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  • #46
    Originally posted by John W View Post
    A similar kind of thing happened at a CSM conference a few years back in Chicago. Kathleen Sluka, a renowned pain researcher here in the US, did a presentation that included video of a clinical interaction with a patient who had persistent low back pain. The only thing I can remember from that presentation was her instructions to the patient. She asked this poor woman, who was obviously in some discomfort and anxious, to "bend over as far you can" and after she did, she then asked her if she could bend over any farther. This is when Cory Blickenstaff and I looked at each other in dismay. How could a therapist who is so knowledgeable about pain ask someone who is obviously in pain to perform a movement that is sure to increase their pain? Where is the disconnect?

    To be clear, I don't think Adriaan would have given the same verbal commands to this patient as part of his clinical reasoning process. But his willingness to do "whatever works", even if it increases pain- or a produces the proverbial "good hurt"- is hardly distinguishable from what Dr. Sluka did. Is it not?

    Whatever it is, it's not therapy.
    She has obviously never watched Peter O'Sullivan in action.
    Diane
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    "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

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    • #47
      I'd like to see this notion of the so-called "good hurt" get deconstructed. To start, isn't such a thing based on an assumption that patients always tell us the truth? Even if they did, since when did we become lie detectors?

      Detection is vitally important to what we do, but discerning the truthfulness of what our patients report to us falls well outside our practice scope and, in my experience, is exhausting and fruitless.
      John Ware, PT
      Fellow of the American Academy of Orthopedic Manual Physical Therapists
      "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
      “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
      be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

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      • #48
        Originally posted by John W View Post
        I'd like to see this notion of the so-called "good hurt" get deconstructed. To start, isn't such a thing based on an assumption that patients always tell us the truth? Even if they did, since when did we become lie detectors?

        Detection is vitally important to what we do, but discerning the truthfulness of what our patients report to us falls well outside our practice scope and, in my experience, is exhausting and fruitless.
        Yes this notion of "hurting so good" is yet another dumb dumb movement our profession has taken up.

        Some (like seemingly over at EIM) kinda understand that it's just playing with pathways....yet somehow find a way to bend their own stunned treatments around it.

        Others....just think the DNIC outcome was an actual appropriate treatment response (like eradicating the mythical trigger point for example)

        Either way it displays a profound lack of insight in my estimation.

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        • #49
          I was surprised by Adriaan's response. Maybe the aggressive nature of debates on this site has desensitized me a bit, but I didn't think proud came off overly aggressive. Adriaan is a really smart guy too, I can't believe that he totally buys his own response. I wonder if he so strongly identifies with and/or is so invested in manual therapy and PT interventions that he has a hard time separating criticism of the interventions from criticism of himself.

          The big question I have with regards to therapy is how to reconcile the need for promoting self-efficacy and patient empowerment with the cultural need to have something "done" to address a problem. The problem with discussions like the one on EIM is that it becomes clear that we, as a profession, are not ready to have that discussion. We spend far too much time trying to rationalize low value interventions rather than trying to develop a rational course of care.

          A rational course of care could include manual therapy or some passive intervention of some sort, but we need to be willing to question those things and have discussions on them. Right now we suck at that.
          Ryan Appell DPT
          @Rappell_PT

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          • #50
            "It hurts good" tends to be confusing for a number of reasons. It reveals more about the person's knowledge trying to defend a method of "treatment" with this.

            It's easily deconstructed.
            Barrett L. Dorko

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            • #51
              Originally posted by proud View Post

              On a blog someone asked him about chronic back pain and this is his response:


              "sympathize, because I have had similar back pain over the past 20 years. The thing that has made the most difference for me is that about 4 years ago I began diligently stretching my hamstrings every time I train. I have used back extensions, reverse hypers, and deadlifts all successfully to rehab this problem, but since I have been stretching my hamstrings I can get my back in the correct position to lift with much greater reliability, and have had FAR less trouble than I used to have with my back. Hip flexors are NOT the trouble -- if your hamstrings are tight you cannot get into proper lumbar extension. Give it a try, and you'll know in a couple of weeks. "


              Uh...
              Proud
              This bloke is describing his experience re: LBP.
              Which part/s perturb you the most?
              Last edited by TonyG; 22-03-2017, 11:50 AM.
              pain is inevitable, suffering is optional

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              • #52
                For me there are two big hiccups in that statement.

                Tight hamstrings limiting lumbar extension? even the most biomechanically oriented person should know that if hamstrings are THAT tight that the spine can't flex - they.can. not. walk.

                Second, he had already "successfully" rehabbed the problem.....but still needed those hammies stretched to have "FAR less trouble". I wonder what successful means to him.
                We don't see things as they are, we see things as WE are - Anais Nin

                I suppose it's easier to believe something than it is to understand it.
                Cmdr. Chris Hadfield on rise of poor / pseudo science

                Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                We don't need a body to feel a body. Ronald Melzack

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                • #53
                  His "HS tightness" became his reassuring, pat on the back, positive feedback loop that his brain could check in on and get reassured his exercise routine would be safe and successful. For some its a foam roll, some a manip, some needling.......add it to the list.

