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Old 21-08-2007, 09:37 PM   #1
Diane
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Default Which side of the nervous system are we on? And which nervous system?

It occurred to me, as yet again I felt the disgust I have for SMT rise up, on another thread current just now, that even if I don't have all the answers for everything, my insula (the buried portion of cortex that registers disgust and feed forwards the emotion to the conscious awareness part of the brain for it to mull over) has very strong opinions about what it will accept and what it won't, and is not shy about taking over my typing fingers when it has something it wants to get off my chest. It's been around as long as I have, and long ago I gave up any thoughts I might have entertained about trying to keep it reined in 24/7.

So here goes, with the help of the cognitive portion of my brain: My insula dislikes SMT because it sees it as crude and rude.

My insula wants me to tell you all that it prefers finesse in exteroception. It wants to take a sensory input and have time to consider the matter closely, observe over a number of seconds for any potential threat factor, and send out memos to all other parts of the brain, to go ahead and see if they can use it for downregulation of pain. It has thalamic input which it reads the way we read weather patterns. It likes nice weather, sunny but not direct sun, warm but not hot, cool but not too cold, and not windy/stormy thank you. It will put up with rain (low grade noxious input) but not happily, and not for too many days in a row. It cannot abide the sensory input equivalent of earthquakes or hurricanes. Or tornadoes. No strong inputs, thanks. If forced to live with noxious input, my insula will make me insane until I seek help.

The basal ganglia are just fish brains. They try to escape from everything. I barely even can imagine that I have them. They tell me nothing yet I realize that without them, I wouldn't be able to move around.

When I get back pain, I'm pretty sure it's just one or more crabby nerves back there acting up. Nothing is orthopaedically wrong with me, but the outer shell of my body, which has motor control from higher upstream, is in some sort of impasse with the spinal core part of me, a motor standoff between motor bits innervated from front bits of brain and motor parts innervated by back bits of brain. The last thing this fish brain needs is more abuse. It's already had enough. It's little tendrils surfacing up to skin in my back are cranky about not being able to move. Forcing movement into, rather than facilitating movement out of, this situation, is abusive. Or at least my insula certainly thinks so. It's been there, and that's what it came up with for my hippocampus to remember. And I have to concur with my insula, of course, because it is my protector.

So, what side of which nervous system are we on, as therapists? I'm on the side of the most good for the most number of modules, and the greatest possible harmony amongst them. I show them all, with some exteroception, where I think they might focus on a particular issue in tissue, but I leave them to sort out what to do. Meanwhile I try to make myself otherwise useful by doing work out on the surface that I think likely helps oxygenate some peripheral or cutaneous nerve that feels to me like it needs some. I stay on track by staying aware of changes in the body of the person I'm treating, and take further cues from progress made and unfolding in the moment. But I do not coerce. Why would I imagine I could impose something on another nervous system and a) expect it to last, and b) think it was a good or desirable thing to do in the first place? What hubris. How contrary to good human primate social grooming. The whole point of which is to assist a complex modular system into more harmony, not more hijack of one by another.

Other primates do not do this thing called SM, whether it's with a T on the end of it or not. They stay together, try to get along, try to survive predation, and try to help each other live less uncomfortably. That's our legacy, not its opposite. SM is a human invention, and like most high risk sports, I suppose it relieves pain for some and boredom for most. Fine, to each his/her own, but I really resent that it gets called "therapy". And furthermore, that it has thoroughly invaded my profession. And wants to take it over, in fact. Yuck. My insula wants to spit on that - spewt.

My insula knows all these things that it likes and that it doesn't like, and let's me know how to be in the world of patient treatment via the mirror neurons system, which for sensation, either my own or for other people, I have mirror neurons to infinity it feels like.
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Last edited by Diane; 23-08-2007 at 03:29 AM.
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Old 22-08-2007, 04:08 AM   #2
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Hi Diane,

I get what you're saying and understand a bit how you're feeling. I'm willing to bet that regardless of whether or not you were positive on the CPR for manipulation that you would not likely experience a dramatic reduction in pain with manipulation.

If it helps any, I'm not much for manipulation either but I can't deny that it works for some people.
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Old 22-08-2007, 04:29 AM   #3
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Thanks Jon. I can't deny that either. Doesn't mean I'm ever going to like it. Doesn't mean I have to. Some things have to be tolerated in one's midst, but there does not have to be obsequious bowing done toward its presence, nor cult-like nodding along or staying silent because thinking of and voicing objections might "weaken the team".
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Old 22-08-2007, 04:53 AM   #4
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Absolutely. It seems to be similar to some pharmacists not willing to dispense birth control (or MDs not willing to prescribe it). I say "seems" because of course there are significant differences. Regardless, they refer patients on in instances where the client wants the product they are uninterested in supplying. Who can argue with that?

