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Foot mobilisation and manipulation any evidence ?

Discussion in 'General Issues and Discussion Forum' started by Simon Spooner, Feb 14, 2011.


  1. Members do not see these Ads. Sign Up.
    Of your bank manager?

    "Sell me a god, it's love time."- Eat.

    I like a bit of shameless self-promotion.

    I'll ask you the same question I asked of you last time you were promoting an event like this.... Any evidence base for this practice (yet)?
    Or is it, as Robert appears to maintain http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=60377 a lot of smoke and mirrors?

    Perhaps you could let us know what it is that qualifies you to teach such a course on "advanced mobilisations and manipulations" here in the UK?
  2. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    I'll direct you to the answers I gave in 2009 when you asked me this question, as well as your responses to my answers.

    Re: Fibula mobilisation for increasing ankle joint ROM


    9th October 2009, 10:57 AM

    Ted, Could you post the references for your "proof" please?

    Please see www.footmobilisation.com/01_references.html


    12th October 2009, 11:59 AM

    Simon Spooner

    Re: Fibula mobilisation for increasing ankle joint ROM
    Thank you for your honest and open reply. I guess that I was "looking for proven alternative treatment options for biomechanical & musculo-skeletal conditions" I understand about immobilisation and it's effects on the tissues of the body, I also recognise that reduced range of motion at various joints has been identified among the predictors of certain foot pathologies, and indeed may define certain pathologies, i.e. hallux limitus. I was hoping, given the statement on your website, that you could provide references which show that mobilisation/ manipulation could alleviate the symptoms of named foot conditions. Or, references which demonstrated an equal or better success rate in the treatment of said conditions, so that we could view this as an "alternative". It is clear to me now that this is not yet the case.

    Don't get me wrong, I have been using manual therapy in my clinical practice for many years and I do believe it is helpful as an adjunct to other therapies. I may even attend your course should you come to the UK.

    Simon, you may be interested in this study that seeks to address some of your questions. It's a RCT comparing chiropractic manipulation with orthotics:


    You are referring to the AK 'study' proposed by Robert. As you would have noted from the content of this thread AK is not part of my course. However, I do explore neurological muscle testing. This is approximately 5.4% of all of the courses I will be teaching. (55 mins of 18 hours of tuition).

    I'm of the view that 'science is the antidote to the poison of superstition' and am really looking forward to the results that Robert's study demonstrates. I do not agree that 'enthusiasm is poisonous'. I shall maintain my enthusiasm for Robert and his endeavours to 'explain' clinically observed phenomena.

    Simon, it is inaccurate to declare the learning of mobilisation & manipulation techniques as 'smoke & mirrors'. You, as a practitioner of manual therapies, ought to know this. The same physiological basis of manual therapies, as practiced by physios, chiros and osteos for many decades, can also be applied to manual therapeutic methods for podiatrists. The plethora of scientific evidence for these professions is widely available. Podiatry doesn't need to reinvent the wheel. However, I do see merit in case specific studies.

    Sure, I'm happy to. Would you please clarify what you are seeking by the term 'qualifies'.

  3. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    So the answer is still the same, that there is no quality evidence that demonstrates efficacy of the techniques.

    I didn't declare anything, I asked a question. Your statement above makes the inference that there is a plethora of evidence to support the efficacy of foot mobilisation, where is this evidence? BTW, have you read "trick or treatment?" Where is this plethora of evidence to support the efficacy of chiropractic manipulation etc...?

    Your C.V.

    "Enthusiasm"? Nothing wrong with it? Tell that to the people who have been left dead or paralysed by the "enthusiasm" of any number of physicians over the years.

  4. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    No, I didn't say that. I said there is a plethora of evidence that supports the efficacy of manual therapies as practised by a number of professions. If you choose to dismiss those professions practising manual therapies then that is your prerogative.

    My reference list identifies the key studies demonstrating the physiological effects of joint immobilisation and the benefits of mobilising these joints. This is the primary premise upon which joint mobilisation therapies are based.

    I agreed with your quest for condition specific studies, this would provide the clinical evidence of how manual therapies works with biomechanical & musculo-skeletal conditions.

    My relevant CV includes specialising in manual therapies exclusively since 1995 and teaching manual therapies at the request of my colleagues since 1996.

    Enthusiastically, (and I haven't killed anyone yet!):D

  5. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011


    Some studies for you so that we can finally put to bed the notion that modern chiropractic care is either ineffective for musculoskeletal conditions or that its safety is questionable:








    Simon you have a bias and that is your right. The unfortunate truth is that many treatments in all health fields have scant supporting evidence of their efficacy and yet we as clinicians see positive outcomes everyday in practice. Is chiropractic a panacea? No. Is it useful? Yes, overwhelmingly and the research is finally catching up to the past claims of the profession and its patient adherents. Of particular interest are the Medicare study on cost effectiveness and the May 2009 Consumer Reports study on patient satisfaction of chiropractic care versus medical care for back pain. We clearly outperform other professions for this service based on end- user feedback. Hard to argue with.

