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  • #46
    Marc, you said:
    I personally believe in giving respect right off the bat, especially to fellow professionals.
    I know chiropractors are drilled in how to behave toward one another. I've seen them spot each other across a room crowded with all sorts of different folk, probably because of the tote bags or sweat shirts sporting an image of a spine, or words that say "I'm a chiropractor" or something... They will approach one another at a measured pace, gaze reverently into each others' eyes and introduce themselves, shaking hands and saying, "Hello, doctor, I'm doctor so-and-so, it's a pleasure to meet you."

    You will find none of that here.

    Differences in opinion are fine and are healthy to move the debate forward. However thinly veiled attacks ridiculing people's beliefs is shallow.
    You may have already noted that on this forum you won't get any respect until you earn some, particularly for any beliefs you might be carrying along with you. Beliefs will weigh you down and keep you from using that shovel that Eric so eloquently pointed out we all must learn to use. You might start by shoveling out of your own brain the pile of beliefs and pseudo-respectful behaviour you no doubt acquired at that 164-page brochure college you attended for $100,000 to learn to pop/act like a chiro doctor. Like Luke, Eric, Emad, Barrett have all said, around here all that matters is what you do to help fill in that god-awful hole Eric mentioned. Get busy or get lost.
    Last edited by Diane; 05-11-2006, 03:23 PM.
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
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    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
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    @PainPhysiosCan
    WCPT PhysiotherapyPainNetwork on Facebook
    @WCPTPTPN
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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

    “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

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    • #47
      It must have been the cold medicine talking...

      Barrett I was thinking of Down the Rabbitt Hole while I wrote, as well as Why We Believe.

      In particular this line:

      ...any discussion of practice that relies upon a belief system will be perceived by many as a threat to their personal survival mechanisms. To put it another way, it is extremely difficult to question anyone’s belief system without getting into personal issues that have no real bearing on the problems inherent to any practice that is not based on evidence or accepted methods of reasoning.
      Last edited by EricM; 05-11-2006, 03:36 PM.
      Eric Matheson, PT

      Comment


      • #48
        Here is something to think about for those who perform SMT on the neck:
        Painonline Nov.5 blog.

        For more about how people in chronic central pain live, visit Kevin McHenry's great blogsite, http://www.painonline.com
        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


        • #49
          Great post Eric!

          Please see these editorials by International Journal of Osteopathic Medicine editor, Nicholas Lucas. OMT in the title stands for "osteopathic manipulative therapy." These are great editorials that are very relevant to this discussion.

          As for the Maigne article, this passage makes my point for me a bit:

          As with all treatments, a placebo effect occurs with SMT.
          A feeling that the vertebra has been returned to its normal
          position, a perception that the cracking sound indicates effectiveness,
          and the manual contact preceding the manipulation
          all contribute to the placebo effect. In addition to this psychological
          effect, many spinal pain syndromes improve spontaneously.
          Finally, patients may perceive the explanations supplied
          by SMT practitioners as more satisfactory than those
          given by physicians [44].
          See the above linked editorials for a more accurate description on what placebo actually is, as well. This passage, like most, still regards placebo as simply a psychological effect.

          As for this article providing mechanisms of SMT, this is just one such passage from the article:

          According to the lesion felt to be
          responsible for the pain, SMT seeks either to return a vertebra
          to its normal position or restore lost mobility.
          There were also many passages of the "this is thought to occur, but has yet to be found" variety. And even "this is thought to occur, but the current evidence suggests otherwise. So, we'll keep looking" variety. Not great science in my opinion.

          EB,
          Even if you make the attempt to educate the patient that "putting bones in place is not what we are doing," my feeling is that they will still come to that conclusion anyway. The cultural meme is just too deeply entrenched. This will be even more likely to occur if you follow the Childs study reasoning of "who cares why, we can just tell them it decreases pain in 98% of patients of a certain presentation."

          I've expressed my feeling and evidence about this topic previously in this post.
          Cory Blickenstaff, PT, OCS

          Pain Science and Sensibility Podcast
          Leaps and Bounds Blog
          My youtube channel

          Comment


          • #50
            2/2:

            To Barrett, Luke, Emad, et al.


            I believe that forums like these attract the "keeners" if you will, or people who want to learn more about manual therapy to get the best possible outcomes for their patients. This is an honourable thing and I am continously impressed with the amount of knowledge on this board. It no doubt sharpens my skills, deepens my knowledge base and, as a bonus, I'll make some good aquaintances.

            Barrett:

            I appreciate your vast knowledge of the history medicine in general. It has served you well in developing your ideas and theories. I am most open to learning about them. In fact, if you ever decide to come to Toronto, I'll attend a workshop. All I ask in return is that you don't publicly call me out for doing SMT and ART I do hope you make it this way though. I will come with an open mind and an eargerness to learn. Luke and Jason, two individuals who I've come to identify with, speak highly of SC.

