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  • CT Spinal Manipulative Therapy: The Great Conversation

    OK, I'm going to start a new thread on spinal manipulative therapy. EB posted this article on Eric's tenderness palpation thread. I think it's time we got down on this, and EB seems willing to play.

    I just read the article, and honestly, what I got was that 90% of people who see chiros get manipulated, that a chiropractor got together with a researcher and a bunch of cats got their muscle spindles examined after being manipulated. (As a cat lover, I had to look past that.. )
    But anyway, I'm still left with this sense that chiros will turn not only themselves but now cats inside out to "prove" that spinal manip does something.. anything. So yes, now we know that cats' spindles fire abnormally for awhile after, before returning to normal. So, the spindles are shocked into abnormal behavior for a time. The bit about the "novel stimulus" to the cortex was interesting given that the cats were "deeply anesthetized".. My question is, and always will be, so what? Why am I supposed to be impressed by this?

    Really, one wonders why go to this extreme to try to save manip from oblivion. It's done on people mostly, not cats, and wide awake people at that, and futhermore, people whose skin has been left intact. There will certainly be a whole whack of other neural factors coming into play at many many levels, long before any effect on any spindles, in real life on real people.
    Attached Files
    Last edited by Diane; 03-11-2006, 04:42 PM.
    Diane
    www.dermoneuromodulation.com
    SensibleSolutionsPhysiotherapy
    HumanAntiGravitySuit blog
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    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
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    @dfjpt
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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

  • #2
    Diane, speaking of anaesthetised cats....

    Unconscious monkeys were presented with novel visual stimuli, and imaging demonstrated high activity in the primary visual cortex, medial temporal cortex and the lateral geniculate nuclei. If the same could be done in unconscious patients (eg passive movements) who knows what bits of cortex light up??

    (This is from Nikos Logthetis, director of the cognitive processes dept at the Max Planck Institute. The full article plus other goodies, including phantom limb pain by Melzack, can be read in the Scientific American Special Ed. on the Senses. Vol 16, #3, 2006.)


    Nari

    PS ....by the way, I think your thread is a good idea!!
    Last edited by nari; 03-11-2006, 04:14 AM.

    Comment


    • #3
      I the same could be done in unconscious patients (eg passive movements) who knows what bits of cortex light up?
      Good question. If the passive movment were delivered with SMT, I would expect to see the areas involved with alarm, defence, and threat light up. I can sorta see why the immune system (see EB's SMT and immune system thread) might kick up a bit. It's probably being stimulated via neurohormonal pathways, by that phylogenetically ancient part of the CNS mostly housed by vertebrae, to try to defend its organism.

      Which begs the question, why would anyone ever in their right minds choose to do this to any patient's nervous system?

      Wait a minute, most manipulative practitioners are not usually in their right minds.. that must be the answer.
      Last edited by Diane; 03-11-2006, 06:48 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


      • #4
        There is great discussion on this topic in The manipulation solution thread also.
        Luke Rickards
        Osteopath

        Comment


        • #5
          Good idea Luke, here's the rehab edge thread, posted earlier by Eric. Might as well get all these threads linked up in this one.
          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


          • #6
            Diane

            My question is, and always will be, so what? Why am I supposed to be impressed by this?
            Not a good way to start a level headed "conversation". Also, please quit it with the anti-chiro propaganda:

            I'm still left with this sense that chiros will turn not only themselves but now cats inside out to "prove" that spinal manip does something.. anything.
            SMT research is not exclusive to chiropractic by any means. PT's, DO's MD's do it too. Your inference that chiro's are try anything to prove SMT does anything shows narrowed mindedness on your part.

            Really, one wonders why go to this extreme to try to save manip from oblivion.
            SMT research is not exclusive to chiropractic by any means. PT's, DO's MD's do it too. Are all manipulators wrong Diane? Some, DC's in particular, seem more wrong than others, right? How can we have a debate when you SMT discussions always turns into an anti-chiropractic statement? Speaking of which, you wouldn't happen to be a moderator at an anti-chiropractic website would you? Just curious.

            Anyways onto a few points of clarification:

            1) You are calling this the great conversation. Conversations are usually respectful, and ideas are exchanged back and forth. Seeing the other "great conversation" threads, they've all turned into flame wars. I'm not going to be the white knight defending SMT. Many professions use it. Many patients benefit from it. It's being increasingly researched, with the research appearing in many peer reviewed journals. It's a difficult topic to study since it's almost impossible to find a good "sham" to compare it to. Furthermore, you're attitude is disrepectful and unbecoming of a mod, IMHO

            Wait a minute, most manipulative practitioners are not usually in their right minds.. that must be the answer
            2) How can I seriously expect a level-headed and fair debate here? It's myself "against" a forum moderator that even has her own following "Dianesians". Asking this forum about the merits of SMT is like asking a hockey player if his favourite sport is football!

