Marketing and the ATM2

I recently received an email titled "Keeping in touch from Steve", from an account titled "Steve Hoffman". As many of you probably got the same one. Here are some excerpts:

"Hi Jason,

I hope all is going well for you.

Coincidentally, I received with in the span of one day, the following two e-mails.  They are quite interesting as the first emphasizes the excitement clinicians experience when they first get their ATM2, and the second emphasizes the confidence clinicians have in the system, after years of seeing the same results over and over again.

I would love to hear your thoughts on this.  Please let me know.  Thanks."

Note the reference to "years of seeing the same [presumably good] results for years". Do you think there's any published evidence regarding the use of the ATM2? You'd probably not be surprised to know I couldn't find any. Even after years of results, huh?

Then there's this: "Only immediate and sustained functional results for back patients should be considered successful in today's competitive atmosphere."
What results would those be? Testimonials?

You might be asking why I chose to post this, as it is just another example of the rampant marketing of approaches occuring in our profession, and is not really different than the laser therapy discussions we've had previously (see "Laser Therapy Disappointment" and "More on Laser Therapy" posts).

I want to bring this up because I think both this and the laser therapy posts highlight the underlying problem: there is a fundamental ignorance about the origins of painful sensation, and a complete lack of interest in an intelligent theory of why something works in favor of some degree of "results".  In this case, even anecdotal and testimonial results.

I have looked at the ATM2 website, which is evidently www.backproject.com, and I cannot find an intelligent theory that underlies this approach, nor can I find any evidence of it's effectiveness, though there are some cool testimonials and pictures of famous people. Though personally, unless Santa Claus is on the faculty, I don't think I'll be buying one...

The "Research" page can be found at: http://www.backproject.com/research/research.html.

Any comments or thoughts on the ever-growing list of disparate and conflicting approaches in therapy today, which promote a "tool box" mentality and de-emphasize the need for a unifying theory of pain and dysfunction, and how to correct it. Or was Jules Rothstein right, and is Thoughtfulness dying in therapy today (editorial Physical Therapy) and is Understanding not in our tool box (editorial Physical Therapy 81, 2001)?

J

Comments

[mark boncser]

I have not heard of this device before but I would like to just make a general comment to those of you that continue to post on the blog. I really appreciate the time and effort you guys put in with your thoughts and passion for our profession. Thanks John, Larry, Rob, Jason and the rest of you which are to many to name. This is a great website that I look forward to everyday because you you bloggers are awesome!

[Carina Lowry]

J--

This looks like the newest gadget on the market today. I took a look at their research, and it looks like a nice pilot project with 8 subjects. The study with 79 subjects in California I couldn't locate. Maybe I just was looking in the wrong place. It would be nice to have a randomized controlled trial on this.

My biggest question though was not answered even with all the "testimonials". What was the inclusion criteria for these studies? How did they classify the patients to know that they would benefit from direction specific exercise? Isn't that what this machine does--puts a pt in relative relief of symptoms (ie direction specific or "relieving" position) and then they stabilize with that position.

The other question I had was about the statement that ROM may not be correlated with pain relief. Isn't the whole premise of this marketing: if we decrease the patient's pain, they will have more ROM? If this is true, they obsfucate their claims that support the use of their equipment. How is this good marketing??

Carina

[Peter Huijbregts]

Hi Jason and all others talking about this topic,

Just wanted to let you know that in the upcoming issue of the Journal of Manaul and Manipulative Therapy we are including the AAOMPT 2006 Conference Abstracts; one of the abstracts discusses a pilot study on the use of the ATM2 in 8 patients with low back pain and 8 asymptomatic patients. I am going to make the abstracts available full-text and free of charge on the journal website for all those interested.

And yes, I know that non-peer-reviewed pilot studies are not exactly high-level evidence but I just wanted to update you on the research efforts out there concerning this device... Even though I too was rather annoyed with this marketing method,

Peter

[cory blickenstaff]

Jason,

I have nothing to add to the discussion of this device in particular that hasn't already been said.

