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NEXT Workshop is on May 21 and 22, 2011 at Cebu, Philippines

NEXT Workshop is on May 21 and 22, 2011 at Cebu, Philippines
CLICK ON PIC TO LEARN MORE! Palpation and "Listening" Skills Lab for Neuromyofascial, Cranial and Visceral Manipulation

What's being said about Manual Medicine?

Sunday, January 25, 2009

Manual Therapy Workshop - February 22, 2009 - Pasig City Philippines


A WORKSHOP-SEMINAR featuring THE LATEST
FUNCTIONAL MANUAL THERAPY APPROACHES
and some of the Time-tested, really good stuff we have all grown to love

RIGHT CLICK over picture AND "SAVE AS" to copy this INVITATION

Features both established, evidence-based techniques as well as revolutionary new case-proven techniques and protocols that can almost instantly result in the elimination of pain,
ablation of hyper-sympathetic / hypertonic / hyper-inflammatory cycles, with significantly measurable gains in joint mobility, ROMs, muscle strength, and
the ever-important general sense of patient well-being.

Book your slot today via:
09274515589—Harold
09052872175—Rey
09297745045—Mich

To cover food and venue:
1,500 (Pre-paid until February 8, 2009)
2,000 (Regular Reg until Feb 17)
2.500 (Late and On-site Reg)

Our little sharing sessions will most likely (it all depends on how much material everyone can handle) include:
Rapid De-afferentaion (RDTs) for pain control + functional gains
Myofascial and Motility Mapping
Advanced Soft Tissue Techniques
Junctional Techniques
Articulatory & Advanced Techniques
Mobilization Techniques review: Mulligan vs Bayliss vs Fryette
Basics and Beyond for the Dorn Method
Harmonic Articulatory and Soft Tissue Techniques

Time permitting, we hope to drag you in for a rousing SHORT SWIM IN:
(1.) The Original Bowen Technique (full exposure courtesy of Bowtech Accredited Practitioners - BTAA / Philippine Bowen Practitioners)
We value your input. Be aware that Workshop coverage may be modified at any time by participant requests.
please visit http://manualmed.blogspot.com/2008/09/bowen-therapy-in-philippines.html
(2.) Instrument-Assisted Connective / Soft Tissue Mobilization (IACSTMs: Gua-sha, Graston, SASTM)
(these would be grouped with Advanced L-D Myofascial Releases (Local, Direct):
CTM - Connective Tissue Mobilization (Based on 2007 Protocol)
IASTM - Instrument-Assisted Soft-Tissue Mobilization
SASTM - Sound-Assisted Soft Tissue Mobilization
Pre-Requisite: Practitioner level for direct local myofascial release
Workshop director is a SASTM Practitioner. He has been successfully using Gua-Sha and CTM techniques in a clinical setting with great results from 2005.
His favorite IASTM tool used to be a Hartmann Tool. He now continues to drool over the results he gets with SASTM.)
(3.)Visceral and Somatic Dysfunction Overlaps and Manipulative Solutions
Includes the preview to Viscero-Somatics II: Visceral Manipulation for Visceral and Somatic Functional Gains
as may be applied to:
a. Post-operative Ileus
b. Somatic Dysfunctions of Visceral Origin
c. Visceral Dysfunctions of Somatic Origin
(Visceral Manipulation has been a part of the Workshop Director's clinical practice from 2005. A functional blend between three main schools of VM practice will be presented.)
(4.)A Brief Introduction To Manual Medicine Techniques (A demonstration of Major Proven techniques THE GROUP hasn't covered in its previous sharing stints)
Since a plethora of techniques exists, a way of synthesizing a flow of techniques into Manual Medicine Practice will be presented.
(5.) Neuro-linguistic Programming in Manual Medicine: Improving the Mind-Body Link
(The Workshop Director is an NLP Master-Practitioner, A Clinical and Medical Hypnotherapist, Psychotherapist, and Pain Management Consultant.
(6.) I wonder if we'll tell you about .. Advanced Spinal Mechanics: Beyond HVLA
Yes, there is life beyond HVLA.

Sharing will be at our Gastronomic Home, the Academy of International Culinary Arts (AICA) at Pasig CIty (near ULTRA, Valle Verde Country Club and Bagaberde)

A full-course set of Evidence-supported Manual Techniques for less than the price of the gourmet food we'll most likely serve.
(Hint: more people = more food prepared. So drag your friends in for the ride of their lives!))

A synthesis of manual therapy techniques geared for remarkably fast, lasting results

Esteemed Audience: P.T.s, M.T.s, M.D.s: clinicians, academicians, and all students interested in clinical protocols that really work
visit us at www.manualmed.bravehost.com; www.manualmed.blogspot.com

You'll let us know what you're interested in, right?
Harold can be reached at 09274515589 and via this site.

Tuesday, January 20, 2009

Manual Medicine Workshop! February 22, 2009


We're hoping you'd love to join us on our next "Sharing." Same time, same place:
AICA at Pasig, 9 am to five pm. This time, on spurring from colleagues that need this material most - those in practice - we're sharing our version of integration. Curiously, we're going to tackle Junctions, Overlaps, Interconnections, Gateways, and Pathways. So i Guess this should have been called the Manual Medicine Roadmap: Module One. Hehe. Too late. We already did the invites. But the invitation holds true: do join us if you wanna know how well your practice can go.

Hoping you pester Harold to sign up with us soon.

And may your beloved patients feel the functional difference that only a well-synthesized set of Evidence-Based protocols can bring.

Sincerely,

Movement With Mobilization

Movement with Mobilization (MWM) is based on Mulligan's work.
His SNAGs = Sustained Natural Apophyseal Glides involve passively (operator) introduced translation that is maintained while the patient goes toward the restricted endrange. The translatory or gliding force is typically maintained while a return to passive neutral is established.

One of the easiest and most useful techniques that can be taught to patients is the one involving a towel drawn against the nape an tugged on forward by the patient via handhold on either side. These have been called self-MWMs.


The Functional Techniques of Osteopathy appear to be the closest analogue.

Thursday, January 15, 2009

AUTISTIC therapist

Today one of my beloved therapists called me autistic. He hasn't bothered to say it was a mis-sent message, so let's assume that he believes he meant what he said. Let's play with that:

His appended message to that comment was: "Since when did you start talking to yourself?" Hmmm. That's a useful question. First, let's define autism, shall we?

au·tis·tic [ aw tístik ]

(adjective)
Definition:
affected with or caused by autism: showing evidence of autism, e.g. failure to use language and perceive surroundings in the expected way

au·tis·ti·cal·ly (adverb)

And then, there's "Talking to yourself:"
Definitions of Talking to yourself on the Web:

Intrapersonal communication is language use or thought internal to the communicator. Intrapersonal communication is the active internal ...
en.wikipedia.org/wiki/Talking_to_yourself

Hmmm. Both useful:
1.) The Autistic way: To use language NOT in the way expected.
I think i best learned to think in a useful "autistic way" when i learned NLP re-framing. I later learned to ask: "what's the context in which that question would be useful?" That assumes that even a seemingly nonsensical question could have a usefulness.
Also, the semantic tools of NLP and hypnosis seem to be an unexpected use of language in that most people don't communicate with a purpose and calibrate to see if their message was properly delivered. Most people just assume that the "other person must be dumb because they didn't understand what I said." This lies in stark contrast with the NLP directive that basically states that "if i wasn't understood, i did not deliver the message in the way it would be best understood by my intended receiver." This model of language transfers the burden of communication on the conveyor of the message and eliminates the hardly useful labeling of the message recipient as "dumb."

2.) The "Intrapersonal Communication Way:" Internal communication.
Doesn't everyone do this?
The way I understand it, everyone talks to themselves in one way or another, at one time or another. Everyone has one variation or another of an internal dialogue. The content and quality of that internal dialogue often dictates how well that individual does in relating to or talking to the world at large. With positive - or at least neutral self-talk, people are generally well-adjusted, productive little beings.

Hmm.. I'm pretty good with being autistic. I need a bit more practice, though. And i probably have to learn to have better conversations with myself.

