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RE: Classification Scheme vs. Biomechanical model
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RE: Classification Scheme vs. Biomechanical model - November 21, 2007 7:41:31 PM
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proud
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quote:
ORIGINAL: SJBird55
I was taught the convex on concave crap and the flexed, rotated, mutated crap... I never, ever practiced it. It went out the window as soon as I walked out the door with my degree - I couldn't feel any of that crap. I refuse to spend a single dollar on any of that type of training because I do believe it is there to financially improve someone's or an institution's financial well-being AND I don't desire to undertake the training to give me an elevated status professionally (especially when I don't believe the evaluative process has any merit). And, as the research is being pumped out, I'm actually feeling happy that I didn't fall prey to the lack of my manual evaluative abilities in feeling/sensing all the bunk.
Oh so correct SJ. The sooner our acedemic insitutions get their heads out of the proverbial sand...the better. It's disturbing to me that so many seemingly intelligent PT's get sold down that river( or are they really that intelligent....?)
The rest of your post was spot on for sure.
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RE: Classification Scheme vs. Biomechanical model - November 22, 2007 2:27:58 AM
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avalon
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quote:
I have a library of articles on my "stick" that I have organized... and with every patient, I can define the research in peer-reviewed literature that is assisting me with treating the patient.
If it was so easy, we will be able to cure everybody.
You're better than me.
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RE: Classification Scheme vs. Biomechanical model - November 22, 2007 8:42:11 AM
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SJBird55
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avalon... there is always something one can find to provide the rationale for what one chooses to do. To assume otherwise is wrong. I can also say that if one doesn't take the time to search, one won't find anything in writing to support or provide a rationale for the basis of the services provided.
(edited - my grammar ain't too good)
< Message edited by SJBird55 -- November 22, 2007 9:20:13 AM >
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RE: Classification Scheme vs. Biomechanical model - November 22, 2007 12:11:51 PM
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steve
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SJ,
Providing rationale for treatment based on the best scientific evidence available - how dare you take the easy way out! We should be treating based on complex, biological theories that although unproven through careful scrutinization by quality research are taught through expensive continuing education gurus who know what is best.
Then to document the sources for your clinical reasoning so others can decide for themselves if your approachis appropriate, that really is too much.
Steve
Steve
< Message edited by steve -- November 22, 2007 12:15:04 PM >
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RE: Classification Scheme vs. Biomechanical model - November 22, 2007 7:51:06 PM
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proud
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quote:
ORIGINAL: Crevidence
Are those physical therapists adhering to the "complex" biomechanical approach of the spine practicing alternative medicine/physical therapy?
The answer is...yes. of course.
The sad thing about these types is that they have unknowingly denigrated our profession into just another unfounded complex "theory". What they percieve as achieving "excellence" in the eyes of their pers, is actually a source of ridicule for other credible healthcare providers.
What is even more maddening is that fact that this "complexity" as a means to achieve psuedo credibility has been done before( chiropractors). Why are we rushing to fill this void when chiropractors are scrambling like mice from the hidden specificity farce? Why walk blindly into that hole when the research is right there in front of you.... screaming at you to see it.
However the very foundation of Physiotherapy is very very strong. It's called exercise and more importantly the aspect of sub grouping patients into the appropriate form or type of exercise, mobilization etc.
The evidence is easily accessible for those diligent enough....intelligent enough to find it. Please avoid the biomehanical trap everyone.....do some research and start treating patients appropriately.
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RE: Classification Scheme vs. Biomechanical model - November 22, 2007 11:51:13 PM
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steve
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Interesting comments Proud and I think complexity of practice is fascinating, particularly when considering clinical prediction rules. The assumption in the physiotherapy world is that complexity is the realm of the expert clinician and enables them to improve their outcomes by sifting through complex theories and testing with significant detail and variations on each test (Ie. an upper limb tension test sequencing or a pivm in multiple planes of movement etc.). The interesting thing is that it now seems the more data we collect and the more intricate the testing the poorer our decision making. This is called retrospective clinical reasoning, where all the data is collected and then looked at to then make a decision with respect to diagnosis and treatment. Essentially, so much data is collected without knowing its diagnostic properties that "Noise" is created and red herrings are chased. Although physios have prided themselves on the thouroughness of our assessment, this has long been considered the traits of the novice clinician in medicine.
