|
|
RE: neck vs. shoulder
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
RE: neck vs. shoulder - May 25, 2008 7:45:35 PM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
Rod,
Chiropractors have survived like parasites using the "patient values" and "clinical expertise" tag line. Unfortunately has third party payors have tightened the leash on that crew...there has been a influx of psuedo wackjobs sliding in there....PT's included if not leading the charge. MFR, CST...etc. All snakoil cosumed by the gallon load by unsuspecting patients. It's a tragic waste of healthcare bucks...
And here's the rub: Healthcare spending on this epidemic we can "chronic" NMSK complaints is being analyzed as we speak. More and more uninsured. Insurance coverage premiums skyrocketing.
Rest assured that the days of "claiming" something works are numbered. And I think it's the right move. Plenty of evidence out there on how best to treat persistent pain( hint for slsevins on your patient: CBT/education on pain/graded exercise program and a swift kick in the rear should do it).
Ginger,
Nice example. Interesting I guess. Plausable even. I would love to see your claims put to the test. it would be easy to do. You should do it.
|
|
|
|
|
RE: neck vs. shoulder - May 25, 2008 7:54:33 PM
|
|
|
Sebastian Asselbergs
Posts: 1105
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
Rod, as you know from another discussion board, I have great trouble with the use of the word "mechanical" as a discrete outcome of ANY manual intervention/action.
Any change in ROM or strength can only take place IF the neural system allows that altered aspect.
Even when i manipulated (in my Cyriax days) a patient's neck or back and occasionally surprised him/her (standards were a bit different then), the ONLY reason that in many I saw a change of motion, was because the nervous system had altered its output - although I did not see it that way then. I really do not think it is any different in many of our techniques; we apply a force, large or small, and the recipient/interactive nervous system has an altered output - different motion/strength/sensation.
This even applies (in my opinion) to those tissues with altered biochemical characteristics; the only way we can manually influence biochemistry, is by neural/hormonal response.
Anyway. I understand ginger's presentations. And I know he does not feel at all put out if people do not follow his suggestions; since he and we know they are only suggestions. I agree with him that we have a BIG set of blinders on in many practices - so focused on patho-anatomy that PTs often miss the boat.
I agree with proud about education - this is a big part of my practice these days. Very big. But proud, do NOT put what ginger is doing
or what Kongen is alluding to, in the same class as CST. No repeatedly disproven "rhythms" or "flexion-extension" movements of the skull or sacrum, no "separate hydrodynamic" activity of the CSF burden the techniques of skin treaters and joint mob-ers. Their concepts have a firm basis in accepted (but not always well-known) neurophysiology. They do not require the invention of a "special" anatomical feature....
_____________________________
Mundi vult decipi
|
|
|
|
|
RE: neck vs. shoulder - May 25, 2008 8:25:15 PM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
Seb,
But they do have one thing in common....no outcome studies to hang their hats on. Is "CM" any better than a thwack to the back of the neck? I don't know?
|
|
|
|
|
RE: neck vs. shoulder - May 25, 2008 9:30:05 PM
|
|
|
TexasOrtho
Posts: 423
Joined: December 22, 2007
Status: offline
|
Proud. I get your enthusiasm and we share many of the same thoughts on the issues. I never thought I would be passing this on as I myself am an evidence-based "hawk" against the likes of the chiros and CST'ers of the world.
An old bull and a young bull on a hill overlooking a field of cows. The young bull says, lets race down to that field and (bleep) one of those cows, to which the older bull replies, lets walk down there and (bleep) them all.
As much as I completely agree with your statements, our criticism cannot sound like hysteria or paranoia. If we keep banging away with evidence and temper our approach, we will continue to win the day. Even if we don't win each battle, we will definitely win the war...it's already happening as our profession has never been stronger while the chiros have never been worse off. In the end, there is room for anyone who practices in accordance with scientific principles.