    What do you say to the patient with radiculopathy of one years duration who having failed medical and physical therapy intervention resolves completely in just a few short weeks in my office (and offices all around the world)? In this particular case a technique called Cox flexion-distraction therapy was utilized until the patient could tolerate manual adjusting (Gonstead) of his lumbar spine (3 weeks). The largest reduction of his symptoms occurred when I initiated manual chiropractic adjustments just one week ago. His VAS went from a 9/10, constant with dermatomal lancating pain to a 3/10, intermittent and mild paresthesia in just 3 weeks time.

    Is spinal manipulation and extremity manipulation effective? Yes. Is it safe? Based on what I pay for malpractice I would say that chiropractors have the lowest premiums of any mainstream health profession after polling other professionals. If you remove the bias, animosity and dogma a clearer picture is revealed: Chiropractic is no longer an alternative for musculoskeletal complaints, it is the leader.

    There are practices and concepts within my profession (and all others mind you) that should be reviewed and possibly abandoned and I remain unconvinced that the vertebral subluxation model valid (and the subject of the commentary which you provided) but that does not negate the profession as a whole, its efficacy, methods or professional standing.

    Best regards,
  6. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    And you have yours, David. Save me a bit of time, which one of those links the efficacy of manipulation for common foot disorders?
  7. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon my response was directed at your question to Ted and the commentary provided which appeared to be very broad:

    Did you mean to inquire about research ONLY related to foot & ankle manipulation? I am sorry if I read that as a denunciation of spinal manipulation as performed by the chiropractic profession but that is how it reads Simon. Especially when I know that no cases of a patient being paralyzed via lower extremity manipulation have been reported in the literature to my knowledge.

    I'm not trying to provoke you Simon, I have great respect for you and I want to be clear that we are discussing the lower extremity not the entire chiropractic profession which is mainly focused on spinal manipulation?

    There is in all honesty scant quality literature supporting lower extremity manipulation (or adjustments in chiropractic parlance) in the chiropractic literature although I believe that there is for extremity manipulation in allied fields. The difference being that most allied fields are well funded for research and we are not. This is slowly changing but chiropractic clearly needs more funding to arrive at decisive conclusions and most of the funding is for spinal conditions and not the extremities. On a side note private insurers do reimburse for this Simon, so there must be some evidence of its efficacy.

    There is also a difference between manipulation, mobilization and the chiropractic adjustment, which typically utilizes a directive force or thrust into the joint space and beyond the physiologic barrier. This is what distinguishes chiropractic from allied fields.

    Ted, does your method employ a thrust into the joint space? If it does it is chiropractic by definition in my opinion. I find it interesting that a segment of podiatry is so enamored with manipulative treatment, it mirrors my own interest in foot orthoses and is testimony that no profession "owns" any therapy apparently. There is a lot of overlap in the health professions, I do not see that as a necessarily bad thing.

  8. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    It was a denunciation of "enthusiasm" over science and evidence based medicine. I could have pointed to George Washington's death at the hands of the blood letters, who were also clearly enthusiastic (some might say over enthusiastic) for their therapy. But on that note are you saying that no-one has ever had a stroke or even died from chiropractic manipulation? Are these just urban myths? And is this statement incorrect too: "The clinical evidence indicates that a treatment of something like ibuprofen and exercise is just as effective as chiropractic for relieving back pain (Ernst and Singh 2008). "? Here's the Cochrane review- with a very broad definition of "chiropractic techniques" http://www2.cochrane.org/reviews/en/ab005427.html and here's the one for manipulation: http://www2.cochrane.org/reviews/en/ab000447.html

    Anyway, back to that evidence for the efficacy of manipulation / mobilisation in the treatment of common foot disorders....
  9. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    I don't think anyone is arguing with you Simon, that evidence based research for efficacy of FMT in the treatment of common foot disorders hasn't yet caught up with the anecdotal observations of practitioners treating such disorders. If you are going to rely on inductive scientific research as your only burden of proof, then I suspect you may be waiting a while.

    However, if you are open to consider deductive reasoning based on scientific research, then it makes logical sense how FMT can be useful for common foot disorders. I.e. compensatory biomechanical forces (e.g. excessive STJ pronation) will lead to connective tissue adaptation (connective tissues always adapt to their shortest functional length, Videmann 1986). This adaptation will lead to reduced mobility and possibly immobility. This leads to degenerative changes of the related joint structures (Woo, Akeson et al).

