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Thread: Ask Rip #58

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    I specifically asked my anatomy professor the question about cracking one's fingers when I was in college. He did not know and produced a massive anatomical reference that I do not remember the name of. Eventually he found what seemed to be the current (at the time) hypothesis on why finger joints "crack".

    It's not nitrogen, but CO2 gas that is removed from the chondrocytes in the cartilage and not in solution in the synovial fluid. Because synovial fluid is a non-Newtonian fluid (shear thickening), the CO2 is able to diffuse out of solution over time with a very small amount of vacuum pressure based stress. When you force it closed (by cracking your knuckles), the shear thickening properties react to the high stress due to the quickly closing volume and the pressure builds. The cracking compresses the joint and forces the CO2 back into solution in the synovial fluid and the sound you get is that adsorption.

    This could be bullshit, but that is my current understanding.
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    This was a very good discussion. Thanks for sharing.

    With respect to the cause of the popping sound associated with spinal manipulation, Rip is correct that this is not due to the escape of nitrogen gas from a collapsed bubble. At this point in time we don’t know for certain what causes the popping sound. A proposed mechanism is tribonucleation, where a cavity is created within synovial fluid by means of joint distraction. http://journals.plos.org/plosone/art...type=printable

    As far as the mechanism of action of spinal manipulation is concerned, there is no conclusive mechanism of action to speak of. I don’t know why the antiquated false narrative of realigning the spine continues. This paper outlines the proposed mechanisms of SMT and the need for further study in the hopes of ascertaining a definitive model. https://www.ncbi.nlm.nih.gov/pmc/art...hms-140696.pdf

    This doesn’t mean that there is no place for SMT as a means of short-term pain modulation in order to facilitate engagement in physical activity and exercise, but practitioners need to be honest with their patients in explaining that they do not yet understand the mechanism of action behind the therapy. At the same time, not knowing the mechanism of action does not excuse practitioners who espouse the “subluxation theory”, which should be stricken from all chiropractic curricula, to loosely associate the adjustment with having the ability to cure a wide variety of visceral disorders, as this simply is not true.

    In terms of “corrective exercises”, physical rehabilitation is taught in chiropractic schools but the problem is the people teaching these courses are not strength coaches or experts in teaching and explaining the barbell exercises. This problem poses an excellent opportunity for Starting Strength to get involved with open-minded leaders of such institutions who understand the value of strength training in a physical rehabilitation setting and possibly incorporate the Starting Strength method as part of the formal curriculum. This would produce chiropractors with a solid understanding and foundation in prescribing and coaching the basic barbell exercises as part of their treatment plans.

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    Quote Originally Posted by JHG View Post
    This problem poses an excellent opportunity for Starting Strength to get involved with open-minded leaders of such institutions who understand the value of strength training in a physical rehabilitation setting and possibly incorporate the Starting Strength method as part of the formal curriculum. This would produce chiropractors with a solid understanding and foundation in prescribing and coaching the basic barbell exercises as part of their treatment plans.
    I'm pretty good at answering the phone.

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    Quote Originally Posted by Mark Rippetoe View Post
    I'm pretty good at answering the phone.
    I will call you tomorrow.

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    Quote Originally Posted by Mark Rippetoe View Post
    The Chiro and PT professions are slowly killing themselves. PT's want to "pop" people now and Chiros want to do corrective exercises. I have worked along side 2 DPT and none of them prescribed progressive strength. Their exercises were things Bachelor PTs were doing 25 years ago. However, its all about manipulations and dry needling right now. Crack a back, stick some needles, and out the door. Both are way overused, while progressive strength exercises are not. Strength is by far the common denominator with chronic pain, but when you have to convince your therapist and the patient that this is what is needed, one begins to wonder what all this schooling is about.

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    Andrew: we were taught the exact same thing in PT school. There are some imaging studies out there that seemed to support the CO2 hypothesis. I give that as a "theoretical explanation" when asked in the clinic, but as Dr. JHG stated, we should refrain from speaking in absolute terms with patients.