And those practitioners don't stay quiet about their point of view either, nor should they. Of course, people with the opposite point of view typically don't like it but that's the way these things unfold. I'm sort of getting used to it.
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Old 22-08-2007, 12:56 PM   #5
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Well, no one should have to do something or talk about something they don't want to. However, if they make strong emotional statements about how awful some treatment is - especially if they make claims such as potential to create chronic pain or claims disparaging those who do provide that treatment - then some "push back" should be accepted, if this is a scientific debate we're talking about.

It may be that otherwise well-spoken and intelligent people have certain topics that they cannot speak about without becoming sort of unhinged and going on a rant about their hatred for a commonly-used, respected, and successful therapy for many people. If that's the case, then OK. However, a quiet exit from the discussion is more likely to provide someone's insula with the space it needs, rather than throwing down the gauntlet.

I've got my buttons, too - animal research, anyone? But I don't make claims not consistent with available evidence and then make disparaging statements about people and treatments because they disagree with me on the relevant science. Isn't this exactly the sort of nonscientific direction that we are supposed to steer away from?
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Old 22-08-2007, 03:50 PM   #6
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uh-oh... I get the feeling that someone is suggesting I ought to "behave". That does not please my insula.
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Old 22-08-2007, 04:29 PM   #7
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If it helps any, I'm not much for manipulation either but I can't deny that it works for some people.
Agreed.

However, the fact that it works for some is offset, for me, by the patient I saw this morning. Went for chiropractic manipulation earlier this year; not sure where he fit on the CPR. Didn't ask today, because it wasn't relevant.

He was sent to me for a gait evaluation following spinal surgery, which included a discectomy. Following the manipulation, he lost control of his bowel and bladder. Still hasn't regained it, even after surgery. Also has saddle parasthesia, and poor sensation to the lateral aspect of his feet.

Fortunately, he is able to ambulate and scored 54/56 on the Berg Balance Test. Beyond that, however, he is trying to cope with the reality that he will likely not return to his job that he enjoys, and is reimbursed well for, because he cannot control his bowel and bladder. There is also significant lifting at this job. His MD is suggesting he pursue disability.

Now I'm certain this type of scenario has been discussed elsewhere on this site, however it still raises the concern of benefit vs. risk. Yes, risk is probably pretty low as most who manipulate will contend. However, the impact of the risks are quite significant.

As mentioned above, I can't argue that manipulation helps some. But, I'm not of the opinion that it is the only, nor the best way, to achieve results.

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Old 22-08-2007, 05:01 PM   #8
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Originally Posted by Diane
I get the feeling that someone is suggesting I ought to "behave". That does not please my insula.
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Old 22-08-2007, 05:13 PM   #9
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Forcing movement into, rather than facilitating movement out of, this situation, is abusive.
It seems this is the type of phrase that makes this seem a personal preference issue. From a risk vs. benefit perspective, as Wes pointed out so well below, manipulation does indeed carry more risk than many other interventions, especially at the c-spine.

I think if you take away all of the cultural, societal baggage that manipulation carries with it (bone out of place thinking, controlled by another that tells me I need more indefinately, etc.) as the CPR has attempted to do, it would still come down to this risk vs. benefit issue for me, in addition to the fact that working superficially will create explanatory models more consistent with a neural mechanism in the patient.

That is why I do not use SMT even with the outcomes it has behind it. Oh, and also it is illegal for me to do so in Washington state. But, that is irrelevant for me.

Diane,
if you take away all of the "stuff" that comes with manips that it has built up in society and the culture of our profession over time, would your descriptions of why you do not use it change?
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Old 22-08-2007, 05:32 PM   #10
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Diane,
if you take away all of the "stuff" that comes with manips that it has built up in society and the culture of our profession over time, would your descriptions of why you do not use it change?
I doubt I would change. There would be less need/my insula might perceive less need to object to it (so strenuously) , perhaps.

From a pain perspective, manip can not accomplish anything by first conceptualizing then placing abnormal forces into the spine, way deep in the axis of the whole body, that staying out on the surface of the body cannot accomplish better, more kindly, and by eliciting the patient's own nervous system(s) to fix its/their own problem with movement; and I'm still willing to bet the farm on that. The rest is fallback on something perceived to be reliable (not), efficacious (only in terms of time allotted), studied (from a mesodermal mentality and standpoint, mistakenly, and justified later by clapping on some neuroscience after the fact in a sly attempt to keep the whole edifice updated), thoroughly imbued and preserved with snake oil, the smell of which my insula cannot stand, and wants to puke at. I've had patients like Crazy Pole's, and I think it's time we started to point a finger at this parlor trick called manip, and name it for what it is.

