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Try it, Use it or Lose it! Hands-In approach to forget pain, useful tips

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Old 25-07-2006, 03:58 PM   #1
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Default Manipulation practice

Hi all ;

Regardless of all objections , i like to apply manipulation practically !
Had any one ,here, practiced Manipulation before ?
Could anyone lead me through practical trying of manipulation ?

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Old 25-07-2006, 10:18 PM   #2
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emad

I don't know if you will find many who regularly use manipulation.
It is not taught to any extent in Australia, and not used much. I think the tendency was to leave it to the chiropractors while we used other methods.

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Old 25-07-2006, 11:05 PM   #3
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Quote:
Originally Posted by nari
emad

I don't know if you will find many who regularly use manipulation.
It is not taught to any extent in Australia, and not used much. I think the tendency was to leave it to the chiropractors while we used other methods.

Nari
Huh? What do you mean Nari? I learned my manip skills at Uni in Australia. Hmmm.
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Old 25-07-2006, 11:38 PM   #4
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Hi Oljoha

Excuse my mistake; some manips are taught in undergrad years, but the students I have been involved with over ten years or so don't really use them.
As part of registration, one has to fill in a form every year saying whether manips are practised or not; and if so, have there been adverse events and so on. Clearly the PT registration board takes it seriously.

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Old 26-07-2006, 10:50 AM   #5
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They seem to use them in New Zealand. You can find a video demonstration of the manipulation they used in the Child's Clinical Prediction Rule online. I don't have the link right now. Maybe Jason will chime in or I will find it tomorrow.

It's pretty simple.
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Old 26-07-2006, 12:45 PM   #6
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emad,

If you really feel you want to learn this then you would be much better off finding someone who knows what they are doing to teach you.

Manipulation is not easy (except perhaps a few of the very basic lumbar techniques). To do it well, ie minimal leverage and force, is even harder, and to do it well and be as safe as possible takes years of careful, direct training. You can't learn this from a book or a video.

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Old 26-07-2006, 01:12 PM   #7
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emad

I agree with Luke; in the interests of safety and professional integrity, manipulation is not something one picks up on a casual basis. It is just not worth the risk.

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Old 26-07-2006, 01:21 PM   #8
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emad - I have extensive and expensive specialisation in manipulation - and it's like having a very expensive Hummer in the driveway to get me to work down the street. It is, to me, really not worth the expense. I don't see it as a risky technique when taught properly, but why "buy the big vehicle" when you can "bike to work" with much cheaper, easier and gentler techniques (and be good to the environment [the human])?

Anyway - IF you want to learn do manips, you'll have to pay and take good courses.
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Old 26-07-2006, 01:42 PM   #9
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I agree,

you can`t really learn to manipulate over the internet. You need the hands on experience to get the feedback + lots of practice.

However you can use the internet to look at the evidence and decide what effects you are trying to achieve and what benefits they may give the patient.

regards

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Old 26-07-2006, 01:43 PM   #10
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Hi all :

Actually ,there a discussion on Rehab Edge concerning Manipulation in pregnancy , i shared there with views like yours all ,but i notcied something strange for those manipulators ;

# They think we are NOT open mind enough to try manipulation
# They say ,we do NOT practice Manipulation ,so that we have those views

Something unblievable ,weak reasoning and thinking ,i do NOT like at all someone who is weak at reasoning logically and scientifically my doubts ,goes out to personal issues and criticism . I was speaking about dangers of Manipulation ,brought evidences ,they said we are speaking about lumbar ,finally ending up i am NOT open-minded person to try up to date manipulation .

I caught in one of the reare times ( in which i check long discussions as potural restor.) ,i remember difficulty , as if the person defending belief ,we are discussing science ,science whose first key is developing ,ready to change and accept ,Really , i do NOT know why they defend Manipulation strongly for monney or belief ??????

Luke, I am here in the Earth pole , where no manipulation or mobilization or manual therapy only electrotherapy
Bas,sometimes ,culturally ,big car gives you presentation .


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Old 26-07-2006, 02:12 PM   #11
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emad,

As my posts on Rehabedge have suggested, there is a lot more to physiotherapy life than forced passive techniques; but it is a losing battle. Nevertheless, they won't let the horse go. And I am silly enough to keep on.

Don't worry about the manipulation ethic - it is really not necessary and we can do very nicely without it. Threats about poor care and lack of duty of care if we don't sprong joints are just that - cultural notions.
Save your money for other courses.

