Recently, there has been no shortage in the peddling of structuralist misconceptions. Patients continue to fall prey to misguided efforts by healthcare workers to address their aches and pains. You see bizarre tendon lengthening surgeries, talk of ring shifts and sacral torsions. Worse than all of this, clinicians continue to fall prey to these delusions as well. They take courses taught by gurus with widespread acclaim, but little support for their actual claims. This is where we find ourselves in modern medicine–in the midst of an ever growing debate, discussion, argument (or worse) surrounding the the plausibility or lack thereof for such theories.
We tend to argue our points from research and “evidence.” Which tends to be met with other “research and evidence.” Some take more aggressive maneuvers to call out non-sense, but ultimately clinicians continue to choose to follow these misguided beliefs and practices. And it begs the modern philosophical question, Y tho? And what can we do to move our profession forward?
To understand our present situation, I think it helps to dig a bit into the past. There are surprising revelations in the origins of our structural obsessions, and it all starts with a revolutionary medical device. This device would transform medicine, and forever tie pathology to structure. This device was called…(drum roll)…”the cylinder.”*
What? Not that impressive? Maybe Rene Laennec was a bit off with such a name. Well, indeed he was. He realized the need for a sexy, new sounding name for the sexy new technology. He called it the “Stethoscope” (meaning chest scope). And since it’s inception, medicine has radically changed. For better or for worse.
Listening to the podcast 99% Invisible*, its very clear that this is where the origins of pathoanatomy lie. And subsequent to that, the emergence of structuralism and the biomedical model of healthcare.
A medical historian and physician Dr. Jacalyn Duffin is interviewed and her comments about the revolution following implementation of the stethoscope are striking:
“Doctors loved it. They felt that every disease could be attached to anatomical finding and an anatomical change.”
“Diseases went from being constellations of symptoms felt subjectively by the patient, to anatomical or chemical alterations in the body detected by the doctor.”
“Before the stethoscope, to be sick you had to feel sick. After the stethoscope, the doctor had to find something. It didn’t matter what the patient thought, it mattered more what the doctor found.” (emphasis added)
“…that we should somehow be able to image the pathological, anatomical abnormalities inside the body to reach a diagnosis. Whether the patient has any symptoms at all or not.” (emphasis added)*
Before the stethoscope, we were in a dark age of medicine. There was no way to know what was going on inside the human body. The stethoscope allowed physicians to peer past the veil and discover a new age of disease and pathology.
The podcast goes on to note that the paradigm shift brought on by the stethoscope has altered the patient-doctor relationship. Which is true. The host comments that the doctor no longer has to rely on a field of questions to arrive at a diagnosis, but simply rely on a “collection of data points” to reach a conclusion.
Its time for change. “It’s time to grow up.”
Two hundred years ago, this was okay. The advancement the stethoscope brought forth was life saving. The sad modern day reality, is that for many of those symptoms or clusters of symptoms viewed as whole diseases, we have reached the limits of what our instrumentation can provide (currently, at least). And today, this has been likely devastating for far too many patients. The shift towards pathoanatomical views in orthopedics has led to the development of surgical techniques which may well be viewed 50-100 years from now as no different than the barbarism of the surgical theater in the 1800’s. We have osteopathic, physical therapy, chiropractic professionals (among others) who have been unable to accept and view the nuance of pain and pathology that we as a human race deal with. This lack of critical thinking and quick judgment led to those same professionals creating a whole host of bizarre (obviously in hindsight) structuralist, pathoanatomical, and delusional conditions and ailments. (Which, by good fortune, were all usually followed with simple solutions.)
Advancements in medicine and science are hard fought and hard won. Nothing is simple, and usually, nothing is straight forward or as it seems at face value. The progression of medicine, especially orthopedics, into an exaggerated and extremist view of the effects of biomechanics on human structures leading to pain was not due to a lack of technology or the inherent complexity of the human anatomy and physiology, it wasdue to the human desire to simplify things and make them easy — for us, not the patient. It was, effectually, the path of least resistance for advancing our understanding and conceptual framework surrounding pain.
If we want to advance medicine, if we want to advance physical therapy, we need to abandon the reductionist tendencies we default to in our day to day lives. We need to embrace ambiguity, we need to need to question everything, and we need to realize we will be wrong.