I would like to comment on your statement about the progation of the toolbox mentality however. This way of going about collecting another tool for the toolbox has always bothered me. To me it describes an attitude of "we'll go through the tools until we find the right one." Imagine if a dentist worked this way. "Well, I'm not sure what the problem was, but the the drill is what finally fixed it. Must have needed drilled." I don't think I would use such a dentist a second time. It is analogous to a clinician who, upon relieving someone's back pain with a manipulation, concludes that the problem had been a lack of manipulation. Therefore, recieving occasional manipulations as an adjustment should keep away back pain.

Now, I know that this is not the mentality that everyone has in mind when they mention the good ole toolbox. Therefore, I propose a new term: expanding the methodology, as a replacement. Or, maybe someone else has a better idea for a new term, just please lets find one.

[Rob Landel]

I've just had a similar experience with ASTYM (or ASTM, or the Graston Technique, they may all be one and the same, I can't tell (and don't really care), although there's a possiblility there's a spitting war going on between these people). For some reason it keeps popping up on my radar. Last month a clinician who has one of our students started bugging me about why we don’t teach ASTYM at USC, next I open up the current issue of Orthopedic Practice only to find a very funky article on Graston Technique, and other occurrences as well (including, if I'm not mistaken, an ad on this blog?). What gives?

My initial inclination is to resist teaching it because they won’t let you teach it unless you take their courses and become certified; or, another group won’t let anyone teach it but them. What a bunch of hooey! I’m not bowing to anyone who holds information hostage. And the nerve of them, to say it’s some new technique! As far as I can tell, it’s good old STM repackaged, this time around using metal tools. The OP article actually capitalizes the word Instruments, elevating these tools to the status of nations (as in, America), continents (North America), heads of state (Prime Minister), planets (Pluto--oops!), and deities. I'm old enough to remember that Rolfing was around before STM; I’m sure something else preceded Rolfing (maybe snake oil).

This stuff seems like STM using tools. Don't ask me how these Tools were so carefully crafted that They became Instruments; apparently there is something inherent in the Shapes of the Instruments that makes Them better than using manual contacts. I'll never know, because the only way to buy Them is to take a course.

Don't get me wrong; I'd buy Them in a second if They were made out of crystals, shaped like pyramids, and magnetized. (Geez, is there any way to get a laser to pop out of that thing?)

Part of me wants to say, Hey, whatever: buyer beware; just don't expect me to buy, today or ever. But then, there's the unsuspecting patient: do I owe them the favor of exposing frauds? And what about my reputation: do I want to be lumped together with the suckers who do buy in? Yes to the first, No to the second. I'd like to hear what others think.

Rob L

[John Ware]

Theories and the tools or "methods" that accompany them are a-plenty in our field. Tested theories with proven tools are scarce, however. I think that is why we so frequently encounter the "latest and greatest" technique du jour. Strangley, it seems the more esoteric the explanation for the efficacy of the given technique du jour (e.g. MFR, craniosacral, manipulation to restore "nerve flow") the more willing many of us are to pay money to "learn" it. It reminds me of a poster that hung in my garage when I was a kid. It was a list of Murphy's Laws. The relevant "Law" in this case: Tell someone there are a billion stars in the sky and he'll believe you, tell him the paint is wet on a bench and he'll touch it first to make sure."
John

[Jason Silvernail]

Rob-
Amen. I agree with everything you said, and totally agree on your take on the latest family of soft tissue mobilization "Instruments/ Tools/ Miracle Workers".
Perhaps a closer examination of the theory behind the idea of soft tissue mobilization (I'm on board for tendonopathy, but not convinced on anything else) might be helpful. I think that deserves it's own post.

John W-
I think you got it exactly right about the wet paint thing, people do just want to sample or try things for themselves.

However, all types of these approaches have varying commercial (some would say clinical as well) success. Here's my question then, to add as a corollary to Cory's: if all these different approaches are supposedly needed in therapy today, doesn't that mean that we really don't understand the nature and origin of pain and it's relevant physiology?

