Tip Neck manipulation

[Barrett Dorko]

Then they should get off of their asses and do what their teachers didn't do for them.

Yea, I said it.

[MaxG]

Originally Posted by Barrett Dorko

Then they should get off of their asses and do what their teachers didn't do for them.

Yea, I said it.

One can only search, when one knows that something is missing.

A rigorous knowledge base of the scientific method and its basic premises helps (and no, this doesn't mean EBP). I assume this is sorely lacking in the US as well (it certainly is here in Europe).

[AHB]

And I'm glad you did.. I 100% agree...

[AHB]

Originally Posted by MaxG

One can only search, when one knows that something is missing

I disagree.. It's your own responsibility to stay up to date with information.. If all new grads get out of school, and take what they learned as "good enough".. Then how do they grow as professionals, and how does the profession grow? Sure there are "continuing education requirements" for licensing.. But how much of the courses that are out there are complete BS and used solely for getting the "quick credits"!

Can't just put blame on the teachers.. We all have to take responsibility for how much we really care..

[John W]

Then they should get off of their asses and do what their teachers didn't do for them.

Wouldn't the decision for that action require the right motivation? Where are they going to get that? From their smartphones, Ipods, x-box live?

We're in big trouble.

[MaxG]

Originally Posted by AHB

I disagree.. It's your own responsibility to stay up to date with information.. If all new grads get out of school, and take what they learned as "good enough".. Then how do they grow as professionals, and how does the profession grow? Sure there are "continuing education requirements" for licensing.. But how much of the courses that are out there are complete BS and used solely for getting the "quick credits"!

Can't just put blame on the teachers.. We all have to take responsibility for how much we really care..

I'm not sure we entirely disagree.
I think most of the students I've met are excited about the field and eager to learn, most of them try to keep up to (what they perceive to be the) date.

The problem is, one can spend years in cont-ed courses without learning anything substantial (but gathering many real or metaphrical "tools" in the real or metaphorical "tool-box").

A skeptic, science-based approach to information gathering and interpretation is essential. That can be acquired autodidactically, but should be taught in PT-school.

[Barrett Dorko]

POTENTIAL INFORMATION COMBINED WITH CURIOSITY DRIVES US

Well, me anyway.

Technological advances haven't altered this. It has only made it easier.

I actually agree with Amanda here. Perhaps a first.

[John W]

Technological advances haven't altered this. It has only made it easier.

They've also made it easier to get distracted and to pose as if one is knowledgeable on a subject. John Snyder's blog is very attractive and his blog article on cervical manipulation is replete with graphics, illustrations and links to a bunch of articles. He's very tech savvy.

The content couldn't be more wrong.

[AHB]

MaxG.. I agree with you on that!

John.. And I think that's where John S is going with the idea of his blog.. He's trying to motivate the new generation with the technology that intrigues them.. But he's still only focusing on the ideas brought about while in school.. He's still a student.. We can keep our fingers crossed that he'll be the student to challenge his teachers in providing new information..

Barrett.. I'll take it

[Barrett Dorko]

John,

No doubt there's a change, but it isn't going anywhere.

Curiosity doesn't change, only our ability to satisfy it.

Some use this easier access to look like they know more and then are more certain about the conclusions they've drawn.

All we can do is remain vigilant and vocal as is appropriate.

Banking's easier anyway.

[Diane]

Originally Posted by Barrett Dorko

Banking's easier anyway.

Yeah, plus if you're a bank it looks like you can't lose, no matter how bad you screw up/everyone else in the ear.

[Freshy]

Originally Posted by AHB

I disagree.. It's your own responsibility to stay up to date with information.. If all new grads get out of school, and take what they learned as "good enough".. Then how do they grow as professionals, and how does the profession grow? Sure there are "continuing education requirements" for licensing.. But how much of the courses that are out there are complete BS and used solely for getting the "quick credits"!

Can't just put blame on the teachers.. We all have to take responsibility for how much we really care..

Completely agree with this. In this day & age there is zero reason for a PT/LMT/OT or anyone else that deals with people in pain to NOT be informed about the neuromatrix theory of pain. They should be viewing their treatment though that lens.

Today at my son's soccer practice another father was talking of his foot pain to me and a third Dad that is a PT. He was telling us how his foot was hurting & it was because of bone spurs. How he was going to probably get surgery to remove it. The PT started breaking it down for him. "Bone spur is rubbing on achilles, you need to stretch the gastroc/soleus, get a cortisone shot for the pain, many times the bone spur can cut through the achilles if not removed."

