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  • #16
    BTW, chiros are taught in Oz that subluxation is a figment of past imaginations
    That might be the case Nari, but it is still perpetuated in the clinics. The idea is just too convenient and potent.

    I heard once that Adelaide has more chiros per capita than anywhere in Australia. I rarely see a patient that has not had or isn't currently having chiro treatment. Trust me: the "out of alignment" meme is alive and well in Oz. In my experience, patients have been so well "trained" by chiros that it is practically hopeless to challenge it. You can often get through in the short term but next time they have a problem it's straight off to the chiro first. Absolutely brilliant marketing! It is so effective in fact, that it is not uncommon here for direct debit facilities to be set up so chiros can draw money straight from the patient's account each month so that they can be "kept in line" a few times a week at the 'special bulk price'.

    Marc, I know you are sensitive to 'chiro-bashing' (as you perceive it), but you have to admit that the profession has created a huge problem here. Of course, there are always the exceptions.
    Last edited by Luke Rickards; 04-11-2006, 10:22 AM.
    Luke Rickards
    Osteopath

    Comment


    • #17
      Luke, that could explain why there is such an epidemic of chronic pain in Aus. Ok, I realize this is a correlation and not a proof of cause/effect. However, if everyone is being manipulated by everyone and their thinking is allowed to fester with thoughts and beliefs that are scientifically invalid, no wonder they all end up at Nari's pain clinic sooner or later, she is avalanched by all of them, and must combat all their inaccurate thinking. Maybe there's a reason the pain sciences have gripped the imagination of the PT minds there. They are still slogging along trying to extract themselves from the quicksand of ortho training themselves, but their eyes are on the ball at least.. and the osteos are as well. Well, at least yours, and Nic's.

      Absolutely brilliant marketing! It is so effective in fact, that it is not uncommon here for direct debit facilities to be set up so chiros can draw money straight from the patient's account each month so that they can be "kept in line" a few times a week at the 'special bulk price'.
      This makes me want to heave. I've always maintained that PT is a health care profession whose members might adopt a business model if they want, and chiro is a sales operation that has its own version of "health care" as the product it sells, to patients and to duped chiro students.
      Last edited by Diane; 04-11-2006, 10:54 AM.
      Diane
      www.dermoneuromodulation.com
      SensibleSolutionsPhysiotherapy
      HumanAntiGravitySuit blog
      Neurotonics PT Teamblog
      Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
      Canadian Physiotherapy Association Pain Science Division Facebook page
      @PainPhysiosCan
      WCPT PhysiotherapyPainNetwork on Facebook
      @WCPTPTPN
      Neuroscience and Pain Science for Manual PTs Facebook page

      @dfjpt
      SomaSimple on Facebook
      @somasimple

      "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

      Comment


      • #18
        Nari, you must be VERY busy.
        Luke Rickards
        Osteopath

        Comment


        • #19
          Luke,

          I should not have been so general in my views - clearly Canberra is somewhat different, though I'm not sure why. I will readily admit that many people without any complex chronic pain think something is "out of place" but I am not sure that this perception arises from chiros or wherever. Perhaps that is lost in the memes of time.

          Diane, does Australia have such a high percentage of chronic pain people? I was not aware of that; do you have some stats that show this? Perhaps it is better recognised than in other countries?

          The clinic patients are always asked if they have been to chiro, physio, osteo or "other"; although I have not worked out any percentage, it would seem quite predominant that those who have tried both PT and chiro in the past found neither of any help. Some are openly hostile towards physios, but that is probably because they would not complain about another profession to me.
          Very few are still going to physios or chiros; that is all past history.
          When there is no logical biomedical reason for 10 years of 24/7 pain, or close to 24/7 pain, we have to realise we are only just beginning to understand pain.
          But I have never heard a chronic pain person say that something is 'out'...

          I think it is difficult to lay more than a partial blame for chronic pain on any profession; it is far more complicated than that. What we see, broadly speaking, is a history of psychosocial trauma; that is what really stands out. Inappropriate management can be directed at doctors, nurses,physios, chiros, fitness leaders, massage therapists (probably unlikely) and I don't know about osteos as there are so few here I never hear anything about them. The real origins/causes of chronic pain development are not known; there is talk of markers being developed for identifying people at risk, especially now that chronic pain is being labelled a disease. Rather like alcoholism...

