Read, read, read.

Next month's course is on ethics. Yipee!! My professors are both therapists and lawyers. One of them has authored a short book which I am reading on ethical issues in the health care realm. Within the book he made reference to a philosopher that I found enticing--Von Bertalanffy. He was a biologist who developed thought regarding general systems. His writing pertains mostly to the human sciences (e.g. medicine, sociology, psychology, etc). Just to be an overachiever I ordered Von Bertalanffy's book on General System Theory and am going to read it for my class. I hope to quickly take in his thought and analyze it enough to use it in my papers. Here's to the teacher's pet!

Where are my glasses?

I admit that I author a very boring blog. In an attempt to possible hook one or two readers into my blog I have adopted the strategy of using very simple questions as titles (hence, "Where are my glasses?"). Readers beware: my blogs are just as boring as ever. Hopefully my trick will get a few readers to read through at least the first paragraph of my post.

Continuing with my thoughts on epistemology (the philosophy of knowledge) my mind has been lingering on the question of how knowledge is discovered. Particularly I am asking myself about the limits of research to provide useful (or beneficial) information. For any one research study to properly scrutinize the veracity of a principle it must be extremely near-sighted (to use an ophthamolgical metaphor). An exceedingly small part of existence is chosen for study (i.e. patients with acute neck pain referred below the elbow, or adsorption of a particular gas on a solid surface, etc). Years of thorough examination and testing will provide excellent description about the nature of this exceedingly small area replete with evidence for 'behavior' or 'interactions' of variables within the defined scope of study.

However, clinicians and engineers are charged with the task of working within a relatively enormous swath of reality (i.e. restoring functional wholeness to a person after an accident, or designing a subliming animal repellent, etc.). At times the myopic nature of research will prohibit the clinician from generalizing conclusions from research to the treatment of his patient. Perhaps the research literature has not yet broadly examined the problem at hand or perhaps the research has been primarily laboratory oriented without the intrusion of variables which are present in the clinic. Times like this require the clinician to step beyond the research and either rely on a mentor's imparted knowledge or to intuit a new method for treatment. Does this mean that the clinician (or engineer) is definitely making an error? Absolutely not. The clinician is relying on a different skill set to arrive at knowledge.

Whether or not the clinician arrives at erroneous knowledge does not depend on the research, rather the veracity of the clinicians knowledge depends on nothing more than its veracity. Can it get any simpler than that? Intuition leads the clinician down a path that is either mistaken or correct. Absence of research does not determine the falseness of a principle (and often times the presence of research which apparently counters a principle does not definitively determine the falseness of a principle--this is the case when myopic research is over generalized). Rather it is the lack of parallel between principle and reality that determines a principle’s falseness...empiricism teaches us that much.

Considering the research discussed in my last post it is apparent that the authors have gathered treatment methods from various respected schools of thought within the physical therapy community. These schools of thought originated when an individual therapist experienced an epiphany. For example, a veteran therapist experienced an epiphany of understanding, applied principles from the epiphany in the clinic, empirically observed positive outcomes, and began teaching other therapists what she had discovered. As research developed regarding the therapist's principles the task began of verifying what the therapist already knew to be true. Once again, the research does not determine the veracity of a principle...the veracity (or lack thereof) is predetermined by the principle’s parallel to reality. Instead, the research serves to inform the community of the principle's veracity (or lack thereof). Research is merely a matter of opening up the mind to a pre-existing reality of veracity (or lack thereof).

How can I help you?

People who experience neck pain are not always easy to help. As a younger clinician I have found myself frustrated in my attempts to figure out how to help patients with neck pain. Recently I read a research article which helped me immensely with treating the neck. The article offers a treatment-based classification system for patients with neck pain (Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Physical Therapy. 2007;87:513-524).