            Luke

            The purpose of the academic calendar with to provide proof to a certain person that I'm not a religious zealot who is learning pseudo-science. I wanted to provide full disclosure of the curriculum to provide her with something tangible as opposed to her assumptions that all chiropractic colleges produces unethical, incompetent zealots who five one another while bashing MD's and any other health profession. Your point regarding Barrett's work is well taken. I'm going to learn as much theory as possible from this website and hopefully with have a chance to attend a seminar and learn some of the practical aspects. I love working with my hands, believe I have a good sense of touch, so this should be up my alley.

            Emad:

            Thanks for your empathy, your posts are good natured and I appreciate your debating style.

            Eric

            I enjoyed reading your post, it was a good metaphor. My personal view is that although we are searching for the "magic bullet" that will "cure" all our patients who are in pain, the truth probably lies in a myriad of pain approaches, in some hybrid blend, or perhaps some sequential application of various approaches. Of course, it could always be that certain approaches are best for certain subsets of individuals. I'm looking forward to discovering the answers with all of you here at SS.


            Anyways, upon reading the other SMT thread, I don't think I can further add to this topic. Jason has adequately and eloquently summarized what I also believe with respect to SMT and the papers provided there by Jason and Alex are good ones. There are other topics that I wish to discuss and I will start an appropriate thread for them.

            "the chiropractor that is unwilling to use his name"

            Marc.

            Comment


            • #51
              Marc could you, or anyone else who manipulates for that matter, give me a brief run down of what guides your decision making when you do decide to maniuplate?
              Say someone presents with LBP. What information do you consider when deciding whether to manipulate or not? How do you determine where to manipulate? How do you determine what sort of manipulation you are going to use? How do you evaluate the success of your treatment?

              I'm not looking to be critical here, I really am just curious.

              eric
              Eric Matheson, PT

              Comment


              • #52
                I took a look at the "mechanisms of SMT" paper and noted that they reference the pain-spasm-pain cycle. It is my understanding that this is no longer considered a tenable mechanism of pain--that is, the cycle doesn't exist. If so, anything claiming to break that cycle is necessarily erroneous. Am I mistaken on this point?
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • #53
                  Eric,

                  Since I'm often a point of first contact for patients presenting to the clinic with LBP, I'll do a thorough history (LODRFICARA, PPMFLOATS, ICE) in addition to the intake forms. I'll generally have my main idea at this point with differentials. I use the physical exam to confirm/refute my initial thoughts

                  I'll check vitals and move onto my physical examination with is based on orthopaedics, functional testing and palpation. At this point, I say to myself: "self, is this mechanical/non-specific back pain or is this organic pathology that warrants an immediate referral?" I do my report of findings to the patient, tell them the diagnosis and prognosis that generally occurs for their diagnosis.

                  I always go over informed consent and let them know the benefits and risks to treatment, whether it's SMT, Acupuncture, Soft tissue treatments, etc. I take my time to explain to them what is going on, and always stress to them that I cannot be responsible for their health, but can help get the ball rolling and provide them with the right info (meaning, active care measures and self-responsibility for their own health).

                  Now, in terms of adjustments. After palpation, if I think there are no contraindications to it, and they've consented, I will use SMT depending on my diagnosis. I don't use SMT for QL strains, for example. Personally, I think its harder to feel whats going on in the lumbar spine compared to thoracic or cervicals, but it varies from individual to individual. My palpation is usually joint challenges medial to lateral and PA compression. If something feels "stiffer", and recreates their pain I'm more likely to adjust. Also, Childs' paper further provides me with an idea of who might most likely respond. I personally don't think that is the only subset of individuals who will respond to SMT.

                  In terms of measuring success, I use objective and subjective measures. I'll most commonly use the NRS, VAS and Oswestry Disability Index to monitor subjective measures, and use ROM using a tape measurer and improvements in exercise variables (reps, hold time, sets, weight). I'm more into functional measures personally rather than pain, because I don't want the patient to get pain focused behaviour. And sometimes, there's so many yellow flags and dependency on passive measures, that I may just refer them onto or comanage with a more qualified individual who can deal with the psychological aspect and functional overlay issues.

                  In terms of technique, I mostly use side posture and variations of that, but
                  also do some mobs or thrusting in the prone position, sometimes with a drop piece. The technique part is really the "art" part of it, I compare it a sport where you need to develop good psychomotor skills in terms of speed, depth, amplitude and "feel". In technique class in school those of us who had a sporting background tended to be better adjusters than those who were sedentary or exclusively bookworms.
                  Last edited by Evidencebased; 05-11-2006, 10:47 PM.