Remember the old quote "When many cures are offered for a disease, it means the disease is not curable?"
To apply this to therapy, this means that either:
a. therapists don't know what the essential problem is OR
b. the essential problem can possibly be addressed by many means, but as a profession we haven't been interested in determining which is best

I'm not too happy with either option.

J

[Steve Hoffman]

My name is Steve Hoffman and it was me that sent Jason the e-mail that instigated his initiation of this subject.

Normally I would not post to a clinician-based group, as I am not a clinician, but since you are writing about the ATM2 (and me), I feel it only fair for me to post this response.

I am quite surprised that the e-mail Jason received from me got him to post the message he did, as the main point of that e-mail was to share with him what two individual clinicians wrote about their personal experience with their ATM2. These are not young, in-experienced clinicians. Combined, they have 73 years of experience. Other very-experienced clinicians that have endorsed the system include Brian Mulligan, Don Chu, Sharon Weiselfish and Sandy Burkart to name just a few. All the above have PT, PhD after their names except for Brian Mulligan who is considered one of the seven most influential clinicians in the world according to a survey done by Advance Magazine. No body has ever received a dime from us in return for a recommendation, testimonial or endorsement. They are not doing this to help the manufacturer but rather as a courtesy to their fellow clinicians and for the benefit of all patients that their clinicians have access to this system. Don’t believe me. Ask them directly.

Our website (www.BackProject.com) has a ton of information explaining exactly how the concept works. It also includes a 6-hour CEU approved (by TPTA, NATA & TCA) course (http://education.backproject.com), which answered many of the question, issues and mis-conceptions raised by others.

For those that do not have the time, here is a 30 second explanation of how the ATM2 works:
1. By combining joint repositioning (similar to the Mulligan Concept), with compression (similar to the ASLR test), almost all movement impairments can be normalized with in minutes.
2. The restoration of normal movement is an indicator that the CNS has completely transitioned from a pathological muscle activation pattern to a normal muscle activation pattern.
3. Combining active movements in the neutral range, in a functional, weight bearing position, against an isometric resistance, causes the CNS to memorize the normal muscle activation pattern.
4. Almost all patients will benefit from the ATM2.

Jason and other responders raised many other points, and although it is appropriate to respond to every one of them, I will not at this point, as they were written with out much knowledge of the principals behind the ATM. So please, study our website and I will be glad to answer any questions, concerns or objections any one wants to raise.

Kind Regards,

Steve Hoffman

[Jason Silvernail]

Hi Steve-

Thanks for posting to the blog. I know you're not a clinician, and I appreciate your effort in posting and explanation.

Unfortunately, the points you bring up in your 30 second explantion raise more questions than I even had before.
For example, you stated, "The restoration of normal movement is an indicator that the CNS has completely transitioned from a pathological muscle activation pattern to a normal muscle activation pattern."

Boy, that sounds cool. Unfortunately, it doesn't make any sense.

How does the CNS "transition" from one thing to the next? What is a "pathological muscle activation pattern?" How do I know that my patient's CNS is in such a pattern? This statement of explanation flies in the face of what we know about the motor control of movement. In other words, the existing basic science conflicts with this theory. So, either the science is wrong, or the ATMs theory is wrong. I think you can probably guess which way I'm leaning.

It's probably not fair for me to ask you to engage in a debate about pain and neuroscience if you're not a clinician. I'm sure I would be similarly uninformed were I to try to talk to you about your area of expertise. I wonder, is there anyone in the ATM organization, who might like to post to the blog and discuss some of the concepts?

It would be a great way to educate many therapists interested in science, evidence, and outcomes. If the arguments and theory are persuasive, you may find yourself with some sales as well. What do you say?
Thanks for your time.
Jason.

[Steve Hoffman]

Thank you very much for your kind response. I would like to point out that Cyriax once said that clinicians should not withhold a treatment just because they do not know why it works.

