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Things we have to get over
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Things we have to get over - June 9, 2007 8:58:00 AM
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TMondale
Posts: 131
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From: Newton-Wellelsley Hospital
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Branching off of some of the recent discussions we've had here lately, it seems to me that we as a PT profession have to get over a few eronious and long held notions about manipulation.
1. That it's dangerous; it's not
2. That it creates instability where it wasn't unstable,and risks damage and injury to something that may be slightly unstable (sub-cranial spine in post-mva, Downs, or RA excepted); it doesn't.
3. That it's no more effective than what we've always done; it is in many instances.
4. That it creates dependency in patients; that's completely up to the treating therapist. I know plenty of patients that are dedicated to not only taking good care of themselves generally, and with an individually designed back ex. program, but also thrive for months and years at a time with an ocassional short course of manual therapy including thrust manipulation, and review of their home program.
5. That we're practicing chiropractic, or embracing/acknowledging that they have been right about manipulation. We're not practicing or in any way emulating chiro.(as they continue to commit professional suicide, who would want to do that?), and we do have to acknowledge that manipulation has to have an important role in our future if we hope to live up to our potential. This is just one modality it doesn't and shouldn't define us, just as hot packs, ultra sound and massage shouldn't define us.
As I've said before, we were wrong about these things and we need to get over it.
I think we are the best there is at dealing with the neuromusculoskeletal system. why we struggle so much with embracing thrust manipulation as a usefull tool in our care is beyond me.
As we continue to be the leaders in sound investigation into the effects and safety of the use of all manual therapies including thrust manipulation, I feel we will break through these barriers of issues. We do this not for propaganda but for our continued progress toward the clear lead in this kind of care.
Tim
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Re: Things we have to get over - June 9, 2007 9:39:00 AM
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steve
Posts: 470
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From: Canada
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Tim,
Its interesting how myths are perpetuated based on little scientific evidence. One of my favourite was the extension exercises lead to instability in the lumbar spine and retractions cause a C6-7 shear causing instability.
I would strongly agree with everything you state about manipulation with the exception of the cervical spine. I agree the risk is likely very, very low but based on unproven efficacy above and beyong mobilization, I choose not to employ it as a treatment. I realize mobilization may carry some risk but without a single case study linking mobilization and CVAs it would appear safer.
I think it is worth considering the public perception around cervical manipulation as well. What would happen if a physiotherapist was to perform a manipulation that lead to a death (I believe there was one report from quite a few years ago but have heard nothing recently)? How would this impact our public image?
Steve
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Re: Things we have to get over - June 9, 2007 11:34:00 AM
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OAK
Posts: 184
Joined: September 1, 2003
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Great post Tim!
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Re: Things we have to get over - June 9, 2007 11:55:00 AM
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Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
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Tim,
Interesting stance you have on chiropractic in general, but I think you're a little off on PT"s being the NMSK provider of choice particularly for sports performance. Athletes routinely choose DC"s for their manual therapy skills (soft tissue, manipulation, basics in athletic and rehabilitation, etc..). Every professional sports team from the NHL, NFL, NBA and MLB has a team chiro or an affiliation with one. Lance Armstrong himself said said the most important member of his medical team was the chiro.
Also, just because the chiropractic profession in the USA appears to be in complete disarray doesn't mean the same holds true for other countries. In Denmark, in particular, chiro's are in hospitals working side by side with MD's in an ortho setting and even take the same classes for the first two years before the DC's and MD's branch off and specialize. There's pilot projects in Canada too with DC's in hospitals and community health setting.
My point is, you seem to think that as a whole DC's aren't worthy of any respect, are frauds and are ill equipped to be NMSK specialists in their own right. Although I don't embrace manipulation for non MSK conditions, there has recently been some interesting studies with some positive effects of SMT and hypertension, inflammation, etc... stuff that goes well beyond of simple pain.
Steve,
PT's have already "stroked out" patients using cervical manipulation. Except, as usually is the case, this was conveniently blamed on "chiropractic manipulation" and was published as such. Here's a prime example that likes to be trotted around by the anti-chiropractic propagandists:
Vertebral artery dissection and cerebellar infarction following chiropractic manipulation.
Chen WL, Chern CH, Wu YL, Lee CH.