Contrast this with CPRs where simplicity is key and allows the clinician to decision make with a few key pieces of information and tests to make decisions. This really is a form of prospective clinical reasoning, where the clinician forms a hypothesis and tests it with specific tests and considers the diagnostic (sensitivity/specificity) properties of those tests in forming a diagnosis.
Steve
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RE: Classification Scheme vs. Biomechanical model - November 23, 2007 3:14:13 AM
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avalon
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quote:
Are those physical therapists adhering to the "complex" biomechanical approach of the spine practicing alternative medicine/physical therapy?
I'm not.
quote:
However the very foundation of Physiotherapy is very very strong. It's called exercise and more importantly the aspect of sub grouping patients into the appropriate form or type of exercise, mobilization etc.
Really?
In 1900, the LBP population was around 50%, it is now... greater.
That is a strong evidence that we've got weak results with our simple practice.
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RE: Classification Scheme vs. Biomechanical model - November 23, 2007 7:29:36 AM
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SJBird55
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In the 1900's in the US, was the occupational life the same? Was there the same rate of litigation? Was life expectancy the same? How frequently did the population with low back pain in the 1900's seek physical therapists for low back pain?
Avalon.... your argument makes no sense.
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RE: Classification Scheme vs. Biomechanical model - November 23, 2007 7:42:48 AM
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proud
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avelon,
If you are practicing via the complex biomechanical evaluative process...you are. And the evidence is mounting to drive the mice from the barn. Care to argue that with some soundly backed data? Thought not...
I think reading Steve's latest post would be a good idea.
On a final note....I really don't follow with your last comment. On some level I agree with you....but I think for entirly different reasons then what I gather you are thinking....
Care to clarify?
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RE: Classification Scheme vs. Biomechanical model - November 23, 2007 7:43:35 AM
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SJBird55
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Steve... I think sometimes the reason I don't always hit the mark and do as well when it comes to the shoulder is as you mention - too much noise. There was an article that came out a few years back and I need to sit down and implement it - a classification system for the shoulder was published. I need to review it and piece together the appropriate tests with higher sensitivities/specificities to help me put that system to use. (I know I've been dragging my feet on that project because the system isn't quite as "simple" as I would hope it could be honed down to be, but no one has tested or reduced the published system any further.)
It has already been proven in the cardiac world that when it comes to chest pain just a few variables are key in the decision-making process. Everything else is noise and noise reduces the humans ability to make consistently good decisions.
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RE: Classification Scheme vs. Biomechanical model - November 23, 2007 11:53:00 AM
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steve
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I think Avalon is suggesting a pain sciences approach to treating low back pain. And I would agree with him that our "Medicalization" of low back pain patients has contributed to the chronicity of low back pain but would also argue that classification based treatment considers the fear avoidant/behavioural patient and treats accordingly with good results. It is interesting to note in a study done by Steve George, patients with low fear avoidance beliefs treeated with fear avoidance based therapy did worse than the low fear avoidance patient treated with standard physical therapy.
Steve
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RE: Classification Scheme vs. Biomechanical model - November 23, 2007 12:22:13 PM
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avalon
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quote:
I think Avalon is suggesting a pain sciences approach to treating low back pain.
Yes and I know this study, too.
quote:
In the 1900's in the US, was the occupational life the same? Was there the same rate of litigation? Was life expectancy the same? How frequently did the population with low back pain in the 1900's seek physical therapists for low back pain?
Our ancestors worked a lot more than us and surely harder.
Of course, life expentancy is longer but none was seeking for a PT in the 1900'
And actually, they do and the rate is greater => Search the problem in your clinical reasoning!
< Message edited by avalon -- November 23, 2007 12:41:56 PM >
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 4:10:29 AM
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avalon
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By the way,
If the collection is too large, take only the last ten years:
Has the percentage decreased?
Is there less fusions or surgeries?
