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RE: neck vs. shoulder
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RE: neck vs. shoulder - May 24, 2008 6:41:22 PM
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ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
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Proud , I am so very flattered to have inspired such ire, It's good to remember this is a blog, a chat forum , a site where conversation happens and thoughts and ideas are shared. It is not a scientific paper . This being the case it is for everyone reading here to make careful judgements based on their own reasoning power. From time to time it must be said, some posts are really usefull. negativity rarely is. While I certainly would not suggest you accept posts at face value where virisimilitude is absent, trying out "new' ideas is what science is all about. Want to find out if CM works? , try it. If your hands fall off or your patient explodes let me know. LOL.
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RE: neck vs. shoulder - May 24, 2008 7:08:35 PM
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bonez
Posts: 173
Joined: August 29, 2007
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Ginger thanks for the direct answer.
Ok sorry for stirring up a hornets nest again. My question was put forward as a rather new person to the board because I have seen the group lay into others who have brought treatments here that have lacked evidence to support them and I was interested in finding out more. That being said I am not against clinically observed success as a direction to start evidence gathering.
Hearing that this has been apparently successful for decades and taught to others but not investigated does seem a little concerning. I have seen several posts here and on other boards about this approach for heel pain, elbow pain and now shoulder pain. Many of these come off rather authoritatively. I have also seen numerous references to the need to follow, support and practice in an evidence based way.
As a member of a non physio based profession I wonder how everyone who has been critical of non evidenced based care in the past feels about this?
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RE: neck vs. shoulder - May 24, 2008 8:17:59 PM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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Hi Bonez. Tell me how ginger's approach isn't evidence-based. In order to practice evidence-based medicine we have to use our clinical intution in the presense of best available evidence that is consistent with the patient's value system. The concept of regional interdependence is a widely (not universally mind you) accepted paradigm and many of ginger's ideas stem from this. There is literary support for this approach, it likely clicks with ginger's clinical intution, and has been assessed as consistent with the patient's value system.
I don't think EBM is practicing based on a study or directly from recommendation. It incorporates best evidence, clinical judgement, and patient autonomy. In this context, you could compare ginger's approach to say, myofascial release or subluxation. This can allow us to better assess whether an approach is "evidence-based". I'm not trying to be inflammatory to you by including subluxation, I'm just using it as an example mind you.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: neck vs. shoulder - May 24, 2008 9:07:15 PM
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sslevins
Posts: 15
Joined: June 27, 2006
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Proud,
I too must apologize if I came off as too defensive and irritable about your post. I too have been very frustrated with the tendancy of many PTs to be easy prey to "the treatment of the week". In this case I was just trying to think outside the box as doing the same thing over and over without results is a waste and there really does seem to be a cervical component. I feel that sometimes CM or (insert your favorite mobs here) are the answer, but I am not quite to the point Ginger is, where facet mobs cures all. That said, I respect Gingers experience and wisdom and if he is getting great results then "good on 'ya". After all we should all really be working towards results.
Steve Levins, PT MSc. OCS
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RE: neck vs. shoulder - May 24, 2008 9:15:02 PM
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proud
Posts: 873
Joined: March 22, 2006
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This will sound funny. Offensive even. But I really hate Sackett's definition of EBM....
Or at least I hate how it is so often utilized as a crutch for wonky clinicians to lean( Not you Rod....at least my sense is that based on what I have read from you, very well versed. But you brought up the dreaded "patient values" comment).
It's so easily utilized by Cranio-sacral therapists....who BTW make equal claims to Ginger let's say. It's an open door for crazy things.
I just do not think poking away for 20 bloody minutes at a facet joint has any clinical applicability.
Fact is this patient has longstanding persistent pain. Biology changes at a cellular level. Central chemistry alters. And here it is....no mechanical pathology readily available.
This person needs to get going. Needs to understand the concepts of hurt versus harm. Is she going to hurt herself from moving? Does not sound like it to me.
Educate her about pain. Educate about hurt versus harm. Get all clinicians involved to stop cutting her open, imaging, etc. Get her moving in a graded fashion.
Poking at her C4/C5 for 20 mins when she has had this pain so long. Pointless in my opinion.
