscle length, muscle strength, or biomechanics (Edmondston et al 2007) (Lewis et al 2005) (Nourbakhsh et al 2002)?

When will we cease blaming pain on something found on an image (Reilly et al 2006) (Beattie et al 2005) (Borenstein et al 2001)?

When will we stop thinking that we can change someone’s static posture with strengthening (Walker et al 1987) (Diveta et al 1990)?

When we teach these things to students and say them to our patients, it is misleading at best and fear inducing and hurtful at worst (Zusman 2012).

“In My Experience”remain the three most dangerous words in medicine.

This is perhaps even doubly so in the world of physical therapy, given the litany of non-specific effects that go into a treatment encounter (Hall et al 2010) (Miciak et al 2012).

Physical therapists are in a unique position to make a significant impact on the burden of chronic pain, however, we fail to live up to our potential by holding onto a postural-structural-biomechanical model that has been proven ineffective and incorrect (Lederman 2011).

We need to familiarize ourselves with the work of people like Ronald Melzack, Patrick Wall, Louis Gifford, David Butler and Lorimer Moseley.