    Mobilising the joint(s) reverses the degenerative changes and can restore the joint's functional capabilities (Woo, Akeson et al).

    Connective tissue adaptations contributing to joint dysfunction are observed in almost every common biomechanical foot disorder encountered from HAV (lateral aspect of the 1st MtPJ and sesamoid apparatus) to plantar fasciitis.

    We can deductively reason that a foot without connective tissue restrictions is functionally more efficient than a foot compensating for connective tissue restrictions. This is good enough for me to practice FMT while waiting for the inductive evidence based research catches up.

  10. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon no treatment is without risk. That said the best quality and most comprehensive study to date was performed by Haldeman an MD and DC), Carey and Popadopolous.

    The study was based upon the claims experience of the Chiropractic Protective Association of Canada, the profession’s main source of professional liability coverage in Canada. The likelihood of stroke following a chiropractic intervention was stated as follows:

    -- 1 per 8 million chiropractic office visits
    -- 1 per 5.85 million cervical adjustments
    -- 1 in the career of every 48 chiropractors
    -- 1 in every 1,430 practice years

    The incidence was dramatically less than the reports offered in other publications of 1 per 500,000 to 1 in 1,000,000 million adjustments. The likelihood of a stroke reaction to an adjustment was viewed by all parties involved to be rare.

    That data shows a safety record that is less likely to cause a serious event or side-effect than common aspirin.

    Here is some information from the National Institutes of Health on chiropractic safety:


    Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated. There have been rare reports of serious complications such as stroke, although cause and effect are unclear. Safety remains an important focus of ongoing research. A 2007 study of treatment outcomes for 19,722 chiropractic patients in the United Kingdom concluded that minor side effects (such as temporary soreness) after cervical spine manipulation were relatively common, but that the risk of a serious adverse event was “low to very low” immediately or up to 7 days after treatment. A 2008 study that drew on 9 years of hospitalization records for the population of Ontario analyzed 818 cases of vertebrobasilar artery (VBA) stroke (involving the arteries that supply blood to the back of the brain.) The study found an association between visits to a health care practitioner and subsequent VBA stroke, but there was no evidence that visiting a chiropractor put people at greater risk than visiting a primary care physician. The researchers attributed the association between health care visits and VBA stroke to the likelihood that people with VBA dissection (torn arteries) seek care for related headache and neck pain before their stroke.

    Previous literature reviews by Haldeman and others have concluded that much of the controversy over VBA and adverse events from chiropractic manipulation have been sensationalized in the media and that while attributing these regrettable events to chiropractors, the large (and I mean upwards of 80%) were non DC's in other allied fields perfoorming spinal manipulation (MD, DO, PT).

    This is factual Simon. Can we put the safety record of chiropractic safety to bed now? The issue of efficacy aside from Cochrane's heuristic analysis has also consistently shown a superior efficacy for chiropractic in the treatment of low back pain to medication and all other interventions.

    Look, you clearly don't care for chiropractic. Fine, I won't try to convince you. It is not for everyone or every condition Simon. For others it is a viable, efficacious and distinct choice of treatment for many common musculoskeletal complaints and particularly spinal.

    Maybe Ted has more to say/studies on extremity manipulation.
  11. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    I'm interested in this statement. So the reviewers for Cochrane performed an analysis of the available literature and drew their conclusions, why is this contrary to your conclusion that: "[research?] has consistently shown a superior efficacy for chiropractic in the treatment of low back pain to medication and all other interventions"? Surely the reviewers for Cochrane reviewed the available literature, then why is their conclusion so different to yours?

    I have no beef with chiropractic per se, I am interested in the evidence base supporting therapies.
  12. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Ted, tell me about the limitations of deductive reasoning/ logic... I'm not trying to be a git, I'm trying to learn here. So.. lets start with this "compensatory biomechanical forces (e.g. excessive subtalar joint pronation) will lead to connective tissue adaptation" thing... can you point to any studies which have examined the "connective tissue adaptation" in association with "excessive subtalar joint pronation"?
  13. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon I cannot access the studies via the links you provided although cochrane.org appears to be up and running. Is this the Ernst and Canter review, I want to be certain before commenting?

