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Re: Diagnosis and Palpation in Manual Tx
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Re: Diagnosis and Palpation in Manual Tx - September 8, 2005 10:16:00 AM
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UTDC
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Jason,
In your opinion, what would represent a reasonable level of training for spinal manipulation?
Thanks,
Jeff
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Re: Diagnosis and Palpation in Manual Tx - September 13, 2005 5:56:00 AM
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JLS_PT_OCS
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Jeff-
Excellent question. I assume you mean how many hours or weeks of training before someone already trained in medical basics can become competent? I'm not sure I have a nice tidy answer for you. Though 3 1/2 years clearly seems too much (just kidding, man). :)
I think the primary issue should be the clinical decision-making process, risk/benefit analysis, anatomy, and associated medical training about those sorts of topics. Also, we should be focusing on other things which the research indicates is effective now or in the future, beyond manipulation (eg exercise and neuromuscular retraining, soft tissue work, etc).
Actual time spent practicing technqiue A or B or C is much less important, in my opinion. I do think a level of training, in small groups or one-on-one is necessary to develop the proper positioning and force application through the hands.
However, I have found experience to be the best teacher, and that good levels of skill can be developed quite quickly when they are regularly practiced in clinic or in classroom. This is irrespective of amount of hours spent learning. I have found with myself, that I did best by learning several general techniques, and once I got those down for a while, slowly adding new ones. I find anecdotally most of the LBP population, for example, responds quite well to the one manipulation (provided in the validation study), and my adding more (in sidelying type position) doesn't seem to add much if anything to outcomes.
I think if all of us think about it a little, the interesting thing about manipulative therapy is that if it's going to work, it starts to work very quickly. If it doesn't work soon, it's not going to, no matter how many visits.
For example, there is a very well regarded Orthopedic and Manual Therapy fellowship in the US Army. When we get some of our Army postgrad courses, we are taught and mentored that type of thing even more by the instructors and fellows. When we were practicing, I noticed a definite difference between the instructors (at, say Level 10 of skill, to the fellows (Level 7 skill) and my fellow students (Level 5 skill). Keep in mind the numbers are arbitrary and for discussion purposes only. Now while I was there I kept wondering at what point in the experience continuum the outcomes changed. I also wondered how much of that skill was due to instruction and how much was due to experience. I don't think we'll ever know the answer to those questions for sure. Skill in anything is as much about aptitude and interest as it is about training, so skill and time spent won't always correspond.
Therefore, it would be difficult to sort providers by years of experience for the purpose of determining outcome difference.
This is one of my primary issues with manipulative therapy, that we are assuming that so much is skill dependent, when that doesn't appear to be the case.
I think that, assuming related decision making and medical topics are left out, any time spent that is enough to gain confidence by the individual clinician, which allows them to practice it comfortably on patients and other students, is sufficient.
So...it depends. I think clearly one day is not enough, and clearly many years or months is too much. Where to draw the line in the middle...I'm not sure.
I think that simply giving it the time and attention that is relative to it's worth in outcome studies will go a long way towards making the time spent jive with the clinical effectiveness.
Great question, Jeff, I hope I didn't dance around it too much.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - September 13, 2005 9:48:00 PM
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Alex Brenner PT MPT OCS
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Jeff,
What is your opinion of the amount of time needed to learn manipulative therapy?
I have read on other forums and have seen the ridicule that PTs receive about weekend seminars to learn how to manipulate spines.
I am like Jason and believe that manipulation is very easy to learn and to apply. I was taught manipulation in PT school and was able to effectively apply it during my student clinicals with maybe 10 hours of training. I felt that was sufficient. Of course I became better the more I practiced and became more experienced.
I personally have been to continuing education courses and served as a lab assistant in manipulative techniques and have witnessed students become quite good at several techniques over a few hours having never been exposed to them before the course. In fact, the "chicago technique", the one used in the Child's validation study, can be taught and applied effectively in about 10-15 minutes. It my opinion, not too much skill is needed to learn and apply this.
Jeff, as a chiro, what are your thoughts on this?
Alex
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Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 1:47:00 AM
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Jeep
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My skills when I graduated, after 4 years of DC school, and THOUGHT I was good----seem very crude and primative, by comparison, to the touch, application, and skills that I now have developed after years of adjusting/manipulating daily. Metaphorically, the difference between a "piano-player" and a "pianist".
Anyone that claims to be a "manipulator" after a week-end seminar is only fooling themselves, and more importantly, fooling their patients(and risking their well-being). "A little knowledge can be a dangerous thing". It is only after you become more skilled and proficient at something, that you become aware at how little you used to know.
Alex-
What is the "chigago technique"?
