RehabEdge Physical Therapy Forum

Forums  Register  Login  Forgot Login?
  My Profile 
My Subscription
  My Forums 
Search
  FAQ  Log Out
Follow @RehabEdge

RE: Kaiser no longer paying for neck manipulation

 
Logged in as: Guest
Users viewing this topic: none
  Printable Version
All Forums >> [RehabEdge Forum] >> Open Forum >> RE: Kaiser no longer paying for neck manipulation Page: <<   < prev  1 [2] 3 4 5   next >   >>
Login
Message << Older Topic   Newer Topic >>
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 2:43:26 PM   
bonez

 

Posts: 701
Joined: August 29, 2007
Status: offline
I am not surprised by your response Proud. I suspected it based on past posts. You will have to trust me that there is a little more to be done than cavitate to create good manipulation. I also would not post here if my intention was to manage patients by creating a false construct.

As to your 10-20 techinque comment, you are right there are many more ways to do the job and specificity is but one of the concerns. Patient comfort anatomical variance for the patient or the provider are two others.

It might be somewhat more sucessful if you figure out what caused the up regulation that you seek to down regulate. Joint receptors capsular innervation and some stretch receptors in tissue could be targets. I hope that you agree that some specificity for targeted tissue is needed.

I would also contend that the patient needs to be as relaxed and comfortable with the procedure as well so their system is not providing extra upregulation fighting back against your efforts too. They can only get there if you bring some skill to the table.

I provide manual services for our two PT clinics in my community so I have some experience with PT manipulation. Those PT's that I also treat suggest that we(ME) are better at it than their collegues both in comfort and final effect so to me this suggests that there has to be a difference. My sense is that there are issues with amplitude and velocity in the equation.

(in reply to proud)
Post #: 21
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 3:23:19 PM   
TexasOrtho


Posts: 1090
Joined: December 22, 2007
Status: offline
Now you've defintely stumbled upon something I agree with bonez. The average chiro is typically better than the average PT when it comes to manipulation. This includes the setting up context (expectation / anticipation) and the act itself (psychomotor skill). This better be so because ya'll spend many MANY more hours training and performing them. The bulk of your curriculum is built around one or more paradigms of manipulation. It is no wonder why chiros hold it so dear and protect it. We divide our time with things like pediatrics, neuro-rehab, and learning about diathermy and heat lamps in our modality classes. (sorry I'm still bitter about that)

The big problem, as you well know, is the context and volume of manipulations performed by many chiropractors (and some PTs) is based on an incomplete or innacurate model of care. Kaiser certainly seemed to pick up on the volume bit. I doubt they could care less about context outside those influencing their margins.

PTs and more evidence-informed chiros are attempting to place manipulation in its proper context, but are risking detours down the "move it and move on" treatment roads. I've heard your stance against subluxation-base chiropractic. All I'm doing is trying to keep my profession from jumping on a parallel track.

On a side note. If I am not miskaken, the statement that mobilization is anywhere close to manipulation in terms of risk incredibly myopic. Andrew please forgive me if I'm getting this wrong, but wasn't that statement made in the context of a single case? I'll need to go pull that study because I remember being astounded that such an inference could be made from a single event.

< Message edited by TexasOrtho -- September 2, 2010 3:29:47 PM >


_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to bonez)
Post #: 22
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 4:19:52 PM   
JWarePT

 

Posts: 57
Status: offline
quote:

ORIGINAL: bonez

It might be somewhat more sucessful if you figure out what caused the up regulation that you seek to down regulate. Joint receptors capsular innervation and some stretch receptors in tissue could be targets. I hope that you agree that some specificity for targeted tissue is needed.


bonez,

If you're referring to a nociceptive driver leading to up-regulation of the CNS, then the next question is what process is driving the nociception?  However, before getting into that I think it's important to distinguish between nociceptive drive and up-regulation of the CNS.  The latter can exist without the former and the former can certainly exist without the latter, i.e. pain can exist without nociception (e.g. phantom limb pain).  They are not mutually inclusive states. 