    Ernst and Singh have a huge bias to begin with. I believe that a much of their research to deals with conditions other than musculoskeletal complaints and I agree with their conclusions there. You made a very blanket statement about chiropractic in general and I am just trying to provide you with relevant studies on condition specific research such as low back pain, where the evidence in favor of far outweighs the anecdotal. Does chiropractic cure asthma and infantile colic? I don't think we can draw that conclusion but I haven't seen absolute proof that it does not either and I read a lot of journals. At the same time I accept your point that some very outlandish claims are made at times by chiropractors but that is all that is ever reported on, not the good that we do. As a podiatrist you should understand the bias medicine has for competing profession and their strong hold on the media. We also know that research bias is a very troubling and real entity.
  14. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    No. The first link:
    Combined chiropractic interventions for low-back pain

    Walker BF, French SD, Grant W, Green S

    Combined chiropractic interventions for low-back pain
    Low-back pain is one of the most common and costly musculoskeletal problems in modern society. About 80% of the population will experience low-back pain at some time in their lives. Many people with low-back pain seek the care of a chiropractor. For this review, chiropractic was defined as encompassing a combination of therapies such as spinal manipulation, massage, heat and cold therapies, electrotherapies, the use of mechanical devices, exercise programs, nutritional advice, orthotics, lifestyle modification and patient education. The review did not look at studies where chiropractic was defined as spinal manipulation alone as this has been reviewed elsewhere and is not necessarily reflective of actual clinical practice. Non-specific low-back pain indicates that no specific cause is detectable, such as infection, cancer, osteoporosis, rheumatoid arthritis, fracture, inflammatory process or radicular syndrome (pain, tingling or numbness spreading down the leg).Twelve randomised trials (including 2887 participants) assessing various combinations of chiropractic care for low-back pain were included in this review, but only three of these studies were considered to have a low risk of bias.

    The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain. Any demonstrated differences were small and were only seen in studies with a high risk of bias. Future research is very likely to change the results and our confidence in them. Well conducted randomised trials are required that compare combined chiropractic interventions to other established therapies for low-back pain.

    The second ink:
    Spinal manipulative therapy for low-back pain

    Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG

    Spinal manipulative therapy for low-back pain
    There was little or no difference in pain reduction or the ability to perform everyday activities between people with low-back pain who received spinal manipulation and those who received other advocated therapies.

    This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.

    So I'm not sure how you get from these conclusions, to yours
  15. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Are you suggesting joint mobilisation reverses osteoarthrosis???
  16. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    is rather different from
    Perhaps Ted will enlighten?
  17. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Me I´m just looking at studies - investigating while sitting on a white picket fence.
  18. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Robert & Mark, welcome to the fray!

    First, I want to apologize to Ted in a sincere manner for hijacking his thread although I feel that ted and myself are kindred spirits in some ways with regard to manual medicine.

    I have two sets of studies in addition to the links provided above and am posting the one set of citations that I have on this computer. I believe that they are the older studies and the others, should it be necessary to post them contain high-quality Worker's Compensation studies. Thus far Simon is referencing two studies that I have not had a chance to read thoroughly. If anyone has the full texts I would be most grateful.

    Look, we can all find studies to support our professions and studies that refute or minimize what we see daily in practice. But since you have questioned the issue, here is the first set that supports my contention that there are many high-quality, double-blinded studies on the efficacy of chiropractic for low back pain. That is the only claim that I have made touting chiropractic's efficacy is for low back pain and to be honest it is the primary presentation to my office. I am fine with that, I could treat back pain all day and be content with the help that I offer my patients. I do treat nearly every joint in the human body but more than that, I treat the whole person. This is not a thread about the efficacy of chiropractic for spinal pain though and I apologize again for the course it has taken but Simon clearly challenged the chiropractic profession and not just FMT.

    I like a friendly debate with the people that I respect and admire so I will participate and field your questions and address the research. I hope that anyone with a preconceived notion of my profession will read this with an open mind:

    Chiropractic Treatment vs. Mobilization
    Those receiving spinal manipulation achieved a 50% reduction in their pain levels more rapidly than those receiving mobilization (therapy commonly used by Physical Therapists).
    A Benefit of Spinal Manipulation as Adjunctive Therapy for Acute Low-back pain: A Stratified Controlled Trial. Hadler NM et al. Spine - 1987;12:703-706.

    According to medical researcher TW Meade, M.D. "...chiropractic is a very effective treatment, more effective than conventional hospital outpatient treatment for low-back pain, particularly in patients who had back pain in the past and who got severe problems".
    The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.
    Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment. Meade, TW et al British Medical Journal - 1990;300:1431-1437

    Patient Evaluations Chiro Care vs. Family M.D.
    Mean number of days incapacitated after first visit 11 days vs. 40 days
    Restricted for greater than one week 17% vs. 48%
    Perception of doctor's confidence in diagnosing
    and treating low-back pain 60% vs. 23%
    Satisfied With Their Treatment 66% vs. 22%
    Patient Evaluations of Care from Family Physicians and Chiropractors. ACA Journal of Chiropractic - 198

    Chiropractic Treatment vs. Outpatient Hospital Treatment by P.T.'s and M.D.'s
    In this study, British medical researchers found chiropractic treatment significantly more effective than hospital outpatient treatment, especially in patients with chronic and severe back pain. Significantly fewer patients needed to return for further treatments at the end of the first and second year in those who received chiropractic care (17% compared with 24%). In addition, "two and three years after patients with back pain were treated by chiropractors, they experienced far less pain than those who were treated by medical doctors."
    The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

    Chiropractic Treatment vs. Physiotherapy
    Spinal manipulation provided greater improvement of symptoms in those suffering from persistent back and neck complaints compared with physical therapy. The patients receiving spinal manipulation also had greater improvements of physical functioning in fewer visits.
    Randomized Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up. Koes, B.W. et al. British Medical Journal - 1992;304:601-605.

    Chiropractic Treatment vs. Physiotherapy + Corset + Analgesics
    Statistical benefit for spinal manipulation at 3 weeks.
    Manipulation in the Treatment of Low-back Pain: A Multicentre Study. Doran D and Newell DJ. British Medical Journal - 1975;2:161-164.

    Chiropractic Treatment vs. Bed Rest

    50% of the individuals in the spinal manipulation group were pain free in 1 week compared with only 27% of those receiving bed rest only.
    Low-back pain Treated by Manipulation. Coyer AB and Curwin I. British Medical Journal - 1955;1:705-707.

    Chiropractic Treatment vs. Codeine
    Spinal manipulation provided significant improvement in the subjects overall pain score compared with the commonly prescribed pain medication, codeine.
    Lumbar Spinal Manipulation on Trial: Part 1 - Clinical Assessment. Evans DP et al. Rheumatology and Rehabilitation - 1978;17:46-53.
  19. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    David, you mis-understand. I am not referencing two studies, I am referencing two systematic reviews

    "What are Cochrane Reviews?

    Cochrane Reviews are systematic reviews of primary research in human health care and health policy. They investigate the effects of interventions (literally meaning to intervene to modify an outcome) for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting.

    Each systematic review addresses a clearly formulated question; for example: Can antibiotics help in alleviating the symptoms of a sore throat? All the existing primary research on a topic that meets certain criteria is searched for and collated, and then assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment. The reviews are updated regularly, ensuring that treatment decisions can be based on the most up-to-date and reliable evidence.

    So the studies you cite should have been identified, assessed for quality, either been disregarded as lacking the required quality or included within the analyses.
  20. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Hello David - always a pleasure reading your submissions and thank you for the contributions on foot mobilisation techniques. I'm fortunate to have three osteopaths and a physiotherapist at my practice who prove a very useful adjunct with some MSK problems in the lower extremity. But none of them would suggest that joint mobilisation reverses joint degeneration. Increses mobility - yes. Decreases the level of pain - yes. But reverses degenerative change? Don't think so. What is your position on this?
  21. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    With the greatest respect David, what you said was that:
    My contention is that your "blanket statement" is completely unsubstantiated by systematic reviews of the available literature. So while you might be able to cite references which support your contention, bias, call it what you will, when all the available evidence is collated and reviewed in a systematic way, it just doesn't seem to show what you believe to be true.

    Nobody is denigrating you or your profession, David. We are merely talking about the evidence base for foot mobilisation and manipulation and now, chiropractic intervention for lower back pain. It's not personal, please be assured of that. But you've been around these parts long enough to know how unsubstantiated claims sometimes stick in the craw. Jeez, you want to see the systematic reviews for foot orthoses....
  22. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon I realize that and it is troubling. I can see your point that it is a systematic review but does the Cochrane review trump all other evidence? I am not being flip, I am not as knowledgeable about research as you are admittedly. I would like to see all of the studies in the reviews and that would take just too much time to do timely right now. I am not evading you, just confused how they can even draw those conclusions when there is a preponderance of evidence that suggests otherwise. How do we reconcile the studies that I have provided against one heuristic study?

    Mark thank you, I enjoy reading your contributions as well. I cannot support the position that degenerative joint changes can be reversed no. I can see how we can slow or halt their progression to a degree (but I'm not about to take on anymore research reviews just now).

    Best Regards Gentleman
  23. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Lets say we read each and every study and reviewed them critically and in an unbiased fashion then we could sort them into rubbish design, good design, flawed, unflawed methodologically weak, methodologically strong, under powered adequately powered etc. This is what the reviews have done, to provide guidelines based on the best available evidence. So does it trump your single studies which may be inherently flawed, biased, methodologically weak, under-powered etc- yeah, probably. What they have done is filtered out the crap studies from the good ones and looked at what the good ones tell us. And what the good ones tell us is that....