< Message edited by proud -- May 24, 2008 9:31:32 PM >
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RE: neck vs. shoulder - May 24, 2008 9:32:18 PM
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ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
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Proud , Bonez, Rod, Apart from an interest in throwing what light I can on the value of Cm as a method , I'm keen to alert therapists to the prospects of improved treatment outcomes by a way of viewing difficult pain/dysfunction as referred events. Quite apart from Cm's value as a method pe se, it is the means to discover and relate in a practical way to referred events. There are other means to accomplish this. I am not so much concerned wether therapists become skilled in my method , but feel moved to comment when others fail in the face of common neurogenic problems. We can all agree that were we not to be here discussing this , it is possible that a lot of very usefull experience would go to the graves along with those whose strong wish was to share.
A guru I am not, quite amused by the suggestion really. Not interested in selling intellectual property here or anywhere. As a working family man with many interests, I have worked out the means to accomplish what my time with patients demands, how to solve problems. I have neither the means , finances or time to spend at university doing degrees or pursuing the long ,hard somewhat dry world of research.( maybe when I retire). Till then I'm happy to continue to speak when I believe I may make a difference.
You are all welcome to your doubts , good reasoning and perspectives. It is a pleasure to have a conversation with you.
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RE: neck vs. shoulder - May 24, 2008 9:42:01 PM
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proud
Posts: 873
Joined: March 22, 2006
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Hey wait. I thought you were a female Ginger? Or perhaps I am getting you confused with an ex member here Diane who claims stretching skin in the cure all for persistent pain.
BTW, I am one of those PT's that has attempted CM on a few recalcitrant cases. We all want to help so against my better judgement, I gave it a whirl. It did not work for me. But then again, It's pretty hard to fully grasp a technique through an online chat room.
But I doubt it would work anyway :)_
Still enjoy your input sir....
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RE: neck vs. shoulder - May 24, 2008 10:20:06 PM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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Please...for the love of all that is holy...do not get ginger confused with the lady Diane. For one I was told ginger is actually a dude which (I hope) is but one of many distiguishing characteristics between the two.
Proud...sorry you aren't crazy about the patient values issue. I agree it's a bit fuzzy and probably has been clarified to a much greater extent. I'll see if I can pull something up that might make you a little less distasteful of the idea. If not...oh well. At least I can say I gave it a shot.
I can tell you I have never banged away at a facet joint for 20 minutes. I believe a skilled therapist can distinguish between the varying degrees of referred pain. Referred pain has been studied extensively and is a well documented phenomenon. That being said - what percentage of lateral elbow or shoulder pain is actually the result of a referred event occuring in the neck? In my view, very few. However, it doesn't hurt and takes very little time to investigate the possiblity.
If movement of the neck or cervicothoracic junction reproduces the distal symptom....bingo. However, most of the cases of shoulder and elbow pain are directly reproduced by more standardized (not sure that's the best word there) methods.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: neck vs. shoulder - May 25, 2008 2:12:42 AM
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bonez
Posts: 173
Joined: August 29, 2007
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quote:
ORIGINAL: TexasOrtho
Hi Bonez. Tell me how ginger's approach isn't evidence-based. In order to practice evidence-based medicine we have to use our clinical intution in the presense of best available evidence that is consistent with the patient's value system. The concept of regional interdependence is a widely (not universally mind you) accepted paradigm and many of ginger's ideas stem from this. There is literary support for this approach, it likely clicks with ginger's clinical intution, and has been assessed as consistent with the patient's value system.
I don't think EBM is practicing based on a study or directly from recommendation. It incorporates best evidence, clinical judgement, and patient autonomy. In this context, you could compare ginger's approach to say, myofascial release or subluxation. This can allow us to better assess whether an approach is "evidence-based". I'm not trying to be inflammatory to you by including subluxation, I'm just using it as an example mind you.
Rod no offence taken. But my point was with two decades of application and shared with students do you not think it might be time for someone/anyone to take this past the stage of practice based observation?
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RE: neck vs. shoulder - May 25, 2008 5:00:39 AM
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ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
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Guys , i work in a private practice ( my own ) where I see those who can be said to be the "walking well", employed , largely self motivated thirty forty fifty something folks who make up the bulk of the employed community. It is rare amongst them , for those complaining of non trauma related limb pain ,for their problems NOT to be referred events from spinal joints. To clarify, in my observations of and treatments of their limb pains and dysfunctional issues , for them not to be fully and completely resolved by identifying and treating these issues as spinal referred pain AND NOTHING ELSE. Now either I am in the midst of a completely different group than your own , in terms of their presentations and aetiology of pain , OR , one
of us is getting it wrong.