Department of Emergency Medicine, Cathay General Hospital, Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China. weilung.chen@msa.hinet.net
Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Owing to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand or walk. Vertigo and disequilibrium are the usual presenting symptoms of this condition, which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or haemorrhage; these last two, although rarely seen in young adults, can be caused by traumatic or spontaneous arterial injury, including injury secondary to chiropractic cervical manipulation. A number of cases of VAD associated with chiropractic cervical manipulation have been reported, but rarely in the emergency medicine literature. We present a case of this rare occurrence, and discuss the diagnostic pitfalls.
Apparently done by a PT who also attended a College of herbal medicine too.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: Things we have to get over - June 9, 2007 1:09:00 PM
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ONstudentPT555
Posts: 224
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One thing chiros are very good at is being excellent sales men/women... thats probably what has allowed the profession to survive and get where it is today (ie. professional sports teams). The thing is sometimes thier sales tactics are more in line with a con artist.
I just came across recently a chiro who graduated from CMCC(the great evidence based chiro school) who advertises that she can cure childrens growing pains with spinal manips.. I find this kind of con artistry pretty disturbing.
I know there are good ethical chiros out there too.. but there are many many out there who are not ethical. Thats why as whole the profession may not deserve the same type of respect as other health care professions but some individual good ethical chiros do.
The skills and ethical values of chiros as a profession overall compared to the PT profession overal is limited.
Anywas sorry for starting this whole chiro debate thing up again..but that advertisement was just very annoying.
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Re: Things we have to get over - June 9, 2007 1:41:00 PM
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Randy Dixon
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How is a chiropractor defending his profession "an annoying advertisement" while a PT saying they are the best providers just a statement? How is stating that chiropractors are committing professional suicide, when it has no relevance to the rest of what is being stated, not a thinly veiled attack? I find it strange that you complain about the ethical problems of chiros then use a personal ancedote as evidence? Is that your professional standard? Is insulting chiros by stating their skills and ethical values are limited professional?
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Re: Things we have to get over - June 9, 2007 2:00:00 PM
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ONstudentPT555
Posts: 224
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The advertisement that I was referring to was not what marc wrote but what the chiropractors flyer and website said about how spinal manipulation therapy for childern will help cure thier growing pains. Yes I do find that disturbing and annoying .. when these people are conned into bringing thier children and wasting thier money on absolutely nothing.
You say anectodal evidence ..well Tell me Randy how is this for professional standard?: http://www.icpa4kids.org/why/whychiro.htm
Just for the record.. I did say there are ethical chiros out there too.
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Re: Things we have to get over - June 9, 2007 2:07:00 PM
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physioo
Posts: 184
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From: Canada
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I am a PT, fairly new grad, and last week had a LB patient, which I believed had a tight L4/L5 facet...
I referred him to a Chiro...best one in town apparently...
Client came back to me....very mad for referrin to this so called chiro...
The reason being...
Treatment lasted 5 seconds, and CHiro said, he will need this for life!...
What I learnt...
I need to start my Manip courses asap!
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Re: Things we have to get over - June 9, 2007 2:13:00 PM
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ONstudentPT555
Posts: 224
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physioo,
Why didnt you use what you learned in Jam Braham courses?
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Re: Things we have to get over - June 9, 2007 3:38:00 PM
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OAK
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I had a patient a few weeks ago who had a mild lower back sprain/strain. He's in his mid 20's and a Chiropractor diagnosed "Level III arthritis" and instructed him to attend 3 times per week for 3 YEARS, in order to cure his problem. :confused:
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Re: Things we have to get over - June 9, 2007 3:41:00 PM
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TMondale
Posts: 131
Joined: January 3, 2005
From: Newton-Wellelsley Hospital
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Physioo,
The good news is, and should have been number 6 on my initial list: It takes years to learn to safely and effectively manipulate; no it doesn't. Any PT can if they don't already know how to thrust manipulate can learn in no time at all. Anyone who tries to dispute this by saying it takes years to learn is iether selling something, or defending a bad decission in their own education.
Anyone who knows how can show anyone who doesn't in one session. The SI regional technique used in the CPR for thrust manipulation in acute low back pain can be learned in minutes. Any of the t-spine techniques used in those studies, same thing. Our students (clinical interns, and affiliating)manipulate from the get go if warrented.
Steve, as I've said in the past if you want to interpret the evidence in the neck as dangerous that's OK with me, but we need to stay engaged in progressing the understanding.