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Old 26-07-2006, 04:09 PM   #12
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emad,

Being open-minded is one thing, but I don't think you can simply "give it (manipulation) a try". I am not saying it can't be useful, but learning to do so is a big commitment.
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Old 26-07-2006, 04:21 PM   #13
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Emad, I love your post #10. Right on!
It's about perceived status, ranking the human primate social groomers so that manipulators are the (mostly) alpha males, self-appointed.
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Old 26-07-2006, 04:22 PM   #14
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Nari; Even if i have the intention to attend a Manipulation course , i can NOT .It is overseas for me , i think here in the Capital could be available ,but for me it will be helpless,hopeless.

Luke,so correct your view ,Manipulation needs great commitment ( something like belief ) ,i think this commitment is NOT scientific at all ,to be good professionalist the person needs looking at all aspects .

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Old 26-07-2006, 04:24 PM   #15
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Diane,

In my experience the most skillful and commited manipulators definitely exude an alpha male type aura.
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Old 26-07-2006, 04:29 PM   #16
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emad,

I am not talking about a belief at all. I am talking about the time and effort needed to develop the skill. I remember watching my instructors in second year uni and thinking "Well, that looks pretty easy". Four years later and I was only just starting to develop a sense of confidence with it.

Last edited by Luke Rickards; 03-04-2008 at 11:38 AM.
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Old 26-07-2006, 05:11 PM   #17
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Luke :

I agree with you ,

your view remind me with those discussions going on in my hopsital with doctors and within their groups working in surgery ,Manipulation for me like invasive approaches ,Those Surgeons usually speak about how to learn surgery methods and techniques ,they can NOT practice without learning practically by seniors .Seems the issue is so difficulty .

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Old 26-07-2006, 06:05 PM   #18
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Hi all,

in Germany manipulation is a big issue in PT. There are a lot of further education centers for PTs where you can learn your manip skills. And most of the german PTs say that when you are a "real" Manual Therapist that you can do manips. I don't think so. In the past years I saw a lot of patients with several manips in their medical history and guess what: "Well, after the manip all my problems where gone." Me: "How long did it last?" Patient: "Two to three month." Okay, I see. These patients had up to ten (10) manips and still had their problems.
It is like the thread with the doctors (unfortunately I did not subscribe to it so I do not have the proper link). People come to us and say: "Cure me!" Me: "I can not cure you - sorry about that! You are responsible for your health - not me!" But some PTs here in Germany do manips like ... They just say: "Okay, I know what your problem is. Lay down." Then they do the manip, everythins is fine, Patient is happy - and will be back in two or three month.
Enough of that. There are some (precious few on my humble opinion) PTs out there wich can do ONE excellent manip. And then the problem is realy solved. But I can not do that and would like to add that I do not need it. I think that most of my colleagues are to swift to do a manip.

Regard, Daniel
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Old 27-07-2006, 12:27 AM   #19
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Daniel,

What you say is quite believable; and there is that other side to the quickfix force technique - it does not last for long, so the patient has to return every so often for another quick fix. That's income; and so,not to be too nasty as to the manipulators' motives, the patient believes that a PT is wonderful because one or two sprongs and I'm good for quite a while and I don't mind the money because I feel good for three months.

So to add to the list: money, regular custom, dependency.
Certainly, this is not the case with all PTs who manipulate.

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Old 27-07-2006, 09:59 AM   #20
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Daneil ;

Do you think that One Excellent Manipulation is really existed and is effective ??

I like to hear views from Diane ,nari,bas, regarding that just one excellent trial of manipulation ?

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Old 27-07-2006, 10:07 AM   #21
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Ahhh, there's nothing like a balanced view. There is as much evidence for the effectiveness of manipulation as any other modality or technique available to PT's. The recent research shows that simple, uncomplicated techniques are effective in incidences of LBP. They no more lead to patient dependency and repeat visits than any other technique, including neuromobilization, and it is pretty insulting to suggest that the primary reason PT's do it is to foster dependency in their patients to pad their pocketbook.
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Old 27-07-2006, 11:15 AM   #22
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Randy

It may seem insulting, but I did say:
Quote:
Certainly this is not the case with all PTs who manipulate.
and I stand by that, because I have seen it happen and have read of this as well.
The same goes for chiros, which is why I mentioned the thing about good and bad eggs.
Nothing personal or specific, but it happens in the broad field of practitioners.

Neuromobilisation is unlikely to result in repeated visits, because it is something the patients can easily do for themselves. Repeated manipulation is not something that can or should by done by patients.

Emad,

There have been quite a few patients (I know of PTs and chiros who have done one manipulation with instant success) who respond very well to one excellent manip. From what they say, the fact patients do not return can also mean they have gone elsewhere for continuing sessions. They don't know either way. Only a long followup study can estimate that. I don't know if that exists.

