Aug. 12, 1987

Begins with tape "replicate" About one minute.

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This was made from a magnetic disc, so every time it played it played the exact same thing. There was only one word on it. Everybody hears multiple words even phrases but they are not there. That wasn't on the tape, what you heard. Your mind created it. Our mind controls our perceptions. You can't trust what you see and what you do. One person will hear one thing and another another thing. Even the most simple thing like listening to a word is not reliable.

I want to tell you a story from the 1700's about yellow fever. They had epidemics in Philadelphia, thousands of people died. The mortality rate was very high. A physician in the city, Benjamin Rush, was very well meaning, trying to handle this epidemic. He treated one patient with mercurial purgative, a very toxic substance, and bled them, and the patient survived, so they began to think that this was a cure for this thing, and all those people were going to survive anyway, but got this cure towards the end of their disease, and then survived. Their survival was given credit to the treatment. In reality it was lucky that any of them survived the treatment, not to mention that any of them survived the disease.

This became the treatment of choice everywhere for yellow fever. He in particular felt that if he didn't give this treatment you were committing malpractice and killing these people. Everybody believed this. What went on in Dr. Rush's mind to convince him of the usefulness of such a devastating treatment?. Had to do with the person's needs to help the individual, to feel that he was effective, and this censoring that we do when we are looking at something which we can't look at objectively. Just as you created perceptions that didn't exist on the replicate sound, he and all well meaning health care practitioners will tend to remember the sensory data that makes sense and supports their wishes and throw out some of the data that is contradictory. We want to feel that we are making effective interventions as does the patient.

This gets more pertinent for what we are going to discuss today, which is mobilization What I wanted to discuss in general was the whole kind of ideas of how we know what we know. Just because everybody is doing something a certain way doesn't mean it is right, because we have been wrong many many times. In general orthopedics, in the treatment of the knee, and of the back, some treatments were not effective or deleterious for many generations. At the time everybody was doing it and everybody thought it was right. So everybody can be wrong.

Just stop me and we will discuss things as we go along. This article about yellow fever, is about a disease that was fatal to a lot of people, it was a really severe disease. It had some spontaneous cure rate, but certainly not as high as back pain. So we are dealing with the back which has a 90% spontaneous recovery rate within 6 weeks, 60% recovery a week. So, if you look at that in the context of this article, you can see it would be next to impossible to figure out what treatment worked out for the back since most everybody does well anyway.

Even with severe disease like yellow fever, they believed that something that was probably worse than yellow fever was actually helping people.

There's so much that goes on in the one and one interaction between the practitioner and the patient. The patient comes into the office, he has already changed his mental set so that now he's is going to take care of his problem. Something is going to get done about it. He's probably had this problem for some period of time. Now the psychology has changed, and now he's going to get going. And something is going to be done about it. And that is a huge placebo effect.

Then he comes in the office, and he has an interaction with the person. And that has a very potent placebo effect. And then if it is manipulative mobilization therapy, you touch the patient, that has all kinds of non-structural effects. So it's very very difficult to sort out what is really going on when you treat a patient, because there's all kinds of things going on. It's very difficult to tell especially with backs

because it spontaneously resolves frequently anyway, whether it had anything to do with what you did. And you aren't even aware of what you did, because you are doing a lot of things you aren't even thinking about that might be pertinent.

So it's easy to see why there's so many treatments for backs, and how all kinds of elaborate treatments have developed for backs. Osteopathy, Orthopedics, Neurosurgery, Cranio-sacral, Feldencreis, Alexander Technique, Physical Therapy, Chiropractics, Shamanism, all have there own view about the cause and the answer.

Wyke's article is the British guy who gives the theory of why manipulation works, is because of stimulation of mechano-receptors which inhibit the nociceptive receptors, which is like the gate theory, that it blocks the pain and so forth.

The problem with that, and I don't disagree with his paper, although he makes all kinds of leaps of faith about - he makes a statement about, if you denervate animal joints, the knee joint, animals lose their particular proprioception and have bad balance and wear themselves out and therefore with degenerative changes you have the same thing happening, which is a big leap of faith from an animal knee to a person's back. Having degenerative disease causes the same thing as Injecting the knee does. There's all kinds of things in that article that you hove to take with a grain of salt.

But the point of the article in terms of the efficacy of mobilization is, the bulk of his article says that the best thing you can do for the patient is to keep the patient on the move. That's because the patient has intrinsic instability. Mobilization is stimulating the mechano-receptors to block the pain just like acupuncture or pain medicine or otherwise.

