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  • #16
    From KeithP's FB Page
    October 17. 2014

    LINK (Public, should be avail to all)
    Initial replies included -

    Originally posted by Keith
    what about Mrs Smith who is 40-years-old and wants to get in better shape. She wants to move better. She wants to feel better. She visits a facility and gets to work with a trainer, but is also evaluated by a therapist who discovers (gasp!) asymmetries and postural anomalies that MAY - according to the PT - increase the risk of pain or injury. But here are some exercises to help...Help what? With the aim of what? To what end is the profession willing to chase asymmetries in the name of injury prevention? What seeds are we planting (cognitively) in such an individual?
    Doesn't this have the potential to be as wrong as telling someone to sit/stand with a flat back to avoid LBP/injury? 20 years ago, that made sense. Is there a possibility that such an approach (as well meaning as it may be) could have nocebic and iatrogenic effects 20-years down the line?
    I simply have my reservations about our profession spreading its arms to include more interactions with the healthy (with limited evidence) when we have a long way before we conquer the stuff we are already supposed to have mastered with those who are considered unhealthy (and haven't).
    Originally posted by Kyle
    So, in short. What do you want to do? What's been a problem? Ever been injured/pain? Where? Here is what pain is. Here are some activity recs for you. Here are the benefits of moving. Here's why you are safe. Please feel more empowered and increase your locus of control. You likely don't need much of me (unless you do)...Overall, I think this could be quite powerful for 2 reasons. We have an epidemic of pain and chronic pain. So, let's educate people about pain. Second, we have a population that moves and exercises much too infrequently and not intensely enough. Changing those two things even minutely could have robust population effects. Rationale, general advice on pain and movement are needed, and likely low risk.
    Originally posted by Jason
    while we are wringing our hands about the muscle imbalances one of our well trained and science based based colleagues in PT might tell someone about while they are getting them moving, check Medscape today (17 October 2014) for an article about using statin drugs for primary prevention of cardiovascular disease which carries a 1 in 30 risk of myopathy as well as other health risks. Or let's check the evidence and risk:benefit:cost ratios for the elective orthopedic surgeries commonly used without so much as a "trial" of PT. Or let's check the adverse events of NSAIDs that people are swallowing by the bucketful to manage their chronic aches and pains, many of which can be alleviated with a short low cost low risk episode of care by a physical therapist...We need to pop this bubble of self referential hand wringing about every little thing a colleague might say that we don't agree, with and start seeing the big picture of where we fit and can have an impact in health care.
    Originally posted by John
    The gyrations outpatient practices are resorting to in an effort to get paid in a shrinking reimbursement environment have gone from the sublime to the ridiculous- with all the counting of treatment minutes, arbitrary compartmentalization of the therapeutic encounter, and strategic scheduling based on payer source. The problem is no longer the patient who is seeking pain relief, reduced reliance on medications, increased activity/movement, and prevention of surgery; rather, it's finding the most effective ways to extract payment from the patient's insurance company, which is often the government.
    Originally posted by Rod
    Having experienced both elements of this scenario (clinical and fitness/conditioning) I completely understand John's concerns. At the same time, Jason's remarks make it clear (to me at least) that there is a defensible case for dropping a well-trained and thoughtful professional into a preventive (better - risk management) or wellness setting. Of course, I'd be much more supportive of such initiatives if we (physical therapists) were less apt to embrace silly treatment approaches and had a better understanding of exercise science. If those things were to happen, we could have a significant and positive impact on a lot of lives IMHO. If thoughtless and poorly-trained people are placed in such a role, over medicalization will likely remain a big problem.
    Originally posted by Patrick
    When Keith asked "To what end is the profession willing to chase asymmetries in the name of injury prevention? What seeds are we planting (cognitively) in such an individual?" I think that to the extent asymmetries are explained as a biomechanical manifestation of genetic inheritance, "defense" and "defect", we can minimize the creation or promulgation of unhelpful cognitions re the relationship between current state of posture/symmetry and future risk for injury/pain.
    It goes on for a bit - some wonderful contributions by passionate, thinking therapists.

    Blog: Keith's Korner
    Twitter: @18mmPT


    • #17
      November 2014
      Jason Silvernail's page

      I linked to Adam Meakins' "A change in perception" blog entry on his opinion of manual therapy and people who use it ('joint pushers').

      Some excerpts:

      Jason Silvernail I agree with him that using outdated explanations and passive care is a bad idea. Literature reviews have demonstrated that active care involving patient education and exercise therapy gets better results than passive care such as manual treatment or modality treatment (like ultrasound, heat or Estim) alone.

      Anyone using outdated explanations that might create nocebo for their patients should be called out, regardless of what method they use.
      Jason Silvernail But I can't agree with what I perceive as a constant stream of material creating straw men on this issue. He seems to want to portray this approach in the most-indefensible terms and then condemn it with a broad stroke. That's the definition of 'straw man'.
      Jason Silvernail There is a significant body of research in physical medicine demonstrating the value of what I and many others call 'a manual therapy approach.' This is a complex, multimodal treatment that is heavy on active exercise and accurate patient education. In response to a broad dismissal of manual therapy a few years ago by Robin McKenzie, I wrote this response editorial in a journal that applies as much here as it did there:
      [full text at the above link]
      Adam Meakins Thanks for sharing my 'rant' Jason Silvernail and glad it has stirred the grey matter a a little bit... But... Theres always a but... I'm a little confused as to why you think I am or have created a straw man argument and why you think I condemn all manual therapy, I don't say or imply this.

      My rant is solely on the language and explanations used in and around manual therapy, as I state in the blog, I have seen manual therapy help people in pain and distress, and I do use it form time to time, this isnt a broad dismal of manual therapy. I think you have misinterpreted what I am trying to get across, not lets NOT use manual therapy rather lets change our explanations, nothing more... Yet... Thats the next blog... ;0)
      Adam Meakins Also the blog doesn't state that ALL manual therapists use these outdated structural biomedical terms and explanations just MANY... I know many of the SomaSimples therapists and others all excellent and great manual therapists who use sound rationale terms, i am not trying to preach to the converted, rather reach out to some others
      Jason Silvernail "Hate is a very strong word, but simply put, I hate manual therapy. I hate it for the way it is over used, over hyped and over complicated. I hate it for being surrounded by myths, fallacy's and complete and utter bull shit. I hate it for promising much and delivering little. I hate it for cheating me and millions of others with false beliefs and explanations."

      I don't know how I could have misinterpreted this paragraph, Adam.
      Jason Silvernail Nonspecific effects such as 'a change in perception' is only one of manual therapy's proposed effects - descending inhibition, reduction of afferent nociceptive signalling, and other mechanisms are there as well. Though it might very well all be nothing more than nonspecific effects - we don't know. You don't know either.
      Adam Meakins Come on Jason you can't take one paragraph in isolation, now who creating a straw man, what does the paragraph below state, put them together and now how does it read, slightly more balanced!

      And ur right I dont know the whole story of what manual therapy does, again I don't say I do, another straw Man U are making, but the evidence is pretty damming against any structural or mechanical effects I'd say!
      Jason Silvernail You don't say you do? You list one of several options and don't discuss others. You do not use the word 'only' but you provide one explanation. Words mean things.

      We all agree outdated explanations have to go. I've written many times on this issue, as have others. But when you take a complicated topic and oversimplify it while saying you hate it then don't act surprised when people push back.

      I feel like every few weeks you come out with one of these rants about manipulative therapy, and then slowly retreat to more defensible ground after pushback from your colleagues on your oversimplifications. I would think that after a few of those experiences, you would learn to mention the positive evidence or the complexity of the issue. I suppose that's hard to do when you 'hate' something.
      Adam Meakins Whoa...easy tiger, let's try keep things personable and not get into the you seem to... Thingy's can be interpreted wrong way if I was the sensitive type!

      This rant is an opinion piece its my catharsis, and I don't get surprised when manual therapists push back, I enjoy it! And I certainly dont think I retreat, I am well aware strong opinions will attract strong comments, its all part of the process of debate and discussion!

