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  • #31
    Since we are talking about SMT, and it's mechanisms, here is one paper that might help steer the conversation into a more meaningful discussion.

    For the record, it was this paper, as opposed to the cat paraspindle study that I had wanted Diane and/or the others to read. There are other papers that discuss mechanisms of SMT, I simply do not currently have access to them. If any member does, let's get the papers in here and discuss those as opposed to name calling and the repetitive "my theory/approach is better than yours".
    Attached Files

    Comment


    • #32
      There are two "t"s in Barrett. It's my actual name, by the way.

      I've a few things to say about the post regarding my own but they will have to wait while I compose myself.

      Losing that respect so freely offered has been devastating and I'm just desperate to earn it back.
      Barrett L. Dorko

      Comment


      • #33
        Mrac ,

        I am in a hurry to catch a train for a trip of 12 hours , i have read so fastlyt to find out those are no related to any science or Evidnce -Based

        The only thing that is ignorant sir, is your refusal
        I personally believe in giving respect right off the bat, especially to fellow professionals
        You HAD my respect, Barret, but now you've lost it.
        it and I think you are having a hard to accepting that fact.

        By the way ,English is my second language , i like to hear others, views regarding those statements .



        Cheers
        Emad

        Comment


        • #34
          The skill of the clinician is not just when to use SMT but also when not to.
          If the chiropractic profession uses SMT on 90% of their patients, how does that square with what you state above?
          "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

          Comment


          • #35
            let's get the papers in here and discuss those
            What's the point? Perhaps you didn't see this post EB.

            It seems clear to me that any research done that doesn't consider fast skin afferents is missing something. How many patients do you treat that don't have skin Marc?
            Also, how much pain science have you actually learned?
            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


            • #36
              Jon

              If the chiropractic profession uses SMT on 90% of their patients, how does that square with what you state above?
              There a few things I would like to clear up. First, we don't know the reliability of that ONE study which quoted those numbers. I'm guessing it's close to that. But onto my main point.

              Unfortunately, there are 2 types of chiropractors within the profession, and they both share the DC title. The predominant type, is subluxation based who rigidly hold onto chiropractic dogma of "innate intelligence" and the one cause or one cure model. They claim they can cure almost anything with SMT as subluxations is the TRUE cause of dis-ease. Differential diagnosis is not really emphasized. From my last count, 14 of the 17 American chiropractic schools would fit under this description.

              The second and less predominant type are the evidence-based or mechanistic chiropractors who are basically NMSK specialists and who adjust primarily for pain. They have excellent differential diagnoses skills, are taught to use EBP style with respect to chiropractic. Representing only 3/17 schools in the US, they are the overwhelming minority. So, I think it wouldn't be too much of a stretch to suggest that, in the US, a lot of those 90% are seeing subluxation (straight) chiro's who don't care to discern whether or not SMT is the appropriate approach.

              I have been schooled in Canada, at CMCC which adopted the EB curriculum in the late 90's and early 00's. My school was recently given degree granting status, the first private institution in Ontario, which puts it on par with universities. The other chiropractic college is part of a university in Quebec. A third school, is allegedly opening in Western Canada at the end of the degade and is supposedly going to be within or affiliated with a university. So, in Canada it's 2/2, and likely 3/3 It makes a fundamental difference where you went to school for chiro, because it curriculums can be so different and the type of chiro's in terms of knowledge and critical thinking skills.

              There is no bigger, more apparent difference between US and Canadian approach to chiropractic than the vaccination issue. Canada has one body speaking for all Canadian chiropractors, and the official position is that CCA is pro-vaccination. In the US, I think there's 3 different bodies that represents the different factions of chiro's and I don't think any of them endorse vaccination. From what I heard, the chiro schools in Europe are also EB and that's the only true way to legitimacy. I favour a split in the profession so people like myself who want to be NMSK specialists are not affiliated with the straights/subbies. A merger with DPT would be fantastic, although my training is pretty much limited to orthopaedic conditions.