The other article by the physical therapist, I think he's from Washington, he reviewed all of the current articles on mobilization Well, basically It reviewed about 15 articles. But basically they all

said the same thing, there's about 15 articles that are reasonable, have some controls, and some large patient populations, and looking at all of those, the best you con say if you are in favor of manipulation and mobilization therapy is to say that it helps for a short period of time sometimes, and the evidence even for that is weak.

The articles that show good results, there's a couple of articles from England with big groups of patients, and they manipulated people, and they got 80% good results. One study with 4000 patients. But since the spontaneous resolution rate is 90% what does that mean? It doesn't mean anything. So with a spontaneous resolution rate that's so great, any article that doesn't have, uh, very controlled series, is not meaningful. You can't judge it.

There's 4 or 5 articles that do have controls on them. None of them are really great articles. Virtually all of them show that there's no significant long-term effect from mobilization in terms of the patient's pain, and even their mobility, as soon as their mobilization stops, they regress back to the state it was before.

So, in some of the literature it is mentioned that in the medical field there is too much emphasis on empiricism, meaning that, empiricism is what works. In a field like this you have to look at what works, since we don't really understand the disease process well enough, although we are beginning to have a cohesive theoretical idea of what should work.

The concept of pain, and how to handle pain in and of itself, is very poorly understood. At the present state of understanding it is very clear that everybody recommends that you defocus on patient's pain and you focus on function. The manipulative type of therapy, which allows the patient to come in and have something done to them and then have the pain go away for whatever reason it does that, Is kind of reinforcing the fixation on the pain and reinforces their dependence on a thing, or a therapist, or something that can take care of it, whereas in reality the people do best if their pain is ignored. And there are studies on this and they are only kind of reinforced in what they are able to do.

There's one study done on two groups of people. One group they were given a program where they did this one day and this the next day, 'and this the next day, an,d they didn't care how the patients felt while they did it. Add another group of patients would do the things when they felt like it. At the end of the study, the pain in the two groups were the same, but the people who were in the non-time contingent frame, they were just trained no matter what, had a very, very higher return to work rate as compared with the other patients.

Q: Did they ever look at their follow-up medical care? Whether they continued to seek medical care? Many patients, especially around here, go from clinic to clinic.

That's just another one small point. It isn't that good of a study. There isn't any good studies. Nevertheless, though, if you look at all of the studies, though, there's virtually nothing that says that manipulated-mobilization type of therapy makes a big difference.

Q: You have to look at the selection criteria. Identifying the variables of when it works and when it won't work would be like you agreeing to operate on every patient who crosses your doorstep regardless, and doing the same surgery.

I can make this talk even stronger for surgery, because surgery Is even worse because the stakes are even higher. You have to do a surgery. You can't do the controls too well. I mean, the field of surgery is such a morass of conflicting stuff that I am the first one to say that we have no idea what's going on. We don't even know if fusions work or not. And whet effect fusions have, and look how often we do fusions.

But in terms of therapy, it's kind of beside the point, and I don't feel that the answers in because all of the studies are really gross studies, and I think that there are some situations where manipulative therapy may be helpful, and that's not going to be clear until you have a large number of patients where you can say let's say all the people that have a facet type

of syndrome, we treat them this way. All the people that hove a syndrome that we call segmental instability we do the same thing, and you have to break it down into about 15 groups, and have controls, and then see' if there's a difference between, you know, a particular type of mobilization, and if you don't mix it with back school and other things that make people better too, that's the only way that useful information is going to be found.

Q: Don't you think that first we hove to agree on how to name the syndromes?

Well, that's the problem why it's difficult.

Q: You get a syndrome, and then the collection of symptoms resides, it's terrifically good. And if we can somehow computerize and say that we have certain complaints, and certain signs of mobility or tests, but doing it by diagnostic labels is impossible.

That's right, because we don't understand the disease processes. We can mike it down to some things, and may find, and we will never know until we try, but may find some symptom families or constellations of symptoms respond to a particular type of therapy, and I'm sure that we'll find that some day, but right now we are kind of wrapping everybody together and treating these problems the same way.

Q: Just philosophically speaking, 60% to 90% of the people get better and in another group we will just go ahead and increase your function and not address the pain...

That's a good question. That's one of the points of this, we are all to ask ourselves that question. You have to ask yourself the question of whether you're really doing good or not. And when you're in a situation with a patient, the patient may have some problems on the surface, or may be deep psychological needs, and they're trying to manipulate you to feed their psychological needs, but may not be related to the "pain that they come with in the first place, so it's very complicated, and I think it's not easy to say that you're helping. Just because you learn what everybody else is doing and we all learn that. and all do it. if you look at the individual person, it really is not so clear cut that you are helping or not.

Q: Don't you think there Is a hidden factor here? If you had a bad disc problem that might resolve in a years time — would you rather live with that for a year than have it resolved and go on about your life?