      I will say it again, I hate the BS and false promises that MANY not ALL make around manual therapy, I do not hate manual therapy per se, as I have stated in my blog I have seen it help people!

      It seems that many manual therapist take the criticism of manual therapy way too seriously and to heart and just don't want to accept that some therapists use it little or not at all, its personal choice at the end of the day, mine is manual therapy offers little but is not to be ignored or negated completely, that's the crux


      Jason Silvernail I'm not taking anything 'too seriously' or 'to heart', I'm pushing back against your oversimplification and distortion of the processes I and many of our colleagues use and that has published evidence to support it.

      Consider this conversation in another subject, perhaps that will help:

      Blogger: I hate climate science! People make all these elaborate claims about it, and its BS, man. I tell people the planet is warming due to sunspots, it's simple, honest, makes sense and is evidence-based.
      Friend: You can't oversimplify things like that, the climate is changing for many reasons, only one of which is sunspots. There are plenty of people in the climate community not drawing hockey stick graphs and sticking to good science.
      Blogger: Hey you are taking things too personally, I didn't say sunspots were the ONLY reason the planet was warming! You climate people take things too seriously.
      Friend: Just because you don't use the word 'only' doesn't mean you aren't misrepresenting the complexity of the situation.
      Blogger: whoa, easy tiger...
      Friend: What?

      You have already retreated from your position in our conversation here, with a simple acknowledgement that not all people make false promises around manual therapy. Perhaps - and this is just a suggestion - admitting some complexity and uncertainty about the issue might prevent things like having to turn off the comments on your blog or fielding lots of pushback. Unless you like making extreme statements and you enjoy the pushback since it's 'part of the process of debate and discussion.' In which case I'm glad that works for you, but its pretty tiring for evidence-based people who use a manual therapy approach, as I do, to see this cycle repeated and to see you make sweeping unqualified statements about things your colleagues do. Branding the subsequent pushback as oversensitivity on their part is fairly obtuse, wouldn't you agree?

      And my response to your contention that 'manual therapy offers little' is published evidence to the contrary.

      I don't require agreement about the value of manual therapy or anything else in the young field of physical medicine as the collective effect sizes everyone is working with are small and reasonable people can come to different and defensible opinions after reviewing the same research. But I (and I hope you as well) will push back against oversimplification, axe grinding, and distortion of what little evidence we do have in our field.
      It continued from there, and ended thusly:

      Adam Meakins Yes Jason we all have stories and biases and opinions and evidence and I am fortunate enough to be able to express my own personal 'I hate' manual therapy ones via my website through my blogs and I will continue to do so! As i've said I expect 'pushback' as you call it from the skin draggers and joint pushers, nothing new here, as long as it is rationale, reasoned discussion I am happy to engage, so until next time... I wish you all the best!
      Jason Silvernail Joint pusher?

      Wow - see you next week for your next rant Adam. You certainly seem to be fair minded and reasonable about your strongly held opinions.:/
      Adam Meakins Whats wrong with the term joint pusher, thats what many who mob and manipulate do, no? Push joints? Is this incorrect?

      And there is nothing wrong with strongly held opinions, even ones that are different from yours!

      Please don't take this the wrong way Jason but I am going to remove our connection via facebook.

      I reserve this section of social media mainly for friends and family or a few professional colleagues who have a similar mind set to my own, which I seem to have got totally wrong with your good self, and really I don't want to get into in-depth nit picking pedantic debates over flipping manual therapy.

      If you wish to continue these debates then please come find me on my website, or twitter or even on Soma

      All the best

      Jason Silvernail Adam you are free to do as you wish with our connection, of course. I thought you wanted discussion and debate, I certainly have never had a problem with a strongly held opinion. If you don't understand that the characterization of your colleagues as 'joint pushers' might be seen as inappropriate or unprofessional then I definitely understand your surprise at the feedback you've received to date. I don't think there is anything nit picking or pedantic about accurately portraying professional issues, and I'm sorry you disagree. I will see you on Twitter and Soma I suppose. Have a great day.
      Jason Silvernail DPT, DSc, FAAOMPT
      Board-Certified in Orthopedic Physical Therapy
      Fellowship-Trained in Orthopedic Manual Therapy

      Certified Strength and Conditioning Specialist

      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.


      • #18
        The cherry picking of the comments from our facebook conversation feed we have had today seems a little unfair Jason, why havent you posted all the discussion?

        Also me calling manual therapists, skin draggers, joint pushers, fascia fiddlers etc etc is nothing more than some light hearted jest or 'banter' as we brits tend to say, a touch or sarcasm. There is no malice or derogatory intent in it, I call all my manual therapy friends similar things... yes I do have friends who push joints and drag skin, just as they call me a glorified personal trainer, rep counter etc etc, its just some fun

        If you knew me Jason you would realise that I use humour (albeit poor humour) in all situations, taking these things too seriously is just not healthy. I would politly suggest you stand down from hypervigeliance and relax a little more, life is too short!

        Kindest regards

        Adam Meakins
        Do not mock a pain you have not endured


        • #19
          Aw gee, I love Adam's over-the-top blogposts where he rants like a madman.
          Diane the SkinDragger.

          HumanAntiGravitySuit blog
          Neurotonics PT Teamblog
          Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
          Canadian Physiotherapy Association Pain Science Division Facebook page
          WCPT PhysiotherapyPainNetwork on Facebook
          Neuroscience and Pain Science for Manual PTs Facebook page

          SomaSimple on Facebook

          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire


          • #20
            Big big fan of Jason Silvernail but in this instance, I feel strongly that Adam Meakins blog post was a solid piece of work shedding light on the dark side of manual therapy.

            I did not once have the impression Adam was implying all manual therapy is bad. To glean that from the blog post seems to be a case of extreme hypervigilance.

            Manual therapy appears to be a useful tool that gets stripped of it's benefit when shrouded in pseudoscientific explanations.

            And unless I'm living in a bubble (Canada)...this ignorance of the science in manual therapy curriculum seems an epidemic.

            And THAT is where the hypervigilance should be focused.


            • #21
              Originally posted by proud View Post
              Big big fan of Jason Silvernail but in this instance, I feel strongly that Adam Meakins blog post was a solid piece of work shedding light on the dark side of manual therapy.

              I did not once have the impression Adam was implying all manual therapy is bad. To glean that from the blog post seems to be a case of extreme hypervigilance.

              Manual therapy appears to be a useful tool that gets stripped of it's benefit when shrouded in pseudoscientific explanations.

              And unless I'm living in a bubble (Canada)...this ignorance of the science in manual therapy curriculum seems an epidemic.

              And THAT is where the hypervigilance should be focused.
              Thank you For your comments Proud. I have had some 'push back' as Jason calls it from this blog but that has been from the predictable 'my massage alters fascia' crowd.

              I must admit I am surprised and confused at Jasons vehement towards it and the misinterpretations he is seems to be making that I am suggesting that ALL manual therapy invalid or useless etc, I just cant see where I have done this and glad others can not too
              Adam Meakins
              Do not mock a pain you have not endured


              • #22
                As I read through the full comments I noted this from Jason:

                So responsible manual therapists are few and far between? Got a reference for that? If not - expect more disagreement and further discussion...
                Was there not a study of some sort which measured Physical therapists performance on a pain physiology questionnaire...and we did not fair well?

                Or did I dream that one up?

                In any case, I discuss manual therapy with countless colleagues across Canada and in general, the culture of manual therapy in Canada is really....and I mean really bad.

                Like I said...I could be living in a bubble.


