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Old 02-11-2008, 06:24 PM   #1
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Default AAOMPT 2008, Seattle

Well, I'm just back from the American Academy of Orthopedic Manual Physical Therapists (AAOMPT) 2008 conference in Seattle, WA.

The highlight of the weekend for me was getting to meet and spend a great time with fellow moderator Jon Newman and his wife Michelle. The three of us had many conversations, sat through some lectures together and it was most excellent company. Jon is as well reasoned and pleasant in person as he is on line and Michelle is as well.

Also, member Mike Hoy introduced himself and had dinner with us last night along with other fellow moderator Chris B. We had some great fierce conversation over pizza about a variety of topics and I really enjoyed it.

If that all wasn't enough, turns out the conference was pretty good too. I'll go into more detail on the lectures and speakers in another post. I'll say right off the bat to put Steven George, pain researcher from the U. of Florida, on your radar screen if you haven't already.

Anybody else out there go?
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Old 02-11-2008, 06:28 PM   #2
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Thanks for the kind remarks Cory. I'll post a picture of our dinner either very late tonight (I'm working my way home starting in 4 minutes) or tomorrow. I agree with all you said, especially that part about how pleasant I am.
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Old 02-11-2008, 07:42 PM   #3
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Steven George's CV is available here - it's impressive. Can't wait to hear more Cory.
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Old 02-11-2008, 08:37 PM   #4
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Can't wait for the details. Interesting that we flagged George as a person of interest back here.
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Old 03-11-2008, 03:22 AM   #5
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It's nice to know that we have some eyes and ears in places the rest of us cannot go.

What keeps going through my head is a comment made more than once that goes pretty much this way: The effects of manual care, whatever and however they may be achieved with force, coercion, perhaps even trickery of some sort, cannot be explained biomechanically, but only through some neurophysiologic theory.

If I’m right about this, I’m wondering what you might have seen to support the idea.
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Old 03-11-2008, 03:59 AM   #6
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I've been stirring things up a bit over at EIM regarding the pedestal that manipulation (high-velocity thrust technique) has been placed on over there. While I have a tremendous amount of respect for Flynn, Wainner, Childs et al, I'm concerned about the amount of effort and resources being dedicated to showing how effective manipulation is, particularly given there's such limited theoretical basis to support these ongoing efforts.

Theory is supposed to drive research, not vice versa.

My take is that it's motivated in large part by the turf war with the chiros, and I don't see this as a particularly productive or edifying battle for the profession of physical therapy.

Too bad this conference was so inaccessible to me this year because it sounded as if the neurobiological revolution is starting to sway some old and entrenched thinking.

I look forward to Jon and Cory's take on the reaction from the Academy's rank and file.
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Old 03-11-2008, 01:09 PM   #7
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It was a pleasure to have met you guys at AAOMPT. I will do an intro post later on. I am still a bit tired from the trip from Seattle.

David Butler was an amazing speaker and his EP pre-conference class was excellent.

Jon I also enjoyed our "fierce" conversation. I look forward to do more discussions here on SS.

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Old 03-11-2008, 01:23 PM   #8
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I'm so excited to hear about the conference. I was trying to get there, but Butler's preconference course was sold out, and given the cost of getting way out there, I chose instead to attend Explain Pain in Baltimore a few weeks ago. It was great.

Looking forward to hearing all about it!
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Old 03-11-2008, 02:30 PM   #9
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I'll post some thoughts a bit later. For now, here's the picture I promised. Starting in the bottom left and moving clockwise is Cory, Mike, Chris and then myself. Michelle took the picture.
Attached Images
File Type: jpg AAOMPT meeting.jpg (104.8 KB, 103 views)
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Old 03-11-2008, 06:06 PM   #10
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John W.

I can't tell you for sure what the rank and file thought as I didn't chat with any other rank and file besides Mike (assuming Mike can be considered rank and file.) I could sense ripples of dissonance on occasion (my own and others.)

