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manual therapy courses - January 29, 2012 6:53:05 PM   
stacejannel

 

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I just started working in outpatient orthopedics setting after ~3 years in SNF setting. Looking for good CEU's with manual therapy emphasis for C-spine, shoulder, and foot/ankle. Anyone have suggestions?
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RE: manual therapy courses - January 30, 2012 7:36:51 AM   
rwillcott

 

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I find the Mulligan techniques very useful.

(in reply to stacejannel)
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RE: manual therapy courses - January 31, 2012 6:50:25 PM   
Sheld505

 

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I've taken the series of seven courses through University of St. Augustine. Very good for assessment and treatment. I just started a residency through NAIOMT and love it as there is more emphasis on differential diagnosis and HOW you arrived to assess and treat said joint, etc. No experience with Mulligan but will hopefully take a course or so in the next couple years. Grad school was Maitland oriented for me. Expose yourself to a lot; they are are similar in ways and different in ways.

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RE: manual therapy courses - January 31, 2012 7:59:23 PM   
proud

 

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quote:

ORIGINAL: Sheld505

I just started a residency through NAIOMT and love it as there is more emphasis on differential diagnosis and HOW you arrived to assess and treat said joint, etc.



Treat a joint eh....

I would avoid any course series that suggests you can "treat a joint". The science of pain physiology is way beyond that.

The word dinosaur comes to mind....

(in reply to Sheld505)
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RE: manual therapy courses - January 31, 2012 8:32:54 PM   
rwillcott

 

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I agree with proud. The whole concept of finding a dysfunctional joint that is causing pain is outdated. Don't spend thousands of dollars and your valuable time trying to feel joints that can't be felt and are not proven to cause pain. I would begin with a Butler course or even read 'Explain Pain' to gain an appreciation of the nervous system and its role in pain.

(in reply to proud)
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RE: manual therapy courses - January 31, 2012 9:06:20 PM   
jesspt

 

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The International Spine and Pain Institute might be a nice group to look at. Its founder was initially trained as a Maitland manual therapist, but now teaches with Butler's Group. I think he still uses some traditional manual therapy techniques, but he understands quite well that the mechanism of action behind their efficacy isn't what we were once (and sometimes are still being) taught.

< Message edited by jesspt -- January 31, 2012 9:07:46 PM >


_____________________________

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Board Certified in Orthopaedic Physical Therapy

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RE: manual therapy courses - February 2, 2012 4:13:31 PM   
Sheld505

 

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Proud,
  My apologies for my word choice. I understand the concepts of pain science and the neurophysiological effects of joint mobilization/manipulation. One way to affect that change is through, as I said, the joint/joints. Pain science is interesting and I agree with what Butler says quite a bit, but you cannot disparage other treatment techniques and point to "pain science" THEORY with at least offering a technique or techniques to manage the patient's pain. Manual skills and therapeutic exercise are just as important as understanding pain science and treating pain. As long as it's not cranio-sacral.

(in reply to stacejannel)
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RE: manual therapy courses - February 3, 2012 6:55:32 AM   
Sebastian Asselbergs

 

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Where do you disagree with Butler? (You agree "quite a bit" with him).

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RE: manual therapy courses - February 3, 2012 11:01:31 AM   
Sheld505

 

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Are you guys saying there is no such thing as a dysfunctional joint? 100% of the time? That EVERYTHING we see as clinicians is a product/result of pain, real or perceived? I don't buy it. I believe that manual therapy techniques work because of its neurophysiological effects (yes, read: influence on nervous system and yes, pain) however, I do believe that there are times when a dysfunctional joint/s is/are the cause. So, I fall somewhere in the middle of the "chicken or egg" argument we have here. I do believe the OP should look into Butler's theory and courses, as well as look into more of biomechanical-oriented courses (say Paris, Maitland). To lean too far left or right is to fall for dogma and theory and word-of-mouth. To call one or the other a "dinosaur," in my opinion, is a gross attack on the other's evidence. So to PROUD, there is room for both and before you start to throw stones, you should ask first :). In the past, I will admit that I was one who leaned very strongly toward the biomechanical-oriented school of thought and find myself coming more toward the middle based off my own clinical experience and current research. That being said, while the USA courses are biomechanically-oriented, there is still discussion and presentation of evidence for neurophysiological effects on manual therapy on pain in these courses.
  Also, in my opinion, this forum is in and of itself dominated too much by you Butler/Explain Pain guys. You should allow for difference of opinion, or in this case, a belief in both and a meeting in the middle.