                • #23
                  Greg in Canada has deconstructed manual therapy in a brilliant way. :thumbs_up:thumbs_up:thumbs_up

                  HumanAntiGravitySuit blog
                  Neurotonics PT Teamblog
                  Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                  Canadian Physiotherapy Association Pain Science Division Facebook page
                  WCPT PhysiotherapyPainNetwork on Facebook
                  Neuroscience and Pain Science for Manual PTs Facebook page

                  SomaSimple on Facebook

                  "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                  “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                  “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                  "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                  "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire


                  • #24
                    Originally posted by proud
                    And yet I recently had a debate with a Part B clinician (ortho black belt in Canada for those that wonder) about all these things and she was insulted....never heard of such nonsense.
                    There are legions of these true believers in Canada. High priestesses/alpha females of the ortho cult. Very defending of it. I almost was eaten alive by a roomful of these. I do not get invited to present in Canada very often. I wonder why.
                    HumanAntiGravitySuit blog
                    Neurotonics PT Teamblog
                    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                    Canadian Physiotherapy Association Pain Science Division Facebook page
                    WCPT PhysiotherapyPainNetwork on Facebook
                    Neuroscience and Pain Science for Manual PTs Facebook page

                    SomaSimple on Facebook

                    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire


                    • #25
                      Originally posted by Diane View Post
                      Aw gee, I love Adam's over-the-top blogposts where he rants like a madman.
                      I concur! Adam reflects my own internal rants and I tend to agree with every word. Keep the posts and banter flowing!

                      Duncan the manual minimalist


                      • #26
                        Cervical Manipulative Therapy and Stroke

                        There's way more heat than light on this issue and this was about the best most respectful, most evidence-packed discussion I've ever seen on it:
                        Gregory Lehman's page, February 23, 2015, sharing a link from Patrick Lyons' website.
                        Patrick's Link:

                        Here's the discussion, at least the parts I have access to given my Facebook settings:

                        Gregory Lehman A blog is knowledge translation. What is the point of your question? Patrick Lyons is merely repeating the findings of the authors. Findings which aren't discussed in the abstract.
                        February 23 at 9:20pm · Like · 4

                        Gregory Lehman Bobby Maybee isn't the OR of 12 what the authors of the study found? Is that number in dispute? it's a case control design. The authors conclusion just ignored these numbers even though they discussed it in the discussion. Am I missing your point?
                        February 23 at 9:26pm · Like

                        Gregory Lehman Sorry Mark. I can't listen to anything you say because you are neither an epidemiologist or a biomechanist. Your last comment was on Facebook and therefore at level 0 for evidence. Of course it's opinion. Everything we discuss on social media is. It...See More
                        February 23 at 9:45pm · Like · 7

                        Gregory Lehman Bobby Maybee you wrote this:

                        "To me, It reads that of those who've had a stroke, the odds ratio is 12 that they've been to a chiropractor. But that does not mean that there's "a high risk of a stroke within 24 hours of visiting a chiro." Which i...See More
                        February 23 at 10:00pm · Edited · Like

                        Gregory Lehman Marc, those are all good points and your last one is most relevant. If the OR of 12 that Patrick discussed is questionable then lets just hear a good criticism of that.

                        As for #3: that criticism would be leveled at the initial Cassidy study as well...See More
                        February 23 at 10:14pm · Like · 4

                        Gregory Lehman But Bobby aren't they making a statement about lack of risk from the same study design? Do you want the full text. Send me an email if so
                        February 23 at 10:19pm · Like

                        Gregory Lehman Bobby, the authors make a statement like this in the abstract:

                        "The increased risks of VBA stroke associated...See More
                        February 23 at 10:20pm · Like

                        Gregory Lehman OK. What I got from the Blog authors statement was that they just rehashed specific ORs found within the original study. The same data set and design that let the authors make statements about risk. What the blog author suggested was that if you look at the OR for a certain group and within a certain time from the risk is greater. I think thats something worthy of discussing and critiquing
                        February 23 at 10:22pm · Like · 2

                        Patrick Lyons Guys, I picked on the Cassidy study because it is often cited as evidence of an equivocal risk of having a stroke after seeing a chiro or GP (this assessment is necessarily dependent on the extrapolation of risk from odds ratios). All I've done is high...See More
                        February 23 at 10:23pm · Like · 3

                        Gregory Lehman Ok, Bobby, is it false because the data is wrong or because you can't make that statement because of the study design?
                        February 23 at 10:24pm · Like

                        Gregory Lehman OK. So is their statement ...

                        "The increased risks of VBA stroke associated...See More
                        February 23 at 10:27pm · Like

                        Gregory Lehman wait
                        February 23 at 10:28pm · Like

                        Gregory Lehman Is the above statement false too since they only looked at ORs to arrive at that conclusion?
                        February 23 at 10:28pm · Like

                        Gregory Lehman good point
                        February 23 at 10:28pm · Like · 1

                        Jesse Awenus I'm just curious, Gregory Lehman do you utilize cervical manipulation in your practice? Not trying to insinuate anything, just curious is all
                        February 23 at 10:29pm · Like

                        Gregory Lehman Not any more Jesse. But I'd crack your neck for kicks.
                        February 23 at 10:30pm · Like · 4

                        Tyler Krausert At any level or just upper cervical?
                        February 23 at 10:31pm · Like

                        Gregory Lehman Just kidding. I wouldn't. Not appropriate. But I'm also laissez faire. I think there is a very very small risk, I think the risk is not profession or even experience specific and I think there is no good way to screen for that risk in healthy patients with some neck pain
                        February 23 at 10:32pm · Like · 4

                        Gregory Lehman any level Tyler. I just don't think I need to do it. Some of it might be medicolegal. If you a VBA can occur from innocuous movements and since people are horrible at inferring causation from association I don't want to even be associated with the tiny risk
                        February 23 at 10:33pm · Like · 3

                        Tyler Krausert How do you remove the patient belief that they need their neck cracked? Risks and mechanisms aside the crack and pop can be a huge driver of expectation and thus relief.
                        February 23 at 10:35pm · Like · 1

                        Tyler Krausert I was just asking if he didn't manipulate the cervical spine period or just the upper.
                        February 23 at 10:40pm · Like · 1

                        Gregory Lehman I get it Bobby Maybee
                        February 23 at 10:45pm · Like

                        Jesse Awenus Gregory Lehman you can have at it in a few weeks in your course. Go nuts
                        February 23 at 10:48pm · Like · 1

                        Gregory Lehman the data of ORs from the paper
                        Gregory Lehman's photo.
                        February 23 at 10:49pm · Like

                        Gregory Lehman No need Jesse. I just talk to necks about their feelings
                        February 23 at 10:49pm · Like · 4

                        Jesse Awenus Lol I think I want a refund
                        February 23 at 10:49pm · Like

                        Gregory Lehman Ah, but I talk with high velocity and low amplitude pulses!
                        February 23 at 10:51pm · Edited · Like · 2

                        Gregory Lehman looking at the chart above one interesting finding is that OR of 12 for those under 45 and within 1 day of seeing a DC is comparable to the OR of 11.2 of those seeing an MD within one day. The only difference is between the two groups is the case control ORs. In the DC group the ORs are around 1 but around 7 in the case control for the MDs
                        February 23 at 11:08pm · Like · 3

                        Patrick Lyons thanks for pointing that out greg. i will review tonight and amend my blog if i have made an error in interpreting the info. It looks like I have from first glance.
                        February 23 at 11:15pm · Like · 1

                        Jas Randhawa Sorry to chime in late, and I truthfully have nothing meaningful to say but conformation bias is a huge issue as Greg has pointed out. I'm not here to argue for or against cervical manipulation, just make sure you critically assess what your intention is with your treatment.
                        February 23 at 11:21pm · Like

                        Gregory Lehman No, I just went back and looked at Science based medicine. They didn't address it either. I think their main contention is that the OR of showing up to any health care provider within 24 hours of a stroke is higher. However, it is higher when seeing...See More
                        February 24 at 9:06am · Edited · Like · 3

                        Patrick Lyons So we can agree that not much can be inferred from the Cassidy article either way? It's my error to have presented the data as though it identifies elevated risk of stroke from a visit to the DC compared to GP visit... and its Cassidy's error (and anyo...See More
                        February 24 at 12:43am · Like