Underlying the authors' reasoning is the premise that patients with neck pain should not all be treated the same. Rather, these patients should be grouped into categories based on diagnostic testing and patient history. A good deal of discerning symptom trends and discriminatory placement is involved. Once a patient has been 'placed' in the correct group they can be helped with group-matched treatment. Here are definitions of each category as well as matched treatments (taken from the article verbatim):

1) MOBILITY: younger patients with more acute symptoms and without signs of nerve root compression (e.g. pain down into the arm). These patients benefit from upper thoracic spinal mobilization/manipulation and deep neck flexor exercise.

2) CENTRALIZATION: patients with distal symptoms and signs of nerve root compression (e.g. pain down into the arm). Neck retraction (chin tucking) exercises and traction are used.

3) EXERCISE AND CONDITIONING: patients who have chronic neck pain, but who do not have signs and symptoms of nerve root compression. Strengthening of deep neck flexors and the upper quarter (arm and neck muscles) is recommended.

4) PAIN CONTROL: patients with acute, traumatic onset of neck pain with a whiplash mechanism and with very high levels of pain and disability. Evidence for patients fitting this subgroup recommends mobilization, neck active range-of-motion exercises, and avoidance of immobilization.

5) HEADACHE: patients with a chief complain of headache presumed to originate from structures in the cervical spine. Evidence supports strengthening of the deep neck flexors and upper quarter muscles along with mobilization or manipulation of the cervical spine.

My most recent instructor added the following category:

6) NEURAL TENSIONING: patient with thoracic outlet like symptoms (e.g. numbness and tingling into the arm and potentially compromised arm circulation) as well as patients exhibiting positive neural tension tests. According to my instructor these patients benefit from neural tensioning or sliding, positional training, and spinal mobilization.


Ambiguity has been the number one source of frustration for me as I learn how to help people. And so this classification system has been terrific in providing concrete guidance on how to direct the best treatment to various patients with neck pain. Far from being written in stone as the absolute rule of how to treat the neck, this classification system is however a good beginning at definitively expressing how to treat the neck.

Knowing: Critical and Uncritical

In my last post I discussed what I have learned about the mechanics of cervical motion. The information I learned I gained from my text book entitled Management of Common Musculoskeletal Disorders which was edited by Hertling and Kessler. Interestingly, the section from which I took my information has no reference to scientific research. One statement was made that certain cervical mechanics are obvious to observation on dynamic roentgenograms (x-rays). Another reference was made to a text written in the 1970's. Whether the information in this reference was based on research or not is unknown to me.

It appears that I have managed to gain a great deal of knowledge about the mechanical function of the human cervical spine while circumventing modern day scientific practices. How did I do that? I did it in the way that most pupils gain their knowledge--through an uncritical process of information assimilation. I, the learner, uncritically except from my teacher (the text) "factual" information about the spine. The verifiability of this knowledge is not of immediate concern to the novice pupil whose is merely attempting to gain mastery of the teacher's principals. Primary concerns for the pupil pertain to intaking information, assimilating information, learning the teachers story and recreating the teachers story in his words. Doing this process assists the pupil with creating a working theoretical model for interacting with a physical reality. Once this theoretical model is mastered by the student he can interact with the physical reality in various experiments to test the veracity and productivity of the theory.

The philosopher Michael Polanyi compared this uncritical process of learning to a microbiologist who studies the amoeba through a microscope. The microbiologist uncritically looks beyond the lens to critically evaluate the amoeba. His assumption is that the lens has been polished well and the curvature of the lens has been correctly shaped to reflect the image in a non-distorting way. During his crituque of the amoeba it is impossible for him to be critical of the lens. Here the lens is functioning as an extension of his own eye.

And so this is one arguement for personal knowledge in the modern world. I wonder how much knowledge is accumulated in the professional world in this manner?