In the pre-conference I did get to hear what the AAOMPT and the EIM team taught and what participants expressed. The EIM team mentioned the nervous system but were probably deferring to the next day's lecture for a more thorough explanation. Unfortunately many of those participants didn't attend the main conference. The EIM team also tried (I think) to de-emphasize the specificity of thrust techniques and had some data to back that up. Despite that info I heard participants express a variety of concerns during labs and Q/A time. Some people wanted to discuss techniques that isolated specific vertebral levels. I heard one person state that they didn't want their L4-5 manipulated because it was hypermobile but they were ok with higher segments being manipulated. I heard one person express concern over a hip distraction technique because of a variety of pains and imperfections of her own spine/SI and hip. Personally, I think this had more to do with a lack of confidence in me because she just had her other hip manipulated without any such concern being expressed. If high skills are necessary because harm may ensue in the wrong hands I could understand her concern. I assume she knew I had low skills because we were asked to rate our own skill level in manual therapy as we introduced ourselves. I made the mistake of telling the truth.

During the main conference they featured a panel discussion on day 1 featuring the speakers Butler, Deyo and George. (Kudos to them for including a panel discussion.) I asked about reflective and unreflective beliefs and how they relate to expectations due to some of lectures emphasizing the importance of expectations as well as a call to reconsider our natural tendency toward dualism.

In the lectures that followed day one I heard some speakers integrate the message from day 1 more successfully than others.
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Old 03-11-2008, 06:27 PM   #11
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In the Steven George breakout session I asked a question I was wondering about before.

His current thoughts are that pain threshold (as a measure) is a reasonable marker for pain tolerance and that they will likely adjust proportional to each other.
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Old 03-11-2008, 07:25 PM   #12
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Nice to see two unfamiliar faces in the photo - as well as the familiar two!
Also good to hear that dualist thinking should be reconsidered.

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Old 03-11-2008, 08:07 PM   #13
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Quote:
His current thoughts are that pain threshold (as a measure) is a reasonable marker for pain tolerance and that they will likely adjust proportional to each other.
Jon
Did you press him on this? Did he reference any studies?

By the way, after reading through that thread, wouldn't it be best to give the patient a dichotomous choice "pain/no pain" to determine their pain threshold? I can't rectify in my mind how someone could have a threshold of 3/10 on a 0-10 scale. That makes no sense. The stimulus is either painful or it isn't at the threshold point. Perhaps this is where memory comes in to muddy the water a bit? Since we know that memory is unreliable, why would an integer scale of pain that presupposes an accurate memory reference be a useful gauge of pain threshold?
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Old 03-11-2008, 08:32 PM   #14
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Quote:
Jon
Did you press him on this? Did he reference any studies?
No and no. I'm just reporting his current thoughts on the topic. Unfortunately I'm better at pressing from a distance than I am up close. You should have seen me shaking at the microphone during the panel discussion. I couldn't wait to get back to my seat and it took about 15 minutes before the chemical cascade subsided. What a pain in the butt.

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I can't rectify in my mind how someone could have a threshold of 3/10 on a 0-10 scale. That makes no sense.
That's what makes this sort of stuff interesting (for those who enjoy puzzles of sorts.)

Quote:
The stimulus is either painful or it isn't at the threshold point. Perhaps this is where memory comes in to muddy the water a bit? Since we know that memory is unreliable, why would an integer scale of pain that presupposes an accurate memory reference be a useful gauge of pain threshold?
See this thread for more and especially the paper in post number 7 for an answer to your question. Also, the researchers/patients aren't using integers because they're using the VAS. I can't answer your question as it pertains to memory.
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Old 03-11-2008, 08:47 PM   #15
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I'll do my best to present summaries of George's presentations. He gave a pre-conference course on identifying and using psychologic measures that I did not attend (I didn't make any of the pre-conference courses of which there was Butler's explain pain, EIM's class that Jon went to, and George's. Mike, perhaps you could provide some info on EP?). George also gave one of the 3 keynote presentations along with David Butler and Richard Deyo. Finally, he had a breakout session lecture on "variability of pain" in which he presented more of his research.

Keynote address: "How Does Manual Therapy Inhibit Pain?"