Wednesday, January 14, 2009

Example of Abrreviated Clinical Narrative Notes for Physical Rehabilitative Documentation

These are Excerpted notes from the Chart of a 73 year-old male patient.

Chief complaint(s):
Left knee weakness and pain
Left foot pain
Right shoulder pain

#1: Left Knee pain: Pain and functional evaluation:
Left knee with grade 5/10 continuous aching to cramping pain with marked on standing and extended weight-bearing to personal grade of 5-6/10. Pain alternates and is often accompanied by local numbness. In local jargon, pain was described as accompanied by “ngimay.” Home and recreational activities are limited by ambulatory restrictions dictated by left knee weakness, pain, and instability. Instability and weakness at left knee currently pre-dominate pain at the left knee as chief complaint.

Going up a flight of stairs is the activity most limited by knee disability, with going down the flight of stairs a close second on scale of difficulty. Movement on even terrain with plus one minimal assist or staff cane over 5 meters is now tolerable. Patient declares that all activities are affected, with strenuous activities impossible to perform.
With regard compensatory activity related to ambulation, the patient notes (1) frequent rests during the activity, (2) purposeful avoidance aggravating activities (such as purposeful avoidance stair-climbing), and constant requests for mild to moderate assistance to perform and complete ambulation. Toiletry is accomplished slowly sans assistance. Bathing and dressing require assistance.

Left knee pain was first noted at left knee from eight years prior, graded at PS 3-4/10.
Starting point with marked pain exacerbation and functional limitation at three years prior was inability to weight-bear at left knee, and inability to ambulate sans +1 moderate assist plus staff cane. Pain at time of severe exacerbations at one and two years prior peaked at personal grade 10/10, with inability to weight-bear at left knee unless aided with +1 moderate assist plus staff cane on contralateral extremity. Some relief from pain was afforded post local steroid infiltration and hyaluronic acid infiltration.


Our patient is currently undergoing physical rehabilitation, with particular focus on manipulative / manual medicine techniques for decreasing pain, improving muscle strength, and improving soft tissue compliance. Myofascial compliance is maximized at each treatment session. Physical rehabilitation has progressed functional use of knee to unaided weight bearing to 3-5 meters before balance is lost due to weakness and instability at the left knee. Additional treatments incorporated have included Psychotherapy, Medical Hypnosis, Acupuncture, and Osteopathic Manipulative Techniques.

Problem #2: Right shoulder pain and limitation of movement:
Pre-treatment: Today’s Range of motion testing
Active Passive left Shoulder right active Passive
160 130 Flexion 0-180 115 95
60 70 Extension 180 40 70
70 85 Abduction 0-90 60 85
8 10 Adduction 90 10 15
50 55 Internal Rotation 0-90 45 50
65 70 External Rotation 90 65 70

/Sandro Strix S. Toledo, M.D., DHP, DNLP, DMS

An Overview of Selected Manual Medicine Methods

Cranial-Sacral Therapy (CST)
The cranial-sacral system addresses bones and membranes that surround the central nervous system. Restrictions here can strain neural tissues and affect coorespondingly innervated somatic areas, organs, or tissues. CST uses light manual techniques aimed at inducing relaxation responses that decrease, unwind, or remove neural tissue strain. CST, while particularly effective for treatment-resistant headaches, also have positive bearing on varied cases of unresolved chronic muscle and joint pain. Case studies show usefulness in helping resolve some digestive and neuro-endocrine disorders. Learning curves, attention spans, and memory retention are often reported improved.

Movement Therapies and Postural Re-alignment
Postural habituation and any form of trauma or sudden mal-positioning are the most common causes of tissue structure / function imbalance. Compensations include often inappropriate tissue lengthening and shortening. Somatic dysfunctions over time build up and bear heavily on joints and their surrounding / supporting structures. Muscle length / strength imbalance identification allows for both prevention and proper resolution of Neuro-myofascial syndromes. Postural and Movement Rehabilitation addresses these imbalances.

Lymphatic Drainage Therapy (LDT)
Trauma, physical deconditioning, lack of exercise, myofascial restrictions, and local tissue / area inflammation can cause lymph stagnation. Buildup of cellular debris and inflammatory mediators reinforce the nociceptive cycle and somatic dysfunctions. LDT can improves circulation and helps resolve edema. Joint and soft tissue swelling can be significantly reduced. Chronic pain syndromes can be improved or partially resolved.

Neuromuscular Techniques (NMT) / Neuro-myofascial techniques (NMF-T)
Fascial restriction and muscle hypertonus are highly responsive to various NMF techniques. Major techniques include Myofascial Releases, Muscle Energy Techniques (MET), Positional Release Technique (PRT), and Trigger Point-Proprioceptive Therapy.
Reflexive De-afferentation Techniques (RDTs) have evolved from Neuro-myofascial techniques. Pain cycles easily broken with NMF techniques include headaches, nape and shoulder pain, TMJ pain, knee and foot pain. Mechanical and repetitive strain injuries that may be addressed with NMF-T include mechanical low back pain syndromes, thoracic outlet syndromes, “frozen shoulder,” carpal tunnel syndrome, lateral epicondylitis, and plantar fasciitis.

Articulatory techniques (ART)
Soft tissue injury and cumulative joint trauma result in joint ROM restrictions and / or pain. These techniques involve taking joints through their restrictive and compliant motion cycles. They improve joint range or motion and help ablate joint pain cycles.

Visceral Manipulation (VM, Ventral OMT techniques)
Trauma, lack of exercise, physical deconditioning, cumulative soft tissue injury, inflammation, surgery, or obesity can displace, restrict, tighten, or scar ligament and fascia that surround, support, or suspend organs. Fascial and ligamentous injury can result in focal strains that cause tissue or organ dysfunction and injury. Pain and inflammation cycles are facilitated. VM uses soft vectoral techniques aimed at re-engaging normal suspension or movement of internal tissues / organs.
The notion of tissue restrictions or compliance to movement extends to the viscera. Organs, fascia, mesentery, and visceral ligaments move along and in relation to each other in much the same way that we know normal fascia-muscle compartments do. This notion of mobility in relation to each other is differentiated from intrinsic organ motility. Organs are mobile in relation to each other and often possess an internal movement or motility. As all fascia moves with breathing, the lungs move as we breathe, the stomach and intestines move in relation to each other during peristalsis, the urinary bladder shifts location somewhat when we piss. Viscera also move around a bit with ambulation. Visceral mobility restrictions are thought to restrict normal fluid, solid, and impulse conduction through individual organs. VM addresses these restrictions.
Musculoskeletal conditions linked to visceral involvement include:
1. Mid to low back pain: The colon’s attachment to the back of the abdominal compartment may be strained. This can lend ligamentous tightness or displacement which, in turn, can inhibit normal spinal movement. These spinal segmental dysfunctions result in their related pain constellations.
2. Neck stiffness and pain: The suspensory ligaments of the lung and the pericardium all attach to cervical vertebrae. Ligamentous involvement here can cause cervical joint compression and flexion cervical somatic dysfunction. A forward head posture may thus actually be more closely related to a lung problem than to a thoracic spine dysfunction.
3. Shoulder restrictions and pain: Most paramedical personnel are familiar with the fact that gallbladder inflammation can result in pain that radiates to the right shoulder. Nerves that supply the suspensory ligaments of the liver stem from the spinal segment that innervates the shoulder. Liver suspensory ligament involvement may thus result in shoulder somatic dysfunctions.
4. Peripheral joint pain: Visceral compartment restrictions can transmit tension via adjacent myofascial trains into the limbs. These tension lines can cause compressive and torsional joint irritation and dysfunction.
5. Comparative Studies have found Visceral Manipulation also Beneficial for:
Somatic-Visceral Interactions
Chronic Spinal Dysfunction
Headaches and Migraine headaches
Carpal Tunnel Syndrome
Hip and Knee Pain
Sciatica
Whiplash
Seatbelt Injuries
Chest or Abdominal Sports Injuries
Visceral Manipulation has been known to improve:
1. Fatigue: Abnormal fascial tension or scarring from at the visceral suspension system may result from inflammation, surgery, and blunt or countercoup trauma. Loss of organ mobility due to restrictions of surrounding and supporting tissues have been linked to general fatigue. By example, lessened fatigue has been reported by whiplash-injured VA patients. Faster recovery rates and lower incidences of depressive symptoms have likewise been reported.
2. GI motility disorders: Ileus, constipation, and irritable bowel syndrome: Abnormal fascial tension or scarring from at the small and large intestinal suspension system may result from inflammation, surgery, or blunt trauma. This causes restrictions that negatively alter bowel motility and function.
3. Hemorrhoids: The venous drainage from the rectum toward the liver is impeded when the hepatoduodenal ligament is abnormally tight. The resultant vascular congestion can cause or aggravate hemorrhoids.
4. Incontinence: Ligamentous tightness and muscle hypertonus may limit proper urinary bladder expansion and emptying.
5. Comparative Studies have found Visceral Manipulation Beneficial for:
Digestive Disorders
Bloating and Constipation
Nausea and Acid Reflux
GERD
Swallowing Dysfunctions

