L-Spine Coupled Motion?

L-Spine Coupled Motion? (Full Version)

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erniegamble -> L-Spine Coupled Motion? (April 12, 2007 5:11:00 AM)
Anyone read the April issue of JOSPT - Lit Review on L-spine coupled motion? "Clinicians should therefore consider eliminating the use of the concept of coupled motion patterns in thier evaluation and intervention for patients with lumbar spine conditions." What should we make of all the inconsistency in the literature about this topic? Should this change how we mobilize the L-spine?

FLAOrthoPT -> Re: L-Spine Coupled Motion? (April 12, 2007 5:53:00 AM)
it has to do with cadaver vs humans vs closed chain vs open chain vs pathological vs normal vs top moving on base vs base moving on top vs fear avoidance and upper thoracic similar to cerv etc etc etc etc etc etc... just no one is on same page when discussing, but i think it is safe to say the typical spinal mechanics are good to know and are for the most part normal most of the people most of the time

jlharris -> Re: L-Spine Coupled Motion? (April 12, 2007 7:12:00 AM)
When it comes to lumbar mobs, I think it tells us we should quit worry so much of whether if the segments are flexed and rotated/SB right or Flexed rotated right SB left and just do what Childs expressed at his course "just move it and move on". More and more studies are showing that not only can we not truly isolate a specific level, but now that the biomechanics we are trying to make segmental hypomobility Dx with is/are incorrect. Hmmmm, but we still got people better. Why? Because many of them just needed friggin' mobs, and we provided that to them. Move it and move on.

OAK -> Re: L-Spine Coupled Motion? (April 12, 2007 9:37:00 AM)
I've taken numberous spinal mobilization/manipulation courses and the best one was taught by two Norwegian Therapists. There belief was that a manipulation produced the same result whether it was performed in flexion, rotation, sideflexion or extension. All are techniques to move a stiff joint segment.

TC PT -> Re: L-Spine Coupled Motion? (April 14, 2007 4:58:00 AM)
When a drawer sticks and, you wiggle it to free it up, the drawer doesn't care if you approach from the top, bottom, front, rear, right or left...it only wants to move freely. Just wiggle the drawer.

ginger -> Re: L-Spine Coupled Motion? (April 25, 2007 11:47:00 AM)
I maintain that the best way to assert the state of mobility of a specific joint and group of joints is by the same method that works to free them , mobilisation. It is direct , sensitive and though not specific in the sense of being able to control the movements of adjacent joints, is a means to offer credible , real time information on joint function. The effects of mobilisation , done with skill , are able to be continuously monitored by the therapist , particularly when using the Continuous Mob method, along with the state of relative comfort of passive pressures by the patient. The effects of manipulation can be immediately felt in this way also. That is , test for hypomobility before and after manips by passive mobilisation .

Shill -> Re: L-Spine Coupled Motion? (April 26, 2007 3:09:00 AM)
I see it (this example and the other inconsistencies mentioned by Ernie) as a further indication that you shouldn't get too excited about what you think you feel with your hands when palpating motion in the spine, among other things. They are just that, hands. Not magical tools that speak to you about the pathology of the patient by deciphering subtle, minute variations from a supposed norm.

jesspt -> Re: L-Spine Coupled Motion? (April 26, 2007 6:47:00 AM)
I think the actual problem one runs in to when performing positional and motion palpation assessment, no matter what part of the spine one is performing it on, is that we really have no idea if the presence of one of these "dysfunctions" actually means anything clinically. How many of you have taken a muscle energy technique course where you "found" an FRS, ERS, etc. on someone who was totally free of pain? Or, you "found an FRS, but another course participant "found" an ERS at the same level on the same person. So, now we see that the theory that some of this positional palpatory diagnosis is based on is flawed as well. Questionable theory, poor validity and inter-rater relaibility = an assessment technique that I tend to use VERY infrequently.