          Nari

          Comment


          • #20
            I feel badly that I haven't chimed in until now. The constraints of teaching and travel have simply made that impossible.

            As always though, the others who regularly post have done a better job of exploring the issue and exposing the problems with the, uh, "theory" of SMT without resorting to the sarcasm that often forms a portion of my communicative style.

            I am among the few here who not only devoted a portion of their career to using manipulative technique on patients but also taught a few thousand physical therapists how to do this as well. I spent a considerable amount of time with others who had done the same much longer than I had as well. This was during the Disco era so I must admit that we were all dressed rather oddly by today's standards.

            But I digress.

            I put this "tool" aside because my theory of dysfunction within the patient progressed. That is quite simply what a scientifically-based practitioner is supposed to do. I've heard many physicians reminisce about the forms of care they once provided, smiling ruefully when they think about what they were very lucky to get away with. Their appreciation for tradition doesn't extend into the realm of previously ignorant and misguided ideas about human functioning now shown to be false if not downright dangerous. They move on, and the absurdity of evoking the practice (and obvious ignorance) of Hippocrates does not occur to them. Is "the chiropractor unwilling to state his name" here trying to be funny when his says such things?

            Practice done without defendable theory is foolish and nothing less. To my mind, it follows that those who persistently practice in this way are fools, and I will certainly admit that I was once one of them. But maturity is about learning and growing, primarily in your head. It is not about defending your own ideas by demanding first and foremost that you should be personally respected. Respect is something you earn; it cannot be demanded.

            On this site of you've no defendable theory you're unlikely to get that.
            Barrett L. Dorko

            Comment


            • #21
              The Ignorance of Jed comes to mind as I read this thread.
              Eric Matheson, PT

              Comment


              • #22
                Man, I can't believe I'm missing such good stuff!

                I doubt I can improve much on what others have said, perhaps only to chime in with Luke in admitting to still using manipulation with some of my patients. I'm not sure if having another manipulator on the board makes our friend who won't use his name any more comfortable or not, but there it is.

                I am uncomfortable with manipulation for exactly the reasons others have mentioned - no deep model as yet, patient self efficacy, and harmful 'alignment' memes and the potential for chronicity and future expectancy. I do see quite a few people who have been told by PTs that their [insert joint here] is out and that the manipulation fixes that, so it should be said that it by no means is limited to our friends with the "DC" after their name.

                I do think that most of the cutting-edge researchers (in physical therapy at least) have admitted that the effect of the manip is neurophysiological, but the exact mechanisms remain elusive. And are likely to remain so for the forseeable future.

                So, it comes down to a choice we all have to make: how much do we need to know and explain about our interventions in order for us to be comfortable enough to use them? For me, I'm comfortable using manipulation because I know the effect is neurophys and not joint alignment and I make what I consider a good effort to squash any memes right off the bat. For example, I tell them that it isn't their joint, that manip is just a "jump start" for them to find their way out of the pain themselves, that the most important part is their understanding and movement and not the "pop", etc, etc.

                So that's my point of view.
                Off to unpack more boxes (we've just moved) and work on my DPT project, it's only due in 4 weeks...[insert nervous laugh]....

                J
                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.

                Comment


                • #23
                  Marc,

                  I feel sympathy for you just and only because you are alone ! Sure i will go with the all ,you know the human being is weak as its Nervous System as you mentioned You feel its attacking from Diane and re-attacking back ,thus make the discussion not scientific . I like the discussion goes back to science .

                  Put all aside ,no way if i am convinced by Manipulation i would say you are correct and agree .

                  How about safety is my major concern regarding Thrust Manipulation !
                  As weel, i meet many stiff knees ,elbows ..... following traumas Do you think manipulation is appropriate ?

                  Cheers
                  Emad
                  :rose:

                  Comment


                  • #24
                    One of the questions I have is: Why are mobilipulators of whatever stripe so fascinated/fastened on what they call "neuromuscular" effects? Why should I care about that? Please feel free, anyone, anyone at all, to fill me in.