(in reply to stacejannel)
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RE: manual therapy courses - February 3, 2012 6:36:57 PM   
rwillcott

 

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Sheld505,

Yes I beleieve there is such thing as a dysfunctional joint. Do I think I can accurately feel the motion of this dysfunctional joint and say that it is the cause of pain? No. Lots of research supports that our ability to palpate the motion of these joints is poor. Secondly, research also shows that we don't have to be specific with regards to the grade and direction of our techniques. Therefore why spend hundreds of hours and dollars learning very specific techniques?

The reason I mentioned Butler and Explain Pain is because most of these orthpaedic courses place no emphasis on the nervous system and its role in pain. Most orthopaedic courses place too much emphais on the biomechanical model which has failed miserably in its treatment of spinal conditions. I agree that manual therapy should still be a part of treatment of painful conditions. However, not from the view point that I am moving the joint in a specific direction and placing it into a better alignment in order to reduce pain. I am simply applying a manual techniuque over a painful joint that effects skin, fascia, subcutaneous tissue, muscle, nerve (and oh yeah....that thing in the skull called the brain) with the end result being an inhibition of pain. You can't manually move and treat the joint in isolation. Unless of course you are working on a cadaver dissection.

Finally, your patient should never leave your practice with the idea that their asymetrical pelvis, unstable SI, stuck facet joint, leg length discrepancy, atrophied multifidus etc. is the cause of their pain. Research cannot support these claims. This is called a nocebo effect. The exact opposite of what we want to do to our patients. There is already a profession that uses this model. Look where its gotten them.

(in reply to Sheld505)
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RE: manual therapy courses - February 3, 2012 10:27:45 PM   
Sheld505

 

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Rwillcott,

This is excellent dialogue and I had, nor do I have, any intent on anything but a practical, respectful, and educative discussion. I agree with what you said. I agree that there exists evidence that we cannot accurately palpate for position and condition...most of the time. In my mind, and in my hands, I think of a joint this way: Does it move like other joints around it? Too much? Too little? At times, this does influence my treatment direction; I cannot lie to you. For example, a patient comes in and has a "kink" in the neck. This patient reports that he or she woke up this way and cannot move their neck in one direction. Upon palpation (admittedly not as accurate as we would like, but nonetheless, a segment is not moving like the others), I'm going to use MET or mobilization or manipulation to free that segment up and do so with immediate results. So, in cases like this, pain can be non-existent, but lack of movement at that segment does exist. Manual therapy is the first line of defense, for example.
I agree with a lot of current pain science thinking and feel patient education plays a large role in patient management of their own condition. As stated earlier, I once leaned too far to the biomechanical approach but now have come to be somewhere near the middle in pain science and empowering/educating the patient about the role of pain vs. biomechanics. While I have read "Explain Pain," I must admit that I have not taken any courses from the Butler/Mosely group but assuredly I plan to. I'm a younger clinician and I do realize my own faults and biases, and I plan on continuing to educate myself to become well-rounded.
I do have to admit that earlier posts put me on the defensive and it is with this professional discussion that I hope myself and the OP, and others, can come to better understand different treatment approaches and opinions. I think there is room for both opinions/approaches and each compliments the other extremely well.

(in reply to rwillcott)
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RE: manual therapy courses - February 5, 2012 7:33:46 AM   
Sebastian Asselbergs

 

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In the case of your neck patient, my experience nowadays is that teaching them FIRST how their neck can "lock up" without any trauma, already alleviates their defensive and self-perpetuating neuromuscular responses to a likely small irritation. Then, some gentle hands-on can promote further motion - but at least they have already learned that THEY can make the most important difference in their condition. You say "kink" - this is for the patient an uncomfortable experience causing restricted motion. This falls under the umbrella of a pain response. The IASP: “ Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” .

When you find a segment that seems to be not moving properly (I learned to do that for so, so many years) ask yourself: "What is providing me this information?" It is the interpretation, the cognitive processes of your own brain that uses the tactile input from the hands, mixes that with your present beliefs and attitudes about the neck problem, your previous experiences with necks, your anticipation of helping this patient (maybe even to impress this patient) - and bingo: your brain provides you with your solid conviction that the segment is hypomobile.
This process is shown to be rather inaccurate as it pertains to being reliable, as you have already stated; yet you state "but nonetheless, a segment is not moving like the others". Do you not see the discrepancy between acknowledging that this is inaccurate stuff, but then still accepting your perception as a fact?

The desire to add "tools" or "skills" to our "tool box" is normal for almost all therapists. I was one of them. The best tool I found was learning about the science of pain and the human neuroanatomy and neurophysiology, as well as the way the human brain produces our perception of reality. Most of the other tools are variations of providing input to a human nervous system: I do not need any more. In fact, learning more about the brain sciences has made me step away from precise manipulation of joints, targeted MET, pin-point dry needling etc, yet my results have not suffered.

There is really no competition between therapy according to neurosciences, and therapy techniques. The one addresses the most likely and plausible model that explains how patients' pain experiences change, while the other is focused on, well, technique to elicit or promote that response.

If you want to enhance your credentials, in the present system you have to take accredited courses. That is a reality, I know. And may affect your income in some states and situations. And you still get to try some different "handling" of patients - I'd suggest to keep remembering "how" any manual therapy gets effects. I would also remember what Robb said about what you tell your patients; the nocebo effect can be very hard to change. (Ever tried to tell a patient they do not have to see their cranial therapist for an hour every two weeks for three years, or their chiropractor every month for the rest of their lives?)

If you want to empower your patients, make them less dependent on series of visits for every pain they have in the future, go the neurosciences route. They will refer their friends and family.


Sorry, just rambling on a morning that woke me too early....

(in reply to Sheld505)
Post #: 12
RE: manual therapy courses - February 5, 2012 5:09:19 PM   
SpokanePT

 

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I am a level III certified therapist through NAIOMT and I will share my thoughts:

Pros:
NAIOMT does a great job of creating a foundation for a philosophy in manual therapy with a clear decision making process. Level I is all about determining whether or not the patient should be in the clinic because of a medical mimicry situation and narrow your focus on a regional diagnosis. The scan exam is a short yet valuable tool that any therapist could use and is the majority of the Level I coursework. Level II is all about taking a very detailed look at what each joint and ligament should be doing, and learning techniques to asses each joint. Level III is all about taking level I and II into a real situation and determining how dysfunction in the rest of the quarter can influence your treatment. I have taken a few courses through Institute of Physical Art, and while I enjoy some of their treatment techniques, they never really give you a place to start, and the ideas are very disjointed. While this approach may end up being giving you more treatment options, the rationale for the treatment is a little more loose.

Cons:
NAIOMT is fairly systematic in the first two levels, but by the third level, I have found some great deviations between instructors. I hope that someone familiar with recent changes in NAIOMT will chime in and tell me that all of the course books are standardized now, but at the timme when I took the classes, each instructor had their own notes to go by. This became difficult when it came time to study for written and practical exams, as you end up with diagrams of dermatomes, for instance, that don't match up from prof to prof.

Overall NAIOMT will give you a nice foundation that will lend itself to Butler and Mulligan and others that in my opinion have great techniques but lack an organizational structure.

_____________________________

Acceleration Physical Therapy in Spokane WA Acceleration Physical Therapy in Deer Park WA

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RE: manual therapy courses - February 6, 2012 8:06:00 PM   
proud

 

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Sheld505,

quote:

To call one or the other a "dinosaur," in my opinion, is a gross attack on the other's evidence.


I stand by my ascertion that any ortho-driven course still perpetuating the myth that one can palpate tiny inter-segmental movements...and then subsequently correct them with highly specific "techniques".....is
certainly prehistoric.

The evidence is pretty overwhelming in that direction so this is not "leaning to far left or right".

So then:

quote:

Also, in my opinion, this forum is in and of itself dominated too much by you Butler/Explain Pain guys.


I am not a "butler/explain pain guy (what does that even mean?). I am someone who places a high priority on understanding the science behind what I do....and ensuring my subsequent discussions with my patients are congruent with said science (Butler, Wall, Melzack, Moseley etc etc)

Rwillcott nailed it above by the way with this:

quote:

Secondly, research also shows that we don't have to be specific with regards to the grade and direction of our techniques. Therefore why spend hundreds of hours and dollars learning very specific techniques?


You indicated that you "loved" the NAIOMT courses and if my experience with that crew (8 years ago....Jim Meadows to be precise) is any indication....I cannot mesh the emerging science with what they were teaching. May as well have enrolled in Hogworts school of wizardry.

Things could well have changed over the past 8 years...I'll check out NAIOMT site to see what is being served up nowadays.

All I know is the Canadian equivalent ortho-series has yet to catch up. I took one of their courses a few years back and left shaking my head....way way behind.

< Message edited by proud -- February 6, 2012 8:19:55 PM >

(in reply to SpokanePT)
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RE: manual therapy courses - February 7, 2012 9:09:24 AM   
Sheld505

 

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Proud,

You most certainly are all about pain science and have a complete disregard and disrespect for a differing viewpoint, a viewpoint that, if you actually read my posts, incorporates pain science and theory into it. A lot of research that NOI cites for their viewpoint (THEORY) is done mostly by Butler and Moseley (there are exceptions) which in and of itself incorporates bias and leaves me wondering about reliability and validity....... NAIOMT is eclectic; their research and support for their approach does incorporate research from faculty and others with NAIOMT affiliation as well as a huge amount from other sources. University of St. Augustine is moving that way too.

And FYI, I never stated "one can palpate tiny inter-segmental movements." Nor did I give notion to ever approaching a patient about a joint being "out" or subluxated. You very obviously have had a bad experience or experiences with the "ortho-based courses." Sorry. My experiences have made a measurable impact on the way I practice. If yours have done the same, I think that's great.

In the end, you stand by your views and I stand by mine. Looks like my view leaves room for both and is not as abrasive as yours. Take your blinders off.

(in reply to proud)
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RE: manual therapy courses - February 7, 2012 9:50:07 AM   
Sebastian Asselbergs

 

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Sheld.
Please tell me you have read the latest research articles about pain and neuro-education that support in a very significant way how little the actual peripheral input has to do with the perception and resolution of pain.

It seems admirable to give "two sides" equal attention, but that approach is highly unscientific.

NAIOMT references are full of detailed outcomes from manual techniques and the classifications for which it "works". This is NOT in contrast with the pain sciences as you know. Those outcomes have been demonstrated as well with MFR - does it mean you give equal credence to their explanatory model? Their technique outcomes are NOT counter to what pain sciences tell us.

The issue is not one-or-the-other; the issue is, is it (technique/approach) necessary?
Especially since the whole spinal joint assessment and palpation testing is, well, not very well supported for accuracy and inter-tester reliability. You seem to at least agree with that.

What is left then to teach in a manual spinal course?

And as far as Mosely's research is concerned: it is rather weak to blame him for referencing his own studies - he was the first one to explore the subject matter that way!!
Butler openly acknowledges Elvey and others whose work he expanded upon. You can look at Louw, Puendetura, Shacklock, Gifford and others, who have taken their own steps to enhance the foundation for the neuromatrix model of pain.

Finally, no-one is immune to bias. St. Augustine faculty has a HUGE investment to find support - wherever possible, with whatever possible - for their curriculum. Of course. I don't blame them. But they are as biased as the next one.

I have done all levels of the Canadian Orto manipulative therapy (but did not do the tests) over many years of study and practice. My disregard for the overblown approach to (and high cost of) manual spinal care comes from experience.

But, you have invested a lot of time and money in it, at that makes it hard for anyone to step away from it (I had a hard time with that for sure....)

(in reply to Sheld505)
Post #: 16
RE: manual therapy courses - February 7, 2012 10:24:29 AM   
proud

 

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quote:

ORIGINAL: Sheld505

Proud,

You most certainly are all about pain science and have a complete disregard and disrespect for a differing viewpoint, a viewpoint that, if you actually read my posts, incorporates pain science and theory into it. A lot of research that NOI cites for their viewpoint (THEORY) is done mostly by Butler and Moseley (there are exceptions) which in and of itself incorporates bias and leaves me wondering about reliability and validity....... NAIOMT is eclectic; their research and support for their approach does incorporate research from faculty and others with NAIOMT affiliation as well as a huge amount from other sources. University of St. Augustine is moving that way too.

And FYI, I never stated "one can palpate tiny inter-segmental movements." Nor did I give notion to ever approaching a patient about a joint being "out" or subluxated. You very obviously have had a bad experience or experiences with the "ortho-based courses." Sorry. My experiences have made a measurable impact on the way I practice. If yours have done the same, I think that's great.

In the end, you stand by your views and I stand by mine. Looks like my view leaves room for both and is not as abrasive as yours. Take your blinders off.


You appear to be tilting at windmills here....

The only thing I have stated here is that I disagree with most ortho-driven courses that perpetuate the myth that their students will one day be able to become highly specific with their manual therapy techniques (all you have to do is pay $5-10,000....and you to can be a wizard!).

Nothing else. I certainly didn't attack you (I don't know you). Based on what you have stated I would be willing to bet we agree way way more than we disagree (a few glaring exceptions along the way but you get the point).

I am just confused as to what has your knickers all tied up.

So let's break this down into smaller parts so that we don't get carried away accusing the other of things they did not say or intend.

I'll start:

1) Agree/disagree: We cannot isolate, via manual therapy, a specific level that is dysfuntional and subsequently precisely mobilize/manipulate that level?

2) Agree/disagree: NAIOMT teaches it's students how to isolate a hyper/hypo vertebral segment...and subsequently treat that level?

3) Agree/disagree: There are people for whom we may assess via inter-segmental mobility testing (motion palpation) that have hypomobility....and have pain....or alternatively...have no pain.

< Message edited by proud -- February 7, 2012 10:42:31 AM >

(in reply to Sheld505)
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RE: manual therapy courses - February 7, 2012 12:03:32 PM   
Sheld505

 

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Sebastian,
  I agree we all have our biases. You have yours, I mine, Proud his, Butler, Paris, etc, all have theirs. There is a strong amount of evidence to support the use of manual therapy in the orthopedic population. I agree that at times, being specific to a level is not necessary; at other times I believe it is of most benefit to be specific, as in my example about the painless "kink" and loss of range-of-motion.

Proud,
  Fair enough. Overall, I think we are in harsh agreement more than disagreement too. And as I've stated, I do want to take a course or courses through NOI as the book left me wanting to know more. I admit my biases and admit that per our conversations, I have a lot less exposure to NOI and their affiliates than you. I'm on the defensive (knickers all tied up) because I don't see how one can toss aside manual therapy (specific or general) and point to pain and neuromatrix, etc. Can you provide examples of how you treat a patient with LBP (acute, non-radicular)?
As for your questions: 1) Disagree. 2) I don't want to cop out but "yes and no." 3) Agree.
My turn: 1) Agree/disagree: Manual therapy has no realm in the orthopedic PT realm. 2) Agree/Disagree:Manual therapy can decrease pain. 3) Agree/Disagree:Too much attention is paid to pain in the healthcare realm. 4) Agree/Disagree:There is no such thing as a joint dysfunction or positional fault. EVER.
  My goals are to better understand the viewpoints here. I would say that from the sounds of it, a lot has changed in 8 years. For the better.

(in reply to proud)
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RE: manual therapy courses - February 7, 2012 1:48:58 PM   
proud

 

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Indeed I think we can better understand each other with some questioning like this. And based on what you just stated, I am certain that you mis-interpret how I treat.

In any case, I will review your answers to my questions first then proceed to answer your questions:

My question #1) You disagree? I guess this is where we the "harsh disagreement" comes in. I might add however that your beef with this is most certainly not we with...it's with the greater scientific community. It's petty much established at this point that specificity of motion palpation is out the window. Care for references? Hundreds upon hundreds. For simplicity, this article is well written and is referenced:

http://blog.evidenceinmotion.com/evidence/files/does_technique_matter.doc

I fail to see how any one could argue this point in the face of the overwhelming evidence.

My question #2 Really it's either yes or no. Which one is it?

My question #3 you agree. Okay. So if we accept (erroneously) that we can isoloate a specific segment that is either hyper/or hypomobile....how do you know if it's relevent to the clinical presentation.

If you answer with "well...if I treat said specific joint and the patient improves than I know I isolated the right segment" than you have not at all considered the plethera of evidence that points to positive outcomes for non-specific reasons (I would recommend an article by Joel Bialosky "the placebo response to manual therapy: something out of nothing" in the Journal of manual and manipulative therapy Nov 2011). I have the full text but cannot link it here.

To go a step further, as you know, many people have significant abnormalities on MRI...and are symptom free. This is something to think long and hard about because it has profound implications for manual therapists.

Now:

Your question #1: Disagree. I utilize all kinds of manual therapy on a daily basis. Did I suggest otherwise?

Your question #2: Agree...see above.

Your question #3: Hmmm....disagree. I would suggest an alternative phrasing. "To little is known about pain and how it operates in the healthcare realm". Pain has a HUGE (massive) economic impact. Have I mis-understood this question?

Your question #4: Disagree. However the brain will decide if this is a threat...or not. But then this discussion become circular. Even if we could identify a specific joint dysfunction (we cannot...references available), how do we then know it's relevance?

Your question about how I treat acute non radicular LBP is a good one....a bit wide open but I will entertain:

1) Screen red flags

2) screen yellow flags

3) Seeing how non dangerous pain (ie sinister in nature) is basically an alarm system, I educate the patient about pain Physiology (Moseley's work)...and get them moving. Often times this is sufficient. Other times (though less and less), I might perform a non -specific manipulation for the neuro-modulatory benefit if the patient at least somewhat matches the CPR's in this regard (acute, with low fear avoidance). But ultimtately the goal is movement based therapy...and ensuring my patient leaves with a better understanding of why they are experiencing pain (a smarter patient...not more stupid and prone to future exacerbations due to imparting a potential nocebo effect via non-sensensical and non-supported patho-anatomical rationale) I might enhance the placebo reponse with that wizardry....get a nice little "outcome" secondary to meeting patient expectations, etc etc...but I have not helped that patient understand anything in an accurate way.

I use centrailization/peripheralization if it's easy to find, I use therapeutic taping to offload neural structures, I might use a few select mulligan mobilizations...all explanations to patients are based on neuro-science. Non of this stuff about a bone not moving enough or moving too much etc etc (Hogworts school of wizardry).

In any case. Here is a nice little article that is pretty good called the problem with OMT (orthopeadic manual therapy).

http://www.somasimple.com/forums/showthread.php?t=3886

< Message edited by proud -- February 7, 2012 2:11:16 PM >

(in reply to Sheld505)
Post #: 19
RE: manual therapy courses - February 7, 2012 2:15:51 PM   
proud

 

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This is also this one:

http://jmmtonline.com/documents/v15n1/EditorialV15N1.pdf

What is happening with manual therapy?

http://www.ncbi.nlm.nih.gov/pubmed/18316238

Spinal stiffness?

http://www.ncbi.nlm.nih.gov/pubmed/18164644

< Message edited by proud -- February 7, 2012 2:53:28 PM >

(in reply to proud)
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