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A problem arises... - June 27, 2012 7:57:12 AM   
proud

 

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History is a stubborn master.

In Canada, it seems the Chiropractic colleges have been trying to rid themselves of all the years of wizardry and psuedo-science that plagued the Chiropractic profession (this is my understanding).

The problem is that many of the students who enroll in the chiropractic colleges... have been to a wizard. They believe in wizards. They want to be wizards themselves.

Having never attended a chiropractic college, I cannot say for certain, but based on some credible sources it seems subluxation theory and many other anti-scientific beliefs are....not emphasized as much any more. They know the truth.

But as stated, many students who enroll have been to a wizard...so they still believe. Thus upon graduation they take their degree and proceed to promulgate nonsense upon the public because they themselves were once cured by a wizard...so it must be true. Be damed what they learned in school....

Well...thanks to Physiotherapy's years of neglect of science...and belief in the holy grail of ortho razzle dazzle pseudo-science certifications...

We now have students enrolling who have been to a wizard (of the Physiotherapy variety). They believe in wizards. They want to be wizards themselves.

So even if as Sheld suggests, the curriculum is evolving to acknowledge the science and the limitations of manual therapy...I fear it may be too late.

Too many students (and future Physiotherapists) are believers now..

It seems we have followed a path that was already beaten...and led to ridicule.

My question to Physiotherapists is...where did the "science" go from the BscPT, MscPT and DPT?

< Message edited by proud -- June 27, 2012 8:04:02 AM >
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RE: A problem arises... - June 27, 2012 5:02:25 PM   
Chocco

 

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Don't forget their clinical instructors. They are the individuals that guide these students into the profession and many of them are still practicing the same principles and ideas they learned when they were in school 20 years ago

(in reply to proud)
Post #: 2
RE: A problem arises... - June 27, 2012 7:58:56 PM   
proud

 

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quote:

ORIGINAL: Chocco

Don't forget their clinical instructors. They are the individuals that guide these students into the profession and many of them are still practicing the same principles and ideas they learned when they were in school 20 years ago


Wait...how do the instructors guide them into the profession?

I never met one of my clinical instructors prior to getting accepted to Physiotherapy.

You lost me on that one Chocco.

(in reply to Chocco)
Post #: 3
RE: A problem arises... - June 27, 2012 9:10:16 PM   
SJBird55

 

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I'm completely not understanding any of this... Wizard?

(in reply to proud)
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RE: A problem arises... - June 27, 2012 9:37:23 PM   
proud

 

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quote:

ORIGINAL: SJBird55

I'm completely not understanding any of this... Wizard?


You know...mythical beings with magical powers. Like...oh....I don't know....motion palpating the spine in hopes of identifying specific segments for which to manually push back into place?

Come on...a wizard SJ....you know what I mean.

(in reply to SJBird55)
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RE: A problem arises... - June 28, 2012 7:40:51 AM   
Chocco

 

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Proud,

my point was that even if they are able to get a better perspective in school their clinical instuctors are likely to reinforce the "wizardry" when they are most impressionable as a clinician.  

(in reply to proud)
Post #: 6
RE: A problem arises... - June 28, 2012 11:07:18 AM   
rwillcott

 

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From: Canada
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Chocco is correct. There are many manual therapy instructors teaching at the university level perpetuating the myth that motion palpation is an accurate and effective method of treatment. More hogwash from hogwarts!

I was speaking with a new grad that is going through the Canadain manual therapy level system recently. He informed me that one of the instructors is also training to become an osteopath and will teach osteopathic techniques. He was taught how to release the diaphragm for chronic back pain patients by pressing under their rib cage. He inforrmed me that there can be adhesions that need to be 'released'. More hogwash from hogwarts!

If you're looking for an evidence based course for the treatment of back pain I would recommend the 4 day Advanced Lumbo-Pelvic Certification through APTEI:

http://www.aptei.com/courses/coursedetail.jsp?courseid=916

The instrucotor is Bahrm Jam and he is very open and honest about the evidence refuting our ability to motion palpate.