There are two broad categories nociceptive input: mechanical and chemical.  The latter is an indication of an inflammatory process, usually.  The former- mechanical deformation- is the category that movement and manual therapies are more likely to influence in a positive (or negative) way.

Knowing what we know about the properties of mechanoreceptors in joint capsules versus the ones in skin/subcutis, I'm wondering why you think manipulation targeted at joint mechanoreceptors would be more effective in reducing nociceptive drive from the region?

(in reply to bonez)
Post #: 23
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 4:30:46 PM   
Tom Reeves DPT ATC

 

Posts: 1163
Joined: March 15, 2006
Status: offline
quote:

ORIGINAL: JWarePT



bonez,

If you're referring to a nociceptive driver leading to up-regulation of the CNS, then the next question is what process is driving the nociception?  However, before getting into that I think it's important to distinguish between nociceptive drive and up-regulation of the CNS.  The latter can exist without the former and the former can certainly exist without the latter, i.e. pain can exist without nociception (e.g. phantom limb pain).  They are not mutually inclusive states. 

There are two broad categories nociceptive input: mechanical and chemical.  The latter is an indication of an inflammatory process, usually.  The former- mechanical deformation- is the category that movement and manual therapies are more likely to influence in a positive (or negative) way.

Knowing what we know about the properties of mechanoreceptors in joint capsules versus the ones in skin/subcutis, I'm wondering why you think manipulation targeted at joint mechanoreceptors would be more effective in reducing nociceptive drive from the region?


Wow, welcome to the edge JWare.  You just said in three paragraphs what I have been trying to explain for about 1 year. 

(in reply to JWarePT)
Post #: 24
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 5:57:52 PM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Umm... John... another huge category for nociceptive input also includes expectations/perceptions/fears/anxiety/interpretations.... Symptoms can be reported with just thinking about performing a particular activity.

(in reply to Tom Reeves DPT ATC)
Post #: 25
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 7:43:34 PM   
proud

 

Posts: 1834
Joined: March 23, 2006
Status: offline
Bonez,

I never said this:

quote:

You will have to trust me that there is a little more to be done than cavitate to create good manipulation.


Did I imply that cavitation is all that's required?

I did however say this:

quote:

as with anything, practice does improve the ease with which one can apply something.


"ease" would translate to patient comfort which of course impacts on the outcome.

I would echo what Rod stated that no question the average chiro is a better manipulator than the average PT. By a long long long shot. And why not? It's a chiro's bread and butter...ya'll better be really comfortable doing it. My experience with the "average PT" has not been spectacular...in many things..... not only manipulation I'm afraid.

My point is that it does not take 4 years to become quite sufficient with manipulation. In fact....less than one would do it. Could be taught at a local trade school realistically.

On a secondary note...I think you are still struggling with letting go of the search for specificity. I don't think a decade of training is going to make it so that 1) we can be that much more specific and; 2) that it would make that much of a difference overall anyway...

JwarePT,

quote:

Knowing what we know about the properties of mechanoreceptors in joint capsules versus the ones in skin/subcutis,


I'm not sure this comment will be commented on so I am pointing at it for everyone. It's an interesting and perhaps enlightening question.

SJ,

quote:

another huge category for nociceptive input also includes expectations/perceptions/fears/anxiety/interpretations...


wait...are those not outputs rather than inputs?

< Message edited by proud -- September 2, 2010 7:53:14 PM >

(in reply to SJBird55)
Post #: 26
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 9:00:32 PM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Beats me... it rattles around in the brain and is part of what informs the brain or part of the brain's "blink" response.  If I say... "wow... look at the damage on your MRI - you have disc bulges and your nerve is being squeezed and compressed and you have arthritis up the wazoo - your back is messed up."  Isn't that an input?  What if I asked that very same person after being informed about the messed up back to pick up a couple of text books up off the floor?  How does the person or the person's brain now determine how to move?  The movement in my mind is the output, but there's a whole lot of loops within the brain system and interconnections being lit up to help the brain to make a decision on how to move.

(in reply to proud)
Post #: 27
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 9:22:32 PM   
TexasOrtho


Posts: 1090
Joined: December 22, 2007
Status: offline
quote:

ORIGINAL: SJBird55

Umm... John... another huge category for nociceptive input also includes expectations/perceptions/fears/anxiety/interpretations.... Symptoms can be reported with just thinking about performing a particular activity.