When he said the last part about wearing away the tendon my jaw dropped. What the hell is this guy doing? was what instantly popped into my head. This poor Dad is in pain, considering surgery if/when he can take off work & you drop a nociebo bomb like that on him?! I did my best to explain to him that many people have bone spurs when imaged and are without pain(myself included), that the body can lay down & reabsorb bone on it's own,that he could move his foot in slow, novel ways rather than "stretch" the "Tight Gastroc/Soleus muscles", and that they sell a stretchy type of tape at the Wally World up the road for $10 that he could apply to around the area to give his brain some novel input.

The PT Father is a really nice guy, and he was sincerely trying to help no doubt. I find it ridiculous though that a non-practicing LMT has to try & clean up after a PT takes a dump on someone's lawn because they don't know any better. I can only imagine the frustration the PT's on this forum feel. BTW, when I found out he was a PT a few months ago I raved about SS as an information source and gave him the link. Oh well...........

[AHB]

Originally Posted by Freshy

& clean up after a PT takes a dump on someone's lawn because they don't know any better..........

Hahaha.. Pretty much just made my day with that quote

[Frédéric]

I know I'm a bit off topic, but lets suppose for a moment the change we suggest is applied at large by every PT. How many PTs would loose their job? I think many. There is no financial incentives to make this change. Patients will need fewer treatments, fewer conditions will require treatments and there will be a lot less cont ed courses required. There is already a steady decrease in workers comp claims that will surely continue to drop also. At the same time more Universities are graduating more PTs. Simply from a financial stand point the profession sees no incentive to change. So manips will still be taught and used and the chiro turf war for its use will continue. PTs will keep wandering all around the wide spectrum of frivolous therapies.

Insurance companies sure don't want things to change either as such a change would mean a lot less claims so an obligatory decrease in premium not to mention the fact such insurance could become undesired by some as potential client might feel they don't need that much protection afterall.

I can only see incentives for the profession and its current framework to keep outdated therapy models that favor medicalization and entertain a need for its product/service. In this scheme of things (at least the way I see it) the use of manipulation will likely stay more or less the same minus a few variants for its rationnal. I know, I exhibit a keen sense of optimism...

[keithp]

The only thing I will put forth is that you need to be looking in the right places if you are new student who graduated with an indoctrination in the value of RCTs and CPRs in lieu of critical thinking.

The internet is too vast to find the "right" stuff alone...then again...even when led to water, sometimes they still prefer kool-aid.

Respectfully,
Keith

[Diane]

Originally Posted by Frédéric

I know I'm a bit of topic, but lets suppose for a moment the change we suggest is applied at large by every PT. How many PTs would loose their job? I think many. There is no financial incentives to make this change. Patients will need fewer treatments, fewer conditions will require treatments and there will be a lot less cont ed courses required. There is already a steady decrease in workers comp claims that will surely continue to drop also. At the same time more Universities are graduating more PTs. Simply from a financial stand point the profession sees no incentive to change. So manips will still be taught and used and the chiro turf war for its use will continue. PTs will keep wandering all around the wide spectrum of frivolous therapies.

Insurance companies sure don't want things to change either as such a change would mean a lot less claims so an obligatory decrease in premium not to mention the fact such insurance could become undesired by some as potential client might feel they don't need that much protection afterall.

I can only see incentives for the profession and its current framework to keep outdated therapy models that favor medicalization and entertain a need for its product/service. In this scheme of things (at least the way I see it) the use of manipulation will likely stay more or less the same minus a few variants for its rationnal. I know, I exhibit a keen sense of optimism...

Sucks bilgewater through a straw doesn't it?

Another side vision: PT is positioned to take over most of the triage to do with "pain" of the MSK" kind. Which GPs will lobby against...

There will be big upheaval around that. Hang onto the sides of the good ship PT - rough sailing ahead.

[keithp]

Originally Posted by Frédéric

I know, I exhibit a keen sense of optimism...

I cannot find fault with what you are saying Fred...I daily consider some ideas to put in my "Plan B" folder.

It remains empty.

Respectfully,
Keith

[MaxG]

Originally Posted by Freshy

Completely agree with this. In this day & age there is zero reason for a PT/LMT/OT or anyone else that deals with people in pain to NOT be informed about the neuromatrix theory of pain. They should be viewing their treatment though that lens.