And about it "working for some people", I suggest that such people are either a) possessors of a fairly naive nervous system, and /or b) gooney over something that provides a short term "feel good" sensation, but generally, no long term solution to pain issues unless movement therapy accompanies it. Thus does manip with its clinically observed (by me and Crazy Pole) attendant risks, played out into reality for a few unfortunates, remain "popular", by hiding behind other applications delivered in the same session. I say (backed by my insula): messing with the mesodermal housing of peoples' central nervous systems is moronic and unnecessary. At least the craniosacral mesodermalists can't really do any physical harm, just harm by memeplex.
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Old 22-08-2007, 06:24 PM   #11
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I feel about SMT the way Dawkins feels about religion. Just as he is organizing an "out" campaign for those who do not "believe", I think it's important for those of us who do not "believe", and who do not want to support through silent aquiesence, the purported wonderfulness of SMT, to speak up once in awhile. I wonder how much of this supposed support for SMT is mostly just nodding-alongingness for the sake of nodding-alongingness, 'going along to get along', rather than true, firm, rationally-based, based on neuroscientific thinking, conscious choice? This should be a real workout/workthrough of cognitive dissonance. Do others concur?
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Old 22-08-2007, 07:41 PM   #12
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I have had similar experiences with patients as Diane and Crazy Pole and feel also that the risks can be quite dramatic and just don't justify it for me when other methods for me work very well and do not cause this type of potential harm. As Diane said, craniosacral (part of my therapeutic history) has issues with it's theoretical construct but it doesn't cause the potential physical harm that manipulation can do (at least I have never seen anything in the literature or it described to me personally). I have been integrating alot of the neuro concepts learned here to better explain what is happening under my hands and am still working on my "personal" theoretcial construct of my light touch techniques that I now don't necessarily ascribe to a particular "method," but still always feel like I am not the one directing, just assisting. I think that is the key for me, is that I, as Diane, don't feel that our bodies need to be "forced." If we can figure out the neuro language that the body communicates we can become a much better assistance to it's needs and provide a better total outcome for the person for a longer time.
As an aside, from a personal note in regards to the direction of our profession, it seems we marched in the direction of orthopedics, sports medicine, and manipulation as the major emphasis of what we do, and left behind our neuro roots. I think what Diane and others are trying to say is not much different in how I feel, that we need to really check into and not forget about this beautiful nervous system we are provided with.

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Old 22-08-2007, 10:21 PM   #13
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What Cory, Wes and Karie have written is the major reason that not many Aust physios use manipulation; the risk factor - although small, it is still there. All other factors aside, that is enough reason to avoid it; but that's personal choice on their part.

In the end we choose what we 'approve of', and not what a consensus of others is telling us to do. That may well include the discussion of why it works; there has to be an interest in a topic in the first place.
I'm interested in why manips work, purely in an academic sense, in the same way I'm interested in why CST works. But that's just me.

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Old 23-08-2007, 12:18 AM   #14
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What I'd like to see is recognition and relinquishment of what I will (today) call "Mesodermalismo", that propensity to be heroic that Barrett has often discussed in his essays, which boils down to some kind of chutzpah practitioners have, whereby they think they can actually force mesoderm to do what they want by cracking, pressing, popping or stretching it, with no acknowledgment (or maybe even idea!)whatsoever that the nervous system of the patient will take on whatever mechanical input the practitioner is dishing and will respond if and when it feels like it, be it in a positive manner or negative. At least the CST people, like I said before, even if they were misguided, were not doing harm and were likely effectively mopping up pain. Same with the MFR people..(Barnes-acles aside) - they were being "neuro" even if they didn't realize that's what they were being.

And I think it's about high time that SMT people enjoyed a bit of cognitive dissonance themselves, because they seem to imagine they are somehow exempt. Au contraire. They are just as implicated in perceptual fantasy as anyone else has ever been. Mesodermalismo is Mesodermalismo, regardless of what level of mesoderm is being "attacked"/poked/prodded/continuously mobilized/yanked/stretched/tractioned/pummeled/rolfed or massaged. Plus the SMT people have more to answer for, because they are trying to ignore TWO peripheral nervous systems, at the same time, one of which is purely reflexive, both of which are at odds with each other, and a third (CNS) which is in the center of that which they think they can mess about with free of consequence. I'm glad others have noticed the painful trail of tears from cavalier, nonchalant unwitting or witting overuse/abuse of peoples' nervous systems by this reDUNCulous approach, and are starting to speak up.

