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Re: L-Spine Coupled Motion?
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Re: L-Spine Coupled Motion? - April 26, 2007 6:34:00 PM
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jlharris
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[QUOTE]Jason , so how do you know so much about rats? [/QUOTE]I haven't always been a PT. My undergrad studies were in psychology, specifically physiologic (behavioral) psychology. And they tend to use a lot of rats for behavior modeling. Enjoyed the link to the "water rats"
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Jason L. Harris, PT, DPT
My PT Blog
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Re: L-Spine Coupled Motion? - April 26, 2007 6:59:00 PM
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ginger
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The pulling apart of cervical facet joints for its short term benefit is rarely the method of choice for me. Though at times I am asked to do so and for want of a reason not to , comply with the request. having expained that, "no, this is not an adjustment for the purpose of straightening out your spine". Also that the effects are usually short term pain relief and ROM improvements. I will proceed to mobilise the joint a.p., to establish its state of mobility, manip ( 'lateral thrust')and retest with an a.p. mob again. It will then be noted that change to joint muscle tension and its resistance to AP glide will be improved, along with a reduction in the pain associated with that passive movement. This is a very straight forward intervention,. One that the trained physiotherapist will be manifestly skilled at, provided thay have the right training and experience. To argue that inter tester reliability/unreliability will somehow negate the prospects of this kind of problem solving is just nonsense.
The real world ( and not the kind we sometimes believe it to be )includes many PTs/physios who will never be capable of the abovementioned intervention with skill. So be it. Should those who can, be constrained by the limits the less skilled apply to themselves?, should we rule out the high achievers altogether? Not likely.
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The Grand Pediculator
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Re: L-Spine Coupled Motion? - April 27, 2007 12:37:00 AM
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nari
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Jason, there has to be a middle ground.
Sure, there are some studies out there which indicate that technique A is superior to technique B or C.
And it is feasible that technique A could be done first and followed by other stuff.
It doesn't mean everyone drops technique B, because NO study has indicated that one technique works for everyone, given the same sort of complaint. With the manip technique the CPR is so narrow that one, blinded by EBP, would have to say that nothing can be done for 80% of back pain patients. Which is, to quote Ginger,"just nonsense".
The usefulness of EBP is to avoid useless treaments. Like all hypotheses, treatments have to be proved wrong, or useless or ineffective or whatever. Proving something is right and true is impossible, given human nature's quirks, and to wholly believe a popular RCT is true is simply not science.
Nari
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Re: L-Spine Coupled Motion? - April 27, 2007 10:22:00 AM
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jlharris
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Nari,
There is a middle ground. I know my post was long, but read the whole thing. My point was were we _start_ when it comes to our treatments choices. EBM is the best model out there to guide us with our treatment choices.
As I said, there is not a RCT for every condition we treat (not even for most of the conditions we treat). What then? EBM helps guide in how we select the information in selecting or treatment. Clinical observation is part of that model.
I am against one treatment for all. Whether it's McKenzie, CST, myokenetic restoration, MANIPULATION, continuous mobs, and even exercise. Literature can help us move beyond the confines of our individual clinical observations to find the most beneficial treatments for a particular pt population.
Of course what is best now, may not be tomorrow and we HAVE TO stay abreast to the new info and be willing to evolve and change our practice patterns accordingly.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: L-Spine Coupled Motion? - April 27, 2007 10:26:00 AM
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jlharris
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BTW, I still think nay sayers to EBM are too hung up on one treatment (manip for certain LBP) pt's. At least on this site, that Flynn article and Child's reproduction of the findings are constantly abused as to why EBM is "cookbook". It is a VERY STRONG body of work that we should all fully understand and at least consider how it affects our practice; but it is not a monster out to destroy all of our beliefs. Learn from it, evolve your practice, move on and continue to learn.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: L-Spine Coupled Motion? - April 27, 2007 11:24:00 AM
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nari
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Jason,
A good reply but you have missed my point.
Adherence to EBM/EBP tends to narrow our field, not widen it. I am sure nobody uses just one or two methods. I have never manipulated and never will, because I have not been trained and am not interested in learning. Shock horror? There are many alternatives which are available. There is no obligation to manipulate, but there is an obligation to keep up to date.
There is also the need to think for oneself when updating.
Nari
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Re: L-Spine Coupled Motion? - April 27, 2007 11:24:00 AM
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yarringtonpt
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Jess:
"My question in return is, how do you know what you're manipulating?"
Through PPIVM and PAIVM testing to get a sense of the involved segments. I agree that research show the relative lack of specificity, but it gives a basis for where to begin.
Jason:
I agree with your last two posts. I don't really think there are many nay sayers to EBM on this site, just those who feel as nari does: there has to be a middle ground - she stated it much more eloquently than I.
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Eric Yarrington, PT, MPT, OCS
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Re: L-Spine Coupled Motion? - April 27, 2007 2:07:00 PM
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jlharris
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Nari,
Unfortunately I don't think I missed your point, I disagree with your point. Not that EBM can narrow certain aspects of our field, but that this narrowing is inherently a bad thing. I believe that if you go to 5 different PT's for X problem you shouldn't be treated with 5 different approaches. That DOES NOT mean you get the exact same exercise/mob/modality at each clinic. Huh? you ask. Even though though PT A does continuous mobs, and PT B does simple PA's as long as they are doing it on the appropriate pt, that's a good thing. Now, if the pt -as shown through good clinical studies (which don't have to be RCT's)- benefits most from mobs but PT C refuses and treats just with myofascial release, that's what I consider substandard care. If you want to do the mob and supplement with myofascial, more power to you. But EBM is there to show us what (according to the best evidence at the time) should be the bare minimum given for the treatment for best outcomes.