Here are two points to prove that the ATM2 works:
1. No body, including the high profile, international PT/Educators that I listed in my previous posting would risk their reputation to help in the sales of a commercial product, unless they knew that it works or they were paid to do so. Since no body has received anything in return for their endorsement, you can trust that they stand behind what they say.
2. We provide a 100% money back guarantee that the ATM2 works as we state. If this were not the case, we would have been out of business a long time ago.

Following is an e-mail I received yesterday from the Oakland Raiders NFL team: “Hi Steve, I too have a high degree of confidence in our ability to help patients gain pain free movement with the ATM2. I wish I could explain with 100% certainty why it works, but it really doesn’t matter because I know it does help us. We continue to use it and see great results. Hope you are well. Scott.”

While we continue to discuss the “why it works?”, please get an ATM2 in to your clinic, so you can see the results first hand. Remember, most new concept do not evolve from the research lab, but rather from the clinic and only later on they are substantiated in the lab.

Following are replies to your specific questions:
How does the CNS "transition" from one thing to the next?
First of all, when you reposition and compress a particular body area such as the pelvis, the CNS will change the muscle activation patterns every single time with everybody. You do not need mountains of double blind, peer reviewed & published research to know this. All you need is a hand held sEMG device to see it for your self every time you do it. The reason this happens is very simple; the CNS detects the external stabilization and so it figuratively says to itself: “aha, there is external stabilization, so I do not have to stabilize”, and so it simply relaxes those muscles that are stabilized. Just as an example, lets say we have a patient with low back pain while she bends forward. Typically, people with low back pain are going to have elevated muscle activity in that same region for whatever reason. It could be guarding, compensation or even something else. Whatever the reason is, the fact remains that they have elevated muscle activity in that region. If you were to ask that patient to bend forward, the CNS will have a little problem as many of its muscles are going to be pre-occupied with the increased muscle activity that comes with pain. Once you provide external stabilization using the ATM2 belts, and the CNS relaxes those muscles, then now when you ask the patient to bend forward, the CNS will have all of its muscles available for the task at hand and thus it can transition to a different muscle activation pattern that is more efficient and pain-free. There are other things that are going on but I will leave the description of these other things for another posting if requested.

What is a "pathological muscle activation pattern?"
Obviously we cannot see a person’s muscle activation patterns. Even if we could, it would be way too complex for our cognitive brains to disciple this. So we have taken the approach that when there is pain in movement or limited ROM, then there is a pathological muscle activation pattern. I believe that there is plenty of double blind, peer-reviewed and published research to support this.

How do I know that my patient's CNS is in such a pattern?
Once again, if there is pain in movement or even just limited range of motion, you can assume it is a pathological muscle activation pattern.

Please let me know if you have any further questions.

Steve.

[John Ware]

Steve,
I've seen the ATM2 in action at an AAOMPT conference recently, so I have some idea of how it works. I think you're going out on a limb by stating that "the CNS will have all of its muscles available for the task at hand" resulting in a "more efficient" muscle activation pattern. Certainly, the increase in pain free motion can be easily observed, but you would have to design some elaborate research designs,if that's even possible, to show that these changes in activation patterns result in "more efficient" use of "all the available muscles." More importantly, though, is the question of whether the device actually provides additional benefit in the clinic to improving outcomes for patients with spinal conditions. That is a relatively simple research design- and one I have not seen published in any peer reviewed journal.

I think it's misleading to state that Brian Mulligan has nothing to gain by endorsing your product. Your machine blends well with his mobilization with movement approach and, therefore, adds a "tool" for implementing the techniques he has pioneered over the last couple of decades- and for which he receives income to teach all over the world. I can't speak to the other PT, PhD's that you mention, other than to note that they have very high name recognition for all of their product endorsing (I wish I could get my name on thousands of product brochures sent to PT's all over the world.) By the way, I'm not saying that there's anything wrong with trying to achieve name recognition, nor am I implying that your machine might not be the best thing since sliced bread. But, you really need to prove it before you come onto this blog with your glittering PT personalities and bold statements of scientific fact without the science to back it up. This blog will eat your lunch.
John

[Steve Hoffman]

Thank you very much for your reply.