Ectodermalismo, si - Mesodermalismo, no.
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Old 23-08-2007, 04:06 AM   #15
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I think there is growing acknowledgement that manipulation effects are far more neuro than was once suspected. If it is affecting ectoderm, it does so by communication. The question then is, "what is being communicated?"


Don't mean to put words into your mouth Diane, but judging from many of your other posts, I think part of your disagreement with manipulation is the propagation of a particularly virulent meme. One that can make our work more difficult, I might add. There is A LOT of smoke and mirrors around manipulation. Perhaps it would be more palatable if people weren't so insistent on its panacea-like powers and that anything less is suboptimal. For the record, I think Luke and Jason are great examples of balanced thinkers and practitioners (not that I necessarily choose to practice int he same way) - they see the benefits or SMT but also realize its significant limitations.

If we accept that general joint popping on a well chosen client is effective and that such technique and reasoning / testing re: safety can be learned in a very short period of time, then maybe we can drop all the window dressing, self-congratulation, $1000+ con ed courses, etc., and finally see it for what it is. Just another tool in the toolbox for someone feeling the need to do something with their hands.

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Old 23-08-2007, 04:20 AM   #16
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The question then is, "what is being communicated?"
Nick, I agree that this is the real question.
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finally see it for what it is
Much ado about very, very little?
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Old 23-08-2007, 06:50 AM   #17
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I agree that there are many issues around manipulation that need to go. However, the most current researchers and clinicians DO see manipulation from a neurophys point of view and not otherwise. I would think we should be supporting those who are "being neuro" about this treatment.

Arguably some of the most qualified group of clinicians and researchers in the PT world - the EIM people, teach it as exactly a neurophys technique and are actively stripping the mysticism from it.

Far from much ado about "very, very little" - it's usefulness in the right patients has been established, and patients ask for it. Even if we don't provide it, shouldn't we at least want to understand it as best we can?

Regarding risk- it's extremely small for the lumbar spine - it may be "lightning-strike" small. Especially compared to NSAIDs.
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Old 23-08-2007, 07:03 AM   #18
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Quote:
Regarding risk- it's extremely small for the lumbar spine - it may be "lightning-strike" small. Especially compared to NSAIDs.
Hi Jason,

I understand this and have heard this argument before, that it is less dangerous than such and such medication or whatever. I think there is some problem in that logic however. In most risk/benefit comparisons, the risk of not having the treatment should be worse than having the treatment. For example, the risk of getting a disease and dying is higher than the risk of dying from an immunization side effect.

One lightning strike in a career would be one more than necessary.
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Old 23-08-2007, 07:04 AM   #19
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Well, here's crazy pole's post.

So just today I treated a new patient (just dropped in from Belfast for a BC holiday) who, 15 years ago developed sciatica, went to a chiro, was manipulated. She felt better, and went back for a followup visit, said, thanks, I feel better, whereupon he maniped her again, which he should not have done - he should have left her well enough alone, and there she was, back where she started. Anyway, she ended up with a discectomy. Guess why she came in to see me? Because after sitting on a plane 8 hours, her leg was hurting again. Oy. I swear. I hate SMT.

I'm glad the mysticism is being stripped, but the love affair continues I'm afraid.
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Old 23-08-2007, 10:27 AM   #20
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Just a couple of days ago I saw a middle age woman with a history of severe leg pain and numbness in the left foot following a treatment for simple low back pain 1.5 years ago. It resolved over a period of 4-5 months. She still has some problems with her left leg. Needless to say, the treatment was manipulation. I think that many therapists who utilize manipulation don't know why they are doing it, when they should be doing it, do not have an appreciation of the materials they are handling and use too much force. They palpate for "stuck joints" and let rip... believing all will be good. Just my thoughts.

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Old 23-08-2007, 01:35 PM   #21
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Perhaps I should write here about dozens of horror stories involving massage, MET, positional release, stretching, exercise, medication, surgery ....etc. Of course they would all tell you much more about the competence and attentiveness of the practitioner than the actual treatment method itself (I'm not at all trying to play down the potential risk in SMT here). Perhaps I could then add dozens of stories involving patients with who had been myofascial unwinded, craniosacraled, touch healed, BLTed, etc and then had the problem solved with a single manipulation.

Quote:
maybe we can drop all the window dressing, self-congratulation, $1000+ con ed courses, etc., and finally see it for what it is.
Nick, this may be an American PT issue that I am not savvy to being an Aussie osteopath. I learned HVLA (as we call it) as par for the course in my degree. It wasn't taught as the golden egg in the tool box, and in line with traditional osteopathic thinking we were told it is another method for addressing restricted segmental movement (not to put bones back in place). We don't have manipulation gurus here, or even organised continuing ed on HVLA.