Well technically speaking, expectations and perceptions are inputs, but not nociceptive inputs. Nociception is a somatosensory-discriminative event triggered through activation of peripheral nerve endings. This can be done three ways: mechanical deformation, chemical irritation, or thermally. The expectations and beliefs are cognitive-evaluative inputs.

Nerdy clarification there...sorry.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to SJBird55)
Post #: 28
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 9:26:04 PM   
proud

 

Posts: 1834
Joined: March 23, 2006
Status: offline
Thanks Tex!

It's that nociceptive pain input definition that people need to distinguish if we want to have a healthy discussion.

Oh and Bonez( again) I forgot to add:

quote:

It might be somewhat more sucessful if you figure out what caused the up regulation that you seek to down regulate.


Right...but what if the original nociceptive driver that "up-regulated" is no longer an issue...yet the patient still has pain?

< Message edited by proud -- September 2, 2010 9:28:32 PM >

(in reply to TexasOrtho)
Post #: 29
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 9:53:11 PM   
JWarePT

 

Posts: 57
Status: offline
Maybe geeky, but not nerdy, no sir, Rod.  Nerdy requires an element of social ineptitude, which I don't think exists in Texas.  Am I right?

Those are the kinds of distinctions that I envision PTs making easily, by second nature someday.  They're very important distinctions.  Nociception originates in the periphery.  Cognitive/evaluative (C/E) inputs can of course increase central sensitivity to nociception.  Furthermore, in the right context, C/E inputs can produce a pain output in the absence of a nociceptive driver.  If you've ever seen a hypnotized person react to "standing on hot coals," then you've witnessed an example of this.

Sometimes I wonder if the whole damn Western world hasn't been hypnotized by biomedical, reductionist, pathoanatomical and biomechanical crapola.

What a bunch of saps we are.

(in reply to TexasOrtho)
Post #: 30
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 6:53:36 AM   
rwillcott

 

Posts: 1123
Joined: March 21, 2006
From: Canada
Status: offline
I would like to know if there is evidence that manual therapy directed at the skin is more effective than joint mechanoreceptors. 

(in reply to JWarePT)
Post #: 31
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 7:00:38 AM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Well... something can have a nocebo response and something can have a placebo response.  The "something" is an input.  Those "somethings" include what we say... what we say is actually sensory in a way because hearing is a sense.  To hear means a mechanical deformation occurred... and then the cognitive stuff occurs.  Of course, the mechanical deformation isn't occurring exactly where you are suggesting as with peripheral nerves determining if they are getting squished or stretched to determine danger or harm... but technically, yeah, a mechanical deformation happens first before any cognitive evaluation can occur. 

And, what the heck is mirror therapy?  Whether in the case of someone with an amputation where the existent limb is moved or put into positions and the person is watching in the mirror as if the lost limb is doing it (to reduce the pain/spasm being felt).... OR someone with fibromyalgia where you are stroking the uninvolved limb and the person is thinking it is the involved limb (to reduce central sensitization)... OR you decide to instead be a meanie and using a mirror have the person believe and feel they have a fake extremity (by using a manikin extremity and a mirror and stroking) as a part of their own living body and then take a knife and stab the person on the manikin extremity and they feel pain.  The person felt the pain... obviously something believed the knife would hurt, but there isn't a single darn anything in the manikin extremity for the knife stabbing to be nociceptive (nothing to pick up a mechanical deformation or a chemical irritation or a thermal change)... which means vision and however that happens can be nociceptive too.  So, if we all agree vision is sensory (which was the first step in the whole process)... then what is seen can also lead to nociception.  To me seems to indicate maybe the definition of nociceptive inputs might be too narrow in nature and maybe the definition needs refining - some of the above studies weren't in literature back when nociceptive inputs was defined... maybe the issue needs to be reexamined?

And, technically, as you both get geeky on me, what's better than going back and forth on being so darn precise is actually recognizing all of these different components and how there are complex interactions that do have an impact on someone with pain OR someone without pain who may begin to have pain due to what we say and how we say it.

