Adventures excite me. Being a thirty year old white male in America means that any adventure I experience is usually between my ears. My adventure is an intellectual one, no doubt. It is one that I find difficult to share with others. While I might take the nuances of epistemology to be fascinating, most others have heralded it it as the great cure for insomnia. Nonetheless, this blog page is my feeble attempt at bringing my adventure to others in my world.
I am closer to publishing than I was one year ago. I have written over ten papers and am positioning myself to write a case study and attempt to publish it in the national PT journal. This in itself is encouraging.
Recently I have writen several essays for graduate school. The one recurring theme in my essays is my desire to become a researcher. In this career I hope to be able to contribute to the body of knowledge in physical therapy. Research is not an end point in my desire, though. Perhaps more motivating for me is a desire to become a voice that shapes the way in which physical therapy knowledge is intuited, refined, and published as truth.
I would like to follow in the foot steps of Michael Polanyi. Polanyi was a Hungarian physician who went on to become a physical chemist and then philospher. During his career he worked brilliantly to shape scientific epistemology. Through his work he outlined the personal scope of knowledge; he showed that learning knowledge is not some mechanical process, but is rather a personal process. Gaining knowledge involves everything from epiphany to mentorship to critique. And that's what I want to bring to the table in my writing.
Saturday, February 14, 2009
Saturday, September 13, 2008
My how time flies...
It has been over a month since I last blogged. Time to catch up briefly.
I never did read von Bertalanffy's book. Instead I read and analyzed a bunch of California and Ohio supreme court rulings about duty to warn. For my term paper I chose a California ruling dubbed the Tarasoff rule. This rule holds a mental health professional liable in a situation where a patient confides his intention to harm a third party (that is legal speak for someone with whom the professional has no relationship). The professional is liable only if: 1) the patient ends up harming the third party and; 2) the professional did not warn the third party. I supplemented my case law (case law is court established law) analysis with some statutory law (statutory law is legislatively established law) analysis. I then made some applications for physical therapists. I hope to publish the paper.
I'm curious what my vast readership thinks. Consider a scenario where Bob Jones is being treated by Jack Handy (psychologist) for depression after a rough break-up with his girlfriend. What is the psychologist's duty when Bob makes specific claims that he is "going to bring a knife over to her house and end it all?" According to traditional Anglo-American common law there is no duty to protect between strangers. However, the California Supreme Court made an exception to the common law, stating that when a psychologist enters into a relationship with a patient he then has a duty to protect the public from the patient.
What do you think?
I never did read von Bertalanffy's book. Instead I read and analyzed a bunch of California and Ohio supreme court rulings about duty to warn. For my term paper I chose a California ruling dubbed the Tarasoff rule. This rule holds a mental health professional liable in a situation where a patient confides his intention to harm a third party (that is legal speak for someone with whom the professional has no relationship). The professional is liable only if: 1) the patient ends up harming the third party and; 2) the professional did not warn the third party. I supplemented my case law (case law is court established law) analysis with some statutory law (statutory law is legislatively established law) analysis. I then made some applications for physical therapists. I hope to publish the paper.
I'm curious what my vast readership thinks. Consider a scenario where Bob Jones is being treated by Jack Handy (psychologist) for depression after a rough break-up with his girlfriend. What is the psychologist's duty when Bob makes specific claims that he is "going to bring a knife over to her house and end it all?" According to traditional Anglo-American common law there is no duty to protect between strangers. However, the California Supreme Court made an exception to the common law, stating that when a psychologist enters into a relationship with a patient he then has a duty to protect the public from the patient.
What do you think?
Thursday, July 31, 2008
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!
Saturday, July 26, 2008
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).
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.
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.
Tuesday, July 15, 2008
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?
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.
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.
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