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I think that many therapists who utilize manipulation don't know why they are doing it, when they should be doing it, do not have an appreciation of the materials they are handling and use too much force.
Kongen, I wouldn't disagree with that.
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Old 23-08-2007, 02:50 PM   #22
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This has been mentioned before, I know, but manipulation is a only small part of Aussie PT. It's not rated as superior to anything else, but sometimes a useful adjunct when other methods seem to be slow with results. Something to fall back on....

As Luke has said, I too have dozens of horror stories about lack of progress and increased pain, and that is just with manips, or mobilisations and/or exercises. Sometimes it is just a matter of PTs following well defined 'protocols' which are generalised to anybody and not listening to patients' stories.

I am starting to think as well that some of the SMT hype is only North American/USA in origin??

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Old 23-08-2007, 02:58 PM   #23
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Luke, I really think osteopaths (wherever they may be from) at least get taught to feel the materials. The kinesthetic layers of training are laid in over and over and welded together in there in some sort of way that is safe(r), than chiro at least. My understanding is that there is caution, there is a lot of soft tissue work taught, there is appreciation for all the physiology of every layer. There is not the same chiro 'all hail the spine' cavalier attitude, not apparent anyway. And not like PTs who are trained to be helpers/observers, more than palpators/feelers, with only rudimentary teachings in basic sciences - at least that was the case in my day.

They still get steeped thoroughly in mesodermalismo, however. (...Unless Nic Lucas managed to get equivalent amounts of neuroscience in there to ameliorate the mesodermalismo a little, so did you...). Osteopaths and chiros combined have left much that legacy of all the mesodermalismo about joints that manual therapy has yet to deconstruct. PTs were all about muscles before adding joints to the list. What a huge waste of professional time and hard drive developing a science of biomechanics has been. To it, I say, so what? Just more reinforcement for more mesodermalismo. Which has nada to do with pain.
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Old 23-08-2007, 03:03 PM   #24
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Nari, you are correct IMO. It's much more about Mount Mesoderm and mesodermalismo in general, which in manual therapy, manipulation is merely the pointy part at the top that so many aspire to stand on because they think from there they'll have a good view. What they fail to realize is that it's actually the bottom of a deep sink hole intellectually, and there's a long climb up from there to understand pain and how to treat it. The fact that the US is infested with chiros who have contributed greatly to that gi-normous pile of s**t that is Mount Mesoderm, doesn't help the PTs to focus on anything better than mesodermalismo.
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Old 23-08-2007, 05:45 PM   #25
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Well, I think the "joint-centricity" of manipulation is slowly changing. It probably will take more time to get it instilled in most CEU courses and programs, but it will get there - once the prominent researchers start talking about a neurophys angle, it's just a question of time.

Cory-
I see what you mean about risk, and there has been an effort to try to address this angle as well in terms of relative risk reduction and chronic complaints here.
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Old 23-08-2007, 08:41 PM   #26
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Look, my whole point is that I really don't think it is worth dressing up in new clothing and perpetuating. I still don't think it's worth the powder to shoot a rat. It's still coercive and teaches the nervous system nothing. Especially nothing it couldn't more effectively learn through other kinds of handling. Maybe it teaches it how to remain UNintegrated.

This is what I mean by being in love with manipulation, it makes people find a way to salvage the wretched thing, by trying to retrofit it, with neurophysiology, a misuse of neurophysiology in my opinion. Instead, if neurophysiology were understood FIRST, it would soon become evident that manipulation is a huge counterproductive pseudo-scientific waste of an enormous amount of collective practitioner time and $.

Being a manipulation apologist only helps to perpetuate it along with all its mental clutter and snake oil charm, like a sheltered workshop arrangement for manual therapists who can't really feel anything change in someone else's system through their own hands. Kicking the side of the computer to "fix" it instead of working on figuring out how to help it reprogram itself.
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Old 24-08-2007, 06:34 AM   #27
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Used responsibly with an appropriate explanation, and coupled with education, movement and exercise, it is a very powerful and useful treatment for many people.

If you are unable to separate the "act of manipulation" from the "theory and practice of subluxation-based chiropractic" then your concerns and metaphors make sense.
However, I can and do separate these, so your concerns about banging computers and snake oil just don't apply.