I don't know if I agree.
The neuromatrix theory will likely be adapted, improved, added to a lot in the following years and decades.
In my opinion it is not about knowing ONE thing (the current theory), but about being able to find, read and understand the current scientific discourse and appreciate its complexity.
It is also crucial to know about self-deception, human biases and scientific inquiry into theories.

An institution should teach those, as they are (obviously) not universal amongs clinicians (far from it).

I'd rather the student-blogger thought critically about the data he has at hand than mindlessly babble on about the pain-matrix because he listened to one Moseley-podcast.

[AHB]

I don't know about that...

From what I can gather from the posts on my intro thread.. Most of the PTs on this board still practice manual therapy techniques (although to varying degrees), exercises, and provide a wealth of education..

I don't see how just changing the way we look at manipulations is going to downplay the need of PT.. There will still be injuries, surgeries, and always an importance to educate on prevention ..

I for one don't perform cervical manipulations.. Ever.. But I will say that those manipulations were never even taught to us during school.. We were taught to screen before performing any cervical mobilizations of Atlas/Axis.. But we were not taught manipulations of the cervical spine.. During my internships (maitland based) and work, I have been taught a few different approaches.. But I've never utilized them.. Just never felt comfortable.. I suppose it should be noted that I also took all the MTC courses, just never pursued the actual certification (entirely different subject)

Now.. I don't perform thoracic or spinal manipulations for a different reasoning.. It's not allowed in my state unless you have physicians approval.. Sooooo that's again a topic for another day..

[Barrett Dorko]

I'm pretty sure the PT is more accurately described as willfully ignorant than "doesn't know any better."

I spoke yesterday with a young DPT who never heard of Paris or Shacklock but knew that Butler had written a book. I didn't dare ask her about what but I strongly suspect that she didn't know that. I watched as she applied ankle weights and theraband simultaneously to a patient.

She was also verbally engaged with the COTA about childcare and cupcakes. I didn't feel it was appropriate to interrupt. I also know that I would pay an enormous price if I kept talking.

I'm not kidding.

[John W]

Curiosity doesn't change, only our ability to satisfy it.

I had to think about this for a while, and then I heard this song on Pandora:

I don't mind stealing bread
From the mouths of decadence

But I can't feed on the powerless
When my cup's already overfilled
But it's on the table
The fire's cooking

And they're farming babies
And the slaves are all working
Blood is on the table
The mouths are chokin'

I'm going hungry
I don't mind stealing bread
From the mouths of decadence

The access to vast amounts of information has resulted in a form of decadence and self-indulgence that too many of our young people aren't aware of. It's accompanied by a sort of coarse arrogance that I think is evident in their language and exemplified by their level of certainty about complex things, like human pain, which none of us should be certain about.

They're chokin' on all this crap. They think they're satisfying their curiosity by accumulating inchoate and irrelevant facts and then regurgitating them out in slick electronic media.

Something's missing. We're not teaching them something important.

[Diane]

Originally Posted by MaxG

I don't know if I agree.
The neuromatrix theory will likely be adapted, improved, added to a lot in the following years and decades.
In my opinion it is not about knowing ONE thing (the current theory), but about being able to find, read and understand the current scientific discourse and appreciate its complexity.
It is also crucial to know about self-deception, human biases and scientific inquiry into theories.

An institution should teach those, as they are (obviously) not universal amongs clinicians (far from it).

I'd rather the student-blogger thought critically about the data he has at hand than mindlessly babble on about the pain-matrix because he listened to one Moseley-podcast.

Neuromatrix theory is not "just" another "theory" - in my view, it's a nice stretchy container for everything else that is out there.
It puts "pain" in perspective. Ah, I see: Output, not input.
It puts activity into perspective. Ah, I see: Output. Of course. I knew that.
It puts stress into perspective. Ah. I see: Stress regulation is something the brain outputs, in oder to regulate it. Ah. OK, check.

It provides an overview of a human organism moving through a life span. It sorts everything into logical domains. It shows that thinking is a kind of input into the stew. Ah, I see: thinking can add stress to the system is we aren't careful, and that can affect pain. Ah.

Pain is an output, but it can immediately affect all the input domains as well, setting up a positive feedback situation. Ah, I see: That's probably not a good thing.

It's clinically useful to go over that diagram with patients, because they can start to map themselves in a biopsychosocial way, identify their stress and place it logically on the diagram - it saves a LOT of time, helps people get their locus of control back, provides them with a roadmap.