< Message edited by rwillcott -- June 28, 2012 11:14:28 AM >

(in reply to Chocco)
Post #: 7
RE: A problem arises... - June 28, 2012 11:45:07 AM   
proud

 

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quote:

ORIGINAL: rwillcott

I was speaking with a new grad that is going through the Canadain manual therapy level system recently. He informed me that one of the instructors is also training to become an osteopath and will teach osteopathic techniques. He was taught how to release the diaphragm for chronic back pain patients by pressing under their rib cage. He inforrmed me that there can be adhesions that need to be 'released'. More hogwash from hogwarts!



As this thread suggests...our very own profession used to attract the best and brightest. I fear we attract people who believe in wizadry and where magic isn't an illussion...it's reality...

Release adehesions in the diagphram...cripes.

I'm not suprised though...if you are gullible enough to believe in motion palpation...then magic wands and releasing adhesions in the diaphgram is just one nanostep away...

< Message edited by proud -- June 28, 2012 12:21:11 PM >

(in reply to rwillcott)
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RE: A problem arises... - June 28, 2012 1:58:21 PM   
Tom Reeves DPT ATC

 

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That is an excellent example of the technique actually being helpful sometimes, but the explanation of what is probably actually happening being screwed up.

I went to a PT school affiliated with a DO program. We learned the same technique and were told the same thing (1991). IF anything happens, its probably more due to the neural inhibition of some spasm in the diaphragm or skin contact or teaching them to breath diaphragmatically (thus tilting the ANS toward the parasympathetic) more than anything, not to mention placebo.

(in reply to proud)
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RE: A problem arises... - June 28, 2012 4:25:36 PM   
Sheld505

 

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Proud, Bas, RWillcott, and others,
Keep in mind that if it wasn't for the "gurus" of manual therapy that you continually express disdain for, the profession of physical therapy would not be where it is today. When I say "gurus," I mean Paris, McKenzie, Mulligan, Maitland, Kaltenborn, Pettman, and others. They themselves were influenced by Cyriax, Mennell, Travell, etc. Just remember on whose backs you are riding on gentlemen. Everyone who uses any amount of manual therapy can, and should, give thanks to them. Their science was, and is, exactly that...science that was ahead of it's time, that promoted critical thinking, and that essentially provided evidence that the chiropractic "subluxation" does not exist.
Just like any decent profession, physical therapy is evolving. People like Flynn, Cleland, George, etc, were influenced in one way or another by those listed above. In turn, the sicence of manual therapy has evolved. You all seem to have a strong dislike for the various systems/schools of thought but give credit where it is due. You now have fallen into the "guru-ism" of pain theory/science; just as there was and continues to be evidence that manual therapy works based off biomechanical principles AND neurophysiological effects, there too is evidence for the CNS' influence on pain. Suffice to say biomechanics + CNS influence outcomes produced from the use of manual therapy.
I respect what you have to say and bring to the table, but your approach is not the only one. The constant "wizardry this, wizardy that" hocus pocus stuff is a bit wore out. Argue that you cannot palpate specific segmental joint movements all you want and it's fine with me. I'll acknowledge that motion palpation isn't an exact science. Show me the articles re: pain science/theory and special tests with their psychometric properties that assist you with making your PT dx, PT prognosis, etc. Tell me that when I do a varus/valgus stress test on an injured knee I'm not feeling a hypermobility of that joint after a violent blow to the knee; the fact is you cannot tell me that and therefore must acknowledge that hypermobilities thus exist. Then I'll show an ankle that has been immobilized for 6 weeks, compare ROM, and then tell me that the immobilized ankle does not move like the "normal" ankle; do hypomobilities then not exist? Moreover, if both hypo- and hypermobilities can exist in large joints, what is to say that such a thing cannot exist in ANY joint? Manual therapy works by influencing change within the joint, the associated muscles/tendons/ligaments, and introducing skilled movement to a joint the patient perceives as impaired.
Just another perspective for you guys. Manual therapy doesn't deny the influence of perceived pain/threats to the lack of movement. I've had the opportunity to take continuing education classes from a few "schools of thought/gurus" above, as well as had the pleasue of being instructed in PT school by the "new school." Each offers a viewpoint that is supported by evidence. Realize too, that if it's been awhile since you've take a manual course, things are changing within some of these organizations/schools of though. There is a greater appreciation AND acknowledgement for pain theory in the coursework I'm going through, less "the guru says this," and more the "science tells us this" being dispersed; it's even from an organization with a strong influence from the Canadian system......sorry Proud. I once pursued certification from an organization that was too driven by dogma and guru-ism and found another organization that recognizes the strengths and weaknesses of the past, is adapting and evovling for the future, and is producing good science.
Give the "shame, shame, what about pain" thing a rest. We are in this together.
Gotta go for now. Best Wishes for all.