                    I've always been "superficial" in treating and I've always come back from any course, any continuing ed-venture into the deep mesoderm sick from the mental bends, much prefering life on the raft of skin that floats on top. My patients get better at about the same rate, if not faster than, the mesodermalists. How can that be? Marc? Any clue?

                    A fascinating foray into the world of the neuromatrix and pain science explained myself to me better than any mesodermalist ever could. Suddenly my sights lined up and I was good with forever treating superficially and happily for the rest of my days.

                    Nari, the incidence of chronic pain in Canada varies between 18% to 31% (as I recall), depending on which study you read. What is the stat in Aus? I threw that out because of Luke's enlightening post on how people let chiros make direct withdrawals from their bank accounts. My jaw is still all over the floor.
                    Last edited by Diane; 04-11-2006, 05:05 PM.
                    Diane
                    www.dermoneuromodulation.com
                    SensibleSolutionsPhysiotherapy
                    HumanAntiGravitySuit blog
                    Neurotonics PT Teamblog
                    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                    Canadian Physiotherapy Association Pain Science Division Facebook page
                    @PainPhysiosCan
                    WCPT PhysiotherapyPainNetwork on Facebook
                    @WCPTPTPN
                    Neuroscience and Pain Science for Manual PTs Facebook page

                    @dfjpt
                    SomaSimple on Facebook
                    @somasimple

                    "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

                    Comment


                    • #25
                      This is going to be the first of three posts regarding some of comments and questions I've received in this thread. Please bear with me:

                      Mr. Barrett Dorko:

                      I put this "tool" aside because my theory of dysfunction within the patient progressed. That is quite simply what a scientifically-based practitioner is supposed to do.
                      Interesting point. So anyone now who uses manipulation isn't scientifically based. Whether you like it or not, Barrett, there is evidence to support the use of manipulation. Also, I don't recall seeing YOUR theory of dysfunction published anywhere for that matter. But, I digress...

                      Their appreciation for tradition doesn't extend into the realm of previously ignorant and misguided ideas about human functioning now shown to be false if not downright dangerous
                      Are you implying that manipulation and manipulators are "misguided" and "ignorant" and that SMT is "dangerous"?


                      SMT is extremely safe. It is beneficial for mechanical back and neck pain. These are facts. You have every right to say SMT isn't your cup of tea, but to denigrate those who choose to incorporate this tool reaks of elitism because they aren't practicing "your way". The only thing that is ignorant sir, is your refusal to acknowledge the literature that supports SMT and it's use. And, I have already posted an abstract to Maigne's work if you wan to get into the "theory" of SMT.


                      Practice done without defendable theory is foolish and nothing less. To my mind, it follows that those who persistently practice in this way are fools
                      So you are now resorting to name calling. I practice SMT, believe that it has neurophysiological affects to relieve pain, and now I'm a fool. So are DO's, DC's, PT's and MD's who choose SMT as one of the many ways to help relieve pain.

                      You've said you've been there and done that. Fine. You've found something that works better for you and fits better into your model of practice and understanding. Good. I'm totally open to learning about Simple Contact and DNM. But belittling practitioners who use SMT is unprofessional on your behalf. It lacks professional courtesy. This is something you've done previously, in the MRT thread.

                      You also mention respect. You say, and I quote:

                      Respect is something you earn; it cannot be demanded.
                      I personally believe in giving respect right off the bat, especially to fellow professionals. Differences in opinion are fine and are healthy to move the debate forward. However thinly veiled attacks ridiculing people's beliefs is shallow. Rather than debate the literature, you're whole message boils down to "SMT is for fools". You HAD my respect, Barret, but now you've lost it. We'll see if you can earn it back in future postings.

                      On this site of you've no defendable theory you're unlikely to get that.
                      I definitely have a defendable theory, as defendable as your very own. Except "my" theory is being researched, revised and implemented in practice and peer-reviewed journals whereas I have yet yours meet the same standards. If you have literature supporting YOUR theory, please, my all means, "show me the money". You have drawn your own conclusions, other people shouldn't be chastized for drawing conclusions that differ from yours.