In this address, Dr. George presented research done by his team and others. He started off by explaining "correction philosophy." This is a philosophy that we all know well and discuss here often. It is a broad term to describe the various alignment, subluxation, etc, etc. theories out there that basically are founded in biomechanics and point to a mechanism of action of a correction of some pathoanatomical fault. He pointed to 2 studies showing that this philosophy is not supported. One by Tullberg et al (Spine 1998) in which anatomical landmards were tracked at the level of the bone and a variety of tests were administered and tested pre and post tx. 2 findings: the findings on the part of the clinician for bony palpation were not consistent with the actual position, and the position change or lack thereof had no correlation to the change in presentation, or lack thereof. The second article was Flynn et all (2002 Spine) in which landmarks again did not associate with outcome. So, to start he makes the argument that correction philosophy is not supported to answer the question of "how?"

Next he moved on to a discussion of moving beyond the gate. Butler had already presented, thankfully, so he had no need to spend a significant time making the argument for the central nervous system above the dorsal horn. He specifically spoke in detail of peripheral and central sensitization at this time and introduced the topic of temporal summation. Temporal summation is otherwise known as wind up. The same stimulus applied at a regular interval creates a continual increase in sensitivity at the second order neuron and continually amplifies the signal. It is central sensitivity at the level of the dorsal horn.

Next, George and his team created a model to create and assess temporal summation (which must be done indirectly). They then found that temporal summation was decreased following spinal manipulation when a positive outcome was observed. I believe (notes were sparse here) that they have also observed this effect with neurodynamic technique as well.

Next, and here's the good part, they wanted to see if they could manipulate this effect. So, they created three groups 1) was told that spinal manipulation is a well supported and effective treatment, 2) was told that it is helpful sometimes, but not in others and they expected a neutral effect, and 3) was told that spinal manipulation was ineffective. The purpose was to create an expectation of effect prior to intervention. They found that those who responded and therefore had a decrease in temporal summation at the dorsal horn, were those who expected a positive outcome.

So, the conclusions were
1) Maunual therapy decreases temporal summation
2) manual therapy effect is related patient expectation

I'll move on to the breakout lecture in the next post. Jon and Mike, feel free to jump in a clarify on any of the above.
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Old 03-11-2008, 08:52 PM   #16
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How was Puendetura's and Louw's presentation? Having read through most of their presentation posted previously on SS, I am curious.
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Old 03-11-2008, 09:02 PM   #17
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Hi Bas,

It was the explain pain and neuromatrix model as applied to the whiplash associated disorder population. So, good information for sure and a very good follow up of David Butler's keynote presentation.

They spoke of AIGS and the dorsal root ganglion, the pain "tune", the educational model, fear. They gave one very interesting study on the prevelance of neck pain in the demolition derby population. "Neck pain in demolition derby drivers" Alexander C. Simotas (may be simolas as I can't make out the print very well), Timothy Shen in Arch Phys Med Rehabil Vol 86, April 2005
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Old 03-11-2008, 09:22 PM   #18
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Free on line full text of one of the UF (George) group's studies on SMT, expectation, and pain.
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Old 03-11-2008, 10:09 PM   #19
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Quote:
The same stimulus applied at a regular interval creates a continual increase in sensitivity at the second order neuron and continually amplifies the signal. It is central sensitivity at the level of the dorsal horn.
During the panel discussion George clarified that the change in pain reports were not likely limited and fully explained by changes at the DRG. Rather, since pain is an output of the brain other processing is obviously occurring.

Quote:
Next, George and his team created a model to create and assess temporal summation (which must be done indirectly). They then found that temporal summation was decreased following spinal manipulation when a positive outcome was observed. I believe (notes were sparse here) that they have also observed this effect with neurodynamic technique as well.
During the panel discussion George noted that the inhibition of temporal summation was for thermal stimuli and one cannot assume that the same happens for mechanical stimuli at this point. I think the neurodynamic technique study isn't published yet.