                  Just my take on it from a far.

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                  • #54
                    Tight hamstrings limiting lumbar extension? even the most biomechanically oriented person should know that if hamstrings are THAT tight that the spine can't flex - they.can. not. walk.
                    Bas,
                    I think he meant he was not able to maintain an adequate neutral lumbar spinal position while performing deadlifts. Maybe he thought his HS were so tight that he was starting back extensions and reverse hypers in an excessively flexed position? I don't know- that doesn't make much sense. Like you said, if your HS were that tight, you wouldn't be able to walk.
                    Last edited by John W; 22-03-2017, 06:44 PM.
                    John Ware, PT
                    Fellow of the American Academy of Orthopedic Manual Physical Therapists
                    "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                    “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                    be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                    Comment


                    • #55
                      In Rippetoe’s statement, he ignores the CNS and instead puts forward a biomechanical model as the catalyst for his improvement.

                      Who’s to say that his actions/behaviour (hammy stretching) did not create some kind of safe platform for him to perform; even though he probably doesn’t see it that way? His experience is unique to him, after all.

                      FWIW I don’t prescribe conventional stretching because I see it as the CNS being bullied by its host. Unless it’s a spontaneous movement, in which case I say go with it.

                      John, I imagine Rippetoe is reffering to passive insufficiency in straight leg dead lifts.
                      Last edited by TonyG; 23-03-2017, 04:00 AM.
                      pain is inevitable, suffering is optional

                      Comment


                      • #56
                        If you listen or work with powerlifters or those trying to achieve absolute strength, many will talk about pain. While their self management or suggestions for rehab and treatment may not pass muster, they typically take an active, self efficacious approach. For that I have to give them credit. Its better than many in the "rehab" profession.

                        I also like that Rip calls out the outpatient rehab setting. To me, he does have a point.
                        I may not be as smart as most people, but I'm sure as hell not as dumb....
                        "The views expressed here are my own and do not reflect the views of my employer."

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                        • #57
                          Ugh,

                          I just got done reading the EIM blog as well as Colleen and Adriaan's response. Suffice it to say, and like everyone else, I'm pretty disappointed. Actually, probably a little pissed. I've spoken with Adriaan numerous times. I consider him a mentor in many respects as he was the first to introduce me to Pain Ed (TNE as he calls it) that completely changed the way I practice forever. He is a very significant positive influence for me because of this as well as numerous other insightful discussions I've had with him in person and online. I even got certified through ISPI with a CSMT cert because of his strong influence.

                          But the manipulation teachings as well as the current TDN crap has really left me feeling pretty empty in regards to his courses and discussions. Others have made excellent points here in the way the evidence argument appears to be framed, i.e. find a kewl catchy trendy tool, get in a territorial piss match with other pseudoscience fields over it, grab it with all it's glory and plant a freaking flag on top of it, oh, and then let's try and find some valid evidence to support it. Oh wait, there isn't much? But the outcomes tho.........

                          The other thing is, I was a bit concerned when ISPI joined EIM from the get go for this very reason as well as a blatantly obvious monetary influence being gained with these cont. ed courses (i.e. TDN). I would love to believe this hasn't biased Adriaan and his instructors, but I'm trying not to be too idiotic and naive anymore.

                          I truly believe that Adriaan/ISPI believes he is trying to improve our field. I just feel the course he has chosen has moved a little away from his original Pain science Moseley influence and the biopsychosocial model of pain. It is not the most direct course and at times it is counterproductive.
                          Last edited by mark_luttrell; 28-03-2017, 08:17 PM.

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                          • #58
                            My frustration with Adriaan seems along similar lines. In fact, my frustration with the EIM crew in general is along similar lines.

                            That being...I expected more from them.

                            I attended the manipalooza in 2010 and was wildly impressed with how "business like" the course was.

                            So well run and organized I could hardly believe it.

                            Yet the content...left me with a sinking feeling.

                            Were these guys that I held on a pedestal for the excellent strides they had made in terms of helping uncover mechanisms...becoming businessmen/women first and foremost?

                            Then along came the TDN EIM collaboration and I grow ever more dis-heartened.

                            Then Adriaan comes up with what amounted to one of the worst crafted (in my opinion) responses I might have read in a while in defense of TDN and...well...my skepticism grows.

                            Comment


                            • #59
                              proud,

                              "Content" and "business" are very, very loosely related. How a course is advertised is far more powerful than previously thought. Adriaan has become little more than a shill for EIM.

                              That's just an opinion, and Adriaan might not know it has happened.

                              I don't think he visits.
                              Barrett L. Dorko

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