Thursday, 12 May 2016

I have seen it in my practice




Galileo's Leaning Tower of Pisa experiment and clinical experience
One of the common arguments I encounter from PTs (probably also from patients and others) is personal experience and “i have seen it” argument.
Why is I have seen it argument flawed most of the time:
One of the common notions in Indian and eastern philosophies is the idea of “mayai” or illusion.  An illusion as we are well aware is – what you see is not the truth. I am not going in the philosophical arguments (you may read J. K if you really want to understand) but the scientific one.
I am going to use a simple example which we all learn in school
When you drop a feather (a lighter object) and a ball (heavier object) you will see the ball dropping to the ground faster than feather. The observer may conclude the heaver object falls faster than a lighter.  However anyone who has done 6th standard physics will know the gravitational force is a is a constant- hence the above statement cannot be true.
So you end up tearing yourself- whether what I have seen is untrue or whether the physics I have read has an “alternative”.  Well the physicist does not tear themselves- they look into the flaws and the confounding factors in the observation – they just don’t say- sometimes the G force is behaving badly.
 Well the physicist do not tear themselves- they look into the flaws and the confounding factors in the observation – they just don’t say- sometimes the G force is behaving badly (for this observation)
Well when the same thing happens in clinical setting to most of us. We see our patient getting better with IFT, traction, the K-tape, SI and all the other one hundred things people are selling. But most of the time the justification for all these treatments are flawed, pseudoscience or plain ridiculous.
In medicine most of see something happening to our patient and when it is good, we look for justification. When the physiology or the science is not able to justify we fall back on the alternate ridiculous answer.






These are the top 5 ridiculous statements i like:
1.       Jane Ayres – sensory diet- can’t stop laughing even now
2.       The internal organs are all in the hand and feet- just a insult to one’s own brain
3.       K-tape will facilitate muscle action- really the brain, the psychological factors, the social factors etc is just a joke?
4.       Hands are the physiotherapists most important organ- he touched the patient and he got better- really?
5.       Last but the most ridiculous – Cranio-sacral therapy- should check with your neurologist if you think this is “therapy”
I can hear people screaming- I have seen these being done, seen patient getting better with these magic (could not get to type therapy). Remember the G force is constant – lighter objects don’t fall slower; it is just that we have not controlled the n- number of factors in our observation. That is why you need experiments- with controlling all these parameters in medicine and science in general. Don’t take the easy route in finding alternates to why it happened- rather question first did it happen?- that is did my patient get better or is it an illusion because of the “n” factors- including natural recovery, fooling your brain, fooling patients brain or just wishful thinking. Then think of explanation for what you have observed and not the “alternative one”- the real answer which is hard, cumbersome and hard to come by. Then we will call ourselves as practitioner of science we call Physiotherapy.



PS- the Galileo thought experiments and the moon experiments gives us the right answer why the feather falls down and the remove the illusion and help us see clearly


watch the hammer and feather drop experiment on the moon: https://en.wikipedia.org/wiki/File:Apollo_15_feather_and_hammer_drop.ogg

one of the most interesting videos





love
Hariohm

Wednesday, 30 December 2015

Wish list for 2016- My positive blog


what I think will take us take the next step:
  1. Move from movement specialist to rehab of whole person specialist
  2. Move from reductionism to complex systems paradigm
  3. Move from calling “clients” and call them as “patients”- you are running a health care centre not a grocery store
  4. Move from biological model to complex models in pain and neuro-rehabilitation
  5. Move from named course to science based course- call our course as cerebral palsy rehabilitation or back pain management course (the experts should grow some balls)
  6. Course on how to convey difficult news to patients
  7. Move from osteopathy and other s!@# to physiotherapy (there is a huge science we have no clue- why go behind grocer techniques)
  8. Move from distant education to education (the colleges should grow balls)
  9. Move from cult organization to patient interest groups
  10. Move from publishing in throw away journals to indexed journals


Monday, 28 December 2015

What is in store for physiotherapist in 2016?