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Old 27-07-2006, 01:09 PM   #23
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Nari :

Do you know when you bring eggs usually bad eggs go together grouply and good eggs go grouply ,and testing bad eggs through putting that in water ,you will find bad eggs float up together !!!!!!!

Randy,the issue of money seems personal to some degree ,for neuromobilisation the issue does not need frequent visits .

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Old 27-07-2006, 02:02 PM   #24
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Emad, at the Edge, the clash is about outcomes. Not that manipulation is better, but that it at least has outcomes studies supporting its effectiveness over just exercise. Any neurodynamic or ideomotor techniques don't have that ....For the discussion, that is a great shortcoming. However, when one takes into account the logic and basic deep science of the gentle, neuro-based approach, one can argue that the underlying principles of manipulation are no better than neuromodulation. And if they are no better, then why do the coercive techniques rather than the bentle? Oh, wait. There's that outcome study that shows......

Now, I'd like to ask the manipulators how they treat frozen shoulders. Outcome studies show that doing nothing vs. stretching have the same outcome - i.e. 2 years down the road, the patient is better. Do they leave the patient alone?
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Old 27-07-2006, 05:11 PM   #25
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emad,

here is one example for a manip: torticollis. I am talking of the acquired toricollis (not the congenital one) when you wake up in the morning and can not move your head. If you (PT) then do a proper physical examination and all the features for an articular problem fit then it would be the best to do a grade V mobilisation - wich is a high thrust manipulation. And that is not only my opinion - that is what the IMTA teaches.

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Old 27-07-2006, 05:12 PM   #26
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Bas,
You know the Saying "Goal could reason the method " ,i think they work using this say .

However ,sometimes i spoke saying that reaching the Goal using non-evidenced approach could be possible , i do not know what is the position with manipulation ! My main concern with manipulation is the complications .

Seems there are no studies concerning lumbar-manipulation complications ,look at this one of their views :

Quote:
Emad,
I will post the studies as soon as you post studies supporting that lumbar manipulation causes harm and complications.

I also perform neural mobilizations to patients usually who have radiculopathy symptoms and I find them very helpful. But like with any intervention, you can't tell me that you have not flared someone up with those techniques because it is pretty easy to do with someone with acute symptoms. I would say that lumbar manipulation has the same chance of aggravating low back symptoms as your neural mobilizations
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Old 28-07-2006, 11:09 AM   #27
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As a patient, 21 years old and with a back pain that didn't get resolved any other way, I recieved a manipulation, and I felt better immediately and never had any problems with it again. That is my ancedotal evidence feather I throw in the hat.
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Old 28-07-2006, 11:31 AM   #28
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Randy :

Could you clarify that experssion
Quote:
ancedotal evidence feather I throw in the hat.
do you mean yourself , i doubt !!!!!!!!!!!!

And there are plenty others used Manipulation with no progress,furthermore with complications (cervical to be accurate ).

Cheeeeeeeeeeeeeers
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Old 28-07-2006, 11:50 AM   #29
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Just to complicate things a bit further, the wake-up-in-the-morning-wry-neck thing responds in less than 5 minutes with McKenzie extension in lying. (With of course a sharp eye on the VA response, if any). I would use Mckenzie for this condition over Gr1-4 mobilisations anytime. Painless and smooth resolution...
OK, so that is anecdotal but I did mention a guru's name after all...

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Old 28-07-2006, 01:20 PM   #30
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emad,

In my experience, for certain presentations manipulation can be extremely effective (and occasionally instantaneous, as in Randy's case), with minimal chance of complications.

Regarding the dependency issue, I think this is complicated. I don't see much indication that acute presentations that resolve following manipulation (whether the manipulation was the key or not) develop dependency. In chronic pain, if patients have not found long term relief from any approach, and this is more common than we would like to admit, then I can understand how they would seek the short to mid term symptomatic relief that manipulation often produces. I don't think this ideal of course. Whether this is managed appropriately by the therapist probably has to do with many factors, and I'm sure in some cases it would be financial.

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Old 28-07-2006, 01:58 PM   #31
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Luk;
I can NOT understand how Manipulation could produce short term relief in chronic patients ??
Anyway, i agree Absouletly ,from patient point of view, if there no method works with his/her pain ,i do not blame the patient at all in trying manipulation to address that pain even shortly in lumbar regions only .However ,seems to me as placebo effect ,I think the key point is the believing (from the patient ) /convinced that he/she recieved the appropraite treatement .