(in reply to JWarePT)
Post #: 32
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 7:14:11 AM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
And... with regard to biomechanical crapola... there does need to be balance.  You can shoot me, but depending on the patient, the biomechanical crapola is relevant and important and does need to stay in the picture as something to be analyzed and assessed.  For example... if I have a swimmer and this particular swimmer does have shoulder pain during performance... you better bet I better be considering the biomechanical crapola to reduce pain symptoms and improve performance.  We do have research out there that supports biomechanical crapola.  Why is it with some runners using orthotics and strengthening hip abductors and training landing patterns decreases knee pain?  The nociceptive input was reduced.  Why do I no longer have shin pain when I run?  I changed my biomechanical form of running and viola, no shin pain.  Are you going to tell me that a person who has recurrent ankle sprains isn't going to have ankle pain 10-20 years later due to the arthritic changes in the talus due to the ligamentous laxity?  There won't be spurring and pain? 

Shouldn't patients be categorized?  Someone with acute pain requires us to most definitely think of nociceptive inputs and reduce those inputs... what we really want to do is reduce the likelihood of central sensitization from occurring. I do think that manual therapy, even if it is aimed at joints and joint receptors has a role in reducing symptoms - the inhibition itself can assist with the ability to get the person moving again... and when this happens pathways in the brain are changed and altered which is relevant too.  Those with chronic pain... well, I tend to believe those folks have little to no nociceptive inputs.  They have changes in the brain and it is the brain we need to change in order to help them function with less pain.  There are a whole slew of ways to change the brain...

(in reply to SJBird55)
Post #: 33
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 9:37:00 AM   
JWarePT

 

Posts: 57
Status: offline
quote:

ORIGINAL: rwillcott

I would like to know if there is evidence that manual therapy directed at the skin is more effective than joint mechanoreceptors. 


rwillcot,
Try here: http://www.somasimple.com/forums/showthread.php?t=7446
And here:http://www.somasimple.com/forums/showthread.php?t=4212 (take a look at posts #10 and 11, in particular)

I don't know of anywhere else where there is a such a concentrated wealth of information on the basic science relevant to manual therapy.  One could design an entire curriculum around the information available here, and I hope someday it happens in a PT school and not some other professional program.

(in reply to rwillcott)
Post #: 34
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 9:45:53 AM   
JWarePT

 

Posts: 57
Status: offline
SJ,

All I can say is that words mean things.  Nociception has a very clear definition that we should understand well.  I thinks as professionals it's incumbent upon us to make the best choices in words, constructs, and theories that are currently available.  An element of judgment is required here, which means there's an element of risk of having to abandon some treasured beliefs and of potentially making the wrong choices.

Such is life.  I'd rather make an earnest error in judgment based on a rational process of decision-making than become paralyzed, overwhelmed or even deluded by trying to allow for every single possible explanation regardless of its value, of which I've failed to make an intelligent and informed judgment.

(in reply to SJBird55)
Post #: 35
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 10:10:11 AM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
Well, John... since words mean things... I tend to be a little less detailed and nit picky and tend to be more of a generalist and look at the big picture and how things fit into the big picture and think about the relationships.  Explain how someone can feel pain in a manikin upper extremity when the manikin upper extremity isn't even part of the body.  So, the brain, for some reason, decided the manikin upper extremity should be part of the individual's body.  Okay... but then... the knife and pain output.  How exactly does the fake peripheral input lead to pain?  Personally, I'm thinking the definition of nociception needs updating to be a bit more inclusive to help explain the ever involving research.  Hmmm, guess I am somewhat detail oriented.  LOL

edit... AND to think about what I am asking and relationships *will* lead you astray from the skin and the whole darn ectoderm/mesoderm division those at SS seem to have created.  It should make you wonder about the "skin" theory stuff over at SS and should make you wonder if those constructs should be somewhat challenged.  By being SO focused on the skin, one forgets a whole lot of other factors and variables that ARE quite important and relevant when it comes to pain.    