Quote:
Next, and here's the good part, they wanted to see if they could manipulate this effect. So, they created three groups 1) was told that spinal manipulation is a well supported and effective treatment, 2) was told that it is helpful sometimes, but not in others and they expected a neutral effect, and 3) was told that spinal manipulation was ineffective. The purpose was to create an expectation of effect prior to intervention. They found that those who responded and therefore had a decrease in temporal summation at the dorsal horn, were those who expected a positive outcome.
Also, those who had negative expectations had hyperalgesia rather than hypoalgesia.
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Old 03-11-2008, 10:52 PM   #20
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Thanks Cory and also for that link. I find that type of research just fascinating !
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Old 03-11-2008, 11:06 PM   #21
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Next was the breakout session for George entitled: "Individualized Management of Pain: Current Examples and Future Dirction"

In the lecture, data was provided demonstrating pain variability
-within group
-between groups

2 methods of testing were described.
1) A heat diode was gradually increased in heat until the subject had first report of pain.
2) The heat diode was set at 49 degrees celcius for each subject and they rated 0-10/10 on the VAS what amount of pain they had.

Findings:
There is a large variety of report within groups (age, sex, ethnicity). Women tend to report pain earlier than men. This threshold changes with age as it increases until a certain age and then decreases again. African Americans and Hispanic people tend to report pain earlier than Caucasians. When controlled for socioecomonic status, education, etc. the between ethnic group difference is less. When men and women are given a "social norm" such as "most people will rate this a 6/10" then the difference between groups dissapears.

When variability is controlled for by catastrophizing measurement, pain rating is higher as the catasrophizing rating increases.

A gene has been identified as a candidate affecting pain perception called Catechol-O-methyltransferase (COMT). George did a study looking at a group of patients who had a shoulder surgery (I believe it was a rotator cuff repair) and tested for this gene and rated their catastrophizing scale. Those who had the presence of both high catastrophizing and the COMT gene had a poorer outcome than those who had only one of two, or those with neither. They have also found the same effect in a model of shoulder fatigue with a shoulder external rotation activity.

He also went into some info on fMRI studies and discussed the utility of sub-grouping patients.
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Old 03-11-2008, 11:15 PM   #22
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Just looking at the Conclusion section of the abstract of that study, they found that SMT produced c-fiber mediated hypoalgesia in the LE regardless of expectation, but increased pain in the LB with negative expectation, as Jon pointed out.

This, to me is a fascinating paradox. Why would negative expectation trump supposed descending inhibition that appears to account for the LE hypoalgesia? I've reasoned a few times with certain patients that the reason LBP can be so debilitating and persistent is because the brain seems to place a uniquely high priority on it. Perhaps placing a negative expectation in there reinforces this idea and "winds things up" prior to the SMT. It would be interesting to hook these different groups up to EMG prior to the SMT and compare what kinds of muscular "guarding" activity may be occurring prior to the procedure.

I need to read the article to find out exactly what was said and when they planted the "seed of discontent" prior to the procedure.
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Old 03-11-2008, 11:31 PM   #23
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From Textbook of pain... p. 118:
Quote:
Effect of anticipation on pain-evoked activity

Finally, the anticipation or expectation of pain can activate pain-related areas in the absence of a physical pain stimulus. For example, regions such as SI, ACC, PAG, IC, PFC and cerebellum have all been shown to be activated during a period of expectation before the actual pain is presented (Hsieh et al 1999, Ploghaus et al 1999, Porro et al 2002, Sawamoto et al 2000). Similarly, anticipation of painful stimuli, or priming with pain-related adjectives, significantly enhances EEG signals (Dillmann et al 2000, Miyazaki et al 1994).
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Old 03-11-2008, 11:50 PM   #24
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John,

The wording of the expectation statements was specific to the back also. They were surprised by this finding as well, and I believe I remember him saying that this was contrary to their hypothesis. Jon?
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Old 04-11-2008, 12:50 AM   #25
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Quote:
I can't tell you for sure what the rank and file thought as I didn't chat with any other rank and file besides Mike (assuming Mike can be considered rank and file.) I could sense ripples of dissonance on occasion (my own and others.)
I can tell you I am not rank.

I will say though from my lumbar and cervical management classes with Flynn and Cleland they do put the thrust aspect on a pedestal. In my humble observations, Tim does give a large push toward the fear avoidance model in treatment. It seemed as though he would have written in the class forum discussion that the “psychology” is the key issue in treatment. The Regis classes they instructed have a bit to do with lack of isolation and the ultra specificity of technique that many claim.