    Dr. JHG: SMT works. You know it. I know it. We both use it for the exact same reason. I don't know exactly why (various theories), but it is a very powerful tool i can leverage to produce rapid improvements in mechanical symptoms which opens the door for squatting, deadlifting, and actual long term positive improvements in patient outcomes. I have tended to believe more in a centrally mediated analgesic response, but, maybe you have seen it in the clinic, sometimes it really SEEMS like there is a mechanical restriction that the thrust adjustment / manipulation corrects. When questioned by patients, again, i tend to give an explanation as "in theory, we think....but, in the end, it really doesn't matter because you feel better anyway.

    The peripheral joint manual therapy is far more conclusive on its mechanisms of effect, but they don't seem to be as powerful as SMT for short term improvements.

    Everything else in your post is, as far as I can remember, the single best contribution to the board by a DC about chiropractic since I have been associated with it. It is really good having you in this community.

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    Quote Originally Posted by 3rdcoast_slope View Post
    The Chiro and PT professions are slowly killing themselves. PT's want to "pop" people now and Chiros want to do corrective exercises. I have worked along side 2 DPT and none of them prescribed progressive strength. Their exercises were things Bachelor PTs were doing 25 years ago. However, its all about manipulations and dry needling right now. Crack a back, stick some needles, and out the door. Both are way overused, while progressive strength exercises are not. Strength is by far the common denominator with chronic pain, but when you have to convince your therapist and the patient that this is what is needed, one begins to wonder what all this schooling is about.
    I wonder if you might appreciate that most people that enter PT or DC school do so shortly after concluding their undergraduate studies with the intent of doing good work in a field of health care and may have never been exposed to the SS model. When I was studying chiropractic in Dallas, only 2 short hours away from WFAC, I had not heard of Rip or SSBBT as the first edition had not yet been published. The same can be said for anyone in PT school. So, where would we learn proper squat and deadlift mechanics? In PT/DC school? *This may change in the future if I may have some influence on the matter.

    Immaterial of one’s professional background, blanket statements like yours do little to promote the spread of strength training as the medium of exercise medicine in health care. The nice thing about the SS community is that people of all backgrounds who are intelligent enough to appreciate the simplicity and effectiveness of the model, along with the level of expertise demonstrated by Rip and the cadre of SSCs, gravitate to this forum to learn more and engage in useful conversation. If one cannot appreciate the information conveyed by Rip, Drs. Feigenbaum, Baraki, Morris, Petrizzo and Deaton, to name a few, then the individual receiving this information either lacks the requisite intelligence to do so or is happy to appeal to ignorance. You can’t blame someone if they are not intelligent enough to understand something, they are working with what they’ve got, so leave them alone. Ignorance exists as well, but overcoming it requires that one possess the resolve to do so.

    Strength development is not by far the common denominator with respect to chronic pain management. Tackling chronic pain requires a multifactorial strategy, which includes exercise therapy, as we know that exercise confers a hypoalgesic effect in individuals who experience painful syndromes. Understanding and appreciating this demonstrates the added value that evidence-based PTs and DCs, who apply resistance training protocols in the setting of a psychologically-informed practice, bring to the strength training community. I hope this may satisfy of your wonder of “what all this schooling is about”.

    Quote Originally Posted by Will Morris View Post
    Dr. JHG: SMT works. You know it. I know it. We both use it for the exact same reason. I don't know exactly why (various theories), but it is a very powerful tool i can leverage to produce rapid improvements in mechanical symptoms which opens the door for squatting, deadlifting, and actual long term positive improvements in patient outcomes. I have tended to believe more in a centrally mediated analgesic response, but, maybe you have seen it in the clinic, sometimes it really SEEMS like there is a mechanical restriction that the thrust adjustment / manipulation corrects. When questioned by patients, again, i tend to give an explanation as "in theory, we think....but, in the end, it really doesn't matter because you feel better anyway.

    The peripheral joint manual therapy is far more conclusive on its mechanisms of effect, but they don't seem to be as powerful as SMT for short term improvements.