It's WAY better than the strictly bio- theories that currently co-exist. This one is a really good clinical tool for helping people develop better cognition, better detachment from pain, because they can conceptualize it, finally, instead of just feeling it.

It's adaptable to every situation. Frankly, I don't see much room in it for improvement. Minor tweaking maybe.. but it's great, especially the decluttered version.

[MaxG]

Originally Posted by Diane

Neuromatrix theory is not "just" another "theory" - in my view, it's a nice stretchy container for everything else that is out there.
It puts "pain" in perspective. Ah, I see: Output, not input.
It puts activity into perspective. Ah, I see: Output. Of course. I knew that.
It puts stress into perspective. Ah. I see: Stress regulation is something the brain outputs, in oder to regulate it. Ah. OK, check.

It provides an overview of a human organism moving through a life span. It sorts everything into logical domains. It shows that thinking is a kind of input into the stew. Ah, I see: thinking can add stress to the system is we aren't careful, and that can affect pain. Ah.

Pain is an output, but it can immediately affect all the input domains as well, setting up a positive feedback situation. Ah, I see: That's probably not a good thing.

It's clinically useful to go over that diagram with patients, because they can start to map themselves in a biopsychosocial way, identify their stress and place it logically on the diagram - it saves a LOT of time, helps people get their locus of control back, provides them with a roadmap.

It's WAY better than the strictly bio- theories that currently co-exist. This one is a really good clinical tool for helping people develop better cognition, better detachment from pain, because they can conceptualize it, finally, instead of just feeling it.

It's adaptable to every situation. Frankly, I don't see much room in it for improvement. Minor tweaking maybe.. but it's great, especially the decluttered version.

Agree, but such a deep level of understanding implies a thorough analysis of the available science and the ability to question the methods you use skeptically/scientifically.
A dogmatic understanding of pain neuroscience looks very differently (look at all the meso-PT simply adding a sentence about the nervous system into some meso-article, paying lip-service to the "neuro-revolution").

[Mason]

Originally Posted by Diane

It's clinically useful to go over that diagram with patients, because they can start to map themselves in a biopsychosocial way, identify their stress and place it logically on the diagram - it saves a LOT of time, helps people get their locus of control back, provides them with a roadmap.

It's WAY better than the strictly bio- theories that currently co-exist. This one is a really good clinical tool for helping people develop better cognition, better detachment from pain, because they can conceptualize it, finally, instead of just feeling it.

Wouldn't a patient's response to being shown a diagram of this theory be determined by their neuromatrix? In other words, we can explain the concept that pain is an output from the brain, but the patient's brain will ultimately decide what to do with that information, and this can be affected by their ability to integrate those concepts and their past experiences. I don't think we can say that logically the person will come out with a better detachment from pain.

The usefulness of the neuromatrix as a clinical tool is not yet clear.

[student]

Originally Posted by Diane

Neuromatrix theory is not "just" another "theory" - in my view, it's a nice stretchy container for everything else that is out there.

It's adaptable to every situation. Frankly, I don't see much room in it for improvement. Minor tweaking maybe.. but it's great, especially the decluttered version.

Diane, I would tend to agree and think that the article by Isaac Asimov on the relativity of wrong fits in nicely here. If you haven't read it here is a link.

But that tweaking may shift emphasis from one area to another. It is part of why I find emergence, chaos, and complexity so fascinating. It's why I think the ideas proposed by Mosley in his paper on first person neuroscience are worth taking some time to think over.

All in all I think our theories are becoming less wrong. Which is good.

[Diane]

Context is everything. The more one understands it, the better one is able to converse with a patient about it, same as any other kind of tool, e.g., assessment or measurement.

Its usefulness derives from how it can help a patient export their situation onto a piece of paper and become more objective about it.

[John W]

The usefulness of the neuromatrix as a clinical tool is not yet clear.

The usefulness of the model is clear to me, Mason. It's not a clinical tool, like manual therapy or exercise any more than the directions to build a tree house or a swing set are "tools". It's instructional not instrumental.

[Freshy]

Originally Posted by MaxG

I don't know if I agree.
The neuromatrix theory will likely be adapted, improved, added to a lot in the following years and decades.
In my opinion it is not about knowing ONE thing (the current theory), but about being able to find, read and understand the current scientific discourse and appreciate its complexity.
It is also crucial to know about self-deception, human biases and scientific inquiry into theories.