                        Patrick Lyons To Bobby's initial point at the top of thread.. point well taken. it does not demonstrate an increased risk of stroke in first 24 hours when seeing a DC vs a GP... only a relatively higher strength of association. The explanation is up for grabs. Thanks for the critical analysis of my blogpost. I will amend the post, based on this discussion.
                        February 24 at 1:56am · Like

                        Patrick Lyons blog post edited. thanks again for the discussion
                        February 24 at 6:46am · Like · 1

                        Patrick Lyons there's also this from Steve Novella- he is not an epidemiologist, so i'm not sure if his thoughts count.
                        A Statement on Cervical Manipulation and Dissections « Science-Based Medicine
                        The American Heart Association and the American Stroke Association recently published in the journal Stroke a thorough analysis of the evidence for an...
                        February 24 at 7:14am · Like · 2

                        Patrick Lyons A paper that casts doubt over the hypothesis that strokes associated with a HVLA to the CSp are merely coincidental "Based on the patients history we do not have any evidence that in our subjects vertebral artery dissections already existed prior to...See More
                        February 24 at 7:58am · Like

                        Patrick Lyons A paper that suggests that the equivalence of association between stroke events and visits to the DC vs GP may be a result of misclassification. " Cassidy et al suggested that the association between cases and PCP/SMT exposure was because of patients w...See More
                        February 24 at 8:30am · Like · 1

                        Patrick Lyons Marc, thanks for linking the paper about the need for improved quality of case reporting for stroke events associated with neck manipulation. For those following, here is the full conclusion " This paper examined the quality of literature describing an...See More
                        February 24 at 9:13am · Like

                        Gregory Lehman Hey Jesse Awenus, the course is all set but is there anything you would specifically like to see discussed?
                        February 24 at 9:37am · Like

                        Gregory Lehman I agree Bobby Maybee but I think where the debate was festering occurred when people used the Cassidy study to say there was NO risk of stroke. Some were arguing it was just a coincidence. I agree we are back at the same place we were before 2008. So does the Cassidy study really tell anything new?
                        February 24 at 10:54am · Like · 1

                        Roger Kerry Great blog Patrick Lyons once again, and certainly served its purpose in getting discussion going. Just to add another dimension, over the years we have been trying make sense of this whole thing. I think now, essentially, we are arguing vacuous points...See More

                        CAD PhysioFirst 2014.pdf
                        February 24 at 11:49am · Like · 7

                        Roger Kerry Thanks for sharing these Marc. We are certainly in an age where we can start to make data-informed judgements on the situation. Even 5 years ago, this would have been difficult in this subject area. I remain professionaly and emotionally neutral on the...See More
                        February 24 at 2:34pm · Like · 5

                        Lars Avemarie Marc Bronson "Since Crislip isn't an epidemiologist, and that isn't his expertise, and he chose to use a blog as opposed to an LTE, goes to show that this critique lacks a certain validity."

                        Argumentum ad hominem, what Crislip is or isn't in not rele...See More
                        February 24 at 2:51pm · Like · 1

                        Lars Avemarie Marc Bronson "Crislip is not an expert on SMT, biomechanics, stroke, or epidemiology"

                        Again, what Crislip is or isn't in not relevant to the argument.
                        February 24 at 2:54pm · Like · 2

                        Lars Avemarie Marc Bronson "This blog is written recently and didn't even bother to find papers that counter his point as a means of staying objective and not falling to his own confirmation bias "

                        Now, it seem to me to be a very serious accusation, to accuse someb...See More
                        February 24 at 3:09pm · Edited · Like

                        Lars Avemarie Marc Bronson "Nah Lars, you're missing my point which is he isn't an expert in SMT, epidemiology, biomechanics. He's an infectious disease expert. "

                        No, really I'm not missing the "point" I just don't agree (with you), and again what he is or isn't in...See More
                        February 24 at 3:06pm · Like · 2

                        Lars Avemarie Marc Bronson "It actually is because it calls into question the whether or not his conclusions are sound, credible or valid."

                        Let me ask you this, can you evaluate his (Crislip) conclusion and if they are sound, credible or valid without looking at the logic and argument that form the conclusion?...See More
                        February 24 at 3:13pm · Like

                        Lars Avemarie Bobby Maybee "does in fact matter."

                        Everything matters, and expertise matters too, just not when evaluating the logic or evidence, this is how in my opinion many people get led astray.
                        February 24 at 3:16pm · Edited · Like

                        Lars Avemarie "No formal level of evidence is attached to expert opinion, the findings of expert working parties, or anecdotal information. In the absence of empirical evidence, however, or where there is only poor-quality evidence, guidelines may in some instances ...See More
                        February 24 at 3:26pm · Like

                        Lars Avemarie Bobby Maybee "Clinician experience does in fact matter."

                        Yes, most clinician's think that, in my opinion most clinician's with a lot of "experience" view their own experience as something with a high level of value....See More
                        February 24 at 3:37pm · Edited · Like

                        Lars Avemarie Marc Bronson "Conflation with expert evidence and professional expertise, being a scientist who publishes in serious academic journals like Spine."

                        Sorry, what is your point?
                        February 24 at 3:38pm · Like

                        Patrick Lyons Hi Roger Kerry, with regards to a 1 in 10000 risk- if I were a practitioner who used csp manipulation to treat all manner of presenting complaints (as has traditionally been done by the chiropractic profession), I could end up cracking 10 necks per day...See More
                        February 24 at 4:18pm · Like · 1

                        Roger Kerry Hi Patrick, thanks again for stimulating this great discussion. Many apologies, I used the 1:10,000 as a cut-off point for epidemiological worry, as is standard. The risk of VA dissection with HVLA is at most 1:100,000, and probably closer to 1:500,00...See More
                        February 24 at 4:37pm · Like · 5

                        Patrick Lyons well, i suppose you could label me dogmatic for pushing a risk averse approach to treatment. Probably not actually. In order to demonstrate the logical fallacy or excessive reductionism, you might have to provide an argument rather than a witty hashtag...See More
                        February 25 at 5:16pm · Like · 4

                        Patrick Lyons Ok, I'll have to respond later when I have time. For now, it looks like you're taking the risk is negligible compared to the benefits... I think the burden of proof in this sort of debate should be skewed towards establishing the benefit before proceed...See More
                        February 25 at 5:59pm · Like

                        Patrick Lyons Marc, can you provide some evidence to support your contention that hvla to the neck confers a benefit that is attributable to the hvla?
                        February 25 at 6:07pm · Like

                        Patrick Lyons I can cop the comment about reductionism. That's common in cartoons. I won't apologize for it, as I'm also writing sensibly as the cartoon stimulates more debate- which is the cartoons purpose.
                        February 25 at 6:09pm · Like

                        Patrick Lyons As for where I posted the cartoon, it was across several FB groups... Some containing over 10000 members, Thanks for linking it here... As for belief systems and character, I don't think you have enough info to speculate about either of those in relation to me.
                        February 25 at 6:14pm · Like · 2

                        Patrick Lyons It's a bit rich receiving a lecture on the impact of particular words on perceived threat from you Marc, given that the logical conclusion we can draw from your arguing for the benefit of hvla is that it confers a specific effect independent of descending modulation.
                        February 25 at 6:19pm · Edited · Like · 1

                        Patrick Lyons To your last point about the millions of beneficiaries... Can you comment on that? Your not an epidemiologist, right? Can you provide evidence to support the contention that a hvla benefits millions of people? Can you link that evidence specifically to...See More
                        February 25 at 6:24pm · Like

                        Patrick Lyons Ps next time I do a cartoon, I'll be sure to make sure the "rotation lines" are in a plane of motion that more accurately represents the forces applied during a neck hvla, according to you. Because that is the biggest issue in all this.
                        February 25 at 6:26pm · Like · 1

                        Patrick Lyons I guess another basic question is, why do you offer hvla to the csp, Marc?
                        February 25 at 6:31pm · Like