Women’s and Men’s Health Issues
Chronic Pelvic Pain
Endometriosis
Fibroids and Cysts
Dysmenorrhea
Bladder Incontinence
Prostate Dysfunction
Referred Testicular Pain
Effects of Menopause Pain Related to
Post-operative Scar Tissue
Post-infection Scar Tissue
Autonomic Mechanisms


Pediatric Issues
Constipation and Gastritis
Persistent Vomiting
Vesicoureteral Reflux
Infant Colic

Emotional Issues
Anxiety and Depression
Post-Traumatic Stress Disorder
We are at www.manualmed.bravehost.com www.manualmed.blogspot.com

Conversations with Colleagues: (Steve Myles, American D.O)

I've decided do start including communicae with colleagues as posts on this site. The intent is that fellow manual medicine practitioners here may glean inpiration and insight from the strenths of years of experience that our colleagues have gained.

STRIX:
I have a small rehab team here. We train our staff and pass on anything we gain.
Physical therapy as a profession here is rather.. poorly updated. It is only beginning to pick up on manual med / manipulative skills. That puts my team at a fair leading edge insofar as the functional gains they can deliver for our patients, but leaves them with a hunger to pick up anything they can from anywhere they can. The way things look, we are likely to go in and out the country as frequently and as long as necessary in the next few years to pick up the skillsets for manip. As we find even good orthopedic manip protocols to be often less remarkable than OMM / OMT, we hope to learn from as many osteopaths as we can. We are looking for a synthesis, or at least what works best. Thus far, All manual medicine looks similar in principles and practice somewhere down the line. Our biggest bottomline is still to help our patients as best we can. It's still sadly fairly common for patients here to waste 18 sessions to go nowhere with the predominant PT practice here. The reason? It's modality based. Almost fully. That's the second thing we hope to do here - to push for an evolution in manual practice.

STEVE:
I empathize with you. In osteopathy, we learn first to analyze the strain pattern and decide where and why to begin. Then, we may do the correction using whatever paradigm appears appropriate. Diagnosis first and foremost, the treatment choice is just the tool.

STRIX:
Most PTs and MDs here have even never heard of visceral manip. And there are sadly no DO institutions here.

My practice also includes primary care and occupational medicine. It is at heart integrative. I however do not have any homeopathic training as yet. We have medicare / TRICARE coverage here. Dozens of HMOs have birthed and died since 2000. HM insurance is neither standard nor required.

I hope this background makes sense enough for you to help us out with recommendations?

STEVE:
I am familiar with the plight of conscientious physicians and health practitioners working in a system that is more money and resource management than patient care.

I used to do courses (for about 20 yrs), taking health professionals in a few weekends from knowing nothing about osteopathic analysis to learning some principles to apply to any occasion. If you teach someone a technique and the patient's condition doesn't apply, the practitioner is lost. If you teach principles, then the practitioner can always figure out what to do and where to begin.

To start with homeopathy, you might consider the Homeopathic Course - I review about 20 remedies in an easy-to-learn format. After you have had success with this acute prescribing for about 6 months, you might contact me for other resources to expand your knowledge.

Both osteopathy and homeopathy are easily each lifetime studies. The amazing contributions you make to your patients health keep you enthusiastically studying and learning.

I seem to have started another book here, Strix. If we can get the time zones straight, perhaps we could set a time to talk on the phone.

Take care, Strix.

Steve

Osteopathic Manipulative Treatment: Diagnosis, Treatment, and Results

Introduction

We say that pain from a specific segment, relayed via its dermatomal level, is “radicular” in origin.
In practice, sensorimotor deficits and reflex abnormalities may be noted when we have pain that radiates to an extremity. Segmental innervation dictates where to look for a neurogenic lesion.

Capsular, tendinous, and musculoskeletal pain are usually addressed conservatively, with anything from traditional modality-based physiotherapy, medication, and exercise prescription.

Special attention to palpatory and positional reactions of soft tissue enables us to identify somatic dysfunctions.


Diagnostics
Upon diagnosis, osteopaths establish deviations in the relative position of the different vertebrae by means of palpation and examination. To that end, an imaginary line is drawn between the fingers of the examining practitioner, which are placed on certain sites of the patient's body. These sites are determined on the spinal column, for example, by the spinous processes and the transverse processes, etc. Account is taken of the fact that the joint surfaces between the various vertebrae on the spinal column are practically all different in shape and size and their position relative to the co-ordinate system is consequently different each time. Knowledge of this is essential.

What are the deviations from the usual position that a vertebra in the co-ordinate system may display relative to the neighbouring caudally located segment? (The standard abbreviation used in osteopathic medicine is shown between brackets.)

1. The vertebra may rotate around the anterior-posterior axis (AP axis). It is assumed that this rotation continues so far, due for example to overloading, that it becomes locked in this position. This applies to cervical, thoracic and lumbar vertebrae. The vertebra tilts, as it were; it is in a lateroflexion position (LFP).

2. The vertebra may be displaced dorsally, both unilaterally and bilaterally, and will then be forced by the shape of the joint surfaces also to rotate slightly in the other two body axes. This applies to cervical, thoracic and lumbar vertebrae. The vertebra is displaced backwards, as it were, and we call this a dorsal displacement; it is in a dorsal position (DP).

3. The vertebra may shift sideways. Again, this is possible in the case of cervical, thoracic and lumbar vertebrae. Lumbar vertebrae present differently on palpation than cervical and thoracic vertebrae due to the shape of their joint surfaces. The vertebra shifts, as it were, laterally; it is in a lateral position (LP).

4. The vertebra may be displaced ventrocranially, either unilaterally or bilaterally. This is accompanied by rotation around a longitudinal axis and around the anterior-posterior axis; however, the latter occurs only in unilateral displacement. Bilateral displacements are seen after whiplash trauma: the vertebra is in a ventral position (VP).

5. The vertebra may rotate around a longitudinal axis. When this axis runs through the vertebral body, the dorsal part of the vertebra - in particular the spinous process - is displaced away from the median line. The vertebra rotates; this is a rotation position (RP). The positions may occur singly or in combination, i.e. a single vertebra could display all five of the deviations from the usual position at the same time.


How does one establish these deviations from the usual position in the separate parts of the spinal column?

In the case of the cervical vertebrae, the transverse processes and the spinous processes can be extremely well palpated, thereby allowing the position of the neck vertebrae to be well determined. The examination is done while the patient is seated with the head hanging down.
In the case of the thoracic vertebrae, the ribs give a magnified image of the position of the vertebrae. Together with palpation of the musculature adjacent to the spinous process on both sides while the patient is sitting straight and while the patient is lying in the ventral decubitus position, this provides sufficient indicators to determine the deviations from the usual position.
In the case of the lumbar vertebrae, the diagnosis is largely made while the patient is lying in the ventral decubitus position. The position of the individual spinous processes is examined and the position relative to the underlying vertebra is also determined, as well as the position of the palpating thumbs, pressed into the tissue lateral to the erector trunci muscle.
In addition, the position of the vertebrae relative to one another is also examined while the patient is lying in the left or right lateral decubitus position with the pelvis on a cushion. A properly functioning back should then show a certain curvature. The above-mentioned deviations from the usual position can soon be identified in this way.
The pelvis plays an important role in the diagnosis of deviations from the usual position in the spinal column. Three deviations may be established in the pelvis, viz.:

tilted sacrum relative to a vertical line;
distorted pelvis without fixation of the sacroiliac (SI) joints, and
distorted pelvis with fixation of one or two SI joints.