What is in store for physiotherapist in 2016?
1.       Jokers will teach NDT, SI, carnio-sacral therapy and gullible PTs will still do it
2.       The IAP and other millions of associations will think they are still relevant
3.       PTs will think these associations can change their lives and call for “unity”
4.       Bunch of dedicated PT s will get disillusioned and will go into their shell
5.       We will still teach the same nonsense they taught me in 1990 and think that is good science (our new syllabus proposed is a great example)
6.       PTs will share more pseudoscience than real information in social media
7.       Collages will “make” the students attend workshops and conference
8.       Clinical therapist will still say- “you can’t exercise with pain”
9.       More self proclaimed experts (jokers) will –teach pseudoscience and ruin as more (examples- osteopathy, chiropractice and dry needle)  
10.   We will still think evidence is for losers and uneducated slobs not for intelligent people like us (and practice the same thing)
Well in 2 words “no s!@#
                
Happy new year folks

Friday, 27 November 2015

Speak up against pseudoscience series - Part I

These are course we think intelligent therapist should shun, So we are starting with the current fad- dry needling
Dry needling- well because it is reinventing the wheel. A group of intelligent people thought- how can we sell our crap? We they were lazy and so they just rehashed some already available assumption with poor science- ie- trigger point and mashed it acupuncture. In acupuncture they have this idea called- ashi point, if I can remember correctly, which are tender points or as they renamed it trigger points with some modifications.
In the last decade they have done thousands studies on acupuncture and it has been found it works only in china when done on Chinese people. So these intelligent people took the lessons from a marketing guru and did what any good execute will do- rebrand it. So as a first step like Airtel called there 3g as 4g they called acupuncture which has lost some credibility among proper medical professionals- they called it dry needling. ( for PT who want to learn wet needling you need to contact Gowdhama Kumaran )

Major problems in this area-
·         No research evidence- that is natural. I know people who teach this will say it is evidence base- don’t worry they have not know clue what is evidence is like most of our us- making it easy to fool us.
·         no physiological sense-  Trigger point is not science as people are made to believe (you can do your own research to learn about it, but start with https://www.ncbi.nlm.nih.gov/pubmed/1404132 done by the people who wrote this )
·         also remember the map they show for trigger point- pulled out of there ass rather than from any study
·         latent trigger point- well, you want to believe this kind of shit no amount of evidence to the contrary is going to shake your faith
·         Remember we have good evidence for multifactoral pain management in chronic low back pain- hence you have to prove it is good than that rather than doing nothing.

Next time i hear someone says i am a expert in this crap i am going to give them an award for being the best therapist in the whole word with my own money



Monday, 26 October 2015

II anniversary of our book: Stroke rehabilitation: an activity based approach

It is 2 years since I and Vasanthan (with great deal of contribution from V. Prakash) released our book stroke rehabilitation: an activity based approach. I still consider it to be my best achievement in terms of scholarly work, even though when I read it, I find the language to be pedestrian.
So what is the book about? Well it is evidence based stroke rehabilitation with non-linearity ideas implemented within the task oriented paradigm.


The ICF model of functioning tells us that function of humans is in 3 levels body level, at the activity and participation level.  Importance to context was given its due diligence and the made clear the multifactoral nature of the influencing factors. Influencing factors were shown in a complex manner influencing each other rather than in a straight line.

Above picture shows- model of influencing factors of activity and participation in stroke. © Stroke Rehabilitation: A Functional Activity Based Approach, K. Hariohm
One of the assumptions I made when I read this was these influencing factors will influence each other in a complex non-linear manner. This was the time we were learning dynamic theory and I interpreted this model as non-linear model. (Well as Vasanthan always accused me – I always interpreted science as I like it or according to my bias rather than looking at it objectively.).
At the same time motor control ideas and motor behavior ideas were also pointing towards a dynamic perspective.




The Venn diagram shows where we have derived our ideas from for our book-as principle of treatment.