1. An ATM2 pilot study done by California State University in Sacramento, will be presented at the upcoming AAOMPT meeting.

2. Knowledge of how the body works and why it works is still in its infancy, and it is uncertain that any one person has the whole answer. That is why we must listen to all clinicians questing to solve the mystery of pain and particularly how backs and back pain responds to what we can do with conservative care.

3. As mentioned in my last response, James Cyriax, M.D. at St. Thomas’ Hospital in England, is the acknowledged father of physical medicine, as we know it. He has said many times that clinicians should not withhold a treatment just because the mechanism of how it works is not clear or unknown.

4. Nobody, including yourselves and especially high profile international physical therapy educators would risk their reputation to help in the sales of a commercial product unless they are satisfied by personal use, observation and experience, that it does what it claims with regard to reducing pain and improving mobility. The ATM2 manufacturer does not pay for endorsements.

5. We provide a 100% money back guarantee that the ATM2 works along the principles I have stated. If this were a placebo effect only, we would have been out of business a long time ago.

6. While we continue to discuss “why it works” condemning it out of hand with no personal experience is unscientific. Using an ATM2 personally (in your clinic) would let you see the kind of effect it is capable of firsthand. Most new concepts do not evolve from the research lab, but, rather, from the clinic and the clinicians reporting similar finding, which only later are likely to be substantiated in the lab.

7. I will finish off here with providing you with a copy of one of many testimonials I receive on a regular basis. This one is from an orthopedic Manual Physical Therapist with 4-5 years experience in using an ATM2:

----------------------- Original Message -----------------------
From: Jonathan Flores
To: Steve Hoffman
Date: Mon, 11 Sep 2006 04:52:32 -0700 (PDT)

I have been using the ATM2 for the past 4-5 years and have been very pleased with its results clinically. I have used the device for several different musculoskeletal and neurological dysfunctions. It has been a very effective approach with my very difficult patients and has been a very effective marketing tool in my competitive area. I have patients walking in my door asking me about the “HUGS” machine (the ATM2 feel like someone hugging you). Many patients have tried multiple physical therapy interventions that have failed and this device gives them the motivation to continue with this modern physical therapy technique. I have estimated that I have provided at least 40 treatments a week using this device for the past 4-5 years and have continued to get excellent outcomes. As you use the ATM2 consistently, you will be able to select the appropriate movement patterns that will assist you in your treatment plan of care. The ATM2 device is a very effective device that enables you to provide a skillful treatment in a functional standing position. We do most of our activities of the daily living in a standing position and not a supine position (using a plinth for treatment). In addition, I have also provided treatment with physicians, orthopedic surgeons, and professors in health care who have all been amazed how the ATM2 can localize movement patterns, improve neurological postural awareness, and have immediate results. Overall, the ATM2 is an effective approach to treating multiple musculoskeletal and neurological dysfunctions in a safe and functional way which can give your clients immediate pain-free results.
Respectfully, Jonathan G. Flores, PT
---- END OF EMAIL ----

I look forward to hearing back from you,

Steve.

[Selena Horner]

Steve,

From Peter above, "non-peer-reviewed pilot studies are not exactly high-level evidence."

Cyriax is being quoted, but what was the rest of the context of that quote? Was he speaking about something that DID have proven outcomes? If something has proven outcomes, then definitely, one should not necessarily withhold a treatment because the mechanisms of how or why are unknown. Is ATM2 proven? Once something has proven outcomes, then Cyriax's quote is a nice argument, until then it sounds more like a sales pitch.

In your number 4... I'm just going to laugh. Yes, people risk their reputations every day. There must be some motivating factor for a high profile clinician to endorse a product that has no proven outcomes. The days of buying something because someone says it works are becoming history. Now, if George Clooney said it worked THAT would be a different story!

5. Technically, you should be giving all the money back - per your #1 knowledge of how the body works and why it works are in its infancy, so how are you so positive that ATM2 DOES work along the principles you have stated? Along with, does it work?