A tilted sacrum is established by placing the patient in the ventral decubitus position, if necessary with a cushion under the abdomen if the patient fails to relax sufficiently. You then stand at the patient's head and place both index fingers at left and right of the cranial end of the sacrum alongside the superior articular process and press the fingers in the caudal direction. When one finger then moves more caudally than the other, this indicates that the sacrum is tilted and clamped between the two halves of the pelvis. In many cases this can also be clearly seen when the patient is in the seated position. This deviation may be caused by an asymmetrical vertical force, as in:

falling on the buttocks;
sliding down the stairs while seated;
manual expression during labour.

A distorted pelvis is a pelvis in which one or both ossa are rotated into the SI joint in the rest position, causing one or both cristae iliaca to be more cranial than the other. This is observed with the patient seated by placing the fingers left and right purely lateral on the crests.

In the case of a distorted pelvis without fixation of the SI joints, the functioning of the SI joints is checked as follows: sit behind the (standing) patient and place the right thumb on the sacrum alongside the spina iliaca posterior superior at the left side. A notional line is drawn to the left trochanter major and the left thumb is placed 2 cm away from the right thumb on this line. The patient is then asked to draw the left knee up to the abdomen, if necessary with the assistance of the hands. During the last part of the knee-lifting motion, the left thumb must describe a semi-circular movement and finish above the right thumb. If this happens, the functioning is in order. This examination applies to the left SI joint. For the right SI joint the placement of the hands should be symmetrically reversed.

The cause of the distorted pelvis may be due to deviations from the usual position of the lower lumbar vertebrae and/or to functional deviations or deviations from the usual position of the hip joint. A fused symphysis, which as syndesmosis should nonetheless show some mobility, may also be the cause of a distorted pelvis.

When no movement is observed in the SI joints bilaterally during functional examination of these joints in a distorted pelvis, there is nearly always a fairly appreciable (apparent) lower limb length discrepancy. This discrepancy is not true because it is based on the fact that the examination to determine the height of the two crests is repeated in the standing position and not in the seated position. If it is found upon repetition of this examination in the seated position that a tilted pelvis is still present, there is therefore mention of an 'apparent' lower limb length discrepancy.

A distorted pelvis due to bilateral SI joint locking is caused by fixation of one os ilium ventrally, as a result of which the acetabulum moves caudally; the other iliac bone is then fixed dorsally, which causes the acetabulum to move more towards the cranium. When these fixations are loosened, most of the torsion overstress is usually relieved. When the fingers are subsequently placed on the crests, bilaterally on the erector trunci muscle with the patient seated, one finger is frequently still found to be higher than the other; in this case a tilted pelvis is involved, where one of the os ilii has been displaced cranially or caudally.

A long existing tilted pelvis is 'cushioned' by the spinal column by allowing the vertebrae to rotate around the longitudinal axis, alternating left and right dorsally, up to and including C5. These twisting moments form a fixed pattern with fixed turning points. These fixed patterns are called 'formulae'. One of these formulae can be seen by asking a person with an anatomically normal back to rest one foot on an approximately 2 cm high platform and then stand with the knees straightened. One of the formulae - of which there are four - will then be formed. After removing the platform everything is restored to normal. The formulae are therefore physiological adjustments that can turn into deviations if they become fixed because the tilted pelvis becomes permanent. After correction of the tilted pelvis the formulae do not disappear unless they are treated adequately. This treatment, by manipulation, has a fixed, systematic sequence. The formulae are corrected in five treatments.

The cause of the tilted pelvis is excessive loading of the sacrum with opposing pressure in one of the acetabula; this occurs in sideward strain when lifting a load or in a fall on one of the os ischii.

The deviations from the usual position of the individual vertebrae are largely covered by the formulae. All the additional deviations of the vertebrae cannot be separately assessed and treated until approximately three treatments have been completed.

Complaints and symptoms
The above-mentioned deviations from the usual position of the vertebrae, which are often associated with dysfunctioning, frequently cause 'referred' complaints. The complaints are situated in the dermatome, viscerotome or myotome. In this way, for example, it is possible that complaints of pain in the leg with no radicular compression symptomatology on physical examination are caused by low lumbar deviations in the manual therapy sense. This also applies, of course, to cervicobrachialgia and to dizziness and headaches of diverse origin. With regard to the viscerotomes, it is noted that a connection is frequently found between diffuse cardiac complaints and deviations of the midthoracic spine. In nonspecific abdominal complaints a connection is also frequently seen with deviations of the lumbar spinal column. There is consequently also mention of a therapeutic approach to vegetative complaints that cannot be determined by means of instrumental diagnosis and which are susceptible to spinal column manipulation.

Therapy
Treatment consists generally of light pressure in the opposite direction to the deviation from the usual position, causing the vertebra to resume its normal position in the co-ordinate system. This will usually require several combined manipulations. It has been demonstrated empirically that the spinal column is governed by fixed laws. These laws entail, among other things, that:

each vertebra must be treated separately;
each deviation from the usual position must be treated separately, and
there is a certain sequence in the treatment of these deviations from the usual position.
This local and specific pressure is exerted on the transverse process or spinous process, in the course of which the adjacent segments either have to be relaxed or possibly fixed in torsion. During this treatment, use is made of cushions of different heights.


For reprints and communicae, please contact M. SICKESZ AND E.B. BONGARTZ. The authors would like to express their thanks to their colleague E. Keijzer, M.D., Doctor of Osteopathy, of Lelystad, for his valuable comments.

References
Cyriax F. Textbook of orthopaedic medicine. Vol. I. II. London: Baillière Tindall, 1980.
Lewit K. Manuele therapie. Part 1 and 2. Lochem: De Tijdstroom, 1979.
Niboyet JEN. La pratique de la médicine manuelle. Saint-Ruffine: Miasonneuve, 1968.
Williams PC. The lumbosacral spine. New York: McGraw-Hill, 1965.
Sickesz M. Orthomanipulatie. Alphen a.d. Rijn: Stafleu, 1981.
Biesinger E. Diagnosis and therapy of vertebrogenic vertigo. Laryngol Rhinol Otol (Stuttg) 1987; 66: 32-6.
Kunert W. Wirbelsäule, vegetatives Nervensystem und innere Medizin. Stuttgart: Enke Verlag, 1978.

What is Gua-Sha?

Gua Sha / Gua-sha / Guasha is a connective / soft-tissue mobilization technique commonly used in Asia by practitioners of Traditional Chinese Medicine. Gua Sha is used by TCM clinics and practitioners with the most frequent intent of restarting circulation and releasing "Sha," held by many TCM practitioners to reflect blood "trapped" in the peripheral capillaries. Gua-sha would literally translate into "releasing (the) Sha."

In Gua Sha, a scraping handheld tool is applied to skin, to fascial depth, in longitudinal strokes. This is meant to release the "exterior Sha." A stimulation of movement of lymph and blood flow occurs. This is interpreted as a means of discharging "cold negative energy" via the skin surface. Many TCM practitioners swear by Gua-sha, saying it helps cure many diseases.

In the TCM context, Gua Sha is held to be valuable in the treatment of pain, in the prevention and treatment of acute infectious illness, upper respiratory and digestive problems, and the resolution of many acute or chronic disorders.

Gua Sha is the Traditional Chinese Medicine analogue of today’s Connective Tissue Mobilization Techniques that use tools. In a strictly Manual Medicine analysis of the technique and its results, Gua-sha is a local, direct, tool-enhanced myofascial release. The body of techniques Gua-sha is thus categorized in is more popularly known now as Instrument-Assisted Connective / Soft Tissue Mobilization (IASTM / IASCTM). The more popular of the branded techniques include the Graston Technique and SASTM (Sound-assisted Soft-Tissue Mobilization).