As far as "using" patient values. Dude...a fool and his money... The fact that some folks are regrettibly gullible enough to fall for crap therapies doesn't make the ideal of patient value less relevant. It actually makes it more relevant, adding another dimension to the reasons for avoiding the sheisters. Fools and money will still part. We can just make sure their are fewer of them.
< Message edited by TexasOrtho -- May 25, 2008 9:35:25 PM >
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
|
|
|
|
|
RE: neck vs. shoulder - May 25, 2008 10:47:03 PM
|
|
|
Sebastian Asselbergs
Posts: 1105
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
Proud, outcome studies are NOT the gold standard of evidence. There are many levels of evidence, and if you think that the neuro-approaches are at the same level as CST and such, you are wrong.
If all that sways you are outcome studies, and the underlying processes are of lesser importance, than I guess I could say you are indeed being held hostage by those insurance payors.
_____________________________
Mundi vult decipi
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 6:25:22 AM
|
|
|
ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Proud , Id really like to explore the concept of fixing MSK pain with "a swift kick in the rear".
Are there any RCT's for this?. Have you any direct experience you can share?. Either as kicker , or indeed , kickee.
Also should we come to terms with a common language on this a priori . In Oz we say , kick up the bum, as in " give her a decent kick up the bum bruce". I'm personally less familiar with the US colloquialism "but", or is it "butt", or even " Butte". "Rear" is probably more likely as a common usage noun that allows a certain palliability across the ocean.
Next issue sure to dominate the scholarly pursuit of rear kicking , would be, I submit, footware.
I'm a lacky sided boot man myself. Easy on , easy off. takes a nice shine , silent exits, non squeak.
Is there a gold standard for the walk up , or is it just anything goes?.
I'm off to the gym this arvo to gain any pointers I can from the kung foo guys who wear those black belts. Hell, could they be put to use in my practice or what!.
gotta go.
where's the cat.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 10:55:26 AM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
Rod,
I agree with you. However, it depends on who's money the fool is using. I have no problem with a guillible person dropping money if they wish. But Rod, third party payors are paying for this stuff( CST, MFR). Outcomes( true outcomes) are likley terrible yet they pay. What happens do you suppose?
You guessed it....premuims go up and millions eventually cannot afford to be covered. It's not fair that the guiible chew up the garbage and bill it to their insurance. THAT is where "patient values" gets in the way of good, effective, efficient medicine.
Seb,
Never said they were the same. They are not. And no...I do not think outcomes studies are the only level of evidence. But I disagree that it is not the gold standard. I'm not understanding you there. In the end, how else do you determine if treatment X results in better outcomes than treatment Y?
And I certainly am not held hostage by insurance payors, but I do have an ethical responsibility to ensure that I practice in a manner that is not frivolous. And if I try CM...and the patient "get's better", that's great. But in the end, I still want to know the particulars of that "getting better".
Ginger,
Kick in the butt. Simply means stop placating to this persons life of pain. Eventually persistent pain patients almost "become" the pain. They talk about with family members, they talk about with friends, they go to PT's Physicians, Orthopeadic surgeons, massage etc etc. All of whom have a different "take" as to what the underlying patho-anatomical explanation might be. When many of these patients are in true neurological "wind up" and nothing we can do with our magical mittens is going to change the fact that they have pain.
They need someone to lay it out. Either they slay that dragon...or it will continue to slay them. Poking at your facet joint for 20 mins may modulate the pain for a spec of time. But overall, they need someone to tell them the truth about pain. Tell them THEY own the pain and to stop searching for the next guru that is going to suddenly fix them. Ain't gonna happen.
Some people simply lack life coping strategies. Not much we can do about that. But what we can do is stop sending them on the wild goose chase.
< Message edited by proud -- May 26, 2008 11:05:58 AM >
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 5:10:36 PM
|
|
|
ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Dear me Proud , I think you may have had so many treatment failures that you may see lack of success as the normal. I was actually having a joke with you. Not AT you . I mean no disrespect I assure you.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 7:03:21 PM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
Ginger,
I got the joke. I'm not sure how you thought....that I thought.....that you...disrespected me. I was just trying to clarify "kick in the arse"( or butt...).