                        John Ware I'm not seeing the reduction to absurdity in Patrick's arguments here. He has repeatedly cited the critique of Cassidy showing that the risk of stroke from HVLA is significantly higher than what those authors stated in their conclusions. What's abs...See More
                        February 25 at 6:31pm · Like · 3

                        Patrick Lyons Marc, you also appear to have not responded to any of this part of my previous comment - not that you're obliged to, of course. What's driving your position in this debate, Marc? Do you claim there is an absence of risk? Or that its negligible? How strong would the association between neck HVLAs and strokes need to be in order for you to agree that the benefits dont outweigh the risks?
                        February 25 at 6:43pm · Like

                        Patrick Lyons " Lastly you seem to presume that manipulative therapists don't discern which candidates are best suited for manipulation based on a relative or absolute contraindications." there's no certainty around such assessments... thats the point. we dont kn...See More
                        February 25 at 7:06pm · Like

                        Gregory Lehman Hi John Ware isn't the OR the same for seeing a DC as it is for an MD? I don't think Cassidy denied this increased OR they just said the risk was comparable between professions. They then suggested that this was because people were presenting with a stroke. I think that last explanation is certainly the grey area that most of us, even the authors, consider unproven
                        February 25 at 7:30pm · Like

                        Gregory Lehman Roger Kerry stated something earlier that we never discussed. That any type of manual handling or neck exercise could lead to a dissection. Roger could you give your thoughts on whether you think hvla is riskier than say gentle neck skin stretching. I ...See More
                        February 25 at 7:37pm · Like

                        John Ware Greg, I think Patrick addressed the age stratification issue issue way up towards the top of this thread. He cited the study by Cai et al, which analyzed the current OR data based on age stratification. Those under 45 are more susceptible to CAD-related strokes, and they are likely to be a larger percentage of those who receive cervical manipulation.
                        February 25 at 7:45pm · Like · 1

                        Gregory Lehman Ok John Ware it's just that your comment suggested that Cassidy didn't acknowledge the risk. In their defense, they did but i dont think they made a big enough deal about it. I'll have a look at the Cai study.
                        February 25 at 8:22pm · Like

                        Patrick Lyons Marc, turning your head, conducting an orchestra, checking a blindspot etc confer considerable benefits to an individual... hvla to the neck, not so much. You don't appear to be grasping the risk/reward argument. We need to demonstrate that the benefit...See More
                        February 25 at 8:32pm · Like · 1

                        John Ware Marc, you're making straw man arguments with the comparisons of HVLA to entirely voluntary, self-generated movements of the neck. Patrick has repeatedly asked you, given the benefits of cervical HVLA, what level of risk you are willing to accept- 1/50,000, 1/10,000? 1/1000? Where do you draw the line?
                        February 25 at 8:46pm · Like · 3

                        Roger Kerry Thank you Gregory Lehman. There are key characteristic differences between Lawrence and Rampion, although sub-text would support that Huxley certainly conceptualised Lawrence in this case. Thank you for raising this important point! Now, where were we...See More
                        February 26 at 4:59am · Edited · Like · 7

                        Patrick Lyons Thanks roger. Very informative post. That pain edu biased mis diagnosis is a concern I've been banging on about on somasimple for months. We have lots of work to do in terms of learning how to make judgments about the relative contribution of pathology...See More
                        February 26 at 6:19am · Like · 1

                        Roger Kerry " So again it comes down to an assessment of the cost/benefit of raising the possibility with the patient that the symptoms are driven by a particular pathology. Where the pathology is potentially fatal, I think we should act to rule out the pathology, and not assume it's a case of maladaptive sensitization " I think this says a lot Patrick!
                        February 26 at 6:39am · Like · 1

                        Patrick Lyons " We know that rotation and extension create mechanical stress on VAs and ICAs respectively, but THIS IS FINE, because healthy vascular tissue tolerates this stress for roughly the period of a life-time. " Roger, can you expand on this comment at all? ...See More
                        February 26 at 6:49am · Like

                        Tyler Krausert I think part of the reason HVLA has been shown to be more effective than non thrust at times is due to an inability to use an adequate control. You run into this with things like acupuncture where it's pretty easy to tell when certain things are being ...See More
                        February 26 at 7:26am · Like · 2

                        Patrick Lyons I guess the next questions that pop up are; how good are we at identifying those with ED vs those without? and for those with ED, how good are we at identifying neck pain from vascular nociception vs neck pain from lets call it, peripheral nerve/muscul...See More
                        February 26 at 7:26am · Like · 2

                        Patrick Lyons Good point Tyler. I think it is just about impossible to demonstrate a specific effect of any type of manual therapy intervention... since we cant separate the effect of the afferent input supplied by the therapist from the patient's nervous system's appraisal of it. So Roger, I dont think we can advance the debate about HVLA by discussing research that reports on its effectiveness.
                        February 26 at 7:31am · Like

                        John Ware Would vertebral artery hypoplasia necessarily qualify as ED? I think it's possible that a third group exists where the endothelium could by intact and normal, but the vessel could still be vulnerable to mechanical loading due to a congenital defect. There's evidence that hypoplastic VAs are fairly common and pose an increased risk of spontaneous dissection.
                        Vertebral artery hypoplasia and vertebral artery dissection: A hosp... - PubMed - NCBI
                        Neurology. 2015 Feb 24;84(8):818-24. doi: 10.1212/WNL.0000000000001284. Epub 2015 Jan 28.
                        NCBI.NLM.NIH.GOV|BY ZHOU M , ET AL.
                        February 26 at 7:47am · Like

                        Roger Kerry Hi Patrick Lyons, the cumulative effect is something to think about, but again, in people with no predisposition to ED, it is something that happens through life. If here is a cumulative effect of sub-extreme trauma, say 4 x whiplash over last 3 months...See More

                        A ‘system based’ approach to risk assessment of the cervical spine prior to manual therapy
                        This paper presents a clinical overview and update of...
                        February 26 at 11:47am · Unlike · 5

                        John Ware Marc, I'm not sure who that is in that video that you linked of the upper cervical spine manipulation, but it's not Jason Silvernail.

                        I never argued that performing cervical manipulation is unethical. I think with adequate informed consent (which I t...See More
                        February 26 at 4:51pm · Edited · Like · 2

                        Patrick Lyons i agree john. We havent even touched on any of the other risks outside of the risk of causing a stroke. I still dont see any evidence presented here that speaks to the benefit of a HVLA. Also marc says " This also means that that the HVLA in itself isn...See More
                        February 26 at 5:46pm · Like · 2

                        Patrick Lyons " Regarding the manipulation vs. mobilization argument, we have evidence of how "HVLAM has a profound influence on nociceptive stimulus via the possible activation of the DIPM. It seems that the application of this technique activates the periaqueducta...See More
                        February 26 at 5:51pm · Like

                        Patrick Lyons There is no ethical issue so long as informed consent is gained. I dont think it is dogmatic to take a risk averse approach to treatment. Im open to changing my approach, but I would need to see substantial evidence of effectiveness of HVLA (independen...See More
                        February 26 at 5:56pm · Like · 2

                        John Ware Me, too. I'll definitely be more discerning about the next neck I move passively.
                        February 26 at 6:41pm · Like · 2

                        Roger Kerry What about actively John? A pathological vessel will neither know nor care whether the movement it's being stressed by is active or passive. One last thought: the (healthy) VA , paradoxically, relies on repeated, complex, fast movement to keep its inti...See More
                        February 27 at 2:13am · Like · 10

                        Gregory Lehman Hey Roger Kerry do you think there would be value in running an extra analysis on Cassidy s data set? Looking at the OR of patients after seeing a physiotherapist since manipulation does occur it is still less prevalent. If the OR is less with physios (assuming less SMT) would this change your thoughts on the relative risk between hvla and slow mobs or active movements?
                        February 27 at 10:10am · Like · 1