(in reply to Tom Reeves DPT ATC)
Post #: 10
RE: A problem arises... - June 28, 2012 5:20:21 PM   
HarperPT

 

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Great post!

Don't expect those people to respond to you though. They're all "evidence based" therapists. That means that they ignore all those who disagree with them and embrace only those who do.

"Evidence based" treatment is total nonsense.

_____________________________

Stay Hungry!

(in reply to Sheld505)
Post #: 11
RE: A problem arises... - June 28, 2012 6:06:12 PM   
rwillcott

 

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Sheld505,

Great post and you raise some good points. The therapists you list I hold in very high regard since they are the reason I have a profession. When many of those therapists created their theories they were based on the best available evidence at the time. The science of neurophysiology was limited. I'm glad you mentioned Robin McKenzie. I use the McKenzie apporach daily with those that need it. He initially felt that it was the disc that was moving in order to cause centralization and peripheralization. Now he is the first to say he doesn't know and it doesn't matter. What matters most is centralization. He adapted with the research and science which is what an evidence based practitioner does. Another example pertaining to McKenzie is the lateral shift that can be present. For years McKenzie therapists beleived that they could see subtle shifts that represented a lateral component that needed to be addressed. However, studies indicated that identifying the shift had poor inter-rater reliability. So what did McKenzie do? He stopped teaching observing the shift and placed more emphasis on perfroming repeated lateral movements to see what effect it has on pain. He adapted to the research.

Mulligan is a technique I also use daily with those that I feel would benefit from Mulligan. Since of course, not everyone needs MWM or SNAGs. At one time Brian Mulligan taught that he was gliding a joint during an MWM or SNAG and this was the reason patients were able to increase movement without pain. Studies have not been able to prove this theory. Studies trying to identify a distal fibula shifted anteriorly in ankle sprains have been inconclusive. If you look at more recent research on Mulligan for tennis elbow the focus has been its effect on the ANS by measuring temperature and pressure thesholds. Not position of the radio/ulnar joint. The Mulligan camp knows that identifying biomechanical faults is useless. Mulligan teachs that their techniques have more of an effect on the CNS and that their techniques as well as manual therapy induced hypoalgesia is most likely involves a non-opiod mechanism of action. This is directly from a Mulligan course book. This is a far cry from his initial thoughts of gliding a joint. Again, a brilliant scientist adapting with the current research and advances in science.

So you can see that many of these scientists adpat with the research and science. I commend them for this.

The EIM group you make reference to is doing some great work. They are the first to say that motion palpation is useless. If you look at many of the CPR's that they have developed do not include any rules that involve motion palpation. The closest would be the use of PA's for the manipulation sub-group. Which is fine since PA testing is one exam we can agree on as PT's. However, if you apply these CPR's to the right sub-group of patients you can have some great results. In some cases you can identify which patients will benefit from a specific Rx apporach without touching them. Further evidence that trying to feel insignificant motions of the spine is a waste of time. Not to mention the list of studies mentioned throughout this thread that demonsrtate the poor reliability and validity of motion palpation of the spine.