But t further clarify, I have great treatment success. I keep not only short term outcomes...but sometimes 3-5 year outcomes( practice envirnoment allows for this). I record Oswestry, RMQ, FABQ, PSFA, LEfs, UEfs, DASH...to name a few. Also....I track my outcomes with return to full work duties. I am "proud" of my sucess rate.
Having stated that...I am most proud of the fact that I can detect....early...who will be responders to our magic mittens....and who truly needs a kick in the arse. Some serious education and de-emphasis of all the potential "mis-firing" CNS stuff. Some people need to get life coping strategies....some never will and they will go on and on blaming someone else for their "pain". Attempting to find a solution....from someone else for THEIR pain.
BTW: Kick in the asre= a phone call to the physician to get them on board with this de-emphasis. Try all you want but if these patients go from one clinician to another...they are bound to find SOMEONE willing to validate their pain via: "there there...it's alright...it's not your fault...I've been treating these things for years and I've got some "special" treatment for you..."
Hey Ginger...ever wonder how much of your success is the direct result of a variant of the Hawthorne effect? Here's a story for you:
In the Province of Quebec( Canada), there exists these "guru's" that do not belong to any healthcare profession. I am not sure what they are called. Anyway, the treatment basis is that you can show up for any medical aligment and pay "whatever you wish". These people have developed an almost mythical status in that province. I once had a relatively educated patient come to me with persistent sciatica. He reported that two years ago he went to one of these gurus for a 30 second treatment. The treatment: The guru "twanged" the sciatic nerve once and by this patient account.....all the pain "left my body" for nearly two years...uh huh.....
Something tells me that just the thought that he saw one of these gurus resulted in some wackey altered thought process. So was that treatment sucessful? Nope...because a closer look revealed a patient with undiagnosed depression. Referred to a specialist and determined that he was potentially suicidal. If left to the guru...who knows what might have happened.
Guess what....the most important aspect of what we do is not determing what WE CAN treat...but rather WHAT WE SHOULD NOT be treating. If we are true direct acces clinicians, then we best know what our boundaries are.
The patient is doing much better these days.
< Message edited by proud -- May 26, 2008 7:34:09 PM >
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 7:44:23 PM
|
|
|
Sebastian Asselbergs
Posts: 1105
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
proud, congrats on that success rate.
About outcomes:
"But I disagree that it is not the gold standard. I'm not understanding you there. In the end, how else do you determine if treatment X results in better outcomes than treatment Y?"
IF you see outcomes in THAT light, they have good value. Stand alone, they only tell us that "X" was effective. Not "why" - just that they were. If the "guru in Quebec" kept outcomes, or even did outcome studies, his success rate would be great too. One "twang" and Bob's your uncle! For two years!
Fundamental research into how the human functions, how the interaction between humans affects neurophysological aspects, how the brain processes pain and relief from pain, the changes in autonomic responses etc etc. are important as heck - they help us UNDERSTAND. And may make a good explanation why so many different approaches have some or more success.
That's all.
And having been in a direct access situation for 15 years now, I can say that knowing one's boundaries is very helpful. Giving patients the best possible answers to their problems is very important as well. And those answers can contain parts "It is my experience", and parts" Research shows that.." and "outcomes show that" and other parts "The nervous system and brain are ..."etc etc.
And occasionally: "You know, I really do not know what is going on here. But let me give you my best guess and my advise where to go from here".
_____________________________
Mundi vult decipi
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 8:21:40 PM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
quote:
IF you see outcomes in THAT light, they have good value. Stand alone, they only tell us that "X" was effective. Not "why" - just that they were. If the "guru in Quebec" kept outcomes, or even did outcome studies, his success rate would be great too. One "twang" and Bob's your uncle! For two years!