            3) I find it completely intellectually dishonest how you began this thread using that paraspinal spindle study. You had asked in a previous thread how SMT could have an effect a relaxing effect on muscles so I provided you with a study. Next thing I know you are dedicating an entire thread to SMT topic and using this study as the centre piece or a lightning rod.

            Also

            It's probably being stimulated via neurohormonal pathways, by that phylogenetically ancient part of the CNS mostly housed by vertebrae, to try to defend its organism.

            Which begs the question, why would anyone ever in their right minds choose to do this to any patient's nervous system?
            You are speculating here and basing using a rhetorical question to further your point. Besides your own extremely biased opinion, do you have any progressive comments besides calling manipulators names and questioning their intellect?

            Also, what do you do besides DNM? Is that the solution to all NMSK issues? By reading many of your posts, it seems like its a one trick pony solution. I also don't understand why you are constantly pacifying the nervous system like a baby. You make it sound so weak and fragile. It can handle a lot. Do you have any background with sports or sports performance? Training for sports, especially high level sport, is extremely intensive for the nervous system. It's essentially gets maxed out at certain points. Would you consider this bad the nervous system? I'm looking forward to your insight on this point.

            I don't think I can take you seriously as your extremely big anti-chiropractic bias is influencing your opinions to the point where all SMT talk degenerates into an anti-chiropractic rant. I choose to use many tools at my disposal, Diane, SMT being one of them. You don't think its a valid treatment. Research, anectodal and otherwise and millions of patients have benefited from modern SMT for over 100 years. SMT didn't begin and end with DD Palmer. You might recall a certain important practitioner, Hippocrates, also practiced "bone setting" in addition to more allopathic forms of medicine.

            Anyways, I'm all up for a "conversation" I'm just waiting for us to talk about the issues instead of your repeated jabs to myself and my entire profession.
            Last edited by Evidencebased; 03-11-2006, 09:00 PM.

            Comment


            • #7
              Hi Marc,

              I think Diane's question is reasonable. What is it about that study that leads chiropractors to use it on 90% of their patients? For sure other professionals use SMT but not on 90% of their patients. It seems excessive.
              "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

              Comment


              • #8
                Just so it's clear for you, I'm anti-manip. If chiros are mixed up in there, so be it.

                Please be big enough to stand apart from the issue of spinal manipulation and debate that, and do not take this so personally. It's not about you as a human, it's about manipulation and its use/abuse. Stop identifying so strongly with manipulation and maybe we'll get somewhere. Get over yourself. This isn't about you. Unless you'd like it to be.

                You may have noted that we've had more than one "great conversation" on this board. It's the constructs I am interested in discussing. Are the constructs valid, given what we know about the nervous system, how it evolved, what it's doing here in bodies, how to handle it, how to get IT to do all the work of changing its output, without banging it around or falling prey to ideas that we can actually change mesoderm.

                Are you up for this? If not, so be it.
                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


                • #9
                  Hi EB,

                  One issue that I've always had with manipulation is the resulting explanation that the patient is left with. "They popped my back and that helped my pain. Therefore when I have pain I need popped."

                  This alone doesn't sound so bad. However, when the patient thinks the popping is reducing a disolcation or restoring alignment, pain= something out of place, or out of alignment.

                  Even when this is not the explanation that is provided to them, that cultural expectation exists to a degree that they come to the conclusion on thier own.

                  In my experience, people become afraid of thier bodies, afraid that every time they have pain something is out of alignment, effectively that they are broken.

                  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.
                  Cory Blickenstaff, PT, OCS

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

                  Comment


                  • #10
                    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.
                    Some try, with scary results: I have come across several patients who self-manipulate their necks, one of them every half hour throughout the day. (They were not manipulated by chiros, just to keep the field even).

                    No-one denies the effectiveness of SMT; it is the message it sends.
                    If you have pain, come in and I'll fix it for you.
                    This is not restricted to HVLAs - it applies equally to spinal mobilisations, too.

                    We can't fully explain why SMT works - yet - so the patient can be left with the idea of misalignment, weak joints, weak muscles leading irrevocably to pain.

                    Traction used to be done for 90% of patients with LBP and/or sciatica. We got over that, fortunately; no one technique or modality is appropriate for almost everyone; physiology doesn't work that way.