Yeah, but your implication in that is there is something you can do to shorten it up that quickly.

Q: I have a patient that has been the same for a year, and then you make changes. That has to be due to whatever you are doing.

You think that, because we all think that, but you don't know that. Because people spontaneously get better. That's why if you, for instance if you look at psychiatry. If you look at studies that have been done where they have trained psychiatrists treating people and people that are totally non-trained treating people, and they have people coming in and talking to a mirror and telling them that there's a psychiatrist in back of that mirror, and you come in 10 times a week and talk to the mirror. Psychiatrists have a feeling that they are helping some people. When you looked at the results of the studies, untrained people did better, people who stood in front of a mirror talking to nobody did just as well as the people talking to a psychiatrist.

My main point is, is that, it's there for all of us, and even more so for the surgeons, because we have such a gigantic placebo effect that you shouldn't be sucked into that thing that you want to believe, because we all want to be effective, we all wont to believe that we are helping the people, we all want to believe we are doing the right thing.

You can't be sucked into that. You gotta work with what really is true or isn't true. The only thing that proves things, especially in this field, is well-controlled, specific, double-blind studies.

Q: (I don't believe that. Because I think that a person's mind has a lot to do with the healing process. It can be a placebo. Or just talking to a person, and that helps them get better, what's the difference, as long as they get better...

I'm not — all I'm saying - and I think that's very important, but all I'm saying is that we all need to be aware of what we are doing.

Q: But I know that you want to concentrate on function, and to a point I agree with you, but if you...

But I'm not necessarily trying to do that. I'm trying to bring out some points. My point is that we have to be very careful when we say this does that and that does that.

Q: Right, but, I mean, with that study where they had, you know, people doing what they had to do regardless of how they felt, with the people who only did their program, you know, when they felt like doing it, you know, even though the group that did it anyway, their function was higher. You've got to look at the quality of function, I mean, I don't think that we should expect patients to continue on with their function regardless of their pain. I think that you should teach them, or help them maintain their function, or regain function, you need to also address the quality of that function. You shouldn't have to be working on a pain scale of ten out of ten, if you can do some form of treatment or therapy to them and give them a lesser pain, and still maintain their function.

I agree with that.

Q: Would you admit that there are certain conditions, I mean there are a few that we can fairly consistently identify, and do predicable things and make immediate change?

Ye, I do agree with that, and there's things that I feel will work, and I think will work, and make sense to me and so forth, but can I say that that's true? I mean, those are two different things. What I do in my daily practice is different from what we really know.

Q: But if even in simplest form, if we took very small clusters of patients, with very precise or similar signs, say the acute patient that is kyphotic, no deviation, what we call annular tear, just back pain, no reference, midline back pain, you could certainly easily, because it is a small cluster of signs end small cluster of symptoms restriction of flexion, restriction of extension, probably not much of that...

Right it's the same with neck injury, so you take that group out...

Q: Right. And make a predictable form of treatment, likes compares an epidural block with extension exercises, with mobilization, and that would be a reasonable. There are some that are fairly predictable clinically that you see over and over.

I totally agree with you, anecdotally, but the amazing thing is that none of this stuff has been shown, even the simple things. And this being probably the largest group of therapists in a spine center in the world it's ridiculous that we haven't done it.

Q: Where do you cross the ethical issue, of where you know very clearly that if you say, if you do this, they will be better in a few minutes, as opposed to saying, go home and rest and you will get rid of it in six weeks.

Since, there's some ethical issues. I don't think the ethical issue is that big, because the end result is about the same.

Q: You would have to file human subjects.

No, you could send one group to One South, which is standard accepted therapy, shake and bake, and you can do everything else to another group. I agree that it is hard to do nothing.

Q: In research I did for my class last year, I found as soon as I randomized patients, I had to file a human subjects with the state of California.

That's the problem when you maintain too high a profile. You could take a syndrome like that and send them for different treatments which are all acceptable, and see if there's any difference with the treatments.

Q: Aren't the patients that come back after surgeries, or without surgeries, and then they get a course of physical therapy, and when you re-test them and examine them, doesn't that speak enough, when you sees the changes of no more movement abnormalities or much cleaned up, doesn't that speak for itself?

It doesn't because of the placebo effect, and spontaneous remission If you look at surgery, for instance. I had surgery on my knee once, it didn't do much for my knee, but I learned a lot from it. What I learned is when you have surgery on your knee, or on anything done on any part of your body, you are totally reoriented. The first thing is you have a whole lot of pain. And you are used to not doing nothing. As time goes on you gradually improve. You get back up to the ability to do what you did before surgery. But this time you're comfortable with it because you had months and the chance to adjust to redoing your life style. Fortunately, now that we do standardized pain inventories on peoples a lot of our patients when you say, "how are you doing?" They say, "pretty good." You go back and look at their score the first day that we saw them, and now after surgery, and they have circled the exact same pain descriptions and it's exactly the same. But they don't remember. They have gone through all of this crisis and things going on. So there's so many things involved.