< Message edited by SJBird55 -- September 3, 2010 10:12:55 AM >

(in reply to JWarePT)
Post #: 36
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 12:28:16 PM   
JWarePT

 

Posts: 57
Status: offline
quote:

Well, John... since words mean things... I tend to be a little less detailed and nit picky and tend to be more of a generalist and look at the big picture and how things fit into the big picture and think about the relationships.


Huh?  I'm sorry SJ, I can't follow whatever point you're trying to make with that statement.  Are you saying that speaking in generalities about the "big picture" is somehow better, clearer, or more precise than using "nit-picky" terminology that actually describes accurately what we're talking about?

We have to agree on operational definitions of terms, regardless of how tedious that might be, or we will all talk past each other and waste our time on boards like these.

I won't do that.  I'm too damn busy, and I can't afford anymore to waste my time.

I'm a "big picture" kind of guy, too.  I like to assimilate and synthesize as much as the next guy or gal- probably even more so.  But, I think it's a little bit of a cop-out to avoid making the subtle distinctions of terms required for us to understand something as complex as pain.

< Message edited by JWarePT -- September 3, 2010 12:47:49 PM >

(in reply to SJBird55)
Post #: 37
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 12:53:10 PM   
SJBird55

 

Posts: 3332
Joined: May 11, 2004
From: Michigan
Status: offline
You are interpreting me inaccurately.  I was talking about me and I am not very detail oriented and generally understand concepts much better than definitions and the fine points.  Well, if you are a big picture kind of guy, have you thought about the concepts I brought up and how they might fit into the definition of nociceptive pain?  Does the definition need to continue to evolve as we learn more?  In my opinion, the "clear" definition doesn't include outliers.

(in reply to JWarePT)
Post #: 38
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 1:12:30 PM   
Sebastian Asselbergs

 

Posts: 2293
Joined: September 30, 1999
From: Barrie, Canada
Status: offline
quote:

Well, John... since words mean things... I tend to be a little less detailed and nit picky and tend to be more of a generalist and look at the big picture and how things fit into the big picture and think about the relationships. Explain how someone can feel pain in a manikin upper extremity when the manikin upper extremity isn't even part of the body. So, the brain, for some reason, decided the manikin upper extremity should be part of the individual's body. Okay... but then... the knife and pain output. How exactly does the fake peripheral input lead to pain
?

SJ, the difference between "nociception" and "pain" is well-described. Nociception is NOT necessary to develop pain; nor does nociception automatically trigger pain.

One "feels' pain in the brain. The lower brain "projects" the pain experience in the virtual body (the representation of your body, your internal body image) in your conscious brain.

The example you cite, is NOT nociceptively driven pain. It is driven by the cognitive processes and the expectations that the person was trained to have.
In the rubber hand test, first the brain is trained to accept the fake hand as their own, WITH peripheral input on the real hand behind the mirror.

This peripheral input, combined with the- incorrect -visual input of the "hand", creates a neurological "environment" in which the sudden hammer blow on the rubber hand is neurologically processed through vision only, but it is sufficiently abrupt and immediately following the stroking of the "hand", that the visual input alone triggers the process of pain creation in the brain (in the virtual hand).

There is NO nociception involved in the rubber hand example.

(That is not nitpicky, because the terms are both very important and should be used as presently described by the IASP. )

(in reply to SJBird55)
Post #: 39
RE: Kaiser no longer paying for neck manipulation - September 3, 2010 3:46:58 PM   
JWarePT

 

Posts: 57
Status: offline
I think Sebastian pretty well cleared up any confusion that might still exist for some between nociception and pain.

Does anyone have a problem with that?  I don't.

SJ,
Can you provide an example of an "outlier" where this distinction between nociception and pain doesn't apply?

(in reply to SJBird55)
Post #: 40
Page:   <<   < prev  1 [2] 3 4 5   next >   >>
All Forums >> [RehabEdge Forum] >> Open Forum >> RE: Kaiser no longer paying for neck manipulation Page: <<   < prev  1 [2] 3 4 5   next >   >>
Jump to:





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



Google Custom Search
Forum Software © ASPPlayground.NET Advanced Edition 2.5.5 Unicode

0.156