                    Nari

                    Comment


                    • #11
                      Note: A few posts have been moved so the discussion can stick to topic.
                      I've reattached EB's article he posted earlier in one of the moved posts.

                      About the content, we've already been up one side and down the other of the TrA issue, and I doubt adding SMT to the mix of what the deep model is this case of ab recruitment will help much.
                      Attached Files
                      Last edited by Diane; 04-11-2006, 05:01 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


                      • #12
                        I found Ernst and Canter's (2006) systematic review informative in shaping my opinion on the practice of SMT. (I believe it's freely available online) It appears that lots of studies have been performed, a few of them are of good quality, fewer still can report good results and of those that do, problems with experimental design markedly limit the external validity of the findings (as is the case with Child's et al). The search to design the perfect experiment that will prove what everyone knows just has to be true is like watching a dog chase its tail, a long dog with a very short tail. What somehow has been missed is any real understanding of the deep model of pain. With this understanding anyone could tell that the perfect experiment will always be elusive. SMT researchers should spend more time trying to answer why SMT might work rather than trying to prove that it does.

                        eric
                        Eric Matheson, PT

                        Comment


                        • #13
                          I like the image of the long dog chasing a short tail.

                          Dogs do all sorts of things that make sense only to dogs. We're here to try to develop a deep model of why people think SMT works. When it works... If it works... I would propose we remember to include skin in the mix, since it has all the fast receptors.

                          Maybe what we'll also uncover in the process is a profile of those who use it, defend its use, try to salvage it as a preferred method.

                          Let me ask you this EB: How do you think SMT reduces pain?
                          Last edited by Diane; 04-11-2006, 05:54 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


                          • #14
                            In many ways, the modern history of STM has been similar to that of acupuncture. Both are extremely popular and extremely contraversial. When acupuncture made the big move into the west in the 50's, its popularity was driven by anecdotal reports of efficacy. The construct i.e. balancing Qi in meridians etc, however, was obviously very distracting to those who take the biomedical science seriously, and consequently there has always (and justifiably) been a considerable resistance to its practice in the mainstream. Over the last 10 years though (particularly with the use of fMRI and PET-which was invented by an acupuncture researcher BTW) there have been some extraordinary advances in our understanding of how such an intervention produces its effects. Even though research validating the efficacy of acupuncture for many of the conditions for which it is used is still wanting, its seems that the emergence of a more solid biomedical model has lead to an increasingly astounding (compared to the situation when I starting studying it) mainstream use. Regarding the evidence for efficacy, no doubt the issues discussed in this paper posted by Jon play a part, and the same should be acknowledged of HVLA research.

                            Most people agree that for certain presentations HVLA can be very effective. Although my idea of therapy has changed considerably since The Naniamo Experience, there are still situations for which I will use HVLA, and in many cases the effect is instant. However, just as acupuncture has had its Qi and meridians, SMT has had the "out of alignment" hypothesis and it appears that this meme might be even harder to shake off than the meridian. Investigation has shown that this idea is false. Unlike acupuncture though, it seems that no one is much closer to illuminating the mechanisms behind its effects. I agree with Eric (and many others) here- such an understanding is necessary. Although there will always be researchers out there bent on validating their beliefs, there seems to be enough interest in this area that reason will prevail.

                            Because it ain't going way, what to do in the meantime? I think Nari has already covered this; "it is the message it sends". Even if we do develop an understanding of how this treatment works and exactly when it should be used, it has to be divorced from the crippling effects it can have on self-efficacy when delivered with the current memes.
                            Last edited by Luke Rickards; 04-11-2006, 02:56 PM.
                            Luke Rickards
                            Osteopath

                            Comment


                            • #15
                              There are not many physios in this country who manipulate on a regular basis, as far as I can determine, although they are held in high regard. I know quite a few manip therapists who have the background education (a heavy 1 year intense post-grad course) but do not use it much; and this was the case long before the Childs 'rules' appeared, so they did know what was appropriate, it would seem.
                              One rationale is that a Gr IV mobilisation achieves the same result, so why crank and force into further range?
                              The public is vulnerable and should not be blamed for misconceived ideas; the notion of a bone/joint slipping out of place is easily visualised, just as the poor IV disc is easily visualised when it goes wandering as well. 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.
                              In the old days they reckoned uteri and placentae wandered as well.
                              BTW, chiros are taught in Oz that subluxation is a figment of past imaginations, but that seems to be not the case elsewhere?
                              Or is it called malalignment?

                              Nari

                              Comment

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