Our model within the task oriented paradigm shifted (as you can imagine- we have to be within task oriented paradigm as that is what is evidence pointing towards). We started to look at the system as non-linear system with inseparable subsystems. Even though it looks like the system is made up of many subsystems with unique function, my contention was it behaved as one unit and not separately.  Even though all this mumbo jumbo language is confusing to some it is in reality very simple.
The human system has many sub-systems- the motor, sensory, cognitive, cardio-pulmonary etc., while doing a function all of them act together rather than as individual systems.
What this lead to change in our model of stroke rehabilitation? Well, as you know task oriented treatment is the evidence based proven model, but the problem is definition what task to choose and whether the underlying impairments were to be treated.
Most of the text we read at that time –we started with Carr and Sheppards MRP and moved to other models and around 2005 we were with Anne shumway cooks motor control theory and practice- were not in tune with our changing perception.  The idea we were evolving at that time was- you don’t need to treat the underlying impairment- as I said earlier the subsystems in a non-linear complex system cannot function independent of the whole system. We also thought meaningful ask which are patient centric are the “task” to be selected rather than anything.
So, we started writing our book starting around 1999. Vasanth was dead against writing it as he wanted to find evidence for what I was saying rather than model validation. Well, we went ahead and when I finished one chapter I send it to 3 publishers got reply from 2 and one of them was willing to publish it- The Atlantic publishers (just grateful to those guys). We wrote our book for issues in Indian setting- example in sit to stand- deep knee flexion activities, in and out of an auto etc. Even though writing a book is such a pain it felt good when it was released 10-27-2013.    
If you want to read more about stroke rehabilitation with evidence and the underlying motor control and behavioural ideas-

AMAZON.IN
http://www.amazon.in/Stroke-Rehabilitation-Functional-Activity-Approach/dp/8126918543     

Or mail me: hariohm@hotmal.com         





Saturday, 24 October 2015

Should i be afraid- i dont know NDT


Lots of people think NDT or the Bobath approach is the pinnacle of rehabilitation model or the model for Neuro-rehabilitation.

Well is it true?
The simple answer is “no”. But because we have many people who think it is true and some even wear it proudly we will look into the long answer.
So we will start with the fundamental question- what and how was this method developed?
Well it was developed by one of a pioneering therapist in Europe along with her husband around the 1960s.

What was their basic premise?
They took cutting edge science of that time- mostly from Sherrington’s experiments and principles of neuro-physiology and along with it added their own ideas- from observation of cerebral palsy patients.

So what was their basic premise?
They say these children with UMN lesion and the one common denominator they could observe was – “Spasticity”. So they like many others in that time they considered this as the primary impairment and thought this is stopping the patient to move normally. They also tried analyzing the abnormal posture from reflex theoretical idea. (I would ask readers to read this book if you are interested in this kind of stuff- THE NORMAL POSTURAL REFLEX MECHANISM AND ITS DEVIATION IN CHILDREN WITH CEREBRAL PALSY- it was available in British council library  -last time I checked in the late 90s)
So one of the basic premises was “you can do normal movement on abnormal tone” – which was the held it dear even in hers last book- ADULT HEMIPLEGIA: EVALUATION AND TREATMENT in 1990. When I went and listened to this nonsense in 2003 they said the same thing.
What was the basic treatment technique?
Well people are going to go berserk (the followers I mean) for saying this-
Step I- you normalize the tone (ask me how and you need to pay me is still their motto) and next question is how?  Nothing extraordinary just holding in static postures- which they called RIP- reflex inhibiting postures and some other bull shit they called handling.  She gave little credence to “motor learning” like in the era where everything was based on bio-physiological model- she thought if you give appropriate sensory stimuli of normal movement s it will change the system.
What was her major influence in neuro-rehabilitation?
Apart from half educated people making money in her name- her contribution is in the recovery model. Brunstrom thought we have to work with the synergy and then break it later (normal movement) and formulated 6 stages of recovery- Bobath said if we reduce the tone then normal movement can be brought about and changed our thinking about recovery. There is never working with the synergy in Adult hemiplegia according to Bobath.

So what is wrong with it?
Well nothing! It just was not the complete picture of what a patient with UMN lesion is. They did not believe after many experiments- that there is anything called weakness in umn lesion. The operative word here is “believe” not proved or anything. Bobath herself was convinced at the end the aptly named RIP did not work and she said so in her last book.  Well the truth of the matter is she could never be right as she was in a different time. Even Newton was wrong, Arayabatta made a small error in calculation, people are questioning Einsteins quantum mechanics ideas- how can medicine be frozen in time.
Last and the most importantly- most of the studies done all around the world- as this was popular in Europe and Australia – and well they all said do anything else- when compared to bobath or NDT- both are equal. There goes 5000- 4 Lakhs in the toilet for people who studied this.