    "This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner."

    Not that:
    Since clearly it hasn't. And clearly you haven't carried out a systematic review of the literature, David.

    They haven't just looked at 39 trials, they've already filtered out a lot of the crap that doesn't even make it to the final cut of 39 trials.

    What if we looked critically at all of the studies you cited and realised that they were all fundamentally flawed in some way? What if we looked at the studies you cited and compared them to other studies which showed the opposite conclusion? Why would we bother, when this has already been done for us by the people at Cochrane?

    Maybe in your mind David, but clearly not in the minds of those who have carried out systematic reviews of the literature. Hint, you know that website you drew all of those links from previously? What was it called? Chiroweb? Do you think they may have a "blanket view" and a "bias" toward the studies which show positive results for chiropractic intervention, regardless of quality? Just a thought.
  24. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Thanks David. I look forward to Ted's clarification on this issue.

    All the best

  25. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    The initial set of links were from a website devoted to chiropractic research yes, but not chiroweb. The Cochane group is funded by whom Simon, care to guess?


    If you look around you will find that numerous allopathic universities, professional associations, hospitals etc. are their funding partners. Are you going to tell me that this is not PAC money (high bias)? Let me ask you Simon, should we be so naive as to believe that these financial contributors do not exert any influence over the outcome of their reviews? The deck is heavily stacked towards allopathy so discovering this I have far less faith in any review from Cochrane when I have provided you quality studies (more than just 2), many of which were not performed by chiropractic researchers (low bias).

    I don't have to tell you the effect that publication bias can have on the outcome of a meta-analysis Simon. Published studies may not be truly representative of all valid studies undertaken and clearly their funding cries bias to me. The problem is significant when the research is sponsored by entities that may have a financial interest in achieving a desired outcome. Sound familiar?

    If Cochrane did a review of the literature on a particular insole casted in a very supinated position at this time what would they find? All of the research done to date was funded by our favorite lab owner and without discussing the design, bias and quality of the studies it would probably have to favor the results. This is why I am cautious with research as opposed to clinical practice, they just do not often support each other.

    In an interview Walker stated"


    "Lead author Bruce Walker, a doctor of chiropractic at the Murdoch University School of Chiropractic and Sports Science in Australia, said that the studies analyzed here were "pragmatic," in that "they reflect the reality of practice, which usually involves combined interventions and not just one.

    This kind of study cannot identify which particular treatment or treatments worked, "but from a consumer's point of view, that matters little, if the care they get is safe and effective," he said."

    In other words, it was difficult to distinguish the effects of one treatment from others that were used in these patients."

    So was he studying manipulation as performed by doctors of chiropractic and the results of low back pain versus other therapies or merely a mixed bag of God knows what? The studies that I provided you were of spinal manipulation for low back pain.
  26. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    You can twist, run and grind however you like, the reality is there is no support for your contention from systematic reviews of the literature. "This is factual" David. Can we put the efficacy of chiropractic in the treatment of lower back pain in relation to other therapies "to bed now"? This is becoming dull. Perform a systematic review of the literature, have it published in a high quality journal, then come back to me. In the meantime, I'll go with the quality reviews we have, rather than the views of someone, who by their own admission is not knowledgeable about research. Thanks. And for the final time, the two reviews that I cited have reviewed the published research, that'll be the vast majority of it, probably including those studies that you cited, quantity is not a replacement for quality, David.

    And BTW, this review http://www2.cochrane.org/reviews/en/ab000447.html which was of spinal manipulation studies concluded that: "This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner."

    How else can I say this?
  27. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    The problem is that systematic reviews of any literature is simply retrospective analysis of what (we hope) is qualitative studies into standardised practice in whatever field. Sometimes an approach works but we don't fully understand why - and the explanation takes time in coming. But it still works. If we wait for the "evidence" part then do we exclude some patients from the benefits? (Yes I appreciate the corollary). I guess that's why I prefer challenging the proposal rather than relying on published evidence, but of course it's a balance. What concerns is the bland use of terminology in support of unsubstantiated claims - like the one illustrated.
  28. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Mark, not just qualitative studies, but quantitative also. The reviews which look at outcomes don't necessarily care for the how, they just look at the quality of the research and the outcomes that were obtained. I'm not saying that we have all the bases covered here. What I am saying is that when someone says that there is a weight of evidence which shows that a certain approach to care for a certain pathology is better than other approaches to care of that same pathology, yet systematic reviews of the literature contradict that claim, it might be better to go with the guys who've performed the systematic reviews, rather than the individual with the vested interest in the therapy which they claim is far superior... just my point of view. Y'all can make up your own minds.