              Also, how much pain science have you actually learned?
              I've learned the basics, but the purpose of school, I believe is to teach you and develop critical thinking skills and carry those tools out in practice. I'm 29. I have a lifetime of learning ahead of me, so I don't think it's neccessarily fair to solely judge my education in terms of what I learned at school. I'm sure a lot has changed since you graduated in 1971 as well!


              Anyways, since there are skeptics, and I'm all for transparency, here is my curriculum at CMCC. Pages 81-124 has all the courses and descriptions of my education. Most people on this forum seem genuine and objective enough to give a DC a chance to contribute. I hope this sheds some light regarding the struggle for an identity in my profession and I can only do my best, as an individual, to practice ethically, competently, and to let EBP guide my decisions as a clinician.
              Attached Files
              Last edited by Evidencebased; 05-11-2006, 12:46 AM.

              Comment


              • #37
                Are we supposed to be impressed with the fact that it is 164 pages of a chiro school seeking to propagate itself?

                Chiropractic seems to always have had a proclivity for taking something really small and turning it into something really big.
                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


                • #38
                  Hi EB,

                  I agree that a single study is insufficient but it was from a very recent study put out by the National Board of Chiropractic Examiners versus some fly by night organization and it was cited in an award winning paper that you posted. I still think it is a legitimate criticism. That said, it doesn't do much to increase our understanding of SMT.
                  "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                  Comment


                  • #39
                    I’ve been in a creative writing mood today…

                    It’s true, I rarely disagree with Diane. It’s hard to find much to disagree with. I have carefully considered the opinions and practices of a number of posters here, met many of them in person even, and am now more likely than not to trust and respect what they write. This was not an easy road mind you, full of doubt I had to study hard over the course of several years, and free my mind from the grip of popular therapy’s memes.
                    In my twenties I became immersed in the culture of personal training, strength, posture, flexibility. How could I not? It is everywhere you turn these days. Along the way I met and worked with manipulative therapists. Wonderful people all of them, caring, dedicated to their craft, and for the most part, effective. It was spellbinding. Here was this exclusive club that one could belong to if one wanted to put in the time and money. It was rich with an aura of tradition, mystique and prestige.

                    So when I began my physiotherapy training I wanted very much to become a manipulative therapist; I was thrilled to have it taught in my undergrad degree. I think this is probably true of most just starting out, especially males. I truly wanted to be able to help people and this seemed to be the best way to do it, and it came with the perks of club membership. Now you’re probably wondering where I went wrong?

                    Somewhere along the way I sensed that there was a large gap in what I was being taught even though I don’t think I recognized the significance of it at the time. To put is simply, the gap was this; most people present to a therapist with the primary complaint of pain, probably not even acute pain, but pain that they have put up with for a while and have lost the ability to cope with on their own. We can presume that there is a large number of people who have episodes of pain who never get to the point of asking for our help. They simply get better on their own. How could this be? The pain education I received failed to explain this. Why would two people with an identical injury have different amounts of pain and require different amounts of help?

                    Fortunately, (and I do consider myself fortunate) I had some spare time between graduating and starting work and I used that time to read. I introduced myself to literature and people who were explaining this phenomena right before my very eyes. Long story short, when I look now upon the club of manipulative therapy, I see a very different picture. It’s sort of like having watched a completely engrossing play and then seeing the set afterwards with all the lights turned on. The props can be seen from different angles and turn out to be just painted styrofoam or plywood. It kind of ruins the magic; I’ll never be able to watch the play again with the same sense of wonder.

                    I think most therapists are ‘painfully’ aware of the hole in their education concerning pain and also know that they must keep finding a way to its other side in order to help their patients. Yet for some reason rather that filling the hole with increased knowledge, they acquire as many different tools as they can to bridge the gap. The therapy culture would have us believe that this is filling the hole but in reality it is just covering it up. If one tool doesn’t fit right they try another. Some of these tools work well and in the right hands many have gone on to lead successful careers, good for them.
                    For some reason this is frustrating for me to watch because I now know that there is a big pile of dirt sitting just beyond the hole (read knowledge) and that if the work of shoveling it in to the hole was done they’d find it much easier to get their patients across. They’d realize as I have done that they don’t need nearly so many tools. Unfortunately it seems as though many, including our universities, are completely unaware of the big pile of dirt, in fact many don’t even want to look into the hole! They have no desire to explore its walls and find its base. Why this is so I can’t say for sure, but I think this curiosity is an attribute that sets the regular posters and even casual readers that visit this forum apart from the majority.

