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Old 29-01-2009, 05:16 PM   #51
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I guess my bridge's construction is rather thin yet and needs more layers
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Old 29-01-2009, 05:20 PM   #52
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A spider silk is very thin but more resistant than steel...
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Old 29-01-2009, 08:29 PM   #53
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Line,

Bernard is right about staying on the bridge. From there you can sense/feel/rationalise because you can 'see' both sides. Both sides alive and symbiotic, but most of the wildlife lives on the ectodermal side visiting the other constantly. PTs tend not to see this ecological fact.

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Old 29-01-2009, 09:25 PM   #54
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Quote:
most of the wildlife lives on the ectodermal side
It used to be we lived on the _______ side of the tracks.
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Old 03-02-2009, 05:55 PM   #55
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Default Meso to Ecto - The Prone Hang

So not only can generalized treatment processes be "Ectodermed", but individual therapeutic activities can also.

The Prone Hang is designed to increase the end range knee extension motion. It is performed with patient lying prone and the knee extended out past the edge of the treatment table. A rolled up towel is often placed above the patella for increased comfort. The patient assumes this position for anywhere from 5-15 minutes, and weights are sometimes placed on the lower leg at the ankle to increase the extension moment of force.

This is often prescribed for patients who have had knee surgery or a knee injury and who cannot regain the full extension of their knee through exercise or via other means.

I have observed other therapists placing ever-larger cuff weights on their patients ankles in an attempt to "stretch out the back of the knee" to allow more knee extension, often increasing the time spent in this position if it is deemed necessary.
I think approaching the prone hang like this is not only counterproductive, but often more than a little bit medieval.

I teach the prone hang much differently. I never use weights, and the patient actively lowers their leg into full extension, and may combine it with ankle dorsiflexion at various points to achieve a neurodynamic effect. The full tension position is never held for more than a few seconds.

How the treatment got ectodermed:
-I cannot provide the requisite force (50-250lbs/24-115kg) to create plastic deformation of connective tissue, so using small loads to try to accomplish this is futile, especially in the time frames required in a therapy environment. See here.
-Many, if not nearly all, of these cases are due to a protective guarding response in the hamstring and gastroc muscles. Trying to directly oppose this by forcing it often creates even more of a protective response - and I have seen this many times. I've met a few therapists who acknowledge this but then they say they need to "fatigue out" the hamstring to allow the knee to drop down into full extension. I'm wondering how they can possibly create a more coercive and threatening environment for the patient's brain, which is obviously trying to protect something in the first place. Throw rocks at them, perhaps?
- The limiting factor here is typically a protective muscular response and I don't believe that forcing it or providing such a stretch to attempt to accomplish this is defensible, given the properties of the materials we are dealing with.
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Old 03-02-2009, 08:02 PM   #56
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How about working with the skin on the back of the hamstrings, knee?

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Old 03-02-2009, 08:26 PM   #57
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Excellent idea, Mary.
I was just trying to put an Ecto spin on that exercise - and certainly supportive manual therapy would be a great idea as well.
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Old 03-02-2009, 08:57 PM   #58
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Default Meso to Ecto- Glenohumeral distraction mobilization

This is fun, can I play?

Most of my shoulder patients at various stages of their recovery "love" getting their glenohumeral joint distracted while held close to the "loose-packed" or "resting" position of the joint.

Aside from the effects of skin stretch provided, which can augment this technique by performing a sort of "balloon" grip over the skin of the deltoid region, it's both plausible and probable that the neural structures of interest (e.g. axillary, suprascapular nn) achieve a considerable amount of gliding motion with this passive movement.

Since being "ectodermed" myself, I tend to perform any "joint mobilization" like this more slowly and gently and with more attention to my grip on the skin. Gently "ballooning" the deltoid is an added kinesthetic effect that I have found provides additional relaxation and pain modulating effects. I also wait to feel what the tissues are telling me, and then stop when the neuromodulatory effects are evident. I don't just keep yanking on their arm for 8 minutes so I can document Manual Therapy code 97140 in my note.

How the treatment got ectodermed:
-Attention is paid towards the movement of the neural tissues of interest, rather than stretching/deforming joint capsule (see Jason's reference to Threlkeld in post #55).
-You don't have to slavishly guess or fool yourself into thinking you are in the actual "resting" position as defined by the various joint mobilization gurus. One just finds a position of comfort somewhere in the neutral part of the ROM and starts moving the humerus laterally from the glenoid in a slow, rhythmic way in order to allow neural tissues to "breathe" better. It's perfectly ok to add different components/moments of IR/ER in order to adjust the treatment as needed. Creativity is allowed and encouraged, not denounced as heresy and poor technique.
-Waiting and feeling for subtle neurophysiological changes in the tissues will tell you when you've done enough, not some arbitrary rule based on a flawed reimbursement system or because some "authority" at a CE course on the shoulder said it takes 6-10 minutes. If your not sure, you can always ask the patient for feedback and then re-assess their motion.