                      Comment


                      • #26
                        2/3:

                        I will try to address some of more valid points addressed in this thread

                        Nari


                        If it turns out that the positive effect of a HVLA is purely neuromodulatory and little else, they will have more difficulty accepting that because of its abstract nature.
                        How come this will be more difficult to accept that DNM which is neuromodulatory or acupuncture? The research is leading us down this path and I think its a great thing. One more tool to modulate the nervous system, in certain instances it may be more effective than other forms of neuromodulation, others it may not. Used in the right cases it works extremely well. The skill of the clinician is not just when to use SMT but also when not to. I'm just saying that at times, for certain conditions, it's effective.

                        Another point about SMT is the likelihood of creating a dependency on a health professional to perform the HVLA; in other words, it is a manouevre which most patients can't perform easily themselves.
                        SMT doesn't create dependency, it's the shady business practices of certain individuals, which unfortunately, has a high association in my profession. But there's also tons of responsible, ethical practititioners like myself who just want to give effective treatment and let word of mouth generate referrals.

                        Regarding it being a manoeuvre they can't do themselves, why is this an argument against SMT? It's a skill learned by health care professionals. It's also a regulated act.


                        Cory


                        So, although SMT undeniably works to reduce pain, the resulting explanation of the patient creates a new threat. Since pain is built on real or potential threat this is significant.
                        I agree, it is difficult explaining this to patients. Like Nari was alluding to, it can be abstract. I don't talk about misalignments, I talk about decreased mobility segmentally, and that SMT can help relieve their pain and improve their ROM. I also talk to them about lifestyle choices, ergonomics and so that I'm trying to eliminate if not negate the "aggravating factors" that may be contributing to their pain. I also try to be cognizant of psychosocial issues which may be perpetuating their pain and try to help out, as much as my scope allows, with those issues.

                        Nevertheless, IMO, it's only recently that there's enough evidence now that we can suggest that SMT works more predominantly on a neurological model than a mechanical model (bone out of place). The paradox or irony for me, is that a lot of subluxation based DC's will be jumping all over this to try and capitalize financially. This is why I advocate a split in the profession for evidence-based DC's and their religious zealot counterparts. But that is beyond the scope of this thread!

                        Eric

                        I don't really have a comment, but rather a question? Have you EVER disagreed with Diane? I mean, really. Every single one of your posts, directly or indirectly have either been condemming me or my opinions. Also, linking to short stories (jed) is definitely not elevating the intellectual status of the thread. Also, where was it espoused, in this thread, that it was all about mechanics with the nervous system playing second fiddle?

                        Anyways, I want to stick to the high road here, and would rather we stick to the literature and debate that as opposed to name calling or questioning other's people's intelligence and integrity because they hold a differing opinion.

                        Luke:

                        I agree that block/advanced billing isn't the best idea, and I've already stated that I repudiate subluxation based chiropractors who use deception and fear tactics for financial gain. It's unethical and conduct unbecoming of a professional. I'm glad that you recognize we aren't all like this and don't paint us all with the same brush. I also fully agree with your interpretation of HVLA.

                        Comment


                        • #27
                          Diane,

                          I've always been "superficial" in treating and I've always come back from any course, any continuing ed-venture into the deep mesoderm sick from the mental bends, much prefering life on the raft of skin that floats on top. My patients get better at about the same rate, if not faster than, the mesodermalists. How can that be? Marc? Any clue?
                          First, let me say that I honestly think it's great that you are getting good results and that your patients are benefitting from your treament. The concept of using skin of a neuromodulator is very intriguing, something that I definitely want to learn more about. I never questioned your approach, and never claimed that SMT, MRT, acupuncture, reflexive inhibition, or any other technique aimed at alleviating pain was better. My only argument was that SMT is a valid form of treatment. There are many doors to the nervous system, including SMT. It's not your cup of tea, I understand that. I respect that. You believe it doesn;t have any value, and you are entitled to your opinion. What I am saying though is that the fact that SMT is a topic that is being researched by many fields of manual therapists has legitimized it and I think you are having a hard to accepting that fact.


                          Sincerely,
                          Marc.
                          Last edited by Evidencebased; 04-11-2006, 09:03 PM.