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 1:14:38 PM
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proud
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quote:
Interesting. It seems you view your world with clear eyes.
Not quite sure of the intended tone of that message...I assume you are insinuating I live in my own little world?
Fair enough.
I still think much of our failures(being clearly exposed), has a great deal to do with the medicalization that Steve referred to as well as our own failure in recognizing that complex theory based treatments are traits of the novice clinician in medicine....not t'other way round....
The complex biomechanical model has the sole purpose of elevating the soft ego's of those selling the bogus product. And yes, I find myself frustrated by the fact that seemingly intelligent PT's take years to figure that out. By that point, they either admit they were duped....or continue with the facade.
I was one of them. I studied within the system in canada that teaches that format( one of our past instuctors is now an instructor within the U.S NAOIMT system now actually). At one point I felt that perhaps I just did not have those magical hands. I know better now....I was duped. Ironically though, I think that the work I went through DID make me a better clinician in different ways, so it all worked out...
It is interesting that much of what we do that works, has historically been viewed as something that "we are too good for". Exercise for example is one of those concepts that these "biomechanical guru" types liked to believe they were too good for. When in fact in turns out, exercise was too good for them. We seem to take these simple yet effective concepts and give it away to other professionals( AT's and Kinesiologists). However we are now finding out through research that understanding the "how" and "when" of exercise is very complex and if applied correctly....very effective. It's just a shame many of our own acedemic institutions continue to push the complex biomechanical model.
I had read that article by George et al previously in the protocol stage. Really interesting stuff there.
< Message edited by proud -- November 24, 2007 1:42:47 PM >
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 1:56:24 PM
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proud
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quote:
ORIGINAL: Crevidence
It should have read: It seems you view the world with clear eyes. It was meant to be a compliment.
I agree with pretty much every sentence in that post. You have said much of what I think.
Proud, I have a question. How do you deal with co-workers that do not feel as you do?
Ahhh. Thanks for the clarification there Crev.
In the past 6 years....I have worked in a small clinic that employes 7 PT's. In that time I have worked with approximately 15 different PT's. Only 2 have been hard core PPIVM/PAIVM types. Simple way to deal with them in my experience. Ask them to prove YOU wrong.....they cannot of course. But you CAN prove THEM wrong. Easily.
And I do not intend to sound arrogant, but in such a small clinic, outcomes "hang out there" like a sore thumb. I think my outcomes speak well for themselves which helps with the message.
Also the fact that I trained in that system makes it impossible for them to attempt to speak circles around me...which is a favorite tactic I find.
< Message edited by proud -- November 24, 2007 2:10:57 PM >
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 4:48:38 PM
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Bournephysio
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This topic always seems to bring out polarized views even without strong evidence supporting them. Probably due to the “guru’s” on one side who don’t want to give up their overly complex theories and those physios who just don’t have the motor skills needed for manual assessment.
I think that I have a unique view on this. Firstly, I have trained with (and worked with) some of the “top” manual therapists in the world. Secondly, I have trained with some of the top biomechanists in the world and I am currently doing my PhD in one of the top biomechanics laboratories in the world.
I can’t respond to everything in this thread but I will bring up a few points.
1.) The “biomechanical model” is anything but. Sure, some of it is based on very good kinematics studies but it basically stops there. This is the problem with most of these complex theories. Some aspects might have very strong support but some critical aspect further down in the logic train may be fatally flawed. This includes many of the so called theories based on pain science.
2.) Biomechanics is EXTREMELY important to physiotherapy. Are we not the movement experts? If you don’t agree you have really have a lot of reading to do (or you are deluding yourself.)
3.) We need to be very careful with what we are arguing.
a. “the convex on concave crap” this is a pretty good guideline for how joints move. If joints don’t move this way, they will fall apart. What exactly are you arguing?
b. Maybe not in this thread but I’ve seen people argue that we shouldn’t be doing motion palpation. Remember, Lachman’s is a motion palpation test. PA’s are a motion palpation test (and a paivm in some systems). flexion/extension pivms have use for diagnosing clinical hypermobility/instability and have published sensitivities/specificities. So where exactly are the “PIVM/PAVM” types wrong? Be very clear with your arguments or you’re not any more convincing than the theory that you are trying to argue against.