Not all classic shoulder "joint mobs" move the neural tissues in this way, and so I have abandoned them.

So, there you go all you "joint mob'ers" out there. Don't throw the baby out with the bath water!
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Last edited by John W; 04-02-2009 at 02:14 AM. Reason: Because Jason said so...
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Old 03-02-2009, 09:30 PM   #59
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I had 2 patients today, 1 with numbness and 1 with pain in the ant thigh. Ballooning near the exit of the lat femoral cutaneous from under the inguinal ligament helped them both. And this they can do at home, too. Skin work really is fun.
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Old 03-02-2009, 09:50 PM   #60
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John-
Ur doin it wrong.

You forgot how the treatment got ectodermed...
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Old 04-02-2009, 02:16 AM   #61
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I very much want to be like Jason, so I fixed my "meso to ecto" post.
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Old 04-02-2009, 02:42 AM   #62
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John, what we really need to see is the "before" and "after" meso-to-ecto posts.
That way we can follow the development of meso-to-ecto reasoning.

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Old 04-02-2009, 03:05 AM   #63
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John, your post 58 is hilarious.
Isn't life a lot easier when you let the patient's nervous system do most or all of its own heavy lifting?
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Old 04-02-2009, 03:53 AM   #64
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This is fun! Good examples! I am finding more and more when I treat patients that I am trying to figure out how to make it "ectodermal". Sometimes it is hard, but it is getting easier. These examples are helpful.

I had a patient today who I am treating for anterior foot pain secondary to a calcaneal fracture and she was describing something she does on the subway platform when her foot hurts. It went something like this: "I bend my knee with my foot flexed and then I straighten it with my foot pointed". I looked at her and said "you are mobilizing your peroneal nerve"
It is amazing what our bodies instinctively do.

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Old 04-02-2009, 04:09 AM   #65
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Mary,
I won't make another move towards that post until Jason gives me permission.

Diane,
Most definitely. Also, my brain likes the challenge and freedom to express itself in the interest of my patient rather than to regurgitate some scripted technique du jour in the interest of its developer.

Erica,
I'm still learning myself, and by no means have it "figured out." But that's part of the fun of it, too- the ongoing learning and newness of each patient interaction. I once mocked Barrett's phrase "individual ways of being," now I relish it.
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Old 04-02-2009, 06:28 AM   #66
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Quote:
Originally Posted by John W View Post
Mary,
I won't make another move towards that post until Jason gives me permission.
Well, you've only needed a minor course correction so far, so please continue. It's a good thing you have me around for such things. How did you get along without me, after all?
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Old 04-02-2009, 06:39 PM   #67
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Quote:
Creativity is allowed and encouraged, not denounced as heresy and poor technique.
oh such luxury, to be allowed to be creative and not be a hairy tic ...

ANdy
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Old 05-02-2009, 01:52 AM   #68
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I very much like your thread Jason, Thanks a lot !

Since you seem to be so good at making things simple and concrete , I would like you to make the samekind of «exemple» with ideomotion. As I understand what ideomotion is, I am just not shure how help it being expressed on my patients. I mean I kidda try but not sure if it is really that...

Or maybe Barrett could do that...

thanks

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Old 05-02-2009, 01:58 AM   #69
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Frederic,

This sentence:

Quote:
I am just not shure how help it being expressed on my patients.
confuses me.

Should it be: "I am just not sure how it helps when expressed by my patients" or, perhaps, "I am just not sure how to help my patients express it."

I want to help but I need some clarification here.
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Old 05-02-2009, 05:51 AM   #70
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"I am just not sure how to help my patients express it."

The latter is what I meant

Désolé pour mon anglais

Merci Barrett

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Old 05-02-2009, 12:51 PM   #71
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Well, I've tried for many years and in many ways to do this in a written form and this site and my own are full of examples of that.

I don't feel that Simple Contact, the manual and/or verbal method I use, requires much in the way of skill but the understanding that underlies its appropriate application might take a while to acquire without the kind of information available in a place like this.

The difference between easy and simple is this: Easy refers to the task itself (gentle touch). Simple refers to the thought processes behind the task.

Simple Contact is easy, but it's not simple.
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Old 05-02-2009, 03:02 PM   #72
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Quote:
Simple Contact is easy, but it's not simple.
In light of the "chasm", Barrett, are you considering a name change? A bit of a Trojan horse, but it might grab the attention of those on the mesodermal side of the bridge.
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Old 05-02-2009, 03:10 PM   #73
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Default Different cultures?