                    I’m still in the process of filling my hole (I hope that doesn’t sound bad), its deep and just when I think I’m getting to the top I find I still have a ways to go. Yes, I have come to see manipulation as just another tool being being used to bridge the gap, sure it can do the job, but it runs the risk of occasionally falling in. Careful research into the intricacies, mechanics and success rates with which tools can be used will not do much to convince me that there isn’t ultimately a safer, more logical, and perhaps even more efficacious way to bridge the gap that only filling the hole can bring about; only time will tell. There are those here who have already done the hard work and are prepared to show anyone ready for it the way to the dirt pile, show you the good places to dig and will even hand out a shovel now and again.

                    I and probably other dirt shovelers here as well, feel rather alone, this at time may make us a little testy. We don’t have a club of our own, at least not a very big one. We get up early to move a few shovels into the hole before work and keep on shoveling at the end of the day. Most of us have to go to work in clinics where manipulation and other forms of tool bridges still reign supreme. In fact you’d be hard pressed to even obtain employment in most clinics if you’re not planning or actively pursuing your manipulative levels. We are opinionated, but those opinions are hard come by and yes they are defensible. We are standing on ground we have put down ourselves. Do we have an agenda? Certainly, I don’t think anyone would argue that. We’d like to see everyone benefit from a better understanding of pain, patients and therapists alike. At times this may seem like we are trying to ruin the enjoyment of a good play, exposing the set for the props they really are, and some unfortunately may take offense to this, even take it personally, such is the power of the manipulation meme. No offence intended.

                    Shovel anyone?

                    eric
                    Eric Matheson, PT

                    Comment


                    • #40
                      Eric, that is an honest and enlightening post (I hope).

                      What captured my attention most was:

                      ...I had to study hard over the course of several years, and free my mind from the grip of popular therapy's memes.
                      and in reference to holes and gaps and shovels, all good metaphors:

                      ..Yet for some reason rather (than) filling the hole with increased knowledge, they acquire as many tools as they can to bridge the gap. The therapy culture would have us believe that this is filling the hole but in reality it is just covering it up.
                      (mt parenthesis and bold)

                      The key word is 'bridge'....

                      I think all of the regulars here have gone through the phase of dissatisfaction with the gap/s in actual understanding of what we do in clinical practice. This is why we seem rather despairing with those who continue doing 'what they were taught' to do x years ago. (I am talking physio here, not chiropractic as I don't know enough about that profession)
                      If someone is satisfied with the status quo, then they will not progress in thought and action. But it takes hard work and consistent harvesting of knowledge; at the same time threshing out the ever present chaff.
                      As Eric points out, the memes are strong and often resting in vested interests.

                      Nari

                      Comment


                      • #41
                        Wow Eric, you took something huge, and distilled it into one page. I'm impressed.
                        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


                        • #42
                          Just an honest account of my experiences, for what they're worth.

                          eric
                          Eric Matheson, PT

                          Comment


                          • #43
                            EB, you said:
                            My only argument was that SMT is a valid form of treatment.
                            I distinctly recall you saying you use it for pain.
                            There are many doors to the nervous system, including SMT.
                            But all of them have to go through skin! It's not my fault that skin completely encircles the entire body, that it has fast myelinated fibers that report directly to the sensory cortex so the brain knows what's happening to its organism at all times, or that it's impossible to discount as a "confounding factor" that will screw up any construct you care to name, or any effort to "purify" an effect that SMT might have on some cat spine or some human spine. It's how the system evolved in vertebrates. The deep stuff is deep for a reason, to reduce threat and enhance survival. Why do people insist on trying to pop the crap out of it? Do they WANT to make nervous systems more cranky? Keep it up and see.

                            As far as I'm concerned that fact that skin is there and actively reading all therapeutic input pretty much puts your nose into having to deal with it. First.