No, the guru would not have great oucomes in a well designed outcome study. Blinding would occur and the variables involved eliminated. Outcome studies on the "twang" would allow us the separate the BS...so to speak.
But let me just say that you're approach to how you might proceed with patients is similar to mine. Of course when decent literature is not available, I lean on my experiences( taping a shoulder to offload nueral structures is an example). My point on here is to call into question the guruesque tone of the ongoing "CM" technique I read hear often.
< Message edited by proud -- May 26, 2008 8:29:52 PM >
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 8:59:02 PM
|
|
|
SJBird55
Posts: 2292
Joined: May 10, 2004
From: Michigan
Status: offline
|
Psst... Proud, I need to interrupt. Isn't it redundant to use the Oswestry and the RMQ? I'm not sure what the heck a UEfs is, but I'm assuming something to do with upper extremities - isn't it redunant to use 2 UE tools? What's the rationale for using basically similar tools to capture basically the same information? I'm a bit lost as to why you'd have patients complete similar tools.
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 9:08:16 PM
|
|
|
rwillcott
Posts: 352
Joined: March 20, 2006
From: Canada
Status: offline
|
Great discussion. I wish there were more PT's that thought along these lines. I often wonder how much of what I do with a patient actally helps them. I often feel that it is the patient's attitude that is the most important factor in their recovery. Of course I still have to do my job and provide my professional opinion. After that it's really how the patient interprets this.
If someone comes to me with an ankle sprain and has great coping skills, a network of family and friends, enjoys their job then my job is easy and they tend to recover quite easily. However, if somone comes to me with the same ankle injury and they hate their job, their in a dysfunctional relationship then I have my work cut out for me.
I couldn't agree more with proud that the option for this non-coping patient to be seen by a 'guru' who performs an alternative technique needs to be eliminated from our health care system. People need to hear the right information and not have endless opinions from less trained or ill-informed "health care" providers.
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 9:38:22 PM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
quote:
ORIGINAL: SJBird55
Psst... Proud, I need to interrupt. Isn't it redundant to use the Oswestry and the RMQ? I'm not sure what the heck a UEfs is, but I'm assuming something to do with upper extremities - isn't it redunant to use 2 UE tools? What's the rationale for using basically similar tools to capture basically the same information? I'm a bit lost as to why you'd have patients complete similar tools.
Pssst...Sj, I utilize one depending on the other. eg....High FABQ....I use Oswestry.
If i suspect( after my subjective HX) that the patient has the coping skills and is truly a straight forward MSK case....I utilze the Patient specific questionaire.
I don't use ALL of them.
Also. Is not oswestry more specific to disability, while the RMQ essentially measures functional change over time. That's different.
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 10:21:55 PM
|
|
|
TexasOrtho
Posts: 423
Joined: December 22, 2007
Status: offline
|
For me it's Oswestry first. If it is > 40% and the history suggests abnormal coping, the FABQ comes in. For what it's worth.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
|
|
|
|
|
RE: neck vs. shoulder - May 26, 2008 10:41:57 PM
|
|
|
ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Proud, as a regular user of quackwatch I find plenty to agree with you on the nature of BS in health care. I go to a kind of hippy community set up in the country twice a year. There arises a swathe of BS practitioners that would make your eyes water. My son and I go for the tranquility and community spirit. Camping is fun. Up to 5,000 people gather , in a way a little similar to the "Burning Man" in your country. Star gazers , gurus , quacks of every description. Energy "medicine" abounds in every shape. More chakras get balanced than at any time in the year.
My self described mission , is to hold up the hand of reason amongst it all. I say BS when I see and hear it. I hold up a bright light to anything requiring belief, faith, or that requires reasoning to be suspended.
BS is everywhere.
None of us is entirely immune , or free of aspects of irrational belief. Churches are good places to find it. Lottery shops as well. At best we can say we can remain alert so when irrational beliefs occur, we can counter them with rational.