yarringtonpt -> Re: L-Spine Coupled Motion? (April 26, 2007 9:13:00 AM)
We could just do cookbook Flynn manipulations on all of our low back pain patients. After all, it has been found to be a valid treatment via a CPR. Just have to make sure you only get those patients that meet the criteria. We can just abandon our body of knowledge and all the manual techniques we have done for years that have gotten our patients better. This way we can give all of the manual therapy over to the chiropractors. Jesspt: I am not a big fan of positional testing either, but even the Flynn study uses hypomobility, or a form of PPIVM, as a marker. If we don't do palpation testing, how do we assess what to mob/manip? Why is it that we want to throw out clinical biomechanics when it comes to the spine but not for other joints in the body??

ginger -> Re: L-Spine Coupled Motion? (April 26, 2007 11:32:00 AM)
Shill is quite right of course , one cannot assume the identity of any pathology from palpation , what is good is that very few of the disorders of movement characterised by spinal hypomobility and palpable tenderness has anything to do with pathology. Protective responses giving rise to disorderly conduct including pain is the product of a threat response and not necessarily any pathological state at all. When palpating spinal facet joints and associated structures we are looking for an indicator for intervention , then later for an equaly direct indicator for improvement , or lack therof. To be stalled by unnecessary concerns about pathology, other than the so called red flags ( perhaps ) would be to rule out useful treatments for most patients.

jlharris -> Re: L-Spine Coupled Motion? (April 26, 2007 11:34:00 AM)
Argument that uses "cookbook" really mean, "I'm afraid to change my way of thinking". Huge copout. Our treatments should be based on the most current literature out there on what works. In the past, the best was based solely on palpation Type 1 and 2 motion restrictions. Now we know that, for the lumbar spine, a select population of LBP pt's need to be treated with manipulation. That's not cookbook, that's knowing the best evidence and using it. Now we have a study that shows couple motion theory is not very accurate. So, as clinicians we should be weary of placing all of eggs in a basket that uses that theory to "diagnose" movement problems. The hard part is for clinicians to evolve their tx approaches beyond the old evidence to the new when appropriate. That doesn't mean we abandon all MT. Protocols are the "skeleton" of the treatment, we fill in the meat and potatoes. For example, if Pt A fits the CPR you need to Manip, but that doesn't mean you can't provide education on joint protection, or use Ice, or supplement with muscle energy. AS long as you include manip, you are following what the best evidence shows. That is not cookbook.

ginger -> Re: L-Spine Coupled Motion? (April 26, 2007 12:07:00 PM)
Jason "Our treatments should be based on the most current literature out there on what works." This quote from you suggests a reliance on literature to support your EBM paradigm, rather than the original one where therapist experience is the ultimate guide to practical problem solving . This notion has been thrashed to death on other threads . Are you serious in saying you rely on literature as this line suggests?

jlharris -> Re: L-Spine Coupled Motion? (April 26, 2007 12:40:00 PM)
I am, and it is my opinion that those who base their treatment solely on their observations are providing substandard care. It used to be thought that old hay produced rats as that's were persons "observed" new rats coming from. Those persons were only right in their thinking until it was shown, through objective measures, new rats came from mating of male and female rats. Evidence based medicine is the backbone we have to build our profession on as it's the only way to move past believing rats come from moldy straw.