                        Glen M. Harris Let's review some of the non manipulation cases...Yoga, backing up my car, getting my Hair done....if I can experience a dissection with this trivial movements...who can say mobs are "safer" than manias?
                        February 27 at 4:30pm · Like · 2

                        Gregory Lehman That's what I'm asking Glen M. Harris if the OR of seeing a physio when people have neck pain that might imply that mobs are safer.
                        February 27 at 4:52pm · Like

                        Glen M. Harris I think we are comfortable with the idea that the Mobs are safer....but in reality, if active ROM can cause the dissection...than is it really safer....'rare and unpredictable event" is often used to describe this
                        February 27 at 5:12pm · Like · 2

                        John Ware Roger,
                        I don't entirely agree with the underlying premise of your statement that the vessel doesn't know or care if the motion is active or passive. Once the HVLA has been performed, the patient is entirely unable to provide any feedback about whether...See More
                        February 27 at 5:53pm · Like · 1

                        Glen M. Harris this brings up the notion of whether the manipulation even stresses the vertebral artery tissue at all....and perhaps the pain associated with the dissecting artery, is what brought the person into the office...looks like a mechanical problem, addressed as one, the dissection fully occurs afterwards, perhaps regardless of what intervention was administered
                        February 27 at 5:59pm · Like · 1

                        Glen M. Harris should add Steve Piper, Greg Kawchuk, Stephen Perle into the discussion
                        February 27 at 6:03pm · Like · 1

                        John Ware Bobby, are you talking about the providers of HVLA who do or do not advertise that they correct subluxations? Where I live, most chiros still try to sell HVLA with this indefensible trope. Many of the PTs who manipulate prefer the mysterious "facilitated segment" angle. Garbage in, garbage out.
                        February 27 at 6:54pm · Like

                        Patrick Lyons "Sometimes, a patient has a painful restriction in their vertebrae that responds to manipulation. It's not that controversial or complicated. " Marc, you're still yet to demonstrate that the observed outcome is a product of the hvla (independent from theatre of the performance). Hvla may be sufficient, but it is never necessary, so it is therefore always superfluous. Why expose the patient to an unnecessary risk?
                        February 27 at 7:40pm · Like · 1

                        Patrick Lyons "Each application involves assessment, active and passive ROM testing, soft tissue work, lighter mobilizations, working up to, when necessary, HVLA after consent and fair warning, without extension in the c-spine." What are your criteria for determining that a hvla is necessary, bobby?
                        February 27 at 7:46pm · Like

                        Optima Fisioterapia Patrick Lyons, theres a not yet validated CPR for cervical manipulation, guess you might know, just pointing to the link to add to the discussion:
                        Development of a clinical prediction rule to identify patients with... - PubMed - NCBI
                        J Orthop Sports Phys Ther. 2012 Jul;42(7):577-92. doi: 10.2519/jospt.2012.4243. Epub 2012 May 14. Research Support, Non-U.S. Gov't; Validation Studies
                        NCBI.NLM.NIH.GOV|BY PUENTEDURA EJ , ET AL.
                        February 27 at 7:49pm · Like · 1

                        Optima Fisioterapia just adding my point of view, I still think cervical manips are risky! But we should go for the evidence, nonetheless.
                        February 27 at 7:52pm · Like

                        Optima Fisioterapia we might go for thoracic
                        Thoracic spine thrust manipulation improves pain, range of motion, ... - PubMed - NCBI
                        J Orthop Sports Phys Ther. 2011 Sep;41(9):633-42. doi: 10.2519/jospt.2011.3670. Epub 2011 Aug 31. Review
                        NCBI.NLM.NIH.GOV|BY CROSS KM , ET AL.
                        February 27 at 7:55pm · Like · 2

                        Optima Fisioterapia Well Marc Bronson, to be honest with you, I might share this opinion that cervic manips might put patients at risk.
                        February 27 at 8:00pm · Like

                        Optima Fisioterapia There are mor soft ways, maybe mobilization with movement, maybe mobilization only... if you going straight at the cervical.
                        February 27 at 8:01pm · Like

                        Optima Fisioterapia Well, let's see: (didnt check for the article's quality, though), but it seems the results were similar.
                        A randomized trial of chiropractic manipulation and mobilization fo... - PubMed - NCBI
                        Am J Public Health. 2002 Oct;92(10):1634-41. Clinical Trial; Comparative Study; Randomized Controlled Trial; Research Support, U.S. Gov't, P.H.S.
                        NCBI.NLM.NIH.GOV|BY HURWITZ EL , ET AL.
                        February 27 at 8:07pm · Like

                        Optima Fisioterapia This one too:
                        See Translation
                        Is one better than another?: A randomized clinical trial of manual ... - PubMed - NCBI
                        Man Ther. 2014 Jun;19(3):215-21. doi: 10.1016/j.math.2013.12.002. Epub 2014 Jan 11.
                        NCBI.NLM.NIH.GOV|BY IZQUIERDO PÉREZ H , ET AL.
                        February 27 at 8:08pm · Like

                        Optima Fisioterapia I have the first not the second.
                        February 27 at 8:09pm · Like

                        Optima Fisioterapia for cervical dizziness, results seem similar (other articles).
                        February 27 at 8:09pm · Like

                        Optima Fisioterapia Marc, another one:
                        See Translation
                        Mobilization versus manipulations versus sustain appophyseal natura... - PubMed - NCBI
                        Eur J Phys Rehabil Med. 2014 Oct 9. [Epub ahead of print]
                        NCBI.NLM.NIH.GOV|BY LOPEZ-LOPEZ A , ET AL.
                        February 27 at 8:12pm · Like

                        Optima Fisioterapia Besides, its inespecific... and
                        Applying Joint Mobilization at Different Cervical Vertebral Levels ... - PubMed - NCBI
                        J Man Manip Ther. 2009;17(2):95-100.
                        NCBI.NLM.NIH.GOV|BY AQUINO RL , ET AL.
                        February 27 at 8:14pm · Edited · Like

                        Gregory Lehman I don't think this discussion can go forward if we don't know if hvla in someone with neck pain is any riskier than the treatment of neck pain (by non MDs) without manipulation. Otherwise we can't evaluate risk benefit without actually knowing the risk...See More
                        February 27 at 8:20pm · Like · 1

                        Patrick Lyons "You really should expand your depth and breadth of knowledge of the science of spinal manipulation because it's becoming apparently clear that you lack the understanding the how's the why's the when's and the clinical process to select this interventi...See More
                        February 27 at 8:24pm · Like · 1

                        John Ware For the record, I'm very dubious of the 18% figure for chiros who espouse subluxation. A cursory google search of local chiro offices belies that statistic. Have a reference for that, Bobby?

                        But, that's beside the point. Safe to say, a large percen...See More

                        GROUND-BREAKING NEW STUDY… Mobilization and Manipulation are...
                        February 27 at 8:24pm · Like · 1

                        Patrick Lyons "A definitive reasonable option. Personally, I work my way up, soft tissue, mobs, neurodynamic testing (doesn't that stretch the arteries in the c-spine when we're doing structural differentiation!) and manips as necessary. " very similar to bobby. Can either of you provide the criteria you use to determine that hvla is necessary?
                        February 27 at 8:25pm · Like

                        John Ware In case you were wondering if mob and manip have been compared in patients with neck pain, here's a reference for that as well:
                        February 27 at 8:29pm · Like · 1

                        Gregory Lehman John Ware there is a reference. It's MacGregor 2014. But only 43% identified as being strictly biomechanical. I've attached the distribution across the different groups. So Bobby is right, only 18% ascribe ONLY to the traditional view in Ontario there are others with a mix.
                        Gregory Lehman's photo.
                        February 27 at 8:34pm · Like

                        John Ware I interpreted Patrick's reference to "necessary" within the context of choosing a manual therapy intervention. Why would hvla be indicated over some other less coercive intervention?
                        February 27 at 8:35pm · Like · 1

                        Optima Fisioterapia John Ware, I had put this one article some comments before
                        February 27 at 8:40pm · Like