I understand your reluctance to embrace what may appear to in that realm. I am at your disposal should you wish to explore my concepts and methods further.
Cheers
|
|
|
|
|
RE: neck vs. shoulder - May 27, 2008 6:23:55 AM
|
|
|
SJBird55
Posts: 2292
Joined: May 10, 2004
From: Michigan
Status: offline
|
Shhh, I gotta interrupt again... I'm always interested in outcomes, so psst... Proud? As you collect your data (as a single clinician), isn't it difficult to have a decent n value to help you understand your outcome numbers when you use a variety of tools? Using a variety of outcome tools sure would make analysis confusingly difficult (way too many queries) and substantially reduces the n values.
As a side note, from reading the literature back in 2000 or 2001, I decided that I wouldn't use the RMQ (can't remember my reason now), so I started out always using the Oswestry. I don't like the Oswestry any longer and instead use the Spinal Functional Index. That tool is more helpful and apparently the psychometric properties and responsiveness are pretty good (still waiting for the Australian to publish - he had me assist with data collection in putting the Oswestry, PF-10 and the SFI head to head and I was the US clinician). Sadly, the only time I really use the FABQ is in situations where I believe my records might be audited (there is enough paperwork already) or to substantiate that a successful outcome might not occur. I have a conversation with patients and their fear and just talk versus measure fear level.
|
|
|
|
|
RE: neck vs. shoulder - May 27, 2008 2:05:26 PM
|
|
|
bonez
Posts: 173
Joined: August 29, 2007
Status: offline
|
Ginger back to the question at hand. When you actually deliver the CM do you mobilize in the preceived direction of restriction or in the expected line of facet structure? I also believe that you try to get to the nearest approximation of the facet in question too?
|
|
|
|
|
RE: neck vs. shoulder - May 27, 2008 7:08:51 PM
|
|
|
proud
Posts: 875
Joined: March 22, 2006
Status: offline
|
Huge caseload Sj. Huge. And really, for any one particular problem I only have maximum two choices. In the U/E it's either the DASH or the UEFs. Low back it's Oswestry or RMQ. Etc.
I do have a sub group of patients I track that I see no Psycho-social component so use the PSFS( No real reason other than it requires more patient involvement and I don't need someone filling that thing out telling me they have difficulty blinking....yes...I once had someone put that there....).
< Message edited by proud -- May 27, 2008 7:14:58 PM >
|
|
|
|
|
RE: neck vs. shoulder - May 27, 2008 7:30:07 PM
|
|
|
ginger
Posts: 647
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Bonez,I don't blaze any trails towards the precise directions of restrictions, mostly because the simplest approach works well enough . That is , for PA's, prone patient, pillows or other support to allow for a comfortable amount of flexion, therapist alongside with elbows straight, sufficient hight above to allow use of body/shoulders to move into mobilisation ,rather than elbow/wrist or hand. Follow the natural direction predicted by an attitude imediately above the desired joint, so that thumb pressues direct the facet towards a combination of side flexion, rotation and extension.
Pressures only sufficient to acknowledge both pain ( that's patient's pain )and resistance as would be expected by a joint where hypertonic muscles limit passive movements. It is then a short period of movements ( from thirty to 90 seconds ) with a frequency of 2 per second, till these two variables begin to change( reduce). Further mobs for as long as time permits or untill full pain free PASSIVE movements are restored is the aim. The purpose being to restore a non protected state of mobility. Active movement tests are not good enough, as they will also involve joints other than the targeted one. It will be immediately noted however , that active movements are improved , along with any suspected referred events related to that joint/nerve. Further restoration of non protected activity beyond the first target add to this , along with a means to offer "security' against the encroachment of protective behaviour from nearby spinal structures. Ie the more you do the better it gets. These changes are essentially permanent, PROVIDED that no local or extreme bio mechanical driver for protective behaviour exists.
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.203
|
Printable Version