#6. You're not on the same page as everyone else from my interpretation of reading what has been posted. The first and foremost question is DOES it work? Are there favorable outcomes with a defined patient population? What was measured to determine improvement and how much improvement occurred? What a view to believe that the total responsibility for providing outcomes for a product rests on the shoulders of clinicians and not with the manufacturing company. And, not just any clinicians for proof that it works, but the actual customers that purchase the product... thanks for that responsibility. Since you have high profile educators, how come they aren't interested in spearheading some outcome data?

#7... yeah, another testimonial. Steve, you need more than testimonials.

[Jason Silvernail]

Steve-
Thanks for your participation. I actually don't dispute the success of your device, and I agree that we shouldn't withhold a treatment just because it can't be fully explained. We should withhold a treatment, however, if it makes no sense or we have reason to believe the effect is placebo only. I'm not referring to your device specifically, just making a general statement.

However, I'm more interested in seeing a coherent, plausible theory that explains efficacy in a way consistent with what we know of human physiology. I can't find that on the ATM site, and your explanations, while interesting reading, are not scientifically accurate. You mentioned you're not a clinician, so I forgive that. Is there a clinical person in the ATM2 organization that can have a dialogue with us? Are they interested in coming here to talk? As I mentioned before, if it makes good sense, you could probably sell a lot more units...

J

[John Ware]

Steve,
What I'm saying is that your coming off as a propagandist trying to hawk a product, not an honest and straightforward inventor/entrepreneur trying to get his machine to market. You may very well be the latter, but your non-factual and inconsistent statements about what your product does or does not do offends my skeptical nature-along with apparently several of my colleagues. We don't need any more "snake oil" salesmen in our midst. Ours is a profession struggling to gain recognition as a leader in evidenced-based practice. I'm frankly tired of sifting through all the bogus claims of efficacy by people trying to hawk their "holy grail." Again, DOES IT WORK. Your saying it does with fancy words and long lists of names doesn't make it so. I don't mean to be rude, but put up or shut up.
John

[Steve Hoffman]

At this rate, we could go back and forth many times, so unless something new comes up, I will leave this blog with the following final comments:

1. I already explained how the ATM Concept works. If you have specific questions I will answer them. If it does not make sense to you, let me know what part is not clear and I will explain it in a different way.

2. Hundreds of clinicians have reported that the ATM2 provides immediate and long-lasting results. One study done in Australia concluded: “The manufacturer’s claim for immediate results has been substantiated”. Another study in Northern California stated that the number of treatments to resolution was reduced from 10.7 to 5. There are several other studies and of course you can find faults in these studies, just like you can find faults in any study.

3. Why don’t you just ask your next patient that has persistent back pain and that you were not able to help, if he or she would like to just try a new treatment that hundreds of clinicians have reported provides safe, immediate and long-lasting results?

4. We all are on the same side of the table. We all care about the patients and we all want to do everything we can to help them. And as much as we all would prefer to offer free services/products to help the unfortunate people with pain, neither of us could continue doing what we do with out making a living from it.

Following is a copy of an e-mail I just got from Brian Mulligan himself regarding the comments made in this blog. No matter what you say, he is the one that was voted one of the seven most influential Physical Therapist in the world, in a survey published by Advance News Magazine. Over the years, many companies have solicited him to endorse their products, in return for very large compensations. The ATM2 is the first device he ever endorsed and with out any compensation.

In his latest book Brian Mulligan wrote: "This incredible apparatus [the ATM2] enhanced my ability to treat the lumbar spine. When indicated it is instantly beneficial and results are gained without pain.”

----------------------- Original Message -----------------------
From: Brian Mulligan
To: Steve Hoffman
Date: Fri, 15 Sep 2006 12:25:16 +1200
Subject: Hang in there.

Dear Steve,

It takes time for concepts or whatever that we know work to be vindicated. It has taken twenty years for me to at last have scientific articles supporting my work. Three great ones this year. Hang in there. Time will overcome your difficulties. ATM2 works and that is the main point.
Let the clever ones prove it. They will eventually.