< Message edited by rwillcott -- June 28, 2012 6:07:39 PM >

(in reply to HarperPT)
Post #: 12
RE: A problem arises... - June 28, 2012 6:11:49 PM   
ginger

 

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...".motion palpating the spine in hopes of identifying specific segments for which to manually push back into place?"

Yes agree, the notion of joints needing to be in place is the heart of the subluxation proposition, one not worthy of any of us . Or indeed that it is possible or valuable to attempt such a thing. You've certainly rallied the anti subluxians well enough here Proud. One thing I can't quite get my head around, are those chiros who claim not to be Palmerites but who give themselve alternate titles which appear to be a deliberate effort to seperate themselves from the routines of back crackin . My brief experience with these folks is that many seem to inhabit an even wierder world of the natural energy flow restoration camp.
Love to know your views on this "movement", Bones, you there?

_____________________________

Geoff Fisher
Physiotherapist

(in reply to HarperPT)
Post #: 13
RE: A problem arises... - June 28, 2012 7:53:42 PM   
proud

 

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I'm not sure I can add anything over and above what Rwillcott put together. But since I'm highlighted... I've a few responses

quote:



Proud, Bas, RWillcott, and others,
Keep in mind that if it wasn't for the "gurus" of manual therapy that you continually express disdain for, the profession of physical therapy would not be where it is today. When I say "gurus," I mean Paris, McKenzie, Mulligan, Maitland, Kaltenborn, Pettman, and others. They themselves were influenced by Cyriax, Mennell, Travell, etc. Just remember on whose backs you are riding on gentlemen. Everyone who uses any amount of manual therapy can, and should, give thanks to them. Their science was, and is, exactly that...science that was ahead of it's time, that promoted critical thinking, and that essentially provided evidence that the chiropractic "subluxation" does not exist.
Just like any decent profession, physical therapy is evolving. People like Flynn, Cleland, George, etc, were influenced in one way or another by those listed above. In turn, the sicence of manual therapy has evolved. You all seem to have a strong dislike for the various systems/schools of thought but give credit where it is due. You now have fallen into the "guru-ism" of pain theory/science; just as there was and continues to be evidence that manual therapy works based off biomechanical principles AND neurophysiological effects, there too is evidence for the CNS' influence on pain. Suffice to say biomechanics + CNS influence outcomes produced from the use of manual therapy


Agree with it all. I have nothing but respect for those that innovated based on what was known at the time. My disdain is saved for those who perpetuate wizardry....in spite of what we know.

quote:

I respect what you have to say and bring to the table, but your approach is not the only one.


I do not have an "approach" so much...what do you mean?

quote:

The constant "wizardry this, wizardy that" hocus pocus stuff is a bit wore out.


Indeed it's meant to evoke that kind of reaction. Disdain for it doesn't make it inaccuarate.

quote:

Argue that you cannot palpate specific segmental joint movements all you want and it's fine with me


While I certainly agree motion palpation is about as useless an endeavor as you can get...I think it's important to highlight that It's not my position. I would say the literature is reaching the point now that makes any argument for motion palpation pretty much laughable.

The ortho divsion teaches spinal motion palpation correct?

quote:

Show me the articles re: pain science/theory and special tests with their psychometric properties that assist you with making your PT dx, PT prognosis, etc.


I can't be sure but this particular sentence of yours has me wondering if you understand at all what is being discussed here. Pain science/theory is not a mode of treatment Sheld...

quote:

Tell me that when I do a varus/valgus stress test on an injured knee I'm not feeling a hypermobility of that joint after a violent blow to the knee; the fact is you cannot tell me that and therefore must acknowledge that hypermobilities thus exist. Then I'll show an ankle that has been immobilized for 6 weeks, compare ROM, and then tell me that the immobilized ankle does not move like the "normal" ankle; do hypomobilities then not exist? Moreover, if both hypo- and hypermobilities can exist in large joints, what is to say that such a thing cannot exist in ANY joint? Manual therapy works by influencing change within the joint, the associated muscles/tendons/ligaments, and introducing skilled movement to a joint the patient perceives as impaired.