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 2:22:00 AM
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Jon Newman
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If I'm not mistaken, here a [URL=http://blog.evidenceinmotion.com/evidence/files/musculoskeletal_monthly205.pdf]picture of the chicago technique[/URL]
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 3:29:00 AM
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JLS_PT_OCS
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Jeep-
That's just the thing, man. We have some good evidence that a very simple manipulative technique that is easy to learn and use is extremely effective. For a lot of people (PTs, DCs, and DOs), that is VERY threatening. I really like that the evidence is really leaching out a lot of the mysticism and guru-ism in this treatment modality.
I think that a lot of us went to great lengths to become very skilled at whatever it is that we do (manip, soft tissue work, exercise rehab, neuromuscular retraining, whatever). That investment in time and effort makes us prone to believe that anyone without a given level of skill (usually restricted to our given profession) is dangerous or "fooling themselves".
I'm not saying that a few patients might not have a movement problem that needs some skilled hands, but given the available evidence to date, there is no reason to think that the vast majority of patients fit into this category.
Let's think of rehabilitation for a minute. Let's say I told a DC that he couldn't do rehab and would be dangerous with it, unless he did X number of hours or went to some school for it. Let's say that I laughed at the Rehab diplomate program you guys have got and called it a "home study kit". Do I have any actual EVIDENCE that a DC providing rehab is dangerous, "fooling themselves" or risking the well-being of their patients or themselves? No, I don't. I do think rehab is an important skill set and that there are a few patients out there who might require someone extremely skilled in rehab. But most patients could do rather well with some basics. If someone's education about safety, clinical decisionmaking, etc is there, then I have no reason to argue that a DC can't be a good rehabber. Or an ATC, for that matter. In fact, I've met and learned from both.
I do agree that as we all get better, we laugh and are sometimes embarrassed at how little we knew way back when. That is a great argument for the influence of experience, but not for a required number of hours/weeks of training. The important thing is the anatomy/physiology, clinical decisionmaking, etc. That is where the safety issue is, not the number of hours in technique.
The actual techniques (be they rehab, manip, soft tissue, etc) really are experience-based MUCH more so than training-based. Wouldn't you agree?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 3:32:00 AM
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JLS_PT_OCS
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Yes, Jon, that is the "chicago technique".
It is named by it's Osteopathic name, like many osteo techniques which are named by a particular school. An old DO buddy explained all this to me...
What Alex and I call a supine Tx opening manipulation, the DOs call the "Kirksville Crunch" (for Kirksville College). I think I like their names better...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 3:34:00 AM
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Alex Brenner PT MPT OCS
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Jeep,
I guess my point is that one can learn to be an effective manipulator in minimal time. They may not be the greatest at it, but I strongly feel that many effective techniques can be learned and applied with minimal training. Of course we all get better with experience and practice.
There was a good study published in the Journal of Orthopaedic and Sports Physical therapy showing that experience was really not a factor in outcome with manipulation. Essentially, even those with minimal experience could administer an effective lumbar manipulation.
Here is just the abstract of that study:
The Influence of Experience and Specialty Certifications on Clinical Outcomes for
Patients With Low Back Pain Treated Within
a Standardized Physical Therapy
Management Program
Julie M. Whitman, PT, DSc, OCS, FAAOMPT1
Julie M. Fritz, PT, PhD, ATC2
Maj John D. Childs, PT, PhD, MBA, OCS, CSCS, FAAOMPT3
Study Design: Secondary analysis of a randomized trial.
Objectives: To examine the influence of experience and specialty certification on outcomes for patients with low back pain receiving a standardized manipulation or stabilization exercise intervention program.
Background: Little research has examined the impact of therapist-related factors on the outcomes of clinical care for patients with low back pain. It is assumed that therapists with more clinical experience or specialty certification will achieve better clinical outcomes; however, few studies have examined this hypothesis.
Methods and Measures: One hundred thirty-one participants in a randomized trial were included(70 randomized to receive manipulation, 61 stabilization). All subjects completed an Oswestry Disability Questionnaire at baseline, and after 1 and 4 weeks of treatment. Therapists were categorized based on total years of experience, years of experience with manual therapy, and specialty certification status. Two-way repeated-measures analyses of covariance were performed within each intervention group to examine the effects of the therapist characteristics on outcomes. Hierarchical linear regression models were used to examine the relative effects of therapist characteristics and intervention on clinical outcomes.
Results: Thirteen therapists participated (average 6.0 years of experience [standard deviation, 4.0],4 (30.8%) with specialty certification). A significant interaction between time and specialty certification status (P = .04) was detected for subjects receiving the manipulation intervention. No significant interactions were detected in the stabilization group. The regression models found that
the intervention group significantly contributed to explaining clinical outcomes, but that therapist characteristics did not.
Conclusions: With the standardized protocol utilized in this study, it appears that the therapist-related factors of increased experience and specialty certification status do not result in an improvement in patients’ disability associated with low back pain.
J Orthop Sports
Phys Ther 2004;34:662-675.
The chicago technique is shown pretty well in Jon's link.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 7:36:00 AM
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Shill
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Is the chicago technique aka the "million dollar roll"?