I like the recurrent use of the "powder to shoot a rat" comparison the best.
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Old 24-08-2007, 06:38 AM   #28
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Is "muscle energy technique" considered "spinal manipulation"? If so, I can concur with your first sentence Jason. If you're just talking about the high velocity stuff, then I don't.

Maybe I shouldn't discuss rats in the same sentence with shooting. I mean, your position re: animals and all.

Yet, you think it's ok to beat up on the fish brain (in the human nervous system), so I feel a bit confused about where you really are at..
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Old 24-08-2007, 06:41 AM   #29
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Quote:
I mean, your position re: animals and all.Yet, you think it's ok to beat up on the fish brain (in the human nervous system), so I feel a bit confused about where you really are at..

Jason, have you been killing and eating your patients again?
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Old 24-08-2007, 06:54 AM   #30
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Quote:
Originally Posted by Luke Rickards
Jason, have you been killing and eating your patients again?
Unfortunately... Yes. Here is a picture.
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Old 24-08-2007, 11:37 AM   #31
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I sort of threw the stinkbomb and ran off. Pretty clever huh?

Why don't we forget about Spinal MT and talk about manipulation of other joints. The cuboid whip was mentioned earlier, has anyone done it and doubt it can be effective? I've had my just about every joint on my body manipulated as a dummy for PT's and sometimes there is a sense of relief, but if there nothing feels wrong it usually give me a sense of uneasiness. I also believe the bones actually move in relation to each other, I am not convinced that the spine, being composed of synovial joints, doesn't also have changes in the relationship of its segments. I'm not sure if that has relevance.

Sorry, Diane, but with all respect to your insula, I don't understand how you reconcile your complaints about mesodermalists not engaging in rational thought and the equivalent of your placing your finger in your ears and going Na-na-na-na. I've brought up the subject of joint mobilization, and asked for it to be discussed rationally without regard to its clinical use, the ones who use it or the bias anyone might have to its use. Your response is, "I don't want to, I just want to talk bad about SMT and anyone who uses it". This is not ag great example for those you constantly preach too/about.
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Old 24-08-2007, 03:08 PM   #32
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So, Randy, why would you want to do high velocity stuff anywhere to any joint? What for? Just answer me this one simple question.

By the way, suggesting that my "behavior" is wrong is something that my insula finds exceedingly displeasing. This is a certain character my insula identifies with. That thing has been seen to take off heads of bad guys. On TV anyway. And a couple times on chirotalk.

As soon as mobilipulators, those suffering from mesodermalismo stop talking about taking over the entire profession and stop tossing ALL soft tissue approaches and ALL the treatment constructs associated with them into the garbage heap from sheer ignorance and fascist (yes, I mean that word in both senses of it) tendencies, I might stop fighting fire with fire. Maybe. Nah, I don't think so. Neuroscience is more on my side than on theirs. Besides, I love to bash SMT, bring it down off its high horse. It is so intellectually underwhelming - I do agree with one point the mesodermalismo-ists are making - it belongs in first year where everyone who knows nothing yet still are. They can be exposed to it there, learn it on each other, see how they like it, get over it fast, (like five-year olds who are given a chance to smoke an entire cigarette, get sick from it and never feel attracted to its shabby former glamor), then move on to something that's actually useful for treating actual pain.
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Old 24-08-2007, 04:48 PM   #33
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You know, those allegations of me killing and eating my patients were never proven, and the baseless charges dropped. Thankfully before the search warrant on my freezer was executed.


Diane, if you continue to see manipulation as "beating up on the fish brain" and as an inherently threatening technique (despite the ample evidence that says for great numbers of people - it isn't), then I don't think we can progress much beyond where we are now.

Quote:
Besides, I love to bash SMT, bring it down off its high horse.
I know, I get it.
But do you draw no distinction between people placing this treatment on a high pedestal (subluxation-based chiros) and people who use it in a scientifically-responsible way?
If so, how do you justify that failure to differentiate, other than "you just hate it"?
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Old 24-08-2007, 05:10 PM   #34
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I hate how it takes minds and bends them to mesodermalismo, then perpetuates itself AND mesodermalismo. If you are immune from that, then good for you. You (and your use of SMT) will be exempted from my smiting.
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Old 24-08-2007, 05:31 PM   #35
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But how shall we deal with the fact that SMTer's think they should lay claim to the entire profession of PT and rule from some sort of mesodermalismo/fascist paradigm?
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Old 24-08-2007, 05:34 PM   #36
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Diane,

Since SMT is quite nothing why are you giving such an importance to a null idea? Doing so, helps to embellish the manipulative house.
A better force remains in indifference.
A thing that does not matter can"t really hurt me and loses its hypothetical magical power.
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Old 24-08-2007, 05:54 PM   #37
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I see what you are saying Bernard, and most of the time, I agree. But at the same time, sometimes I like to smite things like "null ideas." Rub noses in them.