Description of Neck Motion

One joy particular to the study of human motion is that of characterizing motion in specific human joints. Today's task for me has been developing an internal schema (a sort of mental map) for the motion relations between the base of the skull (occiput) and the first two neck bones--C1 and C2 which are respectively referred to as the atlas (for it's rotational role) and axis (for its phallic process). Below is a diagram of the occiput, atlas, and axis. This diagram depicts from top to bottom: the occiput of the skull (with the back of the skull sawed off), the atlas (with the back side of the atals' ring sawed off), and the axis (with the back side or spine of the axis sawed off). Notice that the dens is hidden by a dense connection of ligaments and proceeds upward from the back side of the axis. The ligaments most relevant to motion are: the alar, the apical, and the cruciform ligaments. Joint surfaces that exist between spinal bones are termed facets. These facet surfaces are planar in topography and glide upon one another to allow neck motion. Each neck bone contains two upper facets and two lower facets. The upper facets of C3-C7 are oriented upward (toward the skull), inward (toward midline) and backward (toward the back of the neck) at roughly 45-degrees from horizontal. The lower facets of C3-C7 are oriented downward (toward the feet), outward (toward the outer neck), and forward (toward the throat) at the same 45-degree angle. Consequently, when considering the component facets motions which make up forward bending of the neck, their motion are described as upward and forward. Likewise, during backward bending of the neck their motions are described as downward and backward. The depiction below is helpful for visualizing these mechanics.Furthermore, rotation of the neck to the left can be characterized as downward glide of the left facet and upward glide of the right fact. Interestingly, side-bending of the neck to the left is characterized by the identical facet motions (left downward glide and right upward glide). As such it is clear that when the neck is bent sideways to the left, rotation to the left occurs (this is termed ipsilateral rotation).

These mechanics do not hold true for the upper cervical spine (occiput, atlas, and axis). During left side bending of the skull on the atlas (C1), the atlas rotates to the opposite (right) side. This occurs to allow room for joint congruency between the concave facet of the right atlas as it travels up the convex surface of the right occiput (Hertling and Kessler 2006: page 714). Side-bending of the occiput is checked by the alar ligament. While viewing the alar ligament in the first diagram presented this checking mechanism can be conceptualized. Additionally, the axis (C2) is rotated to the left during left side bending of the occiput (this also can be visualized from the diagram).

The take home messages go somewhat like this:

C3-C7:

1) Forward bending of the C3-C7 can be diminished by restricted upward gliding at the facet joints.

2) Left side bending of C3-C7 can be diminished by restricted left downward gliding or right upward gliding at the facet joints.

3) Left rotation of C3-C7 can be diminished by restricted left downward gliding or right upward gliding at the facet joints.


Occiput-C2:

1) Forward bending at the occipitoatlanto joint can be diminished by restricted backward glide of the occiput on C1.

2) Backward bending at the occipitoatlanto joint can be diminished by restricted forward glide of the occiput on C1.

3) Left side bending of the occipitoatlanto joint can be diminished by restricted left backward glide or right forward glide of the occiput on C1. It can also be diminished by restricted left rotation of C2 (i.e. restricted inferior glide of left C1 facet on C2 and/or superior glide of superior glide of right C1 facet on C2).

4) Left rotation of atlas (C1) on axis (C2) can be diminished by restricted inferior glide of left facet joints or superior glide of right fact joints.

Neck Pain.

Last weekend I finished a paper on neck pain. I spent over 40 hours reading research and formulating my own analysis. The funny thing about spending all that time on research is that my clinical applications were so succinct. They boiled down to this:

Lots of research has been conducted to show that exercise is helpful in reducing neck pain. Research shows that spinal mobilization increases the pain reducing benefit of exercise. For patients who do not tolerate exercise well, simple chin tucking exercises while lying down are recommended. All exercise routines should be performed over at least a three month period to promote muscle growth. This 3-month training period will promote reduction of neck pain into the long-term.

And that is what 40 hours of research will get you. I have to say that I enjoyed the process of discovery and learning. Especially I enjoyed reflecting on the process of arriving at knowledge.