yarringtonpt -> Re: L-Spine Coupled Motion? (April 26, 2007 12:43:00 PM)
Jason: I have the same question as Ginger. I am all for EBM, but do you rely solely on literature to guide each patient intervention? There are no Laws of therapy, only theories. I am aware that coupled motion is flawed and that there exists a huge amount of variability between individuals and between spinal segments. However, we commonly assess and treat joint and muscular hypomobility in all areas of the body. We know that hypo and hypermobility / instability can and do cause impairments and functional limitations. "Now we know that, for the lumbar spine, a select population of LBP pt's need to be treated with manipulation" Problem: How many of us get patients that fit this CPR?? I know that I don't. But we'll mob or manip these folks based on our body of knowledge and clinical experience. Is this wrong? My thinking is that what we do makes compartmentalizing or sub setting patients extremely difficult. This would certainly make my job easier. Problem is that there are way too many variables. So these studies provide further theory that guides and fits with our knowledge base - NOT LAW. What do you do if the manip doesn't work? Stop treating? So, I agree - the SI manipulation in the Flynn and Childs study is great for those select few patients. In our excitement to embrace EBM and treatments substantiated by RCT's and CPR's many therapists DO suggest throwing out our body of knowledge. The problem, as you know, is that there is not enough clinical research available to guide you through every patient. EY

yarringtonpt -> Re: L-Spine Coupled Motion? (April 26, 2007 12:45:00 PM)
Jason: "I am, and it is my opinion that those who base their treatment solely on their observations are providing substandard care." What do you mean by "solely on their observations"? EY

jlharris -> Re: L-Spine Coupled Motion? (April 26, 2007 1:08:00 PM)
Just what it says. I observe that in my clinic people tell me they get better when I hover my hands over their "affected" part. Therefore, I treat all my patients this way, disregarding what the literature shows. PT's (in the US) used to treat pt's only with Heat, US, Massage, and e-stim. Sure people thought it felt good, but we now know it wasn't a good treatment approach. How? With clinical studies. Hell, forget that though because in my clinic people get better with hand hovering so it must work and I can ignore what the scientific community is providing for me to base my treatment on. Also, here is my quote: "Our treatments should be based on the most current literature out there on what works." Now, what happens when there isn't a "cookbook" CPR for my pt? Then I turn to well done case reports and/or what is professionally the common treatment approach. Then, if that doesn't exist, I use my clinical experience (read: my observations). I really feel some PT's are so resistant to change that they don't even want to take the time to learn what EBM is. The Flynn/Childs CPR for LBP is such a small % but that's what everyone seems to get hung up on. "oh no, what do you mean I have to stop doing MET, or continuous mobs, or PRI, etc" because of this one study. Come on, it's probably 10% of your LB population that fits it, and you can STILL use your guru tx's you like...As long as your treatment also included manip for the pt's that fit the CPR. Simple as that. EBM is a hierarchy. Some evidence is better than others. Practicing EBM is learning what constitutes "better" evidence, how to find, and -most importantly- how progress you tx style to incorporate the best evidence. Not every technique has a solid RCT backing it up. That doesn't mean they should be thrown out and never used. I'm finding I'm incorporating more and more continuous mobs into my practice. Does it have a RCT? No, but there is yet a study that shows one manual technique is superior over others. And, in my practice I "observe" that my pts do better when they receive it, compared to simple SP PA's alone.

ginger -> Re: L-Spine Coupled Motion? (April 26, 2007 2:00:00 PM)
Jason , thanks for the clarification, it seems clear to me that your combination of models /solutions/paradigms is as most experienced PTs would be. Eclectic, solution oriented. Cheers

ginger -> Re: L-Spine Coupled Motion? (April 26, 2007 2:04:00 PM)
Jason , so how do you know so much about rats?

ginger -> Re: L-Spine Coupled Motion? (April 26, 2007 2:10:00 PM)
go here http://www.eabf.org.uk/gowr.htm. you can become a Grand Rat!

jesspt -> Re: L-Spine Coupled Motion? (April 26, 2007 4:34:00 PM)
Eric, You state: " I am not a big fan of positional testing either, but even the Flynn study uses hypomobility, or a form of PPIVM, as a marker. If we don't do palpation testing, how do we assess what to mob/manip?" The reliability of hypomobility testing is generally found to be better than that of positional palpation or motion palpation, but, even that's not great. My question in return is, how do you know what you're manipulating? The data on specificity of manipulation indicates that we may not be manipulating at the segment where we think we are.

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