You’ll let us know know as soon as you realize you want to learn CTM / IACSTM with us, won’t you?

Stay well, evolve, and prosper.

Saturday, January 10, 2009

Thnak you for joining us in evolving visceral manipulation skills in the philippines!

ON THE DIVERSITY OF MANUAL THERAPY TECHNIQUES

Manual Healing Diversity and Other Challenges to Chiropractic
Integration

Carl D. Nelson, DC, Daniel Redwood, DC,
David L. McMillin, MA, Douglas G. Richards, PhD, Eric A. Mein, MD
Meridian Institute
Virginia Beach, VA 23454
[NOTE: This article was published in The Journal of Manipulative and Physiological Therapeutics,
March/April, 2000, Vol. 23, No. 3]
Submit reprint requests to: Carl D. Nelson, DC, Meridian Institute, 1849 Old Donation Parkway, Suite 1,
Virginia Beach, VA 23454, (757) 496-6009.
ABSTRACT
Chiropractic has made significant strides in establishing itself as a leading contender for integration in
the emerging health care system. However, recent articles in prominent medical journals illustrate key
issues that must be resolved for chiropractic to fully establish itself within the new health care model.
Manual therapy diversity and the corollary question of whether chiropractic care should be defined solely
in terms of the high velocity-low amplitude (HVLA) adjustment, are issues in need of urgent attention
and analysis. Other problematic areas affecting chiropractic's integration into the health care mainstream
include research methodology issues, treatment of visceral disorders, and professional relationships.
INTRODUCTION
Chiropractic has met many challenges in its development as a healing art. Throughout most of its
existence, the chiropractic profession has battled opposition from organized medicine, suffered
financially as a result of exclusion from health insurance reimbursement, and been widely regarded as a
marginal profession (1). Despite these obstacles, chiropractic has flourished, becoming the third largest
of the learned health care professions (2). Although the quality and quantity of chiropractic research
during the early years of the profession left much to be desired (3), modern research has contributed
significantly to the success and acceptance of chiropractic.
With the rapidly changing political and economic aspects of health care delivery, chiropractic is well
situated to make important contributions to the emerging health care paradigm. However, to fully
participate in this revolution, key issues must be addressed with regard to manual therapy diversity,
research methodology, the treatment of systemic dysfunction, and professional relations.
MANUAL THERAPY DIVERSITY
Chiropractic is one of the main branches of manual therapy. Historically, one of the major challenges
of chiropractic has been to define and maintain its unique identity among the various manual therapy
professions. This has often resulted in a competitive stance toward other forms of manual therapy.
Notably, the rift between chiropractic and osteopathy goes back to the founders of the professions,
who openly debated the conceptual and clinical differences of their respective approaches (4).
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Osteopathy has integrated a wide variety of modalities, most notably the practice of medicine, while
chiropractic has remained primarily focused in the application of manual therapy. While the role of
manual therapy in osteopathy (osteopathic manipulative treatment or OMT) has decreased, the diversity
of techniques practiced by osteopaths has increased. The minority of osteopaths who practice OMT
utilize a broad spectrum of techniques including inhibitive pressure, soft tissue manipulation, and
cranial/sacral treatment.
In chiropractic as well, the short lever high velocity/low amplitude (HVLA) thrust adjustment (typically
associated with an audible cavitation or "cracking" sound) has been supplemented by a wide range of
non-cavitating methods including flexion-distraction, sacro-occipital, Thompson, Activator, Applied
Kinesiology, directional non-force, and dozens of others. Defining chiropractic strictly in terms of the
HVLA adjustment fails to accurately describe the practice of contemporary chiropractic.
Historically, chiropractic has struggled with the dilemma of therapeutic diversity in a number of ways.
To some extent, the battle between "purists" and "mixers" continues to this day (5). Some
chiropractors offer a blend of diverse manual therapy techniques in addition to complementary and
alternative medicine (CAM) options including nutrition, herbal medicine, energy medicine, and
physiotherapy. These DCs view themselves as chiropractic physicians qualified to address a broad range
of disorders, including systemic dysfunction and visceral disease. Many of these clinicians use methods
from the full spectrum of manual therapy, including soft tissue manipulation. Other chiropractors limit
their therapeutic methods to the hands-on adjustment but apply this method to both somatic and
visceral complaints. Still others feel strongly that the role of chiropractic should be limited to treating
somatic dysfunction, primarily back and neck pain.
Manual therapy diversity is more than an historical or academic issue. Structuring research to reflect
this diversity poses a significant methodological problem and, if recent, well-publicized studies are a
harbinger of things to come, represents a potential major stumbling block to chiropractic's full
integration into the mainstream of health care.
ISSUES IN RESEARCH METHODOLOGY
Two studies reported in leading medical journals illustrate the potential methodological problems
confronting chiropractic researchers. In the New England Journal of Medicine, Balon et al. (6)
compared "active" and "simulated" chiropractic manipulation as adjunctive treatment for childhood
asthma.
The active treatment consisted of "manual contact with spinal or pelvic joints followed by lowamplitude,
high velocity directional push often associated with joint opening, creating a cavitation, or
'pop'." This treatment is a standard direct technique used by a wide variety of manual therapy
practitioners, primarily chiropractors and osteopaths.
The simulated treatment involved:
* "soft-tissue massage and gentle palpation" to the spine, paraspinal muscles, and shoulders
* "turning the subject's head from one side to the other"
* "a nondirectional push, or impulse" to the gluteal area with the subject lying on one side and then the
other
* with the subject in the prone position, "a similar impulse was applied bilaterally to the scapulae"
* the subject in a supine position "with the head rotated slightly to each side, and an impulse applied to
the external occipital protuberance"
* "low-amplitude, low-velocity impulses were applied in all these nontherapeutic contacts, with adequate
joint slack so that no joint opening or cavitation occurred"
Jongeward (7) questioned the appropriateness of the simulated treatment, noting that that standard
chiropractic practice commonly includes soft tissue work. Furthermore, the sham treatment in the Balon
et al. study bears a marked similarity to a traditional general osteopathic treatment (8-10). The Early
American Manual Therapy website provides easy access to several such examples from the traditional
manual therapy literature (11).
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The authors of the Balon et al. study summarized the simulated treatment by stating, "Hence, the
comparison of treatments was between active spinal manipulation as routinely performed by
chiropractors and hands-on procedures without adjustments or manipulation." Apparently, these
investigators were unaware of the early osteopathic works addressing asthma (8-10) and more recent
literature on OMT for respiratory problems in general, particularly as cited in Osteopathic Considerations
in Systemic Dysfunction (12). The methodological limitations of the Balon et al. study with regard to
manual therapy were noted by Richards et al. (13). Balon et al. (14) responded that they were
unconvinced by the evidence supporting the efficacy of the simulated treatment.
The results as reported by the researchers were, "Symptoms of asthma and use of ß-agonists
decreased and the quality of life increased in both groups, with no significant differences between the
groups." Based on this equality of improvement, the authors concluded, "the addition of chiropractic
spinal manipulation to usual medical care provided no benefit," (6). In our view, this is unfortunate,
because the data clearly indicate that the subjects in both groups improved after being treated by
diverse forms of manual therapy.
Another article, reported in the Journal of the American Medical Association, also fails to accurately
portray and interpret manual therapy diversity. In certain respects, "Spinal Manipulation in the
Treatment of Episodic Tension-Type Headache" (15) duplicates the questionable methodological choices
in the Balon et al. study. The researchers compared two forms of manual therapy for the treatment of
tension headache. The experimental treatment consisted of HVLA chiropractic adjustments and deep
friction massage plus trigger point therapy (if indicated). The subjects receiving this intervention were
designated as the "manipulation" group. The "active control" group received deep friction massage plus
low-power laser light (considered not to be efficacious for tension headache). Thus, as in the asthma
study, one form of manual intervention was compared to another.
The researchers observed that "by week 7, each group experienced significant reductions in mean daily
headache hours" and mean number of analgesics per day." But because both groups benefited equally
from the diverse forms of manual therapy, the authors concluded that, "as an isolated intervention,
spinal manipulation does not seem to have a positive effect on episodic tension-type headaches." (15, p.
1576). Unlike the Balon study, this carefully worded conclusion is technically correct, though it would
also have been technically correct to conclude that both massage and manipulation plus massage
resulted in measurable improvements for tension headache sufferers.
Both the headache and the asthma studies were widely reported in the mass media as demonstrating
that chiropractic fails to help patients with childhood asthma and tension headache. In our view, a more
informative conclusion is that diverse forms of manual therapy appear to be at least mildly helpful for
these conditions. Although the favorable outcomes could have resulted from chance or placebo effects,
a reasonable person might also justifiably conclude that various forms of manual medicine can be helpful
for these conditions. The diversity and potential validity of the full spectrum of manual therapy
applications significantly confounds the issue.
Although less publicized, Nilsson (16) used the same methodology in an earlier study on cervicogenic
headache (n=39). Standard chiropractic (HVLA spinal manipulation) was compared to deep massage,
trigger point therapy and light therapy (control treatment). The subjects in both the experimental and
control groups showed notable improvement. There was no statistical difference in the outcomes
between the two groups. Ironically and disconcertingly, Nilsson specifically noted in this earlier article
that, "the control group in the present study (massage/trigger points) is normally assumed to have
some effect on this group of headaches." He further noted the inherent methodological shortcomings
of using such a group as a control: "Future studies need necessarily include higher numbers of
experimental subjects, but should take care to use an absolutely inert control treatment (for example,
low-level laser only)." (16, p. 440) One can only wonder why Nilsson elected not to follow his own
clearly stated recommendation, and instead used the same admittedly questionable methodology in the
later tension-headache study.
Future research must seriously consider the full spectrum of diverse manual therapy options rather
than assuming that some forms are ineffective and can therefore be used as sham treatments.
Legitimate alternative methodologies exist, particularly direct comparisons of chiropractic procedures
(allowing the full range of methods typically used by chiropractors in real-world practice settings) versus
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standard medical care. Some comparative studies (17-21) have shown chiropractic equal or superior to
conventional medical procedures, with fewer side effects. If fairly constructed, future studies of this type
will yield data that allow health practitioners and the general public to place manual therapy procedures
in proper context. Comparing manual therapy to highly questionable placebos confuses the issue, and
delays the advent of a level playing field (22).
MANUAL THERAPY AND SYSTEMIC DYSFUNCTION
Apart from the diversity issue, the other fundamental question raised by these studies is the possible
influence of chiropractic (and by inference other primary forms of manual therapy) in the treatment of
systemic dysfunction. Is manual therapy only helpful for somatic dysfunction (i.e., back and neck pain),