    We can go with deductive evidence (which has it's own limitations), but the deductive evidence cannot just be a string of hypotheses, which I guess is what mine, and your questions to Ted were all about.

    I should be interesting to hear of Ted's or anyones responses to our questions regarding his statement on his deductive reasoning for the validity of foot mobilisation techniques (FMT)
  29. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    And on balance I agree with you absolutely. But for every individual there's a line drawn in the sand which determines their own watershed on may or may not be effective practice. And for every new "eureka" publication there's a indeterminable number of practitioners who claim they've been doing that for years - which returns to the anecdotal -v- evidence argument. The really important part is the ability to challenge and argue the veracity of the claim.

    Best wishes

  30. David Wedemeyer

    David Wedemeyer Well-Known Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    So true Mark.

    Simon I am not trying to get your goat here, I do respect your very analytic mind. You're a no nonsense scientist and being able to discuss a point with you is also a learning experience for me. I hope you'll allow me that knowing my intentions are merely to learn and evolve. I freely admit I am not as capable with research, I have never performed any myself. Perhaps one day that will change, you've certainly given me something to think about regarding the chiropractic literature.

    I admit that and at the same time I do not agree with their assessment, especially after reading where "manipulation" was performed by more than one profession. Perhaps I have a bias as well, I don't doubt that.

    Thank you for your polite debate Dr. Spooner. I will sit back now and allow the thread to return to the issue at hand; FMT.

  31. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Apologies for my brief hiatus.

    I understand you are not trying Simon, you just do it naturally;)

    Seriously though...

    Let's start with defining the 2 primary forms of reasoning:

    Inductive Reasoning - This is when empirical (measurable) evidence is taken from a sample group and then the results are applied to the whole group. This is the 'scientific method'.

    E.g. I have found my carrots grow between 4"-6" therefore all carrots are 4"-6".
    Or; Blocking the access to oxygen and nutrients to the tumor cells of mice prevents the recurrence of Glioblastoma in mice therefore blocking the access to oxygen and nutrients to the tumor cells of humans will prevent the recurrence of Glioblastoma in humans.

    Limitations of inductive reasoning: sample sizes being used, results from one species being tested upon then applied to another species, measurement methods, statistical significances, etc.
    Hegel, the ultimate extremist empiricist philosopher declared 'If it can't be measured, it doesn't exist'.

    Deductive Reasoning - Is when a thesis or premise (based on empirical evidence) is applied to the whole.

    E.g. When a joint is immobilised, the related connective tissues automatically adapt to their shortest functional length (Videmann). Just think of someone who has had a fractured arm and has their cast removed after 6 weeks. The elbow's RoM is reduced because of the CT adaptations.

    Limitations of deductive reasoning: the thesis may be wrong. E.g. The earth is flat. This was based on the measuring methods available at the time.

    So again Simon, you declare that your 'burden of proof' is inductive, which is 'can you point to any studies...' It seems to me that you will only accept inductive evidence. This makes sense given your academic history. You do not, however, seem willing to entertain that another form of reasoning could be valid too.

    My thesis; excessive STJ pronation will lead to CT adaption.
    j.e. ant.jpg
    This patient has been pronating excessively for many years. The CT adaptation over the lateral aspect of the STJ, AJ & MTJ now prevents the foot from passively being able to supinate to neutral, let alone to a supinated posture.

    Deductively, I reasoned that physiological evidence tells me that the CTs have adapted to their shortest functional length which supported by the empirical evidence that I can't passively invert the foot. Conclusion: to improve this foot's functional capabilities, I need to free up the CT restrictions.

    I came to this conclusion without any inductive studies telling me that CTs adapt to excessive pronation. Rather, I took the inductive evidence (Videmann) who determined and published this conclusion, used deductive reasoning to generate a successful outcome for this patient.

    If I'm hearing you correctly Simon, you would not provide this type of therapy because it is not 'evidence based', there have been no studies published empirically proving that excessive pronation will cause CTs to adapt to their shortest functional length and impede the foot's functional capabilities.

    On that basis, the patient misses out on a useful treatment option IMHO.

    If it is based on empirical evidence, why not? Science is always catching up proving or disproving hypotheses.

  32. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011


    What are we to deduce from your apparent inability to support your hypothesis that joint mobilisation reverses joint degeneration?
  33. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Let us firstly define 'joint degeneration'; according to Dorland's medical dictionary, 'joint degeneration' is a disease process that causes a gradual deterioration in the structure with a consequent loss of the ability to function.