Wow, that turned into another long post. I apologize.
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Jason L. Harris, PT, DPT
My PT Blog
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Re: L-Spine Coupled Motion? - April 27, 2007 4:27:00 PM
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ginger
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Jason , your apology is not required, the high standards you seek to create and encourage is certainly not the kind anyone should apologise for. Nor should we retreat from the kitchen ( or whatever the best metaphor may be , alluding to the debate/argument in favour of those standards ), where we may feel a little heat from time to time.
It is up to us to fashion the future of our profession . I like the emblem of personal responsibility that goes with professionalism. It really means that if we don't stick to what we know works well , even under pressure from nay sayers, we will not make the kind of contribution we can look back on with pride. If for just a brief period in our working lives we can really stand up and say out loud, 'look over here you guys', I think I may have worked this out' or something like that, we can at least know that our voices were not stilled by the doubtfull , or the ignorant , or the unwilling. Say your piece Jason , keep on saying it , please. We are listening.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: L-Spine Coupled Motion? - April 27, 2007 5:40:00 PM
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nari
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Jason,
I absolutely agree with the bare minimum principle; 5 PTs throwing one technique after another at a patient at various times isn't wise or effective. No apology needed for a long post!! I have waded through pages of some posts which say nothing in them. That's certainly not yours.
It is establishing that bare minimum which is tricky across the board. Ginger makes the point that if we don't stick with what we know really works well (for a majority of patients)then we miss out on so much. (My interpretation of his meaning) I agree.
We do not need to wait for research results every time before we follow up. In saying that, I developed a reputation amongst colleagues of being a 'reductionist' - avoiding all machines, gym apparatus and to some extent, mobilisations of joints in the Maitland/traditional sense.
I know nothing about MFR or ART or a dozen other methods, and don't want to know. Complicating a thinking process with a multitude of dubious methods devised by others should be avoided.
I think we are saying similar things, in a different way. I see EBP often being assiduously followed on forums, and see that not as a wise path, but a narrow one. It takes away our ability to improvise, or think about why we are doing something. Note I said "assiduously" - which is different from keeping an eye on updates, theoretical and practical and using them as one sees fit.
Nari
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Re: L-Spine Coupled Motion? - April 28, 2007 5:45:00 AM
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mcap56
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Regardless of what many of you high level clincians decide to do, there is another issue to consider. Education! Coupled patterns are still being taught in our education programs in both kinesiology and then in spinal orthopaedics when learning manual therapy. It's always easier to tell students "this is what happens and this is how you address it" so I would imagine that theories like coupled motion will persist for some time along with PIVM and PAVM testing which have demonstrated poor reliability and validity.
Students are more than capable of accepting the grey areas provided you give them the proper context. In fact, when you engage them about ambiguity, they actually feel more like scientists and feel they are getting more value for their educational dollar. Giving them the grey also empowers them to feel like they can get into the field and help change the way things are done (albeit in small ways at first). I don't see much of this on the faculty level though.
I am teaching PAs this summer and I am very curious about the differences. With the jump to three years, I wonder how many students who formerly would have chosen PT are going a different route. Should be interesting.
Best,
Marc
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Re: L-Spine Coupled Motion? - April 28, 2007 2:14:00 PM
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ginger
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Marc you make a good point, students are very clever. Particularly PT/physio students. I also see the standards represented by current MSK teaching in OZ as those very much like the ones I was taught in the early eighties. I had to unlearn a lot in order to take on better and better methods/ paradigms . Students that come my way hoping to flesh out the details after three or four years of undergrad study , instead find that I give a major heave ho to much of what they have learned. I have had talks with the heads of two of Melbourne's university physiotherapy schools , expressing my concerns, but the business of change there is a very slow one indeed. It is up to us Marc, up to you and me and the others who regularly put their hands up on this forum, to offer a constructive dialogue towards change. Change of course not for its own sake , but in favour of solution oriented practical ,effective methods . methods that may not have RCT's to support them , methods that are the cornerstone of successfull practice across various countries . We are a community with the same goals , to be the best we can be . Your contribution and that of our colleagues is an important part of the cutting edge of talent and skill defining , discovery revealing education.
Little rant here.
Need breakfast.
Cheers
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: L-Spine Coupled Motion? - April 28, 2007 2:27:00 PM
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ginger
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Nari , I too am a reductionist, possibly an extreme member of that group. By this I mean , unwilling to waste time on the periphery of treatment, eschewing modalities for the power of my hands ( they work way better than machines ), leaving the teaching of involved exercise programs to those who make a good living from it. I also leave the medical diagnoses to doctors of medicine and apart from the concerns good observation can offer about some, stay clear of concerns on pathology.
I like the other kind of reductionism too , the sauce that cooks longest tastes best.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: L-Spine Coupled Motion? - April 28, 2007 4:36:00 PM
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nari
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I also think students mostly appreciate the grey stuff; I tried to present updated work to them without actually canning what they had learnt, and they tended to take it onboard to think about. Sometimes the "Ahha!" factor would result.
It probably should be remembered by all that once a student has completed the PT undergrad course, probably 50% of material taught is out of date.
That is the nature of science-based literature, and the enormous changes in neuroscience in particular.
It would seem appropriate to introduce ambiguity to students; nothing is proven or true. The sooner they catch onto not the greyness of science but the lack of black and whiteness, the better.
Good posts, Marc and Ginger.
Nari
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Re: L-Spine Coupled Motion? - April 29, 2007 5:48:00 AM
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jma
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I do agree that by the time students learn material, it is out of date. However, if the professors know this, they should incorporate a topic like this and others in the Evidence Based Practice courses that I see in their PT programs.
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