Now this is often an ortho guru's "golden child argument" and it's wrought with logical fallicies. You are comparing things that cannot be compared and generating a red herring in the process. It's also a variation of special pleading:

"Because I can feel A; it therefore follows that with special training, I can also feel B"

We no longer require these sort of debates Sheld. The verdict is pretty much out on what we can....and cannot reliably palpate. Why develop fantastical arguments and cling to special pleading?

Besides, that argument is circular anyway because it will always come around to these well established items:

1) Literature tends to suggest that there is no causation....let alone correlation between certain osteokinematic/arthrokinematic findings and pain. (just for an appetizer...check out reference # 5 that I gave to Geoff in the "tough patient" thread.)

2) And even if there were...we have no reliable way to determine if they exist.

3) And even if we could...we cannot impart specific or enough force to affect them in any meaningful way (Thelkland is a good start point here).

quote:

Give the "shame, shame, what about pain" thing a rest. We are in this together.


Well, I am quite sure this is a complete mis-characterization of what is being discussed here. And I have no intention of giving it a rest. In fact...expect to hear more from me outside of the blogsphere.

I agree Sheld...we are all in this together. I'd like to see our profession check the ego at the door....re-vamp what needs re-vamping...and move forward.

I maintain the ortho division has a long way to go. I'm glad to hear they are moving along though.

< Message edited by proud -- June 28, 2012 9:05:58 PM >

(in reply to Sheld505)
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RE: A problem arises... - June 28, 2012 9:55:17 PM   
honker23

 

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Proud, when a therapist places a pt in prone and performs PA mobs to a hypomobile spine and 5 min later the spine feels normal Now the pt has less pain, is taken through exercises, pt has even less pain, and leaves happy. Did the pts ligaments, fascia, joint capsules lengthen thanks to the therapists skillful technique, allowing for more flexibility and strength which helped reduce the pain.....OR.....did the manual technique provide input to the mechanoreceptors that the brain processed in the context of treatment and determine the back was OK to move, reduce defense mechanisms, allow movement through specific exercises and determine there is less threat to the back, and produce less pain as the pt leaves with improved movement?

Isn't this the difference we are debating. I'm sure we all agree that a skilled PT can feel a stiff and flexible spine. Isn't the main difference that some feel this change is because the therapist masterfully applied a technique to the fascia, muscle, capsule, joint...vs....the pts nervous system received input from a skilled caring therapist and determined the threat was reduced and decreased the defense mechanism or pain.

Sorry if this makes no sense...sipping on a scotch and reading!

(in reply to proud)
Post #: 15
RE: A problem arises... - June 29, 2012 6:05:35 AM   
proud

 

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I'm heading out on vacation so not much time to reply but.

quote:

ORIGINAL: honker23

Proud, when a therapist places a pt in prone and performs PA mobs to a hypomobile spine and 5 min later the spine feels normal Now the pt has less pain, is taken through exercises, pt has even less pain, and leaves happy. Did the pts ligaments, fascia, joint capsules lengthen thanks to the therapists skillful technique, allowing for more flexibility and strength which helped reduce the pain.....OR.....did the manual technique provide input to the mechanoreceptors that the brain processed in the context of treatment and determine the back was OK to move, reduce defense mechanisms, allow movement through specific exercises and determine there is less threat to the back, and produce less pain as the pt leaves with improved movement?


I can agree with that.

quote:

I'm sure we all agree that a skilled PT can feel a stiff and flexible spine. Isn't the main difference that some feel this change is because the therapist masterfully applied a technique to the fascia, muscle, capsule, joint...vs....the pts nervous system received input from a skilled caring therapist and determined the threat was reduced and decreased the defense mechanism or pain.


Don't agree with above...so much.

Literature suggests new graduates and "masterful PT's" have the same ability to feel things. It's not the technique that requires mastering....it's the clinical reasoning process...

That's my beef with wizardry.


quote:

Sorry if this makes no sense...sipping on a scotch and reading!


Perfect sense. I'll be having a few scotch myself over the next couple of days!

Take care Honker.

(in reply to honker23)
Post #: 16
RE: A problem arises... - June 29, 2012 9:03:01 AM   
honker23

 

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I was trying to add my bit of sarcasm and jest when saying masterfully, skilled.  I guess it's hard to determine that online. 

(in reply to proud)
Post #: 17
RE: A problem arises... - June 30, 2012 3:18:42 PM   
Sebastian Asselbergs

 

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Sorry to come to this rather late.
Harper, my apologies for disappointing you and responding anyway. But I won't respond to your rather confused little post #11. Look up the contrast between "science based" and "evidence based".

Sheld,
quote:

Keep in mind that if it wasn't for the "gurus" of manual therapy that you continually express disdain for, the profession of physical therapy would not be where it is today. When I say "gurus," I mean Paris, McKenzie, Mulligan, Maitland, Kaltenborn, Pettman, and others. They themselves were influenced by Cyriax, Mennell, Travell, etc. Just remember on whose backs you are riding on gentlemen.


Please point out where I have ever disdained these people. I was taught by Janda, Cyriax, Kaltenborn, Evjenth, Sahrmann, Butler and others. They were very good at what they did.
That does not mean that we should revere everything they developed: whether it be a method of treatment or a model of therapy, all is and should be constantly under scientific scrutiny.
Many assessment and treatment techniques by Cyriax have been shown to be bunk. Janda simplified muscle-histology and neuromuscular control way too much. McKenzie should be recommended for modifying his own original explanatory model as science provided him with more data. Travell....Do not get me started.

I DO wish that these people had been LESS guru. Our profession might have included the neurophysiology of human pain years earlier.....

It is not about the people.

And finally, do not assume too much about my knowledge of the present-day teaching of orthopaedic and manual courses (here in Canada). There is still too much focus on outcome studies of techniques and much, much too little on the complexities of the neurophysiology and psychoneuroimmunology. Yet the evidence and plausibility of the importance of these facets is well documented.
We are on the same ocean, but not in the same boat: my boat is pointing in a different direction.

(in reply to honker23)
Post #: 18
RE: A problem arises... - July 1, 2012 8:19:42 PM   
Niko

 

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quote:

ORIGINAL: proud
My question to Physiotherapists is...where did the "science" go from the BscPT, MscPT and DPT?



The science behind BSPT, MSPT and DPT, is heavily derived from Exercise Science, not manual therapy. Manual therapy is not more “scientific” than any other passive modality including massage therapy alone or the original chiropractic. If you ask me manual therapy is more of an abstract art than a science. And there is nothing wrong with that. Manual therapy is a great tool to create a therapeutic environment by helping the patients get in touch with their body. By facilitating this awareness alone, you help the patients confront their pain and realize it is a pass through to healing. The specific technique used has very little to do with any dramatic functional outcomes (I’m not talking about pain), unless you do a lot of facilitated stretching,MET and prolonged joint mobs. Then you are basically doing the exercise for the patient, and in the expense of straining your own body. I believe in self management, and I like being efficient with my sessions while taking care of my own body, so I only do what the patients cannot do themselves and nothing more than that.

I think that we over embrace manual therapy in PT and the outpatient therapist now is doing manual therapy before exercise. Then we go on and on with each other which technique is “the best“, and argue if there is enough evidence for each technique, or argue which pathway each technique is operating under. All these arguments are pointless. If you are wondering where is the science then look into exercise. Nobody can argue against the benefits of exercise and it’s direct positive effects on functional outcomes.

(in reply to proud)
Post #: 19
RE: A problem arises... - July 2, 2012 11:29:35 AM   
Sebastian Asselbergs

 

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Niko, I do not know where you find that anyone goes "on and on" about what technique is "the best". You must be reading different threads than I am.
I do not think you will find anyone disagreeing with the idea of more movement being good for most any condition; the whole idea of "exercise" is still poorly defined and delineated.

(in reply to Niko)
Post #: 20
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