or can systemic dysfunction (including visceral disease) also be effectively treated by chiropractors and
other manual therapy practitioners?
Interestingly, the origins of both chiropractic and osteopathy can be traced to positive outcomes in
the treatment of systemic dysfunction. D. D. Palmer's treatment of a patient with hearing impairment
marks the beginning of chiropractic (23). A. T. Still used an inhibitive technique (lying with his head in a
sling) to relieve his own headaches. This, in addition to his grief over the death of three of his children
from meningitis despite the best available medical treatment, drove Still to create a system for healing
systemic dysfunction (24).
In recent years, the treatment of systemic dysfunction by chiropractors has declined (25), although
reports of effective treatment for nonmusculoskeletal problems continue to be published (26-29).
Although osteopathy has seen a general decrease in the use of manual therapy, interest still exists with
regard to the treatment of systemic dysfunction (12).
To clarify the role of manual therapy in the treatment of systemic dysfunction, Sawyer et al., (1)
recommended clinical research aimed at investigating outcomes and effectiveness of chiropractic care on
somatovisceral disorders. The priority list of disorders included dysmenorrhea, asthma, otitis media,
essential hypertension, irritable bowel syndrome, and peptic disorders. This research has begun, but is
still in a preliminary phase.
This is a controversial topic with profound ramifications for the future role of chiropractic in the overall
health care system. With recent changes in the health care system toward incorporation of CAM
approaches, chiropractic has emerged as a leading candidate for integration in the new health care
model. Thus far, however, this has been predicated on an implicit assumption that chiropractic's
therapeutic domain is the treatment of somatic disease. In large measure, chiropractic is perceived,
rightly or wrongly, as a form of specialized physical therapy. If chiropractic is to be smoothly integrated
into the health care mainstream, the path of least resistance calls for dropping the notion of manual
therapy for systemic dysfunction. To do so, however, would fly in the face of a century of chiropractic
practice.
Manual therapy for systemic dysfunction is controversial from a scientific perspective. Nansel and
Szlazak provide a comprehensive and insightful review of the conceptual and biological problems
associated with the systemic dysfunction issue (30). Basically, these authors reframe the apparent
influence of manual therapy on systemic dysfunction as an etiological misunderstanding, the result of
misdiagnosis. According to Nansel and Szlazak, the visceral symptoms in question are actually "somatic
mimicry syndromes" produced by somatic nerve reflexes which simulate (rather than cause) internal
organ disease. Thus, chiropractic treatment in such cases merely removes the "somato-somatic reflex."
The abundance of citations provided by the authors strongly supports their position of the improbability
of manipulation's effects on true somato-visceral disease.
However, a more recent article by Sato presents strong biological evidence of somato-visceral reflexes in
animals, where cutaneous stimulation of somatic afferents evokes reflex sympathetic efferent activity.
Sato's basic scientific work appears to strongly support the concept of somato-visceral disease. Sato's
conclusion is that "a great deal of work remains to be done." (31, p. 601). It is noteworthy that Sato's
studies have been presented in osteopathic and chiropractic publications (32), and have appeared in a
variety of neurophysiology journals as well (33-36). Sato's nonpolitical, interdisciplinary approach is
exemplary of the cooperative attitude needed in this type of research.
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PROFESSIONAL RELATIONSHIPS
What role will chiropractic play in the emerging health care system? As Lamm et al. (37) have asked,
"Are chiropractors portal-of-entry physicians, primary care givers, first contact physicians, generalists,
specialists, or a hybrid of these?" In order to establish and maintain constructive relationships with
other health care providers, chiropractors must come to terms with who they are and what they do. The
process of integration into the evolving health care system may involve an identity crisis for
chiropractors.
As a group, chiropractors are highly individualistic and independent. With changes in the health care
system, opportunities are being created for chiropractors with the ability to adapt and cooperate to
become more fully integrated into mainstream health care. Therefore, as the health care system is
reformed, relationships with other professionals become a critical issue. The previous discussions of
manual therapy diversity and the treatment of systemic dysfunction are relevant to evolving patterns of
professional interaction.
To take one important example, will interactions with osteopaths become more collegial rather than
perpetuating the historical division between chiropractic and osteopathy? Will respect for manual
therapy diversity become the new ideal? Cooperation makes sense. Osteopathic research and clinical
experience can contribute to chiropractic efficacy and vice versa. Perhaps some chiropractors worry that
too close a relationship with osteopaths may be contagious - that whatever prompted most osteopaths
to largely abandon manual therapy will somehow afflict chiropractors.
While this fear is based on a kernel of truth, the future of chiropractic need not mirror the past and
present of osteopathy. One crucial difference is that, unlike the osteopathic profession, chiropractic's
political and academic leadership, and the vast majority of today's practitioners, are united in support of
maintaining the profession's central emphasis on the core concepts of chiropractic - the link between
structure and function, the critical mediating role of the nervous system, and the primacy of the
adjustment in chiropractic practice. This is strongly supported by both ACA and ICA, and was
unanimously endorsed by all North American chiropractic college presidents at the historic 1996 meeting
of the Association of Chiropractic Colleges. (38). Most significantly, no broad-based chiropractic political
organization or educational institution has ever endorsed giving up manual therapy or limiting its
application to strictly musculoskeletal conditions.
While working at building relationships with practitioners of other health professions, chiropractic
must also attend to splits within its own house. Traditional conflicts between "straights" and "mixers"
are well-known and continue to be a source of contention. A modern counterpart of this division is the
primary care physician/manual therapy specialist distinction. Some chiropractors endorse an exclusively
somatic dysfunction model. At the same time, other DCs are carving out a niche as primary care
physicians by treating somatic and systemic dysfunction with a broad range of therapeutic modalities.
Others, perhaps the majority of the profession, find themselves in the middle ground between these
two poles. While basic research and outcomes studies may help to eventually resolve this split, such
resolution is unlikely to occur soon.
The interdisciplinary team model is a plausible vehicle for passage to a more diverse and integrated
health care system. Lawrence (39) suggests that the rural setting is an ideal environment for
interdisciplinary teams with chiropractic members, but also recognizes the inherent challenges of such
cooperation:
"The involvement of chiropractors as members of interdisciplinary teams will no doubt suffer from
initial problems, such as lack of professional acceptance by medical physicians and nurses, ill-defined
roles for chiropractors, intraprofessional conceptual challenges (for example, will we be autonomous in
decision making on a par with other professionals?), etc." (39, p. 78)
The increasing interest in CAM therapies is an especially promising track for improved professional
relations. Interdisciplinary teams which include CAM practitioners are increasing, especially on the West
Coast and in large urban areas in other parts of the country (40). If chiropractors are unable or unwilling
to create a niche in such groups, other manual therapy practitioners (ranging from massage therapy to
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reflexology to therapeutic touch) may fill the void.
Emphasis on research is helpful in these settings. Honest research acknowledges an openness and
desire to learn. These are essential qualities for members of an interdisciplinary research team.
Research also provides an umbrella for mainstream practitioners to safely explore alternatives.
The authors of this article are members of an interdisciplinary team with diverse backgrounds in
chiropractic, medicine, osteopathy, biology, and psychology. The rich diversity of the group enhances
the research process. Manual therapy diversity is not a problem, but an opportunity to explore the
efficacy of a variety of techniques. Likewise, the use of manual therapy for systemic dysfunction is an
enticing hypothesis that will require much time and effort to test. Commitment to an ideal higher than
the advancement of a particular profession is necessary for such teams to work closely together over
time. Such an ideal may be as simple and direct as improving the quality of patient care via whatever
means available.
CONCLUSION
Health care is in a time of great change. Chiropractic has much to offer the new health care system.
With its rich heritage of therapeutic pragmatism, its growing body of research, and its well-developed
professional infrastructure (41), the profession is well positioned to influence the future direction of
health care. However, to fully participate in this transition, several key questions must be addressed.
* Will chiropractic be defined solely in terms of the high velocity/low amplitude thrust adjustment or in
terms of the full spectrum of manual therapy techniques?
* Can chiropractic provide efficacious treatment of systemic dysfunction or will it be limited to the
treatment of musculoskeletal ailments?
* Will chiropractic research address the methodological pitfalls which result from a failure to recognize
the diversity of manual therapy approaches?
* Will further basic research into the biological mechanisms of somato-viseral disease be pursued?
* Will the common ground between chiropractic and other forms of manual therapy (particularly
osteopathy) be recognized and utilized?
* Will the economic and political pressures to integrate into the mainstream diminish the unique
contributions of chiropractic?
* Will chiropractors be viewed as doctors equipped to address a wide range of human ills or as
specialists in advanced musculoskeletal physical therapy?
These are controversial questions worthy of discussion and debate. Chiropractic is at a crossroads.
The direction taken by today's chiropractors may well influence the role of manual therapy for years to
come.
Historically, chiropractic has maintained itself as a relatively independent entity. Initially, chiropractic
education, research, and clinical practice were isolated from the mainstream due to a variety of factors
(1). Despite undeniable progress, for the most part chiropractors are still outsiders looking in. Now
that the door has begun to swing open, will chiropractic come into the mainstream?
In the past, chiropractic had to distinguish itself to survive. Emphasizing differences between itself
and other similar professions (especially osteopathy) was helpful in creating a unique identity. While
maintaining identity is still important, chiropractic has matured to the point where it can benefit from
mutually beneficial professional relationships. As health care reforms continue, it will be helpful to
emphasize common ground rather than exaggerating differences. Where differences exist,
acknowledging diversity without attacking will increase the chances of building positive professional
relationships.
As long as chiropractic provides cost-effective, efficacious service, its future is bright. A strong
commitment to research (both basic and clinical) is needed to document the efficacy of chiropractic
treatment, while defining its limitations. Chiropractors must come to terms with manual therapy
diversity. The treatment of systemic dysfunction via manual therapy will continue to be a controversial
topic. Improved research design is essential, especially to avoid disregarding positive outcomes when
manual therapy is used for systemic dysfunction. Interdisciplinary research teams offer a promising
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means of integration of chiropractic with other treatment modalities and improved professional relations.
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41. McAndrews JF. Appropriate Care, Ethics and Practice Guidelines. In Redwood D, editor.
Contemporary chiropractic. New York: Churchill Livingstone; 1997. p. 219-227.
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Saturday, January 3, 2009