                          Comment


                          • #28
                            My opinion of any research done by anyone that is mesodermally based and yet is supposed to assist those of us who treat awake and conscious nervous systems is, that it is "Balnibarian." The Balbinarians were that society in Gulliver's Travels that specialized in doing foolish experiments and conducting inside-out research.
                            After requesting to leave the island, Gulliver is lowered to the continent of Balnibari and enters its metropolis, Lagado, where the crops are poorly managed, people wear ragged clothing, and the houses are in bad condition–except for the house of the governor of Lagado. He tells Gulliver that 40 years before, some Lagado residents visited Laputa and came away with a smattering of mathematics that caused them to undertake bold scientific projects and other heady enterprises. They even built an academy in which to carry out their projects. Now every town in Balnibari has an academy, and the people spend most of their time conducting experiments. For example, at the Academy of Lagado, scientists are attempting to do the following: extract sunbeams from cucumbers, turn human feces back into food, erect buildings from the roof down, plow farmland with pigs, make marbles soft enough to stuff pillows and pincushions, breed sheep whose entire bodies are bald, and have students learn mathematics by swallowing wafers on which formulas are written.
                            .......So absorbed in these enterprises are the inhabitants that they avoid taking part in almost all other activities.
                            Diane
                            www.dermoneuromodulation.com
                            SensibleSolutionsPhysiotherapy
                            HumanAntiGravitySuit blog
                            Neurotonics PT Teamblog
                            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                            Canadian Physiotherapy Association Pain Science Division Facebook page
                            @PainPhysiosCan
                            WCPT PhysiotherapyPainNetwork on Facebook
                            @WCPTPTPN
                            Neuroscience and Pain Science for Manual PTs Facebook page

                            @dfjpt
                            SomaSimple on Facebook
                            @somasimple

                            "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

                            Comment


                            • #29
                              EB

                              I was referring to the fact that it is more difficult to accept that the effect of a HVLA is neuromodulatory, because it has been linked into the stiffness=pain concept for so long. Acupuncture and DNM are not linked to 'cranky' joints.
                              That's all.
                              I fully agree that it is a useful method if it is used judiciously and with judgement. If it isn't, then there are risks, which are not inherent in acupuncture and DNM.
                              If there are too many "tools" (an objectionable term, as it suggests we are little more than mechanics) then confusion and careless execution of methods is more likely to happen.
                              The aim to keep physiotherapy simple but very subtle is a worthy one to follow, I reckon.

                              Nari

                              Comment


                              • #30
                                Nari,


                                I was referring to the fact that it is more difficult to accept that the effect of a HVLA is neuromodulatory, because it has been linked into the stiffness=pain concept for so long. Acupuncture and DNM are not linked to 'cranky' joints.
                                SMT hasn't really changed during this time, but our understanding and interpretation has, which will naturally affect when/how we use it. So, the subluxation model and cranky joint model time has come. We move forward.

                                I fully agree that it is a useful method if it is used judiciously and with judgement. If it isn't, then there are risks, which are not inherent in acupuncture and DNM.
                                I personally think there are a lot more risks inherent with acupuncture, especially compared to SMT:

                                1) First it is invasive, and depending on the depth you can really puncture some tissues. Pneumothorax is one of the most common complications that can arise

                                2) Infection, particularly hepatitis is a complication resulting from acupuncture.

                                3) Populations with haemotological disorders are also a higher risk, etc...


                                If there are too many "tools" (an objectionable term, as it suggests we are little more than mechanics) then confusion and careless execution of methods is more likely to happen.
                                I see your point. Rather than tool, perhaps "approach" would be a better word. Either way, I was using tool in the context as an "option" instead of implying mechanics.

                                The aim to keep physiotherapy simple but very subtle is a worthy one to follow, I reckon.
                                I agree. I have the highest respect for your profession and manual therapists in general. I love to learn, which is why I'm on the forum. I would prefer not to have "great conversations" that requires me to take a defensive stance, but it seems that a lot of posts when it comes to this topic aren't fair and balanced. Respectful indifference would be better than labelling manipulators as "foolish"


                                Marc.
                                Last edited by Evidencebased; 04-11-2006, 09:56 PM.

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