                        John Ware But Greg, if you subscribe to subluxation at all, ever, then you've gone off the science-based reservation. It's not a scientific construct. It's hard to see that table, but it looks like at least 26% subscribe to some form of subluxation as a cause of either somatic or general health problems. Those folks are just plain wrong. And where's the biopsychosocial group?
                        February 27 at 8:43pm · Like

                        Patrick Lyons Marc, I don't really care if it's a PT or DC doing the hvla. You've just made an important shift in the way you describe your use of hvla... Backing away from the term necessary, and opting for "indicated", and then talking in terms of who "could" be m...See More
                        February 27 at 8:52pm · Like · 2

                        Gregory Lehman That was my point John only 43% were strictly msk/biomechanical
                        February 27 at 9:09pm · Like · 1

                        Patrick Lyons Bobby, can you provide the criteria you use to determine that a hvla is necessary?
                        February 27 at 10:00pm · Like · 1

                        John Ware I haven't seen any evidence of pissing in this discussion- just rigorous debate. Patrick has asked both you and Marc several times what criteria you use to justify utlizing hvla over some other intervention. This is where the rubber the meets the roa...See More
                        February 27 at 10:22pm · Like · 2

                        Patrick Lyons Agreed John. Ive had this hvla debate a few times. I know you have too... Inevitably, proponents distinguish themselves from the proponents of sub luxation theory (which I think is a good thing) and then go onto explain how hvla is part of their clinic...See More
                        February 27 at 10:29pm · Like · 1

                        Gregory Lehman Pat and John, When I manipulated the cervical spine I don't think I ever thought it was necessary and I doubt most practitioners do. My clinical indication would be that someones neck hurt or they felt tight. If I ruled out sinister pathology and tho...See More
                        February 27 at 10:48pm · Like · 8

                        Patrick Lyons Yes! Nothing is necessary in manual therapy. From that understanding, it is easier to proceed from a cost/benefit analysis basis. I guess I'm a very risk averse therapist. I'd hazard a guess that both Marc and Bobby are risk averse therapists too. I li...See More
                        February 27 at 11:44pm · Like · 2

                        John Ware Bobby said: "I think the assumption here is that providers of HVLA just roll up on patients and provide a massive thrust from out of nowhere, without any pre-assessment, passive mobilization, palpation, soft tissue work, consent, and forewarning be...See More
                        February 27 at 11:57pm · Like

                        John Ware Then who are those 26% from the study Greg cited? Ghosts? Are they possessed by the spirit of DD and BJ Palmer?

                        I have a very strong bias against quackery. Guilty as charged.
                        February 28 at 12:14am · Like

                        Roger Kerry Hi Gregory Lehman do you mean use Cassidy's data againat some new physio data? That would be interesting, but would be difficult to shape-up as good quality epidemiology. Or do you mean tease out the PT data from the original controls? Maybe. However,...See More
                        February 28 at 6:04am · Like · 3

                        Roger Kerry *interventions
                        February 28 at 8:46am · Like

                        Patrick Lyons Hi roger. I'm still curious about the data pointing to the association between stroke and non thrust manips. Can you point me to an author? Thanks in advance.
                        February 28 at 8:52am · Like

                        Gregory Lehman Thanks Roger Kerry

                        1. Yes. I was wondering if Cassidy could use look at the OHIP (thats our health insurance here) and compare the ORs of people presenting with VAD and those that went to Physiotherapists...See More
                        February 28 at 12:03pm · Like

                        Roger Kerry Hi Patrick, re: non-HVLA stroke, perhaps starting with Beaudry and Spence's 2003 ordering of risks for VAD, then every review of VAD risk factors since. We have tried to report and contextualise this in our publications from 2006+. Despite all this, an...See More
                        February 28 at 3:40pm · Like · 3

                        Patrick Lyons Thanks roger
                        February 28 at 4:14pm · Like

                        Patrick Lyons Roger, with regards to identifying those at higher risk of stroke, isn't it true that we just can't tell who is on the verge of a stroke? Aren't these vascular changes often "silent"?
                        February 28 at 4:22pm · Like · 1

                        Scot Morrison Thanks Roger. If I'm understanding what you are saying correctly it would be best for the profession to back up a bit and look upriver vs continuing these debates over risk of some individual method of movement. In light of what you have discussed the whole argument seems pretty moot. Appreciate the input!
                        February 28 at 4:55pm · Unlike · 2

                        Roger Kerry Scot YES! THANK YOU! Hi Patrick, I agree that early stroke is *sometimes* "silent", but I don't think this should prevent us from doing our best to identify the probability of 'this pain being related to vascular pathology' in 'non-silent' cases. The c...See More

                        Cervical arterial dysfunction: knowledge and reasoning for manual physical...
                        SYNOPSIS: This clinical commentary provides...
                        February 28 at 5:40pm · Like · 1

                        Patrick Lyons Marc wrote " Your 'guess' theatrical performance is not even a valid one because the research has shown the benefits go far beyond placebo and there are actual mechanisms of actions that underpin the biological plausibility of spinal manipulation." Hi ...See More
                        February 28 at 9:56pm · Like

                        Patrick Lyons Hi all. In light of this discussion, I have decided to remove the cartoons I have posted until I have further read about the equivalence of association between stroke / non thrust manips and stroke / thrust manips. Thanks to all who have helped shape this debate.
                        March 1 at 3:43am · Unlike · 2

                        Patrick Lyons Roger that makes sense... but what about the chances that a patient presents with (silent) ED, and neck pain unrelated to that ED? That patient would probably pass any therapist applied vascular screening protocol based on symptoms, right? These should...See More
                        March 1 at 4:08am · Like

                        Patrick Lyons marc says (to john upthread) ". I hope you're also not assuming that every patient who presents with neck pain automatically get's an HVLA. That's not the case. What we can do as clinicians is try to screen which patients should not be manipulated." I ...See More
                        March 1 at 5:28am · Edited · Like

                        Patrick Lyons john said " Marc insists that there's all this great evidence for the specific effects of manipulation that goes "far beyond placebo". I'd like to see that evidence." I'd like to see that evidence too.
                        March 1 at 4:31am · Like

                        Patrick Lyons " I work my way 'up' STT, Mobs, MWM, neurodynamic tensioners and sliders. But sometimes a manipulation is exactly what the patient requires and the relief can be instantaneous and allows for more active measures to take place once a restrictive barrie...See More
                        March 1 at 4:55am · Like · 1

                        Patrick Lyons Marc, I'd also add that the "working your way up" to a hvla clinical process does not make sense. It implies that the hvla offers something that the preceding interventions do not... If that's the case, why not just start with hvla? You've already stat...See More
                        March 1 at 9:14am · Like

                        Roger Kerry Hi Patrick Lyons, we have developed a profiling system (nCAD, which means Nottingham Cervical Arterial Dysfunction), which is a progression from the IFOMPT framework. It has 5 sub-classes: nCAD1='normal healthy' MSK patients; nCAD2=MSK pain, with under...See More
                        March 1 at 10:57am · Like · 1

                        Patrick Lyons Thanks Roger Kerry. In that 2nd case study, the risk/benefit analysis was assisted by the fact that the history pointed to the patient having received manual therapy on many occasions over a long period of time, with reported benefit... as well as (wha...See More
                        March 2 at 7:17am · Edited · Like · 2

                        Patrick Lyons BTW, roger, this is not meant to be a criticism of the work you're doing. It does seem though, that you have framed all this as being reflective of a need to shift the debate from the question "does manual therapy cause stroke?" to "how can we identify...See More
                        March 2 at 7:30am · Like · 1

                        John Ware I agree with Patrick that erring on the side of greatest risk aversion makes the most sense with respect to the application of manual therapy in general and coercive techniques, like hvla, in particular. And I don't base this position on the risk of a...See More
                        March 2 at 7:53pm · Like · 2

                        Roger Kerry Hi guys, by and large I do agree with what you are both saying. Both of you have what we class as nCAD2 patinets at the core of your concerns, i.e. those with risk factors for ED, but 'normal' (non-vascular) pain conditions. Quite rightly as these are...See More

                        Vascular profiling: Should manual therapists take blood pressure? - Manual...
                        To view the full text, please login as a subscribed user or...
                        March 4 at 4:47pm · Like · 1

                        Patrick Lyons Roger, I think what's missing in your other examples of risk aversion is the weighting against benefits. I might choose not to go skydiving, but would happily strap on a parachute and leap from a plane that was destined to crash. If we stop selling cof...See More
                        Yesterday at 12:14am · Edited · Like · 4

                        Roger Kerry I totally agree Patrick, it is about contextualising risk in benefits. As I don't think there is a meaningful risk (we can agree to differ on this point!), the issue of whether using HVLA or not is better rationalised with a discussion on benefit.
                        Yesterday at 2:22pm · Like · 2

                        Roger Kerry Fiona Moffatt!
                        Yesterday at 2:38pm · Like

                        Scot Morrison " my concern is that your work runs the risk of being held up as a justification for manual therapists to carry out any technique that pleases them."