Level 3 of Consciousness

Hello, Fellow Traveler!
Can I share with you something that has affected me profoundly?

You are reading about something that most people don’t even know exists.
If you told them, they wouldn’t just not believe you —
they would have no clue what you were talking about.
That’s why I wrote this little essay:
so that I could show it to someone when they had no idea what I was talking about
and, if they were persistent and open-minded, make some progress in their
thinking. And meanwhile I could get on with my other projects.

1. In the beginning, there was attraction. Things attract each other because they like to be closer to some things than other things. This is the root of all change in the whole universe.
Sometimes like attracts like and sometimes opposite attracts opposite. When opposites attract, you’ve got a pair, a couple. That pair is now another unit and you can start the whole process over again. The pair, the new unit, can attract an opposite or a like or just drift along.
When like attracts like, it can end there, like an oxygen molecule made up of two oxygen atoms, or it can continue to attract like, like a Carbon atom. When things continue to attract like, something big gets created.

2. Sometimes a thing will attract just the right stuff to it that the new stuff turns into another copy of the thing. That is self-replication. Self-replication is the most powerful force in the universe. One becomes two,
two become four, four become eight, and soon the universe is full of things.
Sometimes a self-replicating thing makes a copy of itself with a mistake in it. The thing with a mistake will either be better, worse, or the same at making copies of itself. If it’s better, there will soon be more copies of the new thing than the old
thing in the universe.
The only way for new things to get created is by a complex series of "mistakes" (my editing - Strix) that turn out to be better after all.

3. We are self-replicating things. We are the result of a billion years worth of "mistakes" that turned out to be better after all.

4. One big "mistake" that turned out to be better after all was that, of all the animals, we alone can communicate complicated ideas. We can tell stories. We can share recipes. We can make complicated plans. Even dolphins and
whales can’t do these things, we think.

5. These ideas that we communicate are called memes. Memes are a kind of thing. Memes live in our minds.

6. Like all things, memes fit better with some things than others. Some memes naturally fit better in people’s minds. Some memes naturally fit better with other memes. When a group of memes fit well together and pull the strings of
someone’s mouth and vocal cords so that they pass them on to others, a new, self-replicating thing gets created. The new thing is called a memeplex.
Self-replication is the most powerful force in the universe. One person tells two, two tell four, four tell eight, and pretty soon the whole universe is full of people sharing the memeplex.
Sometimes a self-replicating memeplex makes a mistake in copying itself. The memeplex with a mistake in it will either be better, worse, or the same at making copies of itself. If it’s better soon there will be more copies of the new memeplex
than the old in the universe.
The only way for a new idea to gain acceptance is by a series of copying mistakes that turn out to be better after all.

7. All our belief systems, religions, and governments are the result of a series of "mistakes" that turned out to be better at making copies of themselves after all.

8. Every new idea we think of immediately becomes transformed by copying mistakes that change it into something that is better at making copies of itself after all. A key part of the idea may be sacrificed to something better for copying.
The only control we have over the spread of our ideas is in making them as resistant to copying mistakes as possible.