My average treatment period is three by thirty minutes. So some will be fixed and sorted after one treatment , some may take 6. Either way , the prospect of finding a mysterious ( let's say shoulder ) pain problem associated with muscles, nerves or bones OF the shoulder, is roughly NIL. I'm not talking about those who I send off for investigation , those account for less than one percent. Not talking about those who fail to get better, they account for around 3 percent. By far the majority , arrive with a persistant pain problem that has been investigated by others , treated by an assortment of others and failed to improve , that are sorted in short order by attention to their spine, with CM.
Inherant in my own perspective is bias. A feature of having only the one mind. I figure I have something of a reputation, live within a demographic that has features peculiar to it, and so must allow for differences in presentations with your patients.
Al the same , it is a source of some interest to me , that bloggers here and elsewhere, seem to have a black hole where referred events are conerned.
Interesting.
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RE: neck vs. shoulder - May 25, 2008 7:25:07 AM
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proud
Posts: 873
Joined: March 22, 2006
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This...I fail to believe Ginger. 3% failure rate amongst persistent pain population in 1-6 treatment sessions?
Come on now. No educated person is going to buy what you're selling.
However, if it's true....you are a bigger fool than most. You should be getting your techniques studied, published and taking the show on the road. If not for the money than at least think of the millions of people you could be helping.
You do sound convincing though, I'll give you that....
< Message edited by proud -- May 25, 2008 7:31:17 AM >
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RE: neck vs. shoulder - May 25, 2008 8:50:48 AM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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quote:
ORIGINAL: bonez
Rod no offence taken. But my point was with two decades of application and shared with students do you not think it might be time for someone/anyone to take this past the stage of practice based observation?
I agree completely.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: neck vs. shoulder - May 25, 2008 9:04:45 AM
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Kongen
Posts: 7
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quote:
ORIGINAL: proud
Hey wait. I thought you were a female Ginger? Or perhaps I am getting you confused with an ex member here Diane who claims stretching skin in the cure all for persistent pain.
If the CM method is not skin stretch, then what is it? Pressing on the skin over the facet joint will create a skin stretch, a very gentle one at that, especially when you respect pain and resistance in the tissues. And especially in the lumbar spine where the facet joints are buried deep below skin, fat, muscle.. So you can not disregard the input the brain recieves from the more superficial structures.
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RE: neck vs. shoulder - May 25, 2008 11:15:47 AM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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There certainly is a component that involves the skin and subcutaneous tissue and that effect warrants attention to be sure. How could we descriminate between the two effects?
I just realized I have full text access to Manual Therapy through my doctoral program. I hope to pick up some good information from them. Until then all I can offer is conjecture. Right now with the current body of evidence, it is more reasonable to conclude both mechanical and neurolgical events surround the positive effect of manual therapies. The question would be one of degree. I suspect that once the degree is known, it will not likely change the actual technique itself. Rather, it will provide who is on the "winning" end of the argument a reason to bump their chests. Thats fine with me, but the patient doesn't really care who was right.
Proud, this could be an example of patient value. Does ignoring evidence because it doesn't match one's paradigm of treatment warrant not attempting it? Particularly in the absense of high risk or cost to the patient?
There's an article in Manual Therapy that might lend at least some support to central mechanisms contributing to a peripheral problem. I'll be extracting it on my blog later today.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: neck vs. shoulder - May 25, 2008 11:30:09 AM
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Kongen
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Here's another one aswell when your at it :)
Schmid A, et al., Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation, Manual Therapy (2008), doi:10.1016/j.math.2007.12.007
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RE: neck vs. shoulder - May 25, 2008 11:34:10 AM
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proud
Posts: 873
Joined: March 22, 2006
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ROD,
I'm short on time but two things to ponder concerning your queries:
1. Chiropractic upper C-spine manipulation. Evidence suggests mobilization is equally effective but Chiropractors cannot allow this to happen can they? It removes any "special" skill they attempt to defend at every turn. Yet patients readily run to the pulpit for regular c-spine manipulation. Patient values....Paradigm...
2. Custom foot orthotics.....
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RE: neck vs. shoulder - May 25, 2008 11:40:19 AM
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proud
Posts: 873
Joined: March 22, 2006
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Actually, Rod....I just re-read your question. I do not really understand. Are you saying "evidence" or evidence in the form Ginger is providing? Anecdotal evidence...
