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"Manual Therapist"
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"Manual Therapist" - March 11, 2002 7:50:00 AM
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mcap
Posts: 652
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Group:
I know I will get flammed for this one but why not?
In my occaisional browsing of the help wanteds for Ortho PT, you consistently see one requirement - Manual Therapy - "Manual Therapy Experience Required." "Manual a plus," "Manual Therapy Office."
It is a cornerstone of outpatient ortho practice. Much of the continuing ed and specialty exams are manually oriented. Before I ask my question, I will say that many of the manual therapists are great clinicians, do great research and are leaders in the profession. I have the most profound respect for some of them.
However, does anyone else find it troubling that so much of our practice is based on methods with so little support?
mcap
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Re: "Manual Therapist" - March 13, 2002 12:36:00 PM
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henryryry
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From: Brisbane, Australia.
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mcap,
are there anything in particular within Manual Therapy methods that you are pointing towards??
Henry***
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Re: "Manual Therapist" - March 13, 2002 12:47:00 PM
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mcap
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Henryry:
You name it! From the most arcane techniques to doing inferior glides to supposedly increase should flexion. Where is the support?
mcap
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Re: "Manual Therapist" - March 18, 2002 9:48:00 AM
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jma
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Here's my question then. If there is a space to check off manual therapy, this means that this is reimbursable, right? My understanding was that in order to be reimbursed and listed on billing codes, it had to be researched and proven to be clinically effective. I assumed that was how insurance companies viewed these things. Nothing gets listed without proving it effectiveness. Does this mean that the insurance companies are paying for these methods with the little support behind them?. Something does not make sense here.
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Re: "Manual Therapist" - March 18, 2002 6:58:00 PM
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Bobcat
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Whoa.
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Re: "Manual Therapist" - March 19, 2002 8:46:00 PM
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Threeps
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From: Gütersloh, Germany
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mcap
Maybe I've got it wrong but my training in MT always emphasised the importance of the concave-convex rule (from Kaltenborn via Mennell). Applying that rule to an inferior glide to the shoulder would be used to improve shoulder abduction NOT shoulder flexion. This is based on basic anatomical and biomechanical principles and should provide sufficient justification to include it as a component of your treatment. If you need support use it...and measure the difference in ROM!
How about specifying some of those 'most arcane techniques'? It's difficult to debate such a general statement so set it up so we can take a shot!
[QUOTE]Originally posted by mcap:
Henryry:
You name it! From the most arcane techniques to doing inferior glides to supposedly increase should flexion. Where is the support?
mcap[/QUOTE]
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Re: "Manual Therapist" - March 20, 2002 1:40:00 PM
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henryryry
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From: Brisbane, Australia.
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mcap,
All I can say is that looking at the history of Physiotherapy, it has been practiced more as an art rather than a science. Our theoretical basis has been based on hypothesis that has not gone through the rigours of the scientific method. I believe this is changing and a turn towards EBP can be seen. I don't believe EBP is the perfect way to go about enhancing the scientific aspect of Physiotherapy, but it is probably the best method to date.
One example is in doing unilateral PA's on the z-joints of the lumbar spine. I was doing my dissection class yesterday, and was amazed at how deep the z-joint really is underneath the skin. If you count the muscles, fascia, varying fat content and skin, it comes to about one index finger (noting that our cadevar has probably dried a bit as well). Asking Gwen Jull about this, she replied that unilateral PA's still work, but perhaps our theories of why it works should be based on more scientific evidence rather than just our logic or common sense. perhaps instead of doing a unilateral PA, we are doing trigger points, or reducing muscle spasm etc.
I guess what I am trying to say is that most of our techniques are probably wonderfully effective, but our theories on why they work need to be changed, possibly encompass not just mechanical but also the neurophysiological aspects.
I will leave it at that for the time been. Gotta run to a lecture now on the SIJ.
Henry***
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Re: "Manual Therapist" - March 22, 2002 11:51:00 AM
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Diane
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Hello, Mcap, Henry and others,
Speaking of possible neurophysiological consequences of why manual therapy seems to work well, even when practiced as an art, in a scientific limbo of sorts:
At the moment I'm quite content to consider the possibility that cellular behavior as described in The Architecture of Life, (by Donald Ingber, published in 1998 in Scientific American) might be affected by the sort of mechanical inputs into the body that manual therapy can provide.
Diane
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Re: "Manual Therapist" - March 22, 2002 2:48:00 PM
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chipomalley
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From: Baltimore, MD
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I personally feel that we may see the McKenzie method as being based on neurophysiologic effect rather than nucleus pulposus changing position in repeated movments. I am probably dating myself in attempting to describe the Mckenzie derangement reduction theory. I know it has been postulated that way in the past and some studies show migration. I more strongly believe that in the C-spine the effects are very likely neurophysiologic with regard to repeated movements. The morphology of the disks are completley different yet there is a theory about repeated extension. We say, well it works! However we need to know why it works and who may best benefit for the purposes of prognosis. As for manual therapy schools, basic science and clinical sound reasoning processes should be sufficient for providing care. The results of care need to be objectively measured to support the need and benefit for each patient if we can perform consistent and reliable examinations across a population.
------------------
George E. O'Malley, Jr., PT, OCS
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Re: "Manual Therapist" - March 24, 2002 5:50:00 AM
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mcap
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Maybe I've got it wrong but my training in MT always emphasised the importance of the concave-convex rule. This is based on basic anatomical and biomechanical principles and should provide sufficient justification to include it as a component of your treatment. ...It's difficult to debate such a general statement so set it up so we can take a shot!