    Everything else in your post is, as far as I can remember, the single best contribution to the board by a DC about chiropractic since I have been associated with it. It is really good having you in this community.
    Will, we are on a first name basis pal. I agree that we apply this modality for the same purpose: rapid pain relief followed by exercise prescription for more durable relief along with reaping the physiologic health benefits of exercise as a whole. The frustrating aspect of our work is not being able to conclusively explain what is actually happening in the process. We know from being in practice that SMT attenuates pain sensitivity thus lending to the potential mechanism of lessening central sensitization, but I also believe there is a mechanical aspect to what we do, as evidenced by the presence of entrapped meniscoids in zygapophyseal joints in cadaveric studies: a concept you did a fantastic job at explaining in your low back pain lecture. While a common argument exists that SMT confers a powerful placebo effect (ie. by just thinking that it’s going to work, hence it does), I’m not so sure that SMT is the inert intervention that some people believe it to be.

    That being said, I’m happy to be a part of this community, engaging with like-minded professionals, and hope to eventually join the SSC ranks.

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    Quote Originally Posted by JHG View Post
    I wonder if you might appreciate that most people that enter PT or DC school do so shortly after concluding their undergraduate studies with the intent of doing good work in a field of health care and may have never been exposed to the SS model. When I was studying chiropractic in Dallas, only 2 short hours away from WFAC, I had not heard of Rip or SSBBT as the first edition had not yet been published. The same can be said for anyone in PT school. So, where would we learn proper squat and deadlift mechanics? In PT/DC school? *This may change in the future if I may have some influence on the matter.

    Immaterial of one’s professional background, blanket statements like yours do little to promote the spread of strength training as the medium of exercise medicine in health care. The nice thing about the SS community is that people of all backgrounds who are intelligent enough to appreciate the simplicity and effectiveness of the model, along with the level of expertise demonstrated by Rip and the cadre of SSCs, gravitate to this forum to learn more and engage in useful conversation. If one cannot appreciate the information conveyed by Rip, Drs. Feigenbaum, Baraki, Morris, Petrizzo and Deaton, to name a few, then the individual receiving this information either lacks the requisite intelligence to do so or is happy to appeal to ignorance. You can’t blame someone if they are not intelligent enough to understand something, they are working with what they’ve got, so leave them alone. Ignorance exists as well, but overcoming it requires that one possess the resolve to do so.

    Strength development is not by far the common denominator with respect to chronic pain management. Tackling chronic pain requires a multifactorial strategy, which includes exercise therapy, as we know that exercise confers a hypoalgesic effect in individuals who experience painful syndromes. Understanding and appreciating this demonstrates the added value that evidence-based PTs and DCs, who apply resistance training protocols in the setting of a psychologically-informed practice, bring to the strength training community. I hope this may satisfy of your wonder of “what all this schooling is about”.
    You can keeping telling yourself this but it’s not going to save the practice. These undergrads are paying big bucks so they can graduate and actually learn what they need to know at post graduate seminars? Both fields, as a whole are laughable. Yes, there are good people in both, it has a lot to do with individual training. I would like to see chiropractic and OP PT go to self pay services only. It would be interesting to see how long some of these clinics would stay open. I think patients would still return if it wasn’t just feel good stuff and placebo, don’t you? People pay for lasik eye surgery out of pocket because it works. I wonder if this would be the same for these two fields?

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    Quote Originally Posted by 3rdcoast_slope View Post
    You can keeping telling yourself this but it’s not going to save the practice. These undergrads are paying big bucks so they can graduate and actually learn what they need to know at post graduate seminars? Both fields, as a whole are laughable. Yes, there are good people in both, it has a lot to do with individual training. I would like to see chiropractic and OP PT go to self pay services only. It would be interesting to see how long some of these clinics would stay open. I think patients would still return if it wasn’t just feel good stuff and placebo, don’t you? People pay for lasik eye surgery out of pocket because it works. I wonder if this would be the same for these two fields?
    I know several PTs that have began self-pay services only, and they have been wildly successful. The basic premise of your argument would be that PT is useless for everything but palliative modalities and placebo effects, right?

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