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RE: neck vs. shoulder - May 25, 2008 5:54:56 PM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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Proud. You will learn how much I believe in the correct usage of words the more you interact with me. I try as often as I can to choose words carefully. In this sense, "evidence" exists on a continuum from expert opinion through systematic review and is clearly outlined in the literature. In this sense, ginger's evidence is indeed evidence, but exists at a level that must be taken into consideration. Loads of opinion without higher levels of evidence to support it should begin to raise red flags over time. However, EBM gives everyone the opportunity to substantiate their expert opinion with higher levels of evidence. We should expect that someone desiring credibility must be willing to support their claim with higher levels of evidence.
I'm a little confused as to your last statement on patient values as your thoughts didn't get accross to me on this. Here's an exerpt on the issue from CEBM:
"by patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient."
My bolds added. Here's how I might use patient values to support cervical mobilization v manipulation in the example you cited. The fundamental value to the patient would likely to see a resolution of the presenting symptoms. Both manip and mob may accomplish this. However, it is becoming more apparent that upper cervical manipulations present a much higher risk despite having relatively similar clinical outcomes. The patient is likely to value an effective treatment with a lower risk profile. Therefore (in this highly theoretical) using the mobilzation would be a stronger representation of EBP due to the patient's desire to have an effective an unharmful treatment.
I agree that patient values makes me want to hold my nose as well on the surface, but it can be a useful part of the decision making process. It also gives us more ammunition in the face of "alternative" treatments that often run counter to a patients value to get better, not be harmed, and minimize cost. Not sure if that clears up my thoughts on this issue, but there it is...
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: neck vs. shoulder - May 25, 2008 5:58:22 PM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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quote:
ORIGINAL: Kongen
Here's another one aswell when your at it :)
Schmid A, et al., Paradigm shift in manual therapy? Evidence for a central nervous system component in the response to passive cervical joint mobilisation, Manual Therapy (2008), doi:10.1016/j.math.2007.12.007
I've read this...it's also a good piece.
< Message edited by TexasOrtho -- May 25, 2008 6:06:20 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: neck vs. shoulder - May 25, 2008 6:23:57 PM
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ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
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An example.
61 year old runner, keen to compete, had not run for months because of persistant achilles pain R. physios / osteopaths had been mucking about with his ankle, heel etc for months with only minimal effect. Had been told , amongst other things to rest. Patient on the verge of yet another needle to his ahilles. currently having acupuncture twice weekly .
Observations. pronates mildly R>L wears rigid orthotics (only when he runs )
SIJ completely dyfunctional L=R
Lumbar spine occasional sore , stiff in general
Very poor flexibility ( unable to touch toes, fingers reach to mid shin with forward bend knees extended )
R achilles tender posteriorly and with squeeze, some puffiness evident. (Ankle NAD on x-ray )
RX. three thirty minute treatment sessions, with CM to L5S1 R along with CM attention to other lumbar facet joints with elevated protective responses. primary taget L5S1. Good responses till by third Rx little protective behaviour detectable there.
Epineural tissue ballistic stretches introduced at third treatment. Self stretching program introduced( ballistic )
Attempts to restore SIJ mobility failed. ( bodyweight mobs )
Told to wear orthotics full time.
Results. Achilles pain (tested in standing, self stretching of calf/soleus, also squeeze by therapist , jumping on one foot R ) reported halved after treatment one ,swelling gone after 24 hours 20 percent remained after treatment two , nil remained after three. Two weeks later back running and training for australian masters championships without pain. With self stetching program now able to touch toes easily , gaining further flexibilty also.
This is a fairly typical scenario.
No attention to the structures around the achilles at all, other than what could be said to have occurred in the context of stretch of the sciatic trunk and of his already extensive pre-existing self management.
I realise I am drawing attention to achilles "tendinosis " here , I do so only to serve as illustration on the wider front of a central first approach.
Re your comments Proud , Rod about "taking the show on the road' I have done this to a limited extent. Have been doing free lectures for ten years or more twice a year. I also wrote a 7 part undergrad lecture workshop series which I sold to and presented at a uni here in melbourne, teaching myotherapists. (Haven't been back , the administrators thought I was too expensive). This along with teaching physio undergrads who spend time at my clinic. I've had my share of knock backs and resistance from the university community, who all seem to want me to take part in further research in the context of degree/masters/phd courses. I just don't fancy it . couldn't afford it and prefer to provide my skills at the coalface. This blog is my opportunity to reach out beyond the narrow spaces between patients, maybe just like all of you.
Hope this example is of interest, more if you are wanting them.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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