An institution should teach those, as they are (obviously) not universal amongs clinicians (far from it).

I agree that it is important to teach students all of those things Max, but isn't the neuromatrix theory of pain a robust scientific theory that explains pain better than any others at the present time?

Originally Posted by MaxG

I'd rather the student-blogger thought critically about the data he has at hand than mindlessly babble on about the pain-matrix because he listened to one Moseley-podcast.

I'd rather the student-blogger thought critically about the data after having been required to read Butler, Melzack, Moseley, Ramachandran while in school but that doesn't seem to be what happens.

[MaxG]

Originally Posted by Freshy

I agree that it is important to teach students all of those things Max, but isn't the neuromatrix theory of pain a robust scientific theory that explains pain better than any others at the present time?



I'd rather the student-blogger thought critically about the data after having been required to read Butler, Melzack, Moseley, Ramachandran while in school but that doesn't seem to be what happens.

This was (at least supposed to be) my point exactly.
Up to date science is one, critical thinking another necessity.

[Mason]

Originally Posted by John W

The usefulness of the model is clear to me, Mason. It's not a clinical tool, like manual therapy or exercise any more than the directions to build a tree house or a swing set are "tools". It's instructional not instrumental.

I agree John. I think it is an immensely helpful model for guiding clinical decisions and even our word choice with patients. I was responded to Diane's post regarding explaining the theory to patients to help them become more objective about their pain.

My point was along the lines that no matter how knowledgeable we as clinicians are in the theory and how well we can converse with the patients about their neuromatrix, there is no clear cause and effect that this results in the patient becoming more detached from their pain. Some other factors involved are the patient's ability to assimilate new information, which is largely out of our control, and our ability to teach.

[Diane]

Originally Posted by Mason

no matter how knowledgeable we as clinicians are in the theory and how well we can converse with the patients about their neuromatrix, there is no clear cause and effect that this results in the patient becoming more detached from their pain. Some other factors involved are the patient's ability to assimilate new information, which is largely out of our control, and our ability to teach.

It does over the long term - Moseley has evidence for that, from about a decade ago. It was for "pain education", not specifically neuromatrix (which is a lot more biopsychosocial model) I think just the simple bio physiology kind. Here is a C-fibre coming into the spinal cord. Here is another fiber taking its message up to the brain. Here are two hundred fibres coming down from the brain that can either turn the message up or turn it down. That kind of thing plus, "if you had to rescue your toddler from in front of an oncoming bus, you'd likely forget about your sprained ankle and it wouldn't hurt you as you ran to save your child.."

[keithp]

A new posting on SBM: Whack em hard/Whack em once and Stroke

I still suspect that occasionally there is a perfect storm of bad luck, the forces are perfectly aligned in a susceptible patient and they get an embolic stroke or a vertebral artery tear.

...It is very hard to injure people with what the chiropractors refer to as high velocity, low amplitude thrusts. That sounds so much better than whack em hard/whack em once. So the adverse events from a quick partial hanging are rare and proving causality with rare events is not easy.

...Some practitioners consider it a myth and others find no risk

“The 83 chiropractors administered >5 million career upper cervical adjustments without a reported incidence of serious adverse event.”

although rather than complications they had ‘symptomatic reactions (SRs)’:

“Three hundred thirty-eight (31.0%) patients had SRs meeting the accepted definition. Intense SR (NRS ≥8) occurred in 56 patients (5.1%).”

Symptomatic reactions included

“1) neck pain and/or stiffness/soreness, 2) radiating (arm or leg) pain/discomfort, 3) arm or leg weakness, 4) tiredness/fatigue, 5) headache, 6) dizziness/imbalance, 7) nausea/vomiting, 8) ringing in the ears, 9) blurred or impaired vision, 10) confusion or disorientation, 11) depression or anxiety, 12) fainting, 13) low back discomfort/soreness.”

And what are the symptoms of a vertebral artery transient ischemic attack, the most likely effect of whack em hard/whack em once?

“Dizziness, vertigo, headache, vomiting, double vision, loss of vision, ataxia, numbness, and weakness involving structures on both sides of the body are frequent symptoms in patients with vertebrobasilar-artery occlusive disease. The most common signs are limb weakness, gait and limb ataxia, oculomotor palsies, and oropharyngeal dysfunction.”

Anyone besides me worried when comparing and contrasting the two lists?

Respectfully,
Keith