The stethoscope is viewed as a revolutionary device by medical historians, and merely as a tool by modern doctors and healthcare workers. And most telling is the fact that most physicians find it unnecessary to practice, yet insist on having one handy to keep up appearances.* Old habits die hard, but we can’t wait for these postural-structural-biomechanical habits to die. We need to think more critically, to be more selfless in our efforts to progress and grow, and we need to think about the person we are helping instead oftrying to help ourselves.
“Our patients are not cars. And we are not mechanics.”
Its been almost three years since that piece was written as a blog for the BJSM, and I don’t see much evidence of decline in mechanic like thinking regarding the human body. There’s still far too many clinicians unaware of the newer research and concepts; most, if not all, are well intentioned. But we need to do better than that. Clinicians need to be willing to accept updated views, dismiss incorrect and firmly held beliefs, and move forward when research demonstrates futility with any intervention. Most of all, we need more people spreading and disseminating information.
-Spencer
Here are a couple of resources which should point to many more resources on the topic:
–Your Back is Not Out of Alignment
-The Science Behind Why Assessing and Blaming Posture for Pain is BS
–Palpation, is it a skill, an art or an illusion?
–Many Orthopedic Surgeries Don’t Work
*All credit goes to 99% Invisible and Dr. Jacalyn Duffin for their comments and ideas shared in this blog post.
PTbraintrust 
Really enjoyed this one, nice job.
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Let me describe something. It makes energy from oxidizing a carbon based fuel supply. To generate and use energy efficiently, the unit must maintain an optimal internal operating temperature. Our thing can move over the ground at various speeds. It has appendages to transmit power to the ground and determine the direction of travel. These appendages are adaptable. They can adjust how much power is transmitted to the ground and they can absorb shock. The appendages have joints. Each of the various joints has a specified type of motion. Our thing can do various types of work.
What have I described, a human body or your car? Both?
We know about bodies, but what about cars? A typical car burns hydrocarbons for power. To operate efficiently, there is a cooling system to keep the temperature fairly constant. An engine management system uses stoichiometry to keep air/fuel ratio at optimal. The transmission and differentials are made to keep the engine in a specified operating range while transmitting power to the ground through the axles and wheels. The suspension system is made up of many components. Control arms, ball joints, tie rods, springs, struts, bushings, shock absorbers, and the list goes on. The suspension adapts the car to the surface while applying the power to the ground. In a car, just like in a body, all of the parts need to work so that the whole system works. A flat tire is like back pain. A busted ball joint could be thought of as a twisted ankle. The “check engine light” is like a patient’s symptom.
Let me describe a person. You go to this person because you have symptoms of something not working correctly. This person listens to your description of your problem then performs various tests to determine what the problem may be and gives you options on what needs to be done for a solution. And, of course, a bill.
Am I talking about a healthcare professional or a mechanic?
What do we know about a mechanic? Flat tires and busted ball joints are fairly easy to diagnose and fix. What about when your car is running roughly and the check engine light is on. The mechanic, like a PT, goes through a methodical testing procedure to rule in or rule out what is going on. The first thing that the mechanic would do is “pull a code” with a scanner. For example, P0300 is a code for a misfire. There are more than a dozen things that can cause a misfire. Spark plugs, coil packs, fuel injector components, valve train or other engine parts could be faulty. There are specific tests for each component. The mechanic follows a flow chart usually starting with the simplest and/or most common problems and working towards more complex and expensive ones. With all of the different systems interacting with one another sometimes the actual fault is not where you would expect it to be. Google the P0300 code and read a few of the descriptions.
When a client hobbles into your clinic, are you not like a mechanic? We use codes. We do tests to rule in and rule out problems. We know that pain or another symptom in one part of the body may be caused by dysfunction somewhere else. Pain is like a misfire in your car. We have our tests. When we find the problem(s), hopefully it is in the realm of something that we can fix.
I tell most of my clients that they just need a tune up. I usually look for poorly recruited musculature and joint/segment mobility issues. Specific exercises and/or manual therapy are my tune up. Brian
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If any of you are bored over the holidays you can check out my exercise videos on Youtube.com. Just search for Brian Lambert, PT. Comments welcomed.
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