Be good
Cheers

Brian

[Selena Horner]

Steve, I'm curious as to why Brian just doesn't pop on and post? Since he's following along, and he is a clinician, why doesn't he feel motivated enough to take the heat from you and assist in a dialog about a product that works? Of course, I'm not expecting a response because my question can't be answered.

Could you reference the Australian study?

[Jason Silvernail]

Thanks for continuing to post, Steve. It's a shame that no clinician in your organization is interested in posting.

The explanation that you proffer for the success of the ATM2 is flawed, it doesn't make sense. I'm sure I could go into a discussion of the motor control of movement and neuroscience and explain to you why your explanation is not correct, but you did mention you're not a clinician, so I didn't want to seem superior. But you asked. So here we go.

We know that to have a motor output, that feed-forward control is important, and that the motor output is specific to the task, situation, position, kinematics, and kinetics of the required task. I'm just not sure how using the ATM2 provides the proper cues for feedforward control since the task is performed in a contrived nonfunctional environment (ie strapped to the device). I'm also not sure how whatever success is had inside this device can translate to a totally different environment with different cues and different kinematics, kinetics, and context. This is just a start. There is quite a bit of literature out there on motor control to peruse to support my points, but I think you'll find a succinct summary here: Motor control and the management of musculoskeletal dysfunction. Manual Therapy, vol 11, no 3, August 2006, pp 208-213.

I have used Brian Mulligan's techniques in the past. I'm sure they do work on some patients (i've seen this myself), just as I'm sure your ATM2 device will work for some patients. However, neither the ATM2 nor Brian Mulligan's techniques work for the reason you and he say they do, as I've covered earlier. This is important because only a sensible theory can unify the varied approaches we see in therapy today.

And again, I'm going under the assumption that you're a nice guy who only wants good things for patients through your device. I can respect that, and I can respect you. However, the proliferation of techniques and approaches in therapy which don't have a sound underlying theory isn't good for the profession or most of all, for patients.

If we're really out to help patients, and I'm sure you're on my side here, we need to reduce the practice variation that comes from treating patients with approaches and techniques which have no plausible underyling theory and/or no solid outcome studies behind them. Wouldn't you agree?
J

ps Here's another email I got today from Santa Claus, telling me about my posts:
------Original Message-----
From: Santa Claus
To: Jason Silvernail
Date: 18 September 1100 hrs GMT
Subject: I'm Checking it Twice!

Jason-
You've been a very good boy this year, and your posts on Evidence in Motion just get better. You are without a doubt, the smartest man in history. You are headed for a brand new bicycle and a train set for Christmas this year. Great work, keep it up.

Santa.

[Sebastian Asselbergs]

Jason, Santa was just making you feel better...

Steve, I have to agree with the previous concerns and questions: when you look at #2 in your last post: "Hundreds of clinicians have reported"

You need to understand that this is not even close to convincing evidence of any kind. You will find thousands of Therapeutic Touch practitioners who will testify that their technique has been enormously successful. Does not mean a thing.

Then you state that "number of treatments to resolution was reduced from 10.7 to 5" in a study. What was the unit compared to? What were they doing with those patients before? What was the common diagnosis of those patients?

Trying to answer these questions should help a bit in developing an idea of what is needed to make a convincing argument about outcomes.

Central to the issue remains "correcting" human motion dysfunction with an external device.

I wish you well in your endeavours. I think you won't find many buyers here....

[Bubba Klostermann OT, CVE, CEAS, CEO WORK & REHAB, Abilene, Texas]

I have been in practice for 30 years and for the past 16 years have been in private practice and employ PT's and OT,CHT's with up to 31 years experience. We have looked at the ATM for 2 years now and attended 2 CEU courses on it and decided that we would try it. We have been renting this unit for the past 3 weeks. Steve Hoffman last came to Abilene last week to do some training for us and our local PT School who also have an ATM. We have been very pleased so far with the results and it has allowed us to work with a number of pts. in a more controlled, functional position. We strongly believe in objective measurements and outcomes and we are beginning a research project with the local PT School on how the ATM can impact motion, pain,and length of carryover for a number of different diagnoses. Watching the reactions to Steve's comments made me want to comment. As for me and my staff,we enjoy trying just about anything on our patients that can accomplish our goals. We don't feel the need to have every peer reviewed study out there before we feel good about trying something that may or may not work. Plus, what works for one patient does not always work for another.