In the context the issue might need an approach of cultural change, maybe this piece is helpfull:
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File Type: pdf ITIM article on change management.pdf (180.6 KB, 80 views)
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Old 05-02-2009, 07:08 PM   #74
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What an interesting paper Line.
Unfreeze, move, freeze, kinds of clusters... very descriptive, enlightening to some extent.

I guess Canada would fit under .... solar.
US definitely contest.

Canada, maybe a cross between solar and contest, trying to become more network, but too many "contest" values at the top, certainly not well-oiled except at the "queen" level.

As far as human primate social grooming is concerned, ortho culture definitely fits the low Uncertainty Avoidance umbrella (so does chiro IMO, which must fend for itself).

I think it is also a "Masculine" culture plastered onto the side of a different one (a more female one), which evolved, and which was more successful at spreading into every corner of society as a network cluster, and carried the "contest" one along like a backpack. (I think this best describes the story of PT, at least in Canada, which followed the Brit model, since its inception in 1894.)

I wonder how PT sees itself in other countries, using this interesting new cognitive lens?
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Old 05-02-2009, 08:17 PM   #75
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Line, that is an interesting article - thanks.
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Old 05-02-2009, 10:17 PM   #76
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A good article, Line.

I think Australia lurks somewhere between Network and Solar. In my experience of management in a hospital setup, the final decisions come from the top (ie head of physiotherapy) but only after consultation with the senior PTs and then with the entire staff.
Suggestions on improvements are taken onboard, considered, and either accepted or rejected.

The reason for rejection are many, but the deciding factor is the number of people pushing for a change in practice; a lone voice is unlikely to change anything. But three lone voices, along with a senior PT, can swing the pendulum towards improvements.

Which is why this board has a strong chance of swinging others away from the meso-ortho culture towards ectodermalism - but it takes time.

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Old 05-02-2009, 11:11 PM   #77
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Having scrambled around in the depths of the archives, in particular the 2005 discussion around tendinopathy, I wondered if Jason (or others) might, with his clarity of thought, revisit his understanding of tendinopathy from an ectodermal perspective? I am aware this may need to be shunted elswhere from this thread.

ANdy
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Old 05-02-2009, 11:13 PM   #78
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I cannot download this article as adobe reports it damaged. Could a kindly person please repost it?

in anticipation

ANdy
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"Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne
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Old 05-02-2009, 11:54 PM   #79
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Here....
Hopefully this works better...
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File Type: pdf ITIM article on change management2.pdf (203.6 KB, 26 views)
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Old 06-02-2009, 03:07 PM   #80
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thank you Diane, much better

ANdy
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Old 29-06-2009, 05:59 AM   #81
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About the CPR for the «stability» (TrA) treatment protocol

This is how I ectodermalise (!) the results and the logic

Quote:
The supposition I make from the stability and manip CPR's is as follow :

if you're less than 40 y/o, don't have a positive SLR, don't have pain below the knee, don't have to much fear or others psycho issues with pain and don't have concurrent adjacent joint problems (the hip rotation thing), well, I guess you have a high likelyhood ratio of doing much better in a few weeks, and that, whatever I do... or almost !


The other bad thing with CPRs, is that because the treatment was effective it is supposed the logic behind that treatment makes sense. This is a bit bizarre, because some of the predicting factors seem to have nothing to do with the logic anyways.

Plus, it's disregarding other reasons for the findings :

Someone with abberant motion in Lx spine because of fear avoidance is very likely to feel pain on a P/A because of central sensitization. It's seems normal to me that this person will do some gripping with his erector spinae muscles while moving to prevent movement. The prone instability test is doing just that. So less mvt with the P/A : less pain. Because mvt and fear of it is causing pain. Could have nothing to do with trA and joint stability.

Why the exercices worked : the patient was told it would strenghten his back, make it more stable. He thus gained confidence and now as less fear avoidance, and so, less pain.

Coincidally, no fear avoidance is a failure predictor for stabilising exercices. How funny is that!

I guess some good pain education and some graded exposure would have gotten that hypothetical pt an even better result.
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Old 09-11-2009, 03:53 AM   #82
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I'm posting this paper I've written for the Differential Dx course in my DHS work here because it's an attempt to provide some ectodermal reasoning for a patient with traumatic onset of LBP and imaging evidence of spondylolysis.