Doug
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 5:38:32 PM
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proud
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quote:
ORIGINAL: Bournephysio
This topic always seems to bring out polarized views even without strong evidence supporting them. Probably due to the “guru’s” on one side who don’t want to give up their overly complex theories and those physios who just don’t have the motor skills needed for manual assessment.
I think that I have a unique view on this. Firstly, I have trained with (and worked with) some of the “top” manual therapists in the world. Secondly, I have trained with some of the top biomechanists in the world and I am currently doing my PhD in one of the top biomechanics laboratories in the world.
I can’t respond to everything in this thread but I will bring up a few points.
1.) The “biomechanical model” is anything but. Sure, some of it is based on very good kinematics studies but it basically stops there. This is the problem with most of these complex theories. Some aspects might have very strong support but some critical aspect further down in the logic train may be fatally flawed. This includes many of the so called theories based on pain science.
2.) Biomechanics is EXTREMELY important to physiotherapy. Are we not the movement experts? If you don’t agree you have really have a lot of reading to do (or you are deluding yourself.)
3.) We need to be very careful with what we are arguing.
a. “the convex on concave crap” this is a pretty good guideline for how joints move. If joints don’t move this way, they will fall apart. What exactly are you arguing?
b. Maybe not in this thread but I’ve seen people argue that we shouldn’t be doing motion palpation. Remember, Lachman’s is a motion palpation test. PA’s are a motion palpation test (and a paivm in some systems). flexion/extension pivms have use for diagnosing clinical hypermobility/instability and have published sensitivities/specificities. So where exactly are the “PIVM/PAVM” types wrong? Be very clear with your arguments or you’re not any more convincing than the theory that you are trying to argue against.
Doug
Doug,
I take issue with many of your comments above. I am really busy at the moment so will have to respond with more clarity a little latter.
I'll start by agreeing with you in that biomechanics are extremely important to what we do. Then follow up with a question knowing you are a fellow Canuck. Did you read the latest ODR?
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 6:25:17 PM
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Bournephysio
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rotfl, Crevidence, I see that you removed your shoulder question. Did you find out who I was?
For the validity of PAs you need look no further than the Childs,Fritz,Flynn studies.
for pivms:
Abbott et al. Lumbar segmental instability: a criterion-related validity study of manual therapy assessment. BMC musculoskeletal disorders (2005) vol. 6 pp. 56
proud, I read their conclusions. Enough to know they are wrong. They question the use of PAs for clinical prediction rules. This is oblivious to the fact that the stats determined their inclusion and that it was validated with an RCT. The combination of the two studies is a validity study. If something is valid then it is reliable enough. That makes it pretty clear that they don't understand validity and reliability.
Doug
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 8:32:50 PM
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Kaden
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Doug,
Thanks for speaking up for the "other side" and bringing a refreshing view point.
I think many on this post that are so against the biomechanical approach should focus their hateful energy elsewhere. The biomechanical system does have flaws but as Doug points out it does have its good points with evidence to back it up.
We should remember that many therapists using the biomechanical model are considered some of the top manual therapists in the profession. These individiuals continue to work to improve the profression and improve quality of care.
Are there not some other groups where your energy to banish could be better spent.
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RE: Classification Scheme vs. Biomechanical model - November 24, 2007 9:18:18 PM
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SJBird55
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Doug, biomechanical assessment models used for those that become certified manual specialists are what is being questioned. Was the segment really flexed, rotated and sidebent? Did manual treatment really alter anything so that the segment was really unflexed, unrotated and unsidebent and put back to normal? Yeah, I saw that article, Crevidence - must mean that it can't be the capsule that is being impacted, right? Doug, you've also missed the aspect that one really can't feel that a segment is rotated, flexed or sidebent. ;) Some therapists THINK they can feel it, but research indicates they really can't or aren't.
Biomechanics is one of the foundations and definitely important in understanding movement. I don't recall anyone stating biomechanics was irrelevant.
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