    If we agree with Dorland's definition above, we can understand the 3 phases of degeneration:
    Phase 1 is characterised by a narrowing of the joint space as shown on x-ray due to a reduction in the articular cartilage.
    Phase 2 is characterised by the formation of osteophytes with further narrowing of the joint space.
    Phase 3 is fusion of the joint.

    Mobilisation of joints in the phase 1 stage of degeneration can reverse the degeneration process. See A-M Säämänen, M Tammi, J Jurvelin, I Kiviranta and HJ Helminen, Proteoglycan alterations following immobilization and remobilization in the articular cartilage of young canine knee (stifle) joint, J Orthop Res 8 (1990), pp. 863–873
    Also see: Woo, S,L.-Y., Gomez, M.A., Woo, Y.-K. & Akeson, W. H. Mechanical properties of tendons and ligaments II. The relationship of immobilization and exercise on tissue remoldeling. Biorheol 1982 19:397

    Cartilage grows like grass, from its base up. The mechanical forces of articulating wear down the surface while new cartilage forms from below. Abnormal and excessive mechanical forces will wear out the cartilage quicker than it can be replaced. This is the first phase of the degeneration process. We can therefore deduce that joint mobilisation that reduces those abnormal or excessive mechanical forces, will reverse the degenerative process.

    When a joint reaches phase 2 degeneration, this reversal is no longer possible because of the osteophytic development.

    In summary, if discovered early enough (before phase 2 or 3), joint degeneration can be reversed as evidenced by the increase in the joint space visible on x-ray.

    Here's an example from a case of mine showing the increase in cartilage after 3 months. I hope the images are visible for you.


    BEFORE FMT TREATMENT showing narrowing of TNJ joint spaces
    P.C. PRE @ 26' 20'.jpg
    AFTER FMT TREATMENT showing increase in TNJ joint spaces
    P.C. POST @ 14' 14'.jpg
    TNJ CLOSE UP showing normal joint space restored
    PC L 14' post tx.jpg
  34. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Also found this.http://www.bentham.org/open/tobonej/articles/V002/32TOBONEJ.pdf

  35. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011


    Lets take a look at the logic and reasoning in your last post to me
    ad hominem. Poisoning the well fallacy.

    Therefore, in order that the deductive reasoning be valid the empirical evidence obtained via inductive reasoning needs to be valid too. So...
    In order to analyse the validity of your deductive reasoning , we must examine the validity of the inductive reasoning which you provide to support your claim. Hence my question to you. I'm not familiar with Videmann? I have found this reference: Videman T.: Connective tissue and immobilisation: key factors in musculoskeletal degeneration? clin orthop. 1987: 221: 26-32

    It is difficult for anyone to tell from the abstract alone whether or not Videman performed an empirical study to draw the conclusions presented, or whether this too is a deductive theory. The latter being the case we should need to go back to the sources supplied by Videman to assess the validity of the sources employed, etc. Ultimately there has to be some inductive reasoning. And we need to assess whether that piece of empirical research is valid, supports the hypothesis or is being dangerously extrapolated to justify the point in question.

    Straw man.

    The patient has been "pronating excessively for many years"; there is in your opinion "connective tissue adaptation". Therefore, the" pronating excessively for many years" caused the perceived connective tissue adaptation. You can probably take your pick here between a post hoc ergo propter hoc fallacy or a cum hoc ergo propter hoc fallacy. Moreover, "pronating" implies movement, not immobilisation- ignoratio elenchi?. Since the evidence you provided appears to relate to the effects of immobilisation on connective tissue adaptation, how is it valid here?

    As I stated previously, we first need to review that empirical evidence to ensure it's application to your deduction is applicable and valid. If the connective tissues have adapted to their shortest functional length on the lateral side of the joints, what has happened to the connective tissues on the medial side of the joints?

    And potentially fell into either a post hoc ergo propter hoc fallacy or a cum hoc ergo propter hoc fallacy in drawing that conclusion. Again, we need to read the Videman study to ensure that it is a valid source of inductive evidence.

    Straw man fallacy.

    So you ought to be certain that your deductive reasoning is based on sound, valid underpinning inductive evidence then.
    Maybe drifting into affirming the consequent, one-sided assessment fallacy....
  36. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    You're playing with terminology to suit your own goals, Ted. If I treat someone with Functional Hallux Limitus by orthotics and increase the joint ROM, I couldn't claim that orthotics "reverse joint degeneration". For most people, public and professions alike, joint degenerative disease is osteoarthritis. http://en.wikipedia.org/wiki/Osteoarthritis and I have yet to speak to anyone involved in MSK mobilisation who would suggest that it is reversible with manual therapy. Not impressed.

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