I will use this one as an example. Here are a couple of questions.......
1. What evidence is there that the humeral head actually glides inferiorly during abduction?
AND....
2. What evidence is there that treatment with mobilization actually improves range of motion over the long term?
take your shots [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
mcap
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Re: "Manual Therapist" - March 24, 2002 9:00:00 AM
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PTupdate.com
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mcap,
It has been about 6-7 years now since evidence using motion radiographs showed that during elevation (abduction and/or flexion), that the humeral head actually migrates superior, by 3mm on average! The current theory is that we still perform an inferior glide, not so that the head can migrate inferiorly, as previously thought, but to stretch the tissues that may no longer be permitting the humeral head to migrate superiorly! Still no major proof that the mobes work, at least not that I know of. However, I am still surprised that many students are coming for their clinical rotations with the old theory in their head, and get frustrated when they learn otherwise!
Duffy [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: "Manual Therapist" - March 24, 2002 12:19:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Hi there,
I found a website that contains an article by an orthopod that might be of some use when considering shoulder mechanics, and manual therapy in general. I'd like to know what you (in particular) think, Mcap.
[URL=http://www.biotensegrity.com/shoulder.html]http://www.biotensegrity.com/shoulder.html[/URL]
Diane
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Re: "Manual Therapist" - March 24, 2002 1:02:00 PM
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mcap
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Diane:
Thanks for the link! I will try to get to it latter this week. What did it say? For now.....I have to complete midterms/projects so I don't have a chance.
GO TERPS!!!!!!!!!!!!!!
Regards,
mcap
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Re: "Manual Therapist" - March 24, 2002 1:43:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Hi mcap....It said... lots of stuff. I will be happy to wait until you have more time to read, digest, and reply. Then we can talk.
Here is another link to the article I mentioned earlier that I hink poses large if not huge implications for manual therapy.
[URL=http://www.sciam.com/1998/0198issue/0198ingber.html]http://www.sciam.com/1998/0198issue/0198ingber.html[/URL]
Bye now, good luck on your exams,
Diane
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Re: "Manual Therapist" - March 25, 2002 12:18:00 PM
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henryryry
Posts: 100
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From: Brisbane, Australia.
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mcap,
There were 2 articles published on Manual Therapy (latest issue out in February). One was by Michael Lee who tested lumbar PA's on L4 (normal population) and found that there was immediate change in the stiffness after 3 cycles of 5 oscillations, but this change did not sustain over 24 hours. Another study was done by Vicenzino, Hsieh et al looking at a single case study of Mulligan's MWM on the thumb and using MRI to detect any "positional faults." Similarly, they found that there was an initial change after the applications of techniques, but it was not sustained over 48 hours despite the patient stating that there was no longer any pain in the thumb.
I think it is still important to understand the concepts behind manual therapy, whether it'd be anecdotal or evidence based. Until the evidence is hard-based, we can only hypothesize on how and why things may work.
Henry***
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Re: "Manual Therapist" - March 26, 2002 9:46:00 AM
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mcap
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Henryry:
I agree completely. I just find it a little troubling that we place so much emphasis on manual therapy without a lot of support. Some of the basic theories and techniques taught in PT schools may not hold up. When we find out that the humeral head doesn't glide inferiorly during ABD, then we change the theory to support the intervention again.
Here's another example.....does the capsular really help to distinguish intrarticular lesions?
As for McKenzie.....I have suspected for quite some time that there is indeed migration of the nuclues in the opposite direction from the loading applied. The problem is, does it stay there? I don't think it does. Furthermore, if the annulus is incomptentant, how would it ever stay there?
I think the McK exercises are working on a variety of structures producing primarily a neurophysiological effect. But......who knows?
later,
mcap
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Re: "Manual Therapist" - March 27, 2002 12:19:00 PM
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henryryry
Posts: 100
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From: Brisbane, Australia.
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mcap,
The importance of asking even the most simplest questions is how we progress, and it is these questions that are changing and revolutionalizing PT. I agree with your comments and have also thought about the concave-convex rule of the shoulder, and the Mckenzie nucleus pulposis theory. I think Physiotherapy has utilized too much literature from non-physiotherapy journals, such as spine, biomechanical journals etc and have not done enough of its own research until recently.
reading a few more articles recently has convinced me of the need to incorporate the neurophysiology model with our existing models. I can always remember the phrase used by Butler and others: "we (PT's) don't stop at C0/1."
happy easter everyone!
Henry***
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Re: "Manual Therapist" - March 27, 2002 5:16:00 PM
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Bobcat
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Well, God forbid if a physical therapist should return to school to get a degree in materials science, engineering, or even medicine, and then commits herself to a lifetime of scientific investigation into what makes therapy methods tick.
No, that would be like practicing science.
Much easier to go to Upledger courses and moo with the herd.
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Re: "Manual Therapist" - March 28, 2002 4:01:00 AM
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mcap
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Cat:
I am actually strongly considering dropping my program for a biomed engr. program. I beleive strongly that we need more engineers, computer scientists, mathematicians, etc.
For those of you who assume that the above mentioned programs emphasize biomechanics only - they don't. There is a tremendous need for engineers and math people in neuroscience also.
mcap
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Re: "Manual Therapist" - April 4, 2002 5:06:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Mcap,
Have you finished your exams and thought about cell biology aspects to manual therapy yet?
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