What i disagree with at all using of risky (cervical Manipulation ) to address non-risky pain ,what ever that pain ,you know you are working in pain and have experience ,pain could resolve without anything ,do you agree ?

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Old 28-07-2006, 02:03 PM   #32
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Yes, I agree that Cx manipulation is risky.

You are not alone in not understanding how manipulation could produce short term relief in chronic patients, but for many people it seems to. Placebo?- probably. I have recently moved to a new clinic and I have dozens of people a week come to me and say "I think my hips/pelvis/bones are 'out' ", expecting manipulation. They already have an idea of what appropriate treatment should look like. In some cases I have to do it just so we can get to the part where I explain why this isn't a long-term solution.

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Old 28-07-2006, 04:30 PM   #33
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Man, I go on vacation for a week, and all sorts of cool stuff gets talked about...

Luke, I completely agree on people who show up saying their "neck/hip/back, etc" is out, and must be put back in. Whatever that means. But given the biomechanical model in which we were all taught, this is at least faithful to the model of why it works. So, if you look at it that way, it's a case of a clinician educating a patient in the origin and resolution of their pain!

I think that extensive training in manipulation is almost certainly a mistake, and unlikely to make a large difference in outcomes, for those patients who could benefit from it. I'm guessing Luke and I were trained very similarly in manipulation, meaning that a lot of spinal biomechanics and positioning stuff, locking out segments, etc, etc. It's rather unfortunate that all that training has been proven superfluous.
I think that what really matters is the skill of gently handling another person, and knowing when and when not to apply a certain technique.

I still manipulate people, but like most manipulators who are reading the evidence, I'm finding that the subgroup of my patients likely to respond favorably to this treatment does not represent a large portion of my caseload for spine pain. Whereas ideomotion, despite my up and down ability to elicit it, makes perfect sense for just about everyone.

I recommend that those wishing to learn manipulation first ascertain whether they are seeing people who could benefit from the treatment (see the clinical prediction rule study for an example), and if so then seek mentoring from someone who is experienced and skilled in it's delivery.

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Old 28-07-2006, 04:37 PM   #34
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Everyone has an anecdote Randy. I've got one too.. hurt my upper back doing a clumsy situp in 1976 with hands around my neck. Major pain at first, followed by minor pain and restricted neck rotation to right for the next several years.. in 1987 a PT here in Vancouver treated it, four times, and after trying all the other options, finally (with my approval) manipulated the crap out of it, and it resolved completely.

In retrospect, must have been notalgia paresthetica. And trust me, it would have been too overwhelming to my nervous system to have manipulated it in its acute stage. This is a condition that does not fit Child's CPR.

The point is not that it doesn't "work" for such stubborn bits of persistent pain/types of nerve entrapment, rather the point is that no one who does it is even bothering to look at how the dorsal rami might be affected, or not, by this manoeuvre, or peripheral nerves AT ALL!, only nerve roots and DRGs (if we're that lucky) or joints.
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Old 22-08-2006, 06:32 AM   #35
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Nari, I thought the term "spronging" was about mobilisations , now you've really muddied my phraseological waters. Maybe manips could be sproinging and mobs spronging, just to keep things nice.
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Old 22-08-2006, 07:48 AM   #36
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G'dday, ginger!

You should not take my inventive expressions too literally. Actually, spronging would probably apply to any sort of joint focus.....
In a previous life I used to mobilise joints a lot. Nice results, but often flare-ups; then settling. Now I know why flares occurred, a bit better... or I think I understand better, to be more accurate.

How's the study going?

Good to see you on SS.

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Old 23-08-2006, 12:48 AM   #37
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G'day, Nari et al.I've moved to the country, taken up with a college in melbourne where I do casual lectures to undergrads on , guess what, spronging!. Which will lead to the use of their resources and studenets to do RCT's in the new year , after I've brought a number of them up to speed on the method during this and next semester. Loving the country life.
pos pas?
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Old 23-08-2006, 01:00 AM   #38
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Ginger,

Good for you on getting a study going. Is the study to see if spronging works or is the study to see if spronging does what you claim it does?
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Old 23-08-2006, 01:45 AM   #39
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Spronging could became a catchword.

Ginger,

Keep us up to date on your efforts with college studes. I'm interested in this topic which occupies so much of PTs' time; either way, as jon has asked.

Pity about the lousy snow in the Vic alps.

By the way, I came across a patient yesterday who attended a PT for spronging twice a week for three years.

That's one reason why I'm interested, amongst others.