                            Having said this, and I dare you to refute it, how can you justify SMT? For treatment of pain? It just goes against reason. It's like putting on a blindfold and throwing darts at a target after being twirled around a few times. And here you are, going to a school with a brochure that is 164 pages long where your nervous system is taught to throw darts and calculate how many times you've been twirled before you throw/pop. I'm not saying you're not good at what you do, you probably are, but I think SMT is a pretty pathetic thing to spend 4 years and $80 -100 thousand learning to do.
                            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


                            • #44
                              Marc,

                              I don't think Diane's question regarding your knowledge of neurophysiology was a comment on your college education. It is well recognised here that the understanding of pain science that the regulars on this forum prize so greatly is missing from most physical/manual therapy instruction (at any level). Without having a fairly solid grasp of this field it is quite possible that you will misunderstand the meaning or point to many of the questions and comments made on this thread. Sure, STM has neurophysiological effects, but that is not the greater part of the challenge being given here.

                              Any theory (published or otherwise) that you bring here will be scrutinised in light of the deeper models that describe the neurophysiology of the pain experience. Any method that cannot show compatability with this understanding will be challenged. Unfortuntely, the current literature on SMT cannot achieve this. All it shows is some evidence of efficacy.

                              You stated that you are keen to continue your learning. Having discovered this group as a osteopathy student probably receiving a very similar education to you, I can assure you that there is no better place to do that than here (the archives of Barrett's Bullypit and threads in his forum are a great place to start). As Eric has alluded to though, be prepared for some serious cognitive dissonance. You might continue to use SMT for some conditions, but like Jason and I you'll do so with a nagging discomfort at the back of your mind, and you'll no longer be offended by Barrett's comments, because you'll know he is right.
                              Last edited by Luke Rickards; 05-11-2006, 01:12 PM.
                              Luke Rickards
                              Osteopath

                              Comment


                              • #45
                                As many of you know, I sit and write for an hour every morning and much of the rest of the day I do what David McCullough says is the most important thing about being a writer – thinking. I met him personally a couple of years ago and find here that I finally have an opportunity to drop his name. Now I feel better.

                                For all of that effort on my part for many years, I’m not sure I’ve come up with as compelling an analogy for the struggle surrounding manual care as Eric has offered us here. While it’s true that I often speak of “the hole in therapy” that our patients fall through on their way toward the fairyland of “alternative” medicine, I don’t think I’ve ever gotten this additional vision of what’s been done by some therapists to gloss over this hole with illusions similar to those of Hollywood and the stage. I really like this addition to the discussion and will use it in the future. I might even mention that it was Eric Matheson’s idea (ha,ha).

                                Diane is pounding away at the relevance and inescapable nature of the organ through with manual care must pass – the skin. I don’t think I need to say how much I agree, and I find that bringing up the subject often will stop a manual care-giving mesodermalist in their tracks. That is, if they bother to listen and think.

                                In my book Shallow Dive I wrote this in the introduction 12 years ago: “I have the impression that many in therapy, especially in the manual end of it, feel a persistent frustration born of the fact that although we are supposed to change various organs within a patient’s interior, our direct mechanical effect stops pretty much at the surface.”

                                That frustration remains among our colleagues who continue to employ leverage and listen for noises produced by altered relationships between the connective tissue and the ambient air (read manipulate). They’ve found that reality as described by the best neurobiology known today doesn’t justify what they do or say sufficiently so they author a “play.” They imagine a scenario or grasp an inaccurate but convenient and useful meme and draw the patient into this with promises of relief or some kind of “health” unattainable otherwise. Their tendency to justify all of this with allusions to famous practitioners like Hippocrates is (ironically) a transparent manipulation of other’s respect for history and tradition. This tactic is vitally dependent upon their ignorance as well. After all, speaking of the greatness of Galen’s discovery of the blood vessels in 300AD and his subsequent ability save lives is impressive. But it was also Galen’s idea to bleed people for virtually every disorder seen – including active hemorrhage. This sort of “care” then persisted until about 1875. (See Where’s the Revolution? for more)

                                Makes you wonder, doesn’t it?
                                Barrett L. Dorko

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