That being said I think their level of research is going to be directed at the clinical aspect—what technique(s) give us the best outcome? The work by George and Moseley might give us the better neurophysiologic answers—why do the technique(s) give us outcomes? Maybe it is just the resources they have at their disposal. However we need both, theory and application.

When I was in PT school Neuro was the “weeding class”. I think the neurophysiology aspect is very threatening because so many do not understand it. Manual therapy is so deeply based in biomechanics. It was basically birthed from it. Butler made a few comments about what we should call ourselves now because “manual therapists” just wasn’t enough to cover the brain’s involvement. I have agreed with this some time now. Heck I don’t even like the name physical therapist (but that is another story).

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Old 04-11-2008, 01:00 AM   #26
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Mike,

What, if any, differences did you notice between Butler's Explain Pain pre-conference course and his keynote address?
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Old 04-11-2008, 01:22 AM   #27
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Cory,

Inthe preconference he had 10 more hours to discuss his EP. He was able to spend more time on the laterality and graded progression ideas. He did more story telling as well as more history, including ion channels, the smudging, and homuncular refreshment ideas. More time was discussed about the various paradigms he mentioned. Adrainne did a 30 minute lecture on the pain science approach to spinal surgery rehabilitation.

Numerous times he did refer to "issues in the tissues". He stated that although he uses the EP approach and the "pain is in your brain", he still will "knock a back into allignment", or use ultrabullS!#$ ( his words) if it is the patients understanding and it is part of the patients story. I was sitting in front of Louie and Adrianne at the keynotes and they were discussing how people mistake the idea of the "pain is in your brain". They said how some people think that all David does is talk people out of their pain, but that is not true.

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Old 04-11-2008, 01:33 AM   #28
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Mike thinks that Tim Flynn might think "“psychology” is the key issue in treatment." Doesn't that say quite a bit?

I'm working on a post, or, perhaps an entire thread titled Casting a Spell.

Maybe it will link directly to many things we say here.
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Old 04-11-2008, 01:41 AM   #29
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Maybe they would get on the bandwagon a bit faster if this was pointed out to them. What do you think Barrett? Hopefully nothing they would say would end up "misleading"... the term "placebic" is kind of interesting - not quite "placeboic" but sounds a bit like it.
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Old 04-11-2008, 01:42 AM   #30
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By "psychology" I refer to fear based treatment approaches. Not sit on a couch and talk about mom. The fear based & explain pain aproaches can have positive effect. I am wondering if that is why he organized this conference with the speakers it had, but I am not given that kind of information. I am still working on the language of the group here So I hope that is not taken out of context by any.

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Old 04-11-2008, 02:03 AM   #31
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Quote:
The wording of the expectation statements was specific to the back also. They were surprised by this finding as well, and I believe I remember him saying that this was contrary to their hypothesis. Jon?
I also recall that he said he was surprised.

Here's the first study they did

Immediate effects on spinal manipulation on thermal pain sensitivity: an experimental study
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Old 04-11-2008, 04:49 AM   #32
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What keeps going through my head is a comment made more than once that goes pretty much this way: The effects of manual care, whatever and however they may be achieved with force, coercion, perhaps even trickery of some sort, cannot be explained biomechanically, but only through some neurophysiologic theory.--Barrett
I definitely heard the message that our biomechanical knowledge is still important as we consider the patient and the advice we may give. However, such knowledge is insufficient in explaining pain. I don't have the reference but Butler spoke of the content of the education we provide our patients as they relate to outcomes. The study demonstrated that while there were no impressive immediate effects, the long term effects were much better for the neurophysiological education model than for the biomechanical/structure based education.

Can anyone provide the citation?
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Old 04-11-2008, 05:11 AM   #33
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That would be the Moseley article from a few years ago, I think.
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Old 04-11-2008, 05:20 AM   #34
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Moseley et al 2004 Clin J Pain 20:324
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Old 06-11-2008, 04:18 AM   #35
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I look forward to Jon and Cory's take on the reaction from the Academy's rank and file.--John W.
I'm hopeful that the EIM folks will blog it.
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