Yes, in daily practice, something seems to work or not work, but that's a different thing from saying that these things ore doing what we think they ore doing. We have to prove that. And there is no proof.

Q: My own personal thing is, I have to prove it, one, to myself, and one, to the patient. If. I feel good about what I am doing, I also get that patient feeling good, and I see objective changes. I guess, yes, it's nice to have all of these studies, but you try to get all of these things so controlled...

But you should care about it, because sometimes when you please yourself and you please the patient, that Isn't really good for either one of you.

Q: I don't mean that scientific studies aren't right, it's just that some things speak for themselves. Where you do something and you make a change, and It can be seen by eight other eyes seeing that same change, I can't help but believe that you had something to do with making that change.

We know that mobilization, from some studies, has at least a temporary beneficial effect in reducing pain and restoring mobility. But we are talking about hours to one to three days, I think, in the most favorable study. Pain pills and tens units and things like that, it's fun to go in and do something, but you have to - the point is don't kid yourself and think that you understand everything that is going on, that what appears to be happening -

Q: don't think that we do. What I feel is that we are getting into an either or situation. You seem to have the impression that all we are doing is mobilization. Because we combine mobilization with stabilization training, strengthening, endurance, coordination - all of those things.

We are doing all of that stuff blindly. We don't know what is helpful because we haven't really studied it.

Q: I'm curious what results have you seen that are convincing to you that just encouraging the stability of the bock — what results hove you seen?

Again, it's just anecdotal, and I don't believe what I see any mores than I believe what anybody else sees. But peoples's symptoms are very frequently related to their strength.

Q: Total body strength?

Hard to say. Surgically, if we could get the bones not to move at all it is lot's better. We usually immobilize. Patients usually look much better when they are totally immobilized. But that's a big leap from that.

So; I think that there is also a kind of semantic problem, with mobilizationand manipulation, because the words ares used loosely. I think, for instance, the McKenzie kind of therapy for an annulus tear where you put a person In extension, or somebody who's got stenosis you put in flexion. I don't consider that mobilization, although IL call it that when I order it, because it is really postural adjustment. You are shifting the stressors in the segment to get them off the part that's diseased. That's not the same as mobilization. And that seems to work, and to work right away. Very rapidly, if they are able to maintain that position, they are comfortable while the tear heals. And whether the tear heals faster, we don't know. And people with spinal stenosis, we have no choice but to teach them the pelvic tilt, and they do better. To increase the ability to hold the spine still in the postural position. It may not be normal, but it is better for what their abnormal spine is like. That kind of mobilization is not the same as manipulative therapy where you are trying to restore motion to the joint. We accept that is a shot spine, and we want to teach the patient how to live with a shot spine. It may be that from the first episode that spine is now shot, and we should consider that, and only try to immobilize that segment, and not stretch...

Q: Do you think that that is true for the cervical spine as well as the lumbar spine?

The cervical spine is a whole other ball of wax. Anecdotally, that seems to be very effective.

Neck problems are not as common as back problems. The neck is an organ that was made for motion. I think the back is an organ that was made for ambulating, and unfortunately it is in a place where it has to take all of the load.

Q: So what do you mean when we get prescriptions that say... An example, a patient needing flexion-mobilization.

I'm talking about postural adjustment in flexion. And, likewise with extension mobilization. If the patient comes in with a diagnosis of soft tissue dysfunction, or limited (?) dysfunction, I want you to do soft tissue mobilization. And for neck cases I want you to mobilize the neck. That is, the joints.

My views have changed a lot in the last few months, and we're all changing all the time. If we look at what we do now compared with what we did 2 years ago, it's changing all the time.

Q: I remember when you were once very supportive of us mobilizing.

Well I, I'm supportive of anything that seems to work. And my impression of that is it doesn't seem to work. And most of the literature says it doesn't work. Anything that you can show me that works, I'll support it. And I don't care if what you are doing is what you think works or not, I just think everybody ought to be aware that we don't know what works. We need to keep trying to figure out what works. And just because like there's chiropractic, or osteopathy, or all of the different therapy techniques, they're all based on just theories, and some of them seem more or less unreasonable to us but you can't judges any of them if you don't have real objective data about whether they really work or not. So on one level we do what we do during the day, and that's based anecdotally because the field is so much in the Dark Ages but we just have to be aware that we should be actively trying to set these things up. Because we are in a better position to sort these things out than perhaps anybody else in the world.

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