The newer argument:
The newer argument is very clever and it has all the markings of wonderful marketing by a resourceful pharma.
This is the new definition (anyone who can read the whole thing should get a price)- NDT is a holistic and interdisciplinary clinical practice model informed by current and evolving research that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological pathophysiology. Using the International Classification of Functioning, Disability and Health (ICF) model, the therapist applies a problem-solving approach to assess activity and participation to identify and prioritize relevant integrities and impairments as a basis for the establishment of achievable outcomes with clients and caregivers. An in-depth understanding of typical and atypical development, and expertise in analysis of postural control, movement, activity, and participation throughout the lifespan, form the basis for examination, evaluation, and intervention. Therapeutic handling, used during evaluation and intervention, consists of a dynamic reciprocal interaction between the client and therapist for activation of optimal sensorimotor processing, task performance, and skill acquisition for achievement of participation in meaningful activities.
(try writing the above paragragh in the exam for the answer what is NDT)

Well what is wrong you moron you ask me. The answer is that is not the definition of NDT that is the principle of rehabilitation not even neuro-rehabilitation. You can’t define your 2 bit nonsense as that of rehabilitation. For example if you ask what is task oriented approach- you simple say- you keep on doing the task as a whole rather than parts –something like that.  You don’t put a- 15 page definition so that no one can do any study in neuro-rehabilitation without being in your scope. If that is what you want then you should call it science not NDT.

Task oriented practice is NDT:
Well, that is physiotherapy not NDT.  The idea was developed by many people especially 2 Aussies- Shepard and carr (incidentally they also learnt Bobath) and researched by the whole world. (There are 2 wonderful studies from India if anyone wants to read). So you can’t call it yours and charge some poor sap- 2 lakh rupees.
We incorporate from all the new findings as NDT is fluid!
Of course, that is what every PT does- especially if you take the good and practice it is called EBM.  If you add evidence with some mumbo jumbo like handling, key points than it is called NDT and charged 2 lakhs. You don’t brand latest science in physics as Indian physics or European or cipla physics and sell it. you cant take latest finding in research and call it NDT- you should call it PT.

We are educating the masses what is wrong (genuinely there are some people who do that).

Well if you are propagating pseudoscience- I think it is a crime and unethical thing to do. Well any one with half a brain will not take medicine which is not good, then why teach things which don’t work.  So you are not educating the masses you are encouraging half educated nitwits from other country to exploit our novice PTs.
Some nitwits also think they have brought some experts from the land of science and they are doing a service to the society by teaching this nonsense for just 50 thousand. Really?   
How are these people surviving even after so many studies, so many criticism- well they find new ways to market old garbage as antique to gullible PTs.  We as a people have fascination with the word international, certified etc and this is exploited. Over this we have syllabus which still has these in the syllabus- if you ask the nitwits who are experts in academics will tell you- these are important traditions. Well physiotherapy student does not come to study history – they come to study science.

So what should an intelligent Therapist do?
Well it is fairly simple and it is free. Don’t worry about any technique. If someone says he/ she is certified NDT therapist- laugh at them for wasting their money.
Read simple task oriented approach literature or just remember if you want swim- dont go to the gym go to the pool- that in a nut shell is latest neuro-rehabilitation principle.

PS- no homer simpson quote- as the definition of NDT is enough for the joke


Wednesday, 7 October 2015

On cerebral palsy day PT the 10 things we should do:
1. Just come out our cult- whether it is NDT or SI and read science
2. remember there is no abnormal movements
3. well we cant change abnormal movements- but we can make them achieve there goals
4. Educate patients with level IV and V regarding accepting - wheelchair
5. keep you hands of pelvis and trunk and allow the patient to explore options
6. Posture correction -well if this is physiotherapy for children with cp- well just quit peadtrics
7. If you are putting the child in a dark room, binding them etc- well that is child abuse and you should be locked up
8. If you are encouraging kneeling for 15 minute or something- well you are a moron-stop practicing physiotherapy
9. for a child with sitting balance if you are treating the patient in lying or on a swiss ball- well quit or read
10. If you are one the morons who keep on asking me if not NDT what else is there - just read or do nothing- because NDT is as effective as doing nothing.

PS: please for god sake only uneducated people will be impressed if you are trained and certified in NDT

additional reading: 

A systematic review of interventions for children with cerebral palsy: state of the evidence.

http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12246/epdf