Chiros, it's heartening to hear you don't think your profession is in trouble. Just my opinion.
Tim
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Re: Things we have to get over - June 9, 2007 4:38:00 PM
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physioo
Posts: 184
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From: Canada
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Hi ONstudent,
I used the 1 I learnt in Jam Bahram course...but I find that worked more for the L5/S1 region, and tightness was still evident in L4/L5...
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Re: Things we have to get over - June 9, 2007 4:57:00 PM
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Synergy
Posts: 592
Joined: March 11, 2004
From: Texas
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Excellent post Tim! I'm not going to get into the whole chiro vs. PT thing because it's an endless and pointless argument. Bottom line, manipulation, when required, is a great treatment option.
_____________________________
Chris Adams, PT, MPT
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Re: Things we have to get over - June 9, 2007 6:19:00 PM
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Jon Newman
Posts: 1711
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From: Amherst, WI
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Hi Tim,
Your reality check on attitudes will be welcome by most. One point you made caught my attention
[QUOTE]That it creates dependency in patients; that's completely up to the treating therapist.[/QUOTE]and I'm hoping you'll expand on that.
Thanks.
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Things we have to get over - June 9, 2007 8:05:00 PM
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TMondale
Posts: 131
Joined: January 3, 2005
From: Newton-Wellelsley Hospital
Status: offline
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John,
What I meant by that is if we present manipulation as if it's a magic tap on the head that will necessitate the patient to come back on a frequent regular basis for optimum health or whatever, then we are trying to establish dependency. I don't feel this is the most healthy use of this modality. I would much rather see us use short courses anywhere from 3-5 or 6 visits, and always emphasize that exercise and personal responsibility with their care, are the main factors that will maintain health and function. I do on ocassion see patients back for manual care and exercise updates if symptoms dictate.
Tim
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Re: Things we have to get over - June 9, 2007 8:22:00 PM
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steve
Posts: 470
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From: Canada
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Tim,
I agree - far too often we take a standpoint and despite evolving evidence fail to change our practice patterns - I'm all for continued study of c-spine manipulation and will change my practice patterns if and when risk is accurately determined in conjunction with evidence to suggest it is the most efficacious treatment.
Steve
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Re: Things we have to get over - June 10, 2007 9:52:00 AM
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JCOY
Posts: 34
Joined: April 13, 2006
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[QUOTE]I referred him to a Chiro...best one in town apparently...
Client came back to me....very mad for referrin to this so called chiro...
The reason being...
Treatment lasted 5 seconds, and CHiro said, he will need this for life!... [/QUOTE]Stereotypes can be hard to overcome-----
or can be reinforced.................
My patients have never recounted ANYTHING other than a mix of "hot packs, excercise. and ultrasound" as their PT "experience".
In fact, one of my patients recently recounted, that on his last PT "encounter/appt", that the US was broke, so she "just did a bit of massage on my back".....(curious as to what THAT was billed as?)
SOOOOO------
Because of what I have read/been assured of, here, when my father was referred to PT, by his GP(leg problems), I told him to "go ahead" assuming he would get competent care, per Rehabedge.
WELL- I spoke with him last week, and he relayed that it is "the same exercises you gave to me last year"..........MINUS the hot packs.
Hmmmmmmmmmmmmmm?
I have no reason to believe, per patient recount, or now, my personal endeavor, to believe that the stereotype PT is otherwise.
BTW- IF so- can someone refer a PT in the Estero/Bonita, Fla area? For Real?
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Re: Things we have to get over - June 10, 2007 10:32:00 AM
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ONstudentPT555
Posts: 224
Joined: July 25, 2006
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I think there is a difference between a PT perscribing the same exercises for patients and chiros performing spinal manips on infants, claiming to cure arthritis and telling patients they have to come back for ever....
BTW- exercises for leg problems(a very vague term) has evidence to back it up.
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Re: Things we have to get over - June 10, 2007 10:40:00 AM
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JCOY
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I think there is a difference between a PT perscribing the same exercises for patients and chiros performing spinal manips on infants, claiming to cure arthritis and telling patients they have to come back for ever....
Is this response for real?----------REALLY????
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Re: Things we have to get over - June 10, 2007 11:01:00 AM
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ONstudentPT555
Posts: 224
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maybe there was a miscommunication ... I thought you were talking about chiro and PT stereotypes.. ?
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