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Old 23-08-2006, 02:33 AM   #40
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Study one will most likely be an investigation into PFS, which , to answer your qusetion Jon , is not so much to see wether spronging works , but to consider the effects on distal structures . PFS is a good one , partly because it will attract interest in the wider community , including health professionals, and because it is a work I left unfinished from the nineties when I abandoned a similar study for lack of time money and resources.
The students I have at my disposal , so to speak , are ideal I think to be a part of this. All fired up with new grad zeal. The college is backing me so all looks good to firm up the controls, data collection , find patients, selection criteria etc.
Your mention of a patient with a long spronging history Nari , there are many methods of mobs , Mine will never be the perfect method, realisticaly, or rather that method that when performed with consumate skill will always achieve a perfect result. I've had patients for whom slow, or even no results happened for six seven or more treatments. The responsibility of the therapist is of course to stop treatments , no matter how theoretically proper , when no result is happening. There will always be alternatives.
No I'm sure I wont need to reinvent any wheels, just make the ones I know spin better.
Cheers all.
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Old 23-08-2006, 02:38 AM   #41
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Hi Ginger,

Pardon my acronym ignorance but what is PFS?
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Old 23-08-2006, 02:54 AM   #42
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patello femoral syndrome, retro patella bursitis, runners's knee, jumper's knee, fat pad syndrome, etc etc.
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Old 23-08-2006, 03:43 AM   #43
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Thanks for the clarification. What is going to be the alternative intervention that you are randomizing your patients to?
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Old 23-08-2006, 04:36 AM   #44
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Ginger,

Believe it or not, one can add OA, chrondomalacia patella, sprained VMO, quad tendonitis and the infamous Osgood-Schlatters in some cases. Of course, nothing works everytime but...the odds are in favour of referred pain.

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Old 23-08-2006, 04:48 AM   #45
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Quite right Nari, It is odd and disconcerting to read even these days of medical diagnoses of chondromalacia. One just assumes the medical fraternity moves with us , but not so. It is up to us , or maybe even me ( to assume responsibility for percieved ignorance where I may offer insights), in which case all the more reason to keep plugging away.
Jon ,the treatments I've found to have the most immediate and long term benefit for those complaining of the above assortment, is to consider how much is referred from the lumbar spine first. In so doing I have moved towards L3 mobilisations as the most powerful and effective of any interventions I offer, in cases of PFS. Attention then to the factors asociated with the provocation of protective responses at L3, including asymmetry, sij dysfunction and other biomechanical states, provide a permanent fix for PFS.
RCT's will provide further validation to this method, presuming all goes well.
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Old 23-08-2006, 05:02 AM   #46
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Hi Ginger,

I understand that one arm of the study is a specific mobilization you intend to perform but I'm curious what the other arm of the study is going to be. Are you going to compare it to an L4 mobilization or eccentric training of the quadriceps, or US, etc?

Are the measurements you're taking going to be along the lines of some sort of change in pain or are you going to attempt to measure the things you currently understand yourself to be doing such as effecting an anti-inflammatory response in the facet joints or diminished tone in segmental spinal muscles (or both)?
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Old 23-08-2006, 05:05 AM   #47
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Hey Ginger,

What will be your control/alternative technique group?

Perhaps a McConnell group, although the variables in that group would be scary. I have a feeling that Aussie PTs are moving away from rigid McConnell routines after 20 years; do you know what they are doing at present?

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Old 23-08-2006, 05:54 AM   #48
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Jon and Nari , bit pressed for time today to do this proper justice , the other arms of the trial I think should include taping, eccentric exs and depending on the 'n' , a sham Rx. Not happy with sham or null rx, but what do you think?
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Old 23-08-2006, 12:56 PM   #49
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Hi all!

My name is Anders, I'm a manual therapist working in Sweden, fresh from 4 years education, and a lurker on this and other boards.

I was just wondering, Ginger, if your mobilisations are similiar to Maitlands? Or how would you describe them? I've been trained in manipulation, but have investigated and are currently trying out Maitland mobs on my own.
I'm curious if you think there are any differences in the neuro/mechanical effects of manipulating a joint (lets say L3 in this case) and your mobs?

I'm in the process of finding my way, incorporating different techniques, biomechanics and neurodynamics and I must say, it is quite challenging
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Old 23-08-2006, 01:05 PM   #50
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Ginger,

I think jon can answer this better than I, 'cos he has more experience with this sort of investigative stuff.

However, what sort of sham rx are you envisaging?
I think a comparison with the McConnell regime would be very useful indeed. To me it is an excessively complex and rather tedious method, even if it does get good results.

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