I like to point out on occasion that they (SMTers) have no real leg to stand on, no good construct, nothing but a love affair with a set of kinesthetic moves that make no sense neurologically (puts the system into defense mode, which may be the thing that gets it off hurting for a moment, the same way you wouldn't feel your body hurting if suddenly a cougar or bear or rhino loomed at you close range - i.e., a greater threat subsumes "felt" pain briefly) but does NOTHING to help it integrate itself into "action" , along with all the autonomic outflow actions, etc., which all take a little something called "time" to integrate in).. AND which can actually injure teeny vascular bits that feed the cord.

Now, why would I want to continue to battle something this redunculous? Furthermore, the SMTers are trying to drag the whole profession (in the US and by extension, into Canada) down to their level. Which is somewhere just about a zillionth of a degree, in social terms, in public perception effect, above the level of chiro. Intellectually and in terms of understanding pain mechanisms. Gee, I wonder why I'd be piffled about something that innocuous. Furthermore, they continually diss nervous system approaches. So I diss them back sometimes. Diss. Diss.

I can see why they want to take the hill and put a flag on it, but they don't get that the hill is a barren rock, devoid of anything really progressive.

Eric's post 122 on the other thread contains a glimmer of hope, at least for navigating the meme zone, avoid being too intellectually lazy to stop perpetuating ignorance in patients when treating with SM (um.. I hate to use the letter "T"):
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How about,

The (mesodermal) dysfunction that you sense, and that I can palpate (stiffness), is a product of a neurodynamic that is also involved in creating your pain. We are going to try to override that neurodynamic by doing this technique that we call a manipulation. I’ll try to apply it as close to the site of stiffness as I can. This will provide an input into your nervous system that might allow the neurodynamic to change.
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Old 24-08-2007, 06:22 PM   #38
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I hate how it takes minds and bends them to mesodermalismo, then perpetuates itself AND mesodermalismo. If you are immune from that, then good for you. You (and your use of SMT) will be exempted from my smiting.
Hi Diane,

It seems to me that Jason and Luke would both be given an exemption based on this criteria. I'm with you on those who do not warrant this exemption. You know that. However, the fact is that there are those Jasons and Lukes out there who KNOW their neurophys, and pain science and still can justify their use of SMT. I'd be real interested in discussing that. Those who earn the Diane exemption, why do you use SMT? Is their reasoning justified? If not why? If so, where is our reasoning in not using it justified or not?

My guess is this conversation would take us into the decision making process of EBM. Probably a good place to go.
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Old 24-08-2007, 07:02 PM   #39
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Cory-
Now THAT's a discussion worth having.
Who wants to start?
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Old 24-08-2007, 10:37 PM   #40
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Make it a new thread, if you would. And yes, I will give Luke special dispensation as well. Temporary at least.
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Old 24-08-2007, 11:19 PM   #41
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I'm not really interested in having 'The Diane Exemption', thanks. It seems like a strange by-product of "hatred" due to an inability to separate a technique from its operator.

The fact that it exists is worth discussing though. More specifically, does it exist for those who simply know about and use neurophysiology as part of their practice?, or is there some new willingness to consider manipulation as an appropriate intervention in some cases?.
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Old 25-08-2007, 03:43 AM   #42
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It seems like a strange by-product of "hatred" due to an inability to separate a technique from its operator.
No... it's more a puzzle over why operators of any stripe seem to think they need to have this technique in the first place to be considered "manual therapists."
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Old 25-08-2007, 05:01 AM   #43
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Hi Diane,

My take on the impasse is slightly different. I don't get the feeling that those using it do so because they feel they need to to be manual therapists. Although I suppose some might.

More commonly, I think they use it because it works. I think tensions rise the most when those practicing SMT feel everyone should or when those who don't practice SMT feel no one should.
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Old 25-08-2007, 05:41 AM   #44
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Jon,
Quote:
I think they use it because it works.
I think they use it because it's the only thing they've been told of that works. Around here it's tough to even find work in many clinics unless you can prove your manual therapy credentials, and that means the ability to manipulate. At the very least, you must demonstrate an eager desire to pursue this training to be accepted. I sense this every day and I think this is what Diane loathes more than anything.
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Old 25-08-2007, 06:09 AM   #45
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Eric, I agree; there seems to be an expectation from the powers that be within US PT that choosing not to manipulate is not a matter of choice, and any substitute implies suboptimal care. This is what I have gleaned from other sites; there is a lot of pressure to manipulate, of course within the CPR thingy.