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Steve Hill PT
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 8:45:00 AM
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Alex Brenner PT MPT OCS
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The millian dollar roll is a sidelying technique where as the chicago technique also named the lumbosacral region manipulation is performed supine. They are different techniques.
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Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 8:51:00 AM
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Jon Newman
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Do the two techniques do something different?
Alex,
How do you like interacting on rehabedge without the time differential?
jon
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Diagnosis and Palpation in Manual Tx - September 14, 2005 11:15:00 AM
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UTDC
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Jason,
No you did not dance too much, there really is no good answer to the question, I just wanted to see what your thoughts were.
Jeff
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 1:32:00 AM
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Alex Brenner PT MPT OCS
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Jon,
It was nice while it lasted but as of this week I am back in Italy.
Great question and you know as well as I that we dont really know what is happening when we manipulate a spine. In theory, the million doll ar roll is a flexion/opening technique that is aimed at the lumbar segments. Depending on set up you can aim the mobilization towards the various lumbar segments L1-5. A good technique if you are wanting to move the upper lumbar spine. The chicago technique aka lumbosacral region manipulation is a mobilization aimed at the sacroiliac and/or lower lumbar levels.
There will be an interesting study coming out of the US Army/Baylor University PT school in the near future that will be testing the Lumbosacral region manipulation (chicago technique) versus the flexion/opening (million dollar roll) utilizing the same perimeters as the Childs validation study. Essentially they will be taking people who meet the clinical prediction rule and separating them into two groups. One group will recieve the chicago technique and the other group will get the million dollar roll. My prediction is that we will see great improvements in Oswestry score in both groups. Can't wait.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 2:20:00 AM
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JLS_PT_OCS
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Now THAT will be a great study!
Jeff-
I'm glad I was able to answer your question at least a little bit. So, now it's your turn to address that question...
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 6:47:00 AM
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UTDC
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AHH. Well I guess I can't hide anymore. Intuitively, I want to say that experience is an important factor.
I have been aware of the Childs et al study for some time. Unfortunately, my university does not have online access to JOSPT (surprisingly) and I have not viewed the full text (if anyone wants to send it my way, I would appreciate it). Given the authors, I'm sure the methodology is sound.
In any case, this was one study performed on one technique- I'm not sure that we should "hang our hat" on it. Much like Jeep said previously, I certainly experienced an evolution of my manual skills, however the real question is....are outcomes influenced by skill level. As a patient, I have experienced a range of skill levels which I felt had an impact on my personal outcome. I had a friend who had recently finished the manual therapy certification program in Denver who performed some grade 3 and 4 mobs on my c/s which aggravated my pain, while a more experienced person was able to provide me significant relief.
When it comes to HVLA, I believe the key issues are avoiding adverse rxn's. Being able to select a patient population appropriate for HVLA and applying the technique in such a manner so as not to induce soreness/injury is where the skill comes into play. This takes skill, time and experience. I have seen PT's who were good at manipulation and others who were dreadful. I have seen PT's who applied it inappropriately (upslip on EVERY patient), and those who do a good job of application. I think that DC's on the whole are better at the former while being worse at the latter.
What was the question again? LOL.
In any case, I think that manipulation takes enough training to apply the technique appropriately in such a manner as to not cause unnecessary side effects. What is the time frame? I don't know. As far as how to do it, I believe that supervised, hands on application is the key. Ditch the mystic theory and get a feel for it with your own hands.
Alex,
I am very interested in the study you described, who is involved? Childs I assume?
Jeff
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 7:01:00 AM
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UTDC
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Alex,
To address your previous question about weekend seminars, I do not think that they are sufficient. In the context of the Chicago manipulation, I think it is reasonable, but not to HVLA in general. What helped me the most was working alongside an experieced practitioner where we would both put our hands on the patient and try to figure out what I was missing. However, I think that a skilled manual therapist who is frequently puts their hands on patients and is already well versed at mobilization may have a shot at adequetly learning HVLA in a seminar setting.
Does that make sense?
Jeff
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 8:37:00 AM
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JLS_PT_OCS
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I think it makes a lot of sense, Jeff.
We should be clear, that every professional PT program has a large number of hours in manual assessment and treatment means.
No PT is learning manual or manipulative therapy solely through a weekend course.
The seminar format is to introduce new techniques and help provide more of that one on one teaching and help which we can all agree is essential.
I think you're right, in that it will be difficult to set strict standards about how many numbers of hours are required. I would bet both CAPTE and the CCE (our respective accrediting agencies) have a range of hours that they consider acceptable for accreditation. As long as that's going on and it's acceptable, I think we can also agree that it is our experience and our mentoring that made the difference in our skills (god knows mine are still evolving) more so than the hours we got in our entry-level education.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 6:58:00 PM
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Synergy
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I found the following article over at [URL=http://blