Joined: February 27, 2005
BTW Proud, L5S1 is the only area of the vertebral spine that will require any real force when performing unilateral CM there. You may have picked the only area that will test your thumbs to their limit. Start with the cervical spine, responds quicker and is much easier to work at.
Joined: March 23, 2006
I was thinking of this for the past two days while reading this thread and finally spent some time finding the link again.
Spokane...you may find this a bizzare linking but if you read it....you may find it interesting about why even the most similairily educated manual therapists....end up treating people with wildly different approaches. Frankly....I think that variability should make even the least acedemically inclined of us to ask some questions.
I just read the words chicken sexing in a thread about back pain, so I went back to the start of this thread and read the first question again. Going back to the beginning of a road that us to chicken sexing, I think the reason the public is so misinformed about LBP is the people they obtain info from are either misinformed OR they have financial gains in deception. When you think about access, a person with LBP will see 1 of 3 people first; a PA in the ER, a FP doc in the clinic, or a chiro. The PA and FP doc are trained to image and rule out out bad stuff, then provide pain relief, which for them=drugs. Unfortunately the imaging will do more harm than good by labeling a spine as "x" and they will have to come back in 2 weeks to see if the drugs "worked". Chiros will tell about things being out and attempt to put it back over 6-8 weeks. By the time they see an informed practitioner, they have been led down a difficult road by the first 3 over many weeks. So until the front line practitioners have the education required and the financial gain is no longer there for those who perpetuate this, we will be stuck with this mess.
I apologize to PAs, FPs, and chiros that "get" it, and practice differently, but you are in the minority.
We can argue about techniques, but ultimately we all believe movement is good and self-management is key (I think), hopefully we can gain access to patients sooner to help change the current management of LBP.
What position? Depends. Some neck patients in sit, some in lie. Depends on when the opportunity presents itself in the session. Backs? supine or side lie.
let's just talk about low backs, because that is where we started. So, to sum up so far, a patient arrives at your clinic, you take a detailed history, look for red/yellow flags, educate them on pain and the central nervous system, and then you place your hands on them with techniques that resolve some of the protective guarding. My question is do you believe that the techniques that you used while the patient is on the table have a lasting effect when they stand up, or are you saying that by temporarily calming down the CNS long enough for them to move in a way that allows the CNS to stay in that calmed down state through education?
your comments and questions convey such a huge knowledge chasm when it comes to pain physiology and the complexity of same.....that ot makes it near impossible to engage much further... for me anyway.
Joined: March 23, 2006
I just read the words chicken sexing in a thread about back pain, so I went back to the start of this thread and read the first question again. Going back to the beginning of a road that us to chicken sexing, I think the reason the public is so misinformed about LBP is the people they obtain info from are either misinformed OR they have financial gains in deception.
My question is do you believe that the techniques that you used while the patient is on the table have a lasting effect when they stand up, or are you saying that by temporarily calming down the CNS long enough for them to move in a way that allows the CNS to stay in that calmed down state through education?
I am not always following the order of "education first - hands-on after"; that depends on the patient and circumstances - it is sometimes simultaneous, or in opposite order. But yeah, I'd say it is close with the second half of that sentence. We know that their nervous system has had a moment of change that it can learn from and build on. The learning from manual handling like that, is from both cognitive processing and complex peripheral input changes. THAT is why I think so many gentle manual techniques have at least that moment in common.
Now if that would only get followed up/added to with the neurophysiology education part and the cognitive behavioural aspects.......Since especially that aspect of care has quite a bit of good science and support behind it. And hey, it fits the neuromatrix model.
Joined: March 23, 2006
The link is not about Rolfing and Feldenkrais per se Honker. Ever wonder why numerous( and I mean numerous) varied approaches "seem" to "help" people.
I think this goes along way towards explaining why many therapists seem to have no idea why their therapy works, why they are attracted to explanations which are magical as opposed to scientific, and why some are even hostile to very idea of applying science to massage at all.
Science trumps pretty much all of what traditional manual therapists "think" they are doing.
Nope nothing specifically "functional" . We get increase in non-impact activities because their understanding and the relief of their pain helps downregulate their anticipation and response to increased stresses. Walking, bicycling, swimming or aquatic activities are very popular because of the variety they can introduce to their motion and movements.
The increased loading is a product of the increased activities - I don't prescribe any specific exercises for that. They explore that quite well by themselves- based on the advice and education about "graded treturn to activities" and their neuro-sensitivities. I do not choose direction. I do not see that as important in the chronic back pain patients.
Joined: February 14, 2003
From: Madison WI USA
Hi Spokane, Just to add fuel to an already long discussion, I do choose directional preference when I treat LBP, AND address threat level, etc. This direction is of course based on our discussion and subjective interview on symptom behavior patterns, along with the objective evaluation including a detailed repeated movement evaluation. I think that this is a very important part of a treatment program for LBP. So as you can see, there can be varying opinions within what might be similar mind-sets. I also of course use the pain education aspect but dont believe yet that I can talk someone out of pain completely. Settling down the alarm system has HUGE value, but I do believe I am skilled enough to give some recommendations on which directions should be used, and which might be good to avoid for a structured amount of time. The key there is a structured amount of time so as to not kick in the fear avoidance issue, but rather just to have relative rest from aggravating stresses. Of course the other key is often to let them know that their back is not on fire, unstable, or about to explode with disc material. This in and of itself with settle down and down-regulate if you will. I also do not believe that patients do quite well by themselves with just the advice and education, I do think they often need more direction than that. I also think that the more general we become, the less need there will be for our skill, as this is information they could get from a book if it is not specific to their specific presentation. It could become a slippery slope, and we could down-regulate ourselves right out of a job. A bit extreme of course, but something to think about.
Steve, thanks for that . For me "advice and education" is not a one-time shot. (Altough it has been shown to be effective as a stand-alone treatment approach - Mosely). And
I do think they often need more direction than that
is not something I disagree with. I just do not find it necessary to prescribe directional preference routines. They often need more help with cognitive issues and goal setting, as well as the "graded" concept.
But as I said before: there are many ways that patients receive effective treatments - and I can not say one is "better" than another. As always, i am concerned about the explanatory model and the actual facts that we KNOW as opposed to those we have construed.
Joined: March 21, 2006
The more I read literature on pain and the nervous system the more I feel isolated within my profession. I used to be very focused on trying to feel subtle joint movements. I would then make a giant leap and make a diagnosis based on the flawed biomechanical model. I would also find myself very frustrated when I felt like I couldn't feel a certain subtle movement. I would feel like giving up and that I should take more manual therapy courses and then one day I too could feel these elusive joint movements.
What a relief and epiphany when I realized that I am not the only one who does not feel these movements. Also, the introduction to pain science has opened my eyes to a more acceptable and exciting treatment approach. However, know I feel that I have become a minority within my profession. Try going on a manual therapy course and question the reliability of the manual motion palpation approach.
Despite this feeling of being a minority I feel so much more positive and excited about what I can do for people. I am no longer hell bent on finding the specfic tissue at fault. I am also not tearing my hair out trying to push a joint into a very specific direction and crossing my fingers that the patient will feel relief. Instead I apply manual therapy in a much more general sense with the intention of reducing pain. I also enoy educating patient about their pain and injuries. I got into this profession since I felt I could combine my interest in teaching with treating injury. Now I find myself doing this daily. Finally, as a KInesiologist and Physiotherapist I get to teach and recommend exercise.
When you think about it, I feel that my career has come full circle and I am know practising as a physiotherapist.