9. When we are born, our mind is courted by meme after meme after meme, all the result of thousands of years of practice at getting themselves copied into fresh new minds. This is Level 1. We have our instincts, born of millions of years of the genes our body carries striving to make copies of themselves.

Soon our minds become filled with memes and eventually we may develop a map of life that mostly makes sense. We speak a language that we believe expresses anything we want to say. We use geometric and physical concepts that we believe explain anything we encounter. We know stories and myths that we believe relate to all of life’s trials and tribulations. This is Level 2. We have our roadmap, born of thousands of years of the memes our mind carries striving to make copies of themselves.

10. Each of us has a purpose here. When the memes are quiet, it is possible to feel when we are on purpose and when we are off purpose.

11. Once we realize that there are millions of memes battling inside our mind, there arises the possibility of influencing the outcome of that battle. Until we realize it, there is no possibility.
The battle can be influenced in three ways.
First, by noticing the memes.
Second, by detaching from them.
Third, by obtaining clarity of purpose.
When these three steps are achieved, we can begin to select our memes consciously.
We select memes that keep us on
purpose. This is Level 3.

12. A purpose is not a goal. A purpose does not feel like guilt, shame, or vengeance. Guilt, shame, and vengeance are emotions used by memes to gain mastery over your life. By choosing memes consciously, we can eliminate the control that memes have over those emotions.

A purpose feels fulfilling, satisfying, joyful, and powerful.

13. A purpose has to do with other people. A purpose is fulfilled by spreading memes. Every time we speak, write, create, or act we are spreading memes. To fulfill our purpose we must be conscious of which memes we are spreading.
Life is largely composed of conversations. Conversations are composed of memes.
In Level 1 we are unaware of this.
In Level 2 we see the world as a solid, understandable body to be interacted with.
In Level 3 we see the world as a canvas to be painted, an instrument to be played, or a block of marble to be sculpted by us for our purpose. We choose to do
this for good or for evil. If we choose good, good is returned to us in unexpected ways. If we choose evil, evil is returned. Either way, it looks like the way we choose is the way of the world.

14.
In Level 1, we do not understand the world and consequently fear it.
In Level 2, we replace the fear with understanding. The price of understanding is limits. Our approximate models of the universe are never completely
accurate, never useful in all situations.
In Level 3, we start with a vision of what we want to create. From there we choose our models. Sometimes a chosen model may seem insane to the other inhabitants of the little patch of space-time we happen to occupy. No matter. Men with a vision of goodwill have often looked insane in times of mistrust and scarcity.
But in Level 3, we realize that the universe is not a maze to be navigated; it is a baby to be brought up. When we give it love, clarity, and opportunity, we
raise a child to be a joyful, giving, successful adult. This is the opportunity we have to farm our little patch of space-time.

With thanks, from 1/3/2009, to Richard Brodie for his work on
"Level 3 of Consciousness"
please check out Richard's MEMEs at www.memecentral.com/Level3.htm

Friday, January 2, 2009

Unsolicited advice for the young or new manual med practitioners

Yes, i know. Unsolicited advice. I mean, who wants unsolicited advice?
I am, however, extremely glad that you found your way to this page. That can mean any one of several things, of course. I am, however, hoping that you're here because (like us), you are looking for answers. If not anything else, we've only been around slightly longer than you have in this field. We're hoping that that time and exposure difference can still enrich your experience. Of course, if you've been around for thirty years in manual medicine and have an unstoppable need to keep constantly updated, then, well, this part of this site ISN'T for you.

Wee bits of advice for manual medicine / manual therapy / bodywork specialist practice, then (especially in the Philippines):

Ask a lot of questions. Question what you're told. Question what you're shown. Question your results. Question yourself. Find commonalities. Find the exceptions. Sit down with and learn hands-on from the best of every field, wherever you can find these experts. Get off your bench and go out into the world and see patients. Stop worrying about your lack of experience. Start getting experience. Go to clinics. Volunteer. Apprentice. Step out of the box. Think again. Put yourself in your patient's shoes. Imagine what it's like, then imagine what it can be like. See as many teachers as possible before settling to spend the most time with just one teacher. If you have no point of comparison, it's so easy to blindly love and follow the school you've been to. Go to other schools. Use whatever is useful. If it isn't working, do it better or stop doing it. If it isn't working, it's the wrong tool -- use something else. Reflexes are there for a reason. What are they doing? Pay attention. Notice baseline and supposed functional levels. What can your patient not do? What do they need to be doing? Learn first. The earning will follow. Your patient is your bottomline. You take care of your patients, and they'll take care of you. Start with good intent, and it's extremely hard to go wrong. Go evidence-based. If it consistently works clinically, why not use it? Your patients are people. Follow your heart.

Okay, so they sound like truisms. They are, however, statements as true to our practice as we can write them out for sharing with you.

This entire page was written in a frenzied three minutes. My hands aren't as fast as my mind, nor as consistent as my heart. There was no censorship here. Just a sharing. Please, share with us and help us become better at what we do.

Towards an evolution in our field, and the synthesis of true healthcare,

Stay blessed.

manual medicine YAHOO group

For freebies, special offers, training updates and resource materials on manual medicine, please send a request invite to:
http://groups.yahoo.com/group/manualmedicinetechniques

Thursday, January 1, 2009

Neurodynamic Solution Certification Course Philippines

We are furnishing here a copy of a posting by our friends at SOMATIC and UST-CMT:

Neurodynamic Solution Certification Course in
the Philippines
Neurodynamic Solution, Australia in cooperation with Somatic Philippines and Integrated Manual Physical
Therapy invites you to the very first Certification Course in Neurodynamic Solution in the Philippines.
When & Where
April 24-27, 2009
Venue - to be announced
Course Instructor
Kiran Challagundla, BPT, MPT, MIAP, FAGE
Master of Orthopedics, Sport and Manual Physiotherapy
Currently:
Consultant Physiotherapist - Spintas HealthCare, Hyderabad .
Member - Global Teaching Group, Neurodynamic Solutions (NDS).
Director & Course instructor - Maitland’s Foundation for Sports & Manual Therapy
Former Physiotherapist for:
Deccan Chargers (DC), Indian Premier League (IPL).
Hyderabad Heroes, Indian Cricket League (ICL).
CBCOC - The Dolphins Football Club, Adelaide , Australia .
Certification Details
The participants will receive 2 certificates (1 each for the Upper and Lower quarters) certified by
Neurodynamic Solutions (NDS) Adelaide Australia signed byMichael Shacklock that are valid worldwide
1/1/2009 Neurodynamic Solution Certification …
http://angtherapist.com/archives/686 1/10
Neurodynamic Solutions (NDS), Adelaide, Australia signed by Michael Shacklock that are valid worldwide.
These certificates are the same certificates that are given by Michael to all the participants who attend his
workshop worldwide.
Course manual: Candidates who attend NDS course will receive a 200-page Course Manual prepared by
Mr. Michael Shacklock himself, and will be the same one which Michael gives to all the participants who
attend NDS courses worldwide.
Teaching topics and teaching material: The teaching topics, Powerpoint presentation and Course syllabus and
material will be the same one that was prepared by Michael Shacklock himself, and is the same material that
is taught by Michael worldwide.
Free NDS Newsletters: All articipants who attend the NDS course will be automatically registered in the
NDS group, and will receive regular NDS news letters through E-mail. These NDS news letters are written
by Michael Shacklock, and contains most updated Scientific Research in Neurodynamics, Clinical solutions,
conference announcements, books and other resources, web links – other physiotherapy / physical therapy
and educational groups, search engines and physical therapy databases.
Course Fee
Up to March 31, 2009: P12,000
April 1 up to April 23, 2009: P16,000
On-site registration: P20,000
To reserve a slot, you may pay 50% of the fee set for the time you would register. The payment is NONREFUNDABLE
but TRANSFERRABLE.
For inquiries, you may text or call (63) 9194077701 (Valentin C. Dones III) or (63) 9274814155 (Leomil
Adriano).
You may visit the website www.neurodynamicsolutions.com to check more about Neurodynamic Solution.