It's a pretty good example of where meso to ecto reasoning could take us.
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File Type: pdf J.Ware.Pre-course paper.pdf (356.4 KB, 140 views)
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Old 09-11-2009, 11:21 AM   #83
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Hi Line,

Am a bit late with seeing this article you brought in.
Thanks for this... I hope it can be of help for my understanding of the cultural differences ......
Funny that Dutch connexxion

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Old 09-11-2009, 12:49 PM   #84
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John,

This is wonderful work. I think it should become an example for future students but would especially like to hear what your instructors have to say about it.
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Old 09-11-2009, 04:15 PM   #85
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John, I agree that it's wonderful. Love that you included an embryological point.
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Old 09-11-2009, 06:59 PM   #86
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Well-done indeed. What a resource treasure many of you folks are!
With my personal calculation, I owe you all about 275 martinis, 100 cases of beer, 32 cases of wine, and a stinkload of home-made indonesian snacks.....
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Old 09-11-2009, 07:38 PM   #87
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Great job, John. Thanks for sharing this.

Exciting to see the winds of change blowing harder all the time!
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Old 10-11-2009, 03:01 AM   #88
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Thanks, everyone.

I have to give kudos to Frederic for his discerning posts in this thread as well as this one on the lack of discriminatory validity of the various LBP CPRs. This particular case that I present is a good example of where mesodermal thinking goes awry.

On its face, a spondylolysis would seem to fall in a "stabilization" category due to the inherent "loss" of structural stability resulting from the pars defect/fracture. However, this patient met the criteria for both stabilization and specific exercise (flexion) based on most the current version of the "Treatment-Based Classification System" per Fritz et al and Brennan et al.

Notice also that this patient received manual therapy on the first visit. So, while he didn't meet any criteria for the "mobilization" category, I committed the heresy of therapeutically placing my hands on him in order to down-regulate superficial tenderness in the lumbosacral region.

None of the CPRs or classification categories directly address the neuromatrix. Rather, the tangential metrics of fear-avoidance and days since onset superficially deal with the cognitive and affective dimensions of the pain experience. This just won't do for persistent pain.

These classification systems are the product of decades of mesodermal thinking and logic. They are by-products of the biomedical lens that is talked about in this concurrent thread.

I'm going to Indianapolis this weekend for the on-site portion of this course- it's going to be long one...
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Old 10-11-2009, 09:37 AM   #89
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Thanks for the report John. I enjoyed reading it.

Regarding the latest classification study, does anyone have access to it in full?

Brennan GP, Fritz JM, Hunter SJ, et al. Indentifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine. 2006;31(6):623-631.
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Old 10-11-2009, 03:40 PM   #90
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Anders,
I don't have that one on my laptop at work, but if someone doesn't post it sooner, I will later tonight (early tomorrow morning for you) in the SoS.
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Old 12-11-2009, 03:48 AM   #91
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John,

Wow!!!!

I take a few days to go on vacation with the family and come back to fantastic reading...this plus other threads. Good luck in Indy.


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Old 12-11-2009, 04:07 AM   #92
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Quote:
Originally Posted by kongen View Post
Thanks for the report John. I enjoyed reading it.

Regarding the latest classification study, does anyone have access to it in full?

Brennan GP, Fritz JM, Hunter SJ, et al. Indentifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine. 2006;31(6):623-631.
Anders, here it is. Link.
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Old 17-12-2009, 05:54 AM   #93
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Default ectodermalized prone hang technique

I just wanted to say how much I appreciate Jason's description of the ectodermalized "prone hang" treatment technique for the knee.

I just helped a gentleman with an apparent 6 degree flexion contracture (early OA of the knee) to get back to full extension range in a few sessions using this combined with a skin stretch over the posterior knee. It is wonderful to feel the tension slowly melting away and the knee moving further into the range.

thanks
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Old 17-12-2009, 02:44 PM   #94
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Gilbert-
You're welcome.
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Old 17-12-2009, 04:55 PM   #95
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Thank you everyone. This was the most useful thread that I have read and it has helped to explain much to me.
One question though. Does the idea of working "ectodermally" apply to the mobilization of nervous tissue as well as the stimulation of various nerve receptors?
One more question. Could the success of Active Release Treatment be explained better by it's mobilizing effect on the neural structures? (as well, of course, as the skin stretch that is produced)
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Old 17-12-2009, 05:47 PM   #96
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Tim,

There's a thread about ART here, http://www.somasimple.com/forums/showthread.php?t=3173, which you might find useful.
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Old 18-12-2009, 12:31 AM   #97
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Gilbert,

A movement that might be worth considering is prone (on a mat table) knee extension with the ankle in dorsiflexion. The patient would try to move in a manner that would decrease the pressure created at the knee/matt interface. Play with it a bit yourself to see if it is something that might be helpful.
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Old 12-12-2010, 09:18 PM   #98
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Jason,
Thanks for pointing me towards this...very helpful!

Tony Friese, PT
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Old 13-12-2010, 12:47 AM   #99
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You're welcome Tony, glad you liked it.
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Old 06-01-2011, 10:10 PM   #100
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Hi Jason

Just need to say I love this thread. I was hoping to get some answers on here and your examples are really helping me get a greater understanding

Fletch
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