                  Comment


                  • #54
                    Thanks Marc,
                    You lost me on the acronyms, "LODRFICARA, PPMFLOATS, ICE"

                    So essentially, when you find an area that feels stiff and reproduces pain, that is the area you manipulate? Do you restest this area for a sense of stiffness and creation of pain after the thrust?

                    eric
                    Eric Matheson, PT

                    Comment


                    • #55
                      Eric,

                      The acronyms are what I use when doing this history

                      LODRFICARA (for the chief complaint(s)-->pain

                      Location, Onset, Duration, Referral/radiation, Frequency, Intensity, Character,Aggravating factors, relieving factors, associated factors. I also ask about previous treatments for the problem, what worked, what didn't, recurrence rates, etc...

                      PPMFLOATS (for a general medical history)

                      Previous chiro tx, Previous Med (Dx, surgeries) Medications, Family History, Lifestyle (exercise, smoking, drinking, stressors) Occupation, Allergies, Traumas, Systems Review (EENT, CV, GI, GU, MSK).

                      ICE (ideas (of what it could be) concerns, expectations (of the patient)

                      In terms of repalpation following the SMT, I check for differences in the tissue quality. But, I've NEVER adjusted in isolation. NEVER. Even in clinic. We HAD to do some kind of soft tissue treatment. So, I'll frequently do acu/soft tissue work first, SMT, then follow that up with a therapeutic exercise (most commonly based on Stu McGills work and Hodges, Richardson, Hides, and the other great Australian physios). to try and reinforce correct motor programs. If they are seeing me for the performance side of things, than my exercise selection is very different.

                      Basically, I was taught that you judge treatment "efficacy" was whether or not the patient getting better faster than they would with the natural history. I think that makes sense.

                      Comment


                      • #56
                        Thanks for the definitions.

                        Is your assessment of tissue quality before or after you proceed to the other modalities? Does it change?

                        What reasons were you given to NEVER adjust in isolation?

                        eric
                        Eric Matheson, PT

                        Comment


                        • #57
                          Eric,

                          When I worked in Atlanta for Paris we palpated for tenderness and stiffness, "found" them almost all the time, manipulated just about everybody (who didn't get heavy mobilization technique) and figured we had done our job. Oh yes, we then palpated for normal motion, "found" it and declared the patient "better" or "fixed" or "cured."

                          Not so hard, really.

                          Problem was, nobody was able to explain to the patient how it was they were better.

                          It's nice to see that so little has changed.
                          Barrett L. Dorko

                          Comment


                          • #58
                            Is your assessment of tissue quality before or after you proceed to the other modalities? Does it change?
                            I always assess after the fact, of doing all my interventions. I notice a reduction in tone and less "hardness" on the skin if/when I do skin rolling. From what I feel, it changes.

                            What reasons were you given to NEVER adjust in isolation?
                            There never was a reason. In clinic, everyone always did some soft tissue work as part of the treatments. This is what I observed too while I was in years 1-3 of chiro school. Some people had formally taken a soft tissue course (ART, Graston, MRT) some had not but we doing massage-ish type stuff, some had taken Trigenics which is more neurologically based (inverse myotatic, reciprocal inhibition reflexes with deep autogenic breathing) some were using thumper machine. I just never saw a straight up adjustment. I thought this was the norm. It wasn't until I started talking to non-CMCC grads, or older CMCC grads that I learned that a lot of the time only SMT was done. I thought, well, that sucks. It's incomplete. You're a one trick pony. And, you can't confidently address extremity complaints.

                            I consider myself fortunate to been educated nowadays compared to the older DC's. Not that I'm knocking their clinical experience, but I feel I have a better arsenal to deal with a lot of MSK complaints from ankle sprains to headaches of cervical origin. I can also confidently address sports specific stuff too, cause of my background in sports sciences combined with my CSCS certification. I feel that I have a lot more avenues to get patient referrals compared to traditional "back only" DC's but they have argued that my scope it too limited.

                            Comment


                            • #59
                              Problem was, nobody was able to explain to the patient how it was they were better.
                              Show me the money, Barrett! Don't hold back on us! Do you know the ABSOLUTE truth to this? Sure there are many theories, yours included. I could explain stuff about descending inhibitory system, I could talk about relaxation response due to afferents, I could talk about freeing up meniscoids which may be impingement on the PPR medial branch to the facets, etc. Problem is, how do I know which tissue is the pain generator? If I don't know SPECIFICALLY what tissue is causing their pain than how can I SPECIFICALLY tell them the mechanism of their relief? All I know, their pain relief is most likely neurological.

                              M.
                              Last edited by Evidencebased; 06-11-2006, 12:02 AM.

                              Comment


                              • #60
                                Who said they ever got any pain relief?
                                Barrett L. Dorko

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