Could be wrong. I'd like to be proven wrong and to believe that there is freedom to choose how one treats....

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Old 25-08-2007, 06:34 AM   #46
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Eric,
Quote:
I think they use it because it's the only thing they've been told of that works. Around here it's tough to even find work in many clinics unless you can prove your manual therapy credentials, and that means the ability to manipulate. At the very least, you must demonstrate an eager desire to pursue this training to be accepted. I sense this every day and I think this is what Diane loathes more than anything.
Yes! Exactomundo. This is what I mean by reference to fascism earlier. I loathe this implication and I loathe the speed with which everyone is heading for the brink of that pit I referred to earlier, with manip at the bottom - it's like some sort of giant sand worm from Dune is under there hoovering everyones' minds into its gargantuan maw.

That, plus this: nothing about manipulation makes any sense whatsoever in terms of neurophysiology. There is no need to push the spine about in some heroic attempt to stimulate some elusive and exclusively receptive teeny neuron or neural system perched on the edge of or within some facet imbued with the glamorous mystique of being difficult to reach and therefore turning the practitioner into Harrison Ford in Raiders of the Lost Arc. Any nerve anywhere will do, to help the whole system change over to better function, according to neurophysiology and neurodynamics. Why not pick one closer to the outside? Why not hang out on the surface of the body, where there is enormous innervation, and let the nervous system come to you?
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Old 25-08-2007, 06:41 AM   #47
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With regards to the CPR thingy. If one can step back a bit and view the issue with some perspective, it's not too hard to see how a CPR could exist for any old treatment. Just because this has been published for manipulation now really doesn't mean anything in my books, temporally anyways. It won't mean anything until that CPR has been tested against the CPR rules for every other possible treatment and combination of treatments in endlessly diverse populations. When will that be accomplished? Or have we come to the point in PT research where we can sit back and relax since after all we have all the justification we need, right now!! All we have left to do is refine the manip CPR and test it in different populations!! Thats enough from me on that.

With regards to the freedom thingy. I basically had to bluff my way into my present job, told them what they wanted to hear, then practiced how I wanted, and to my employers credit they have granted me the freedom to do so, although there has always been an unspoken recognition that this could not be a permanent fit. I'm not sure that if there were Pt's knocking on the door looking for work that I would have lasted as long. The silence does become deafening. Fortunately for me I also have the freedom to choose to leave, which is what I'm doing next week.
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Old 25-08-2007, 07:40 AM   #48
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I did wonder about the hallowedness of this CPR ruling. Its 'rules' could be applied to any old treatment, and if it (CPR) valid only for a reason for manipulation and nothing else (not sure about that?) then it all seems rather pointless....

Eric, where are you off to?

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Old 25-08-2007, 10:26 AM   #49
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Eric-
We would indeed be lucky if we had a bunch of CPRs coming out showing that several different treatments reduced self-report disability scores by 50% within a week. I'd love to live in that world. Unfortunately, we don't.

There may very well be better treatments than manipulation for those that fit the CPR, but there's no clear evidence of what those might be. We know SMT is superior to "stabilization exercise" in this particular group. Whether it's better than other treatments - hard to say.

I was having a discussion the other day with my current practice partner who doesn't do SMT but recently got his McKenzie certification. I actually have a lot in common with him from a theory standpoint - the solution for pain being movement and not strengthening, importance of education and self-management, disdain for any therapeutic device that plugs into a wall, etc. He asked me about manipulation and why I wouldn't do directional preference exercise instead, and brought up many of the concerns voiced here. It took only about 2 minutes for him to realize that I NEVER use manipulation in isolation, and it is always followed by education and movement. He immediately felt better about it after he saw that I use it only as a supplement, not the primary intervention. I'm not sure that helps or not, but there it is.
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Old 25-08-2007, 01:26 PM   #50
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Hi Eric,

Quote:
I think they use it because it's the only thing they've been told of that works.
Most folks first start using something because they're told something works (e.g. Z health folks, McKenzie folks, PNF, etc, etc.) I think many folks using manipulation would drop it if they found that empirically it doesn't work, whatever "working" has come to mean.

Quote:
Around here it's tough to even find work in many clinics unless you can prove your manual therapy credentials, and that means the ability to manipulate.
Yes, this is an example of that fundamentalist position I'm talking about. I can understand the position because the more people receiving this care, the more people come to expect it as the standard. This makes the life of someone using those techniques easier. Unfortunately, it makes the life of those not using them more difficult, mostly due to the mischief making of expectation. But doing the unexpected can be helpful also, so all is not lost.
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