                        Patrick I am not sure how you see this? What Roger has pointed out (to my understanding) is merely t...See More
                        Yesterday at 4:38pm · Unlike · 3

                        Roger Kerry Thanks Scot, you are far more articulate than I am! Yes, this is what I mean. Thanks for clarifying.
                        Yesterday at 4:48pm · Unlike · 1

                        John Ware For the record, I disagree with Roger when he states that the risk of HVLA isn't "meaningful". He agrees that there's a 3rd category of pts with MSK pain who may have silent VAD, and there's no effective or practical way to screen for this. So there's...See More
                        Yesterday at 4:58pm · Like · 1

                        Roger Kerry ARGGGHHH....! BUT WHERE IS THE EVIDENCE FOR THIS???? All the evidence points in the other direction! Vigorous movement DOES NOT stress the vessel! This is what the data has repeatedly shown! Removing discrete techniques will not solve the issue. If so,...See More
                        Yesterday at 5:40pm · Like · 1

                        Patrick Lyons Scot, there's a difference between what roger is saying, and how advocates of hvla might present his results. Any advocate of hvla prone to motivated reasoning would likely pounce on this research as a justification for hvla (or other interventions tha...See More
                        Yesterday at 5:46pm · Unlike · 2

                        Patrick Lyons Roger, I understand that the bigger issue is the group of patients that present to the clinic with identifiable signs of stroke. I am not challenging that. I agree that working out ways to identify these patients will probably be the most effective way...See More
                        Yesterday at 6:08pm · Unlike · 3

                        Roger Kerry Well siadPatrick!
                        Yesterday at 6:09pm · Like · 1

                        Gregory Lehman I can see your frustration Roger Kerry or that you are pirate. Either way it stems from how some of us view the Mechanical studies of neck SMT on the arteries. You wrote:

                        "Vigorous movement DOES NOT stress the vessel!"...See More
                        Yesterday at 6:10pm · Like · 1

                        Patrick Lyons I agree Greg. Wouldn't it also be more likely that by the time most strokes are symptomatic, said symptoms would drive most people to the GP rather than DC? one would unlikely choose to go to a DC (or a physio) for vbi, cranial nerve symptoms etc). So ...See More
                        23 hours ago · Like · 1

                        Patrick Lyons Marc, you will be doing well to explain any outcome in terms of mechanisms of action that differentiate the effect of sensory/discriminitive afferent flow from the CNS's contextual appraisal of that afferent flow. Can you provide a study, or even a the...See More
                        22 hours ago · Like · 1

                        Patrick Lyons To make that other comment about the Cassidy study clearer. Assuming people with a mid or later stage stroke, will more likely see a GP than a DC (because symptoms would have progressed past neck pain/headache)... we should expect that the odds ratio f...See More
                        22 hours ago · Like · 1

                        Patrick Lyons

                        Cervical Spine Manual Therapy & Stroke | West Belconnen Physiotherapy & Injury Care
                        The risk of stroke being caused or catalyzed by manual...
                        12 hrs · Like · 1

                        Roger Kerry Hi Guys, again, I agree with your interpretations and the idea that in such an uncertain are there is no definitive answer. Thanks for updating your blog Patrick, I'm sure that your perspective will be informative to all. Remember my position was (from...See More
                        Roger Kerry's photo.
                        4 hrs · Like · 2

                        Patrick Lyons Thanks roger. This has been a valuable discussion for me. One that has made me far less certain that hvla to the csp is a risky technique. Your input, as well as Marc's, Bobby's, Greg's and John's have been much appreciated.
                        3 hrs · Unlike · 2

                        Jason Silvernail Fantastic discussion here!
                        14 mins · Edited · Like
                        Jason Silvernail

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                        Jason Silvernail DPT, DSc, FAAOMPT
                        Board-Certified in Orthopedic Physical Therapy
                        Fellowship-Trained in Orthopedic Manual Therapy

                        Certified Strength and Conditioning Specialist

                        The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.


                        • #27
                          Why our children don't think there are moral facts.
                          Facebook - Jason Silvernail
                          April 2015


                          New York Times Article here:

                          My initial comment:
                          Yet another consequence of our failure to have a discussion about values in our culture. It is part of what is broken with evidence based medicine, in my opinion. A failure to decide what our intellectual prior commitments and values should be BEFORE we engage in finding evidence to support or refute things. A hard problem for sure.

                          Matt Folsom asked for some examples and clarification of what I meant. I responded:
                          "Hi Matt, I can do that for you. One of my prior intellectual commitments/values (we'll call these 'priors' for short) is that I want to support medicine that is science-based and not just evidence based. I want plausible treatments and those supported by evidence. This is a value of mine.
                          Therefore, in my assessment of evidence, I take a dim view of treatments we have good reason to believe are placebo only and don't offer any physiological effect beyond that. Even if they are lower risk, or lower cost, or have other benefits. Acupuncture and homeopathy are two examples of those things. I see the homeopathy and acupuncture literature and I see placebo only care and I move on,uninterested.

                          Now many health systems don't have that same prior. Some of their priors include treatments that are popular, low risk, and can be a replacement for problematic things in medicine that are getting attention from the public, regulators, or professional societies. So that system might embrace acupuncture or homeopathy for some conditions if it met those priors. They would review the same evidence that I did, and instead of focusing on the lack of effects beyond placebo they focus on the low risk and low cost of those approaches beyond some comparable things that maybe they are struggling with in their system - such as patient dissatisfaction, or overuse of narcotic medications.

                          We both looked at the same evidence, but we judged it differently because we have different priors. I have no problem announcing that the root of my dissatisfaction with those approaches is based on my values/prior intellectual committment. I don't pretend my objection is strictly based on the unimpressive effect sizes in the studies that actually found any differences.

                          The problem we have (as Jonathan Haidt covers so well in The Righteous Mind) is that we have a tendency to make judgments based on our values / priors but then try to point to evidence/data to justify them to others. Then refuse to acknowledge the uncertainty in the data or the challenges in getting accurate data. We then announce ourselves to be 'evidence based' rather than value based when nothing could be further from the truth.

                          Since we have not found a way to discuss our values and priors well, we end up squabbling over the data points, which leaves people as confused as the little boy when the father asked him whether something could be both an opinion and a fact in the story above.

                          Watch people aligned with the critical thinking and skeptical community share a political story and read their comments - perfect further example of this concept. They announce their position to be aligned with the data and of course with the article - but the article is from a biased source and often doesn't reflect the full picture the data paint. They won't / can't discuss their values/ priors that lead them to believe what the article says because it's easier to discuss and squabble over the data - and that's when confirmation bias really bites you in the butt."
                          Jason Silvernail DPT, DSc, FAAOMPT
                          Board-Certified in Orthopedic Physical Therapy
                          Fellowship-Trained in Orthopedic Manual Therapy

                          Certified Strength and Conditioning Specialist

                          The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.