Oh, by the way, I was one of two clinicians who sent an email to Steve about having the unit only a few hours and had great success with a patient who was able to return to his regular duty job without pain. Obviously, the ATM alone was not the answer, but we sure did make faster progress once we had access to it.

With that, I will close with a summary of my thoughts about some of the comments sent to Steve about the ATM:

No matter what information or data Steve puts on this website about the ATM, it is obvious that nothing will ever be good enough for some of you. I find it interesting that apparently you base every moment of every day that you treat patients on peer reviewed, researched based techniques that someone else developed. I wonder how those techniques and that whole process got started? Also, I find it unfortunate that you use Santa Claus with your sarcasm. As for me and millions of others Santa Claus has brought joy and pleasure to millions over the years, even if it is for a moment, who otherwise would be in pain of some sort.

[Sebastian Asselbergs]

"No matter what information or data Steve puts on this website about the ATM, it is obvious that nothing will ever be good enough for some of you."

Sorry, but I have not seen ANY more than hearsay, personal endorsements and anecdotal evidence. This is NOT good enough for me. And I have been in PT for 23 years now. So, for you to assume that "nothing is good enough", is flat out incorrect. Nothing "good" has been presented thus far.

A RCT is NOT immediately necessary - but a sound theoretically plausible foundation, based on established anatomical, neurophysiological and neuromuscular knowledge is essential to make at least a start. It seems to lack that.

Your comments about the origins of "techniques" tell a lot: in this context, it can be deduced that you approve of any technique "as long as it helps" and the research will come later.

And that is precisely what our profession does NOT need.

[Steve Hoffman]

Has anybody in this group taken (and completed) the online ATM Concept course?

If not, you are welcome to do so.

To sign up to the course, go to:
http://education.backproject.com

[John Ware]

Hey Bubba,
I would sure appreciate it if you could get someone on your ample staff to write up a case report on that pt who got "faster" results on the ATM2. It would be interesting to know how you measured "faster." It would be interesting to know what his diagnosis was. It would be interesting to see anything-other than glossy brochures-published on this device.

Finally, Do I have to be in pain to enjoy Santa?
John

[Jason Silvernail]

Ditto what John W said.

Bubba- you state, "As for me and my staff,we enjoy trying just about anything on our patients that can accomplish our goals. We don't feel the need to have every peer reviewed study out there before we feel good about trying something that may or may not work. Plus, what works for one patient does not always work for another."

This statement admits fundamental ignorance about the physiology of pain. Most aspects of the painful experience have been explained through modern neuroscience. If you and your staff are ignorant of the relevant foundational science, I'm sure you WILL try just about anything. This issue of "trying anything that might help" is at the root of unnecessary practice variation, it is the empiricist argument and in fact is the basis of alternative (read: quack) medicine. Is this really the group you want to practice like?

If I said I heard that singing a christmas carol to someone helped a few of my patients, would you immediately try that as well? It might help, right? Why not?

We don't actually require an RCT. We do actually require a sound theory underlying it's mechanism of action. It doesn't have to have a lot of outcomes behind it, but it has to at least make sense! If it doesn't, then aren't we just offering patients the placebo effect?

Keep in mind that those who point out the flaws in the approach should not be considered the enemy, but rather as friends who want to improve the approach and the science. The world of true science is rough. There's lots of arguments and people get their ideas challenged. Those on this blog are trying to change the sort of "tea party" atmosphere that therapy continues to foster. Everything is NOT okay. You can't just treat patients with ANYTHING you want to. We demand biologic plausibility and a logical, defendable theory at least. The ATM2 doesn't seem to have that.

J

[Jason Silvernail]

For more on the empiricist argument that I mentioned, read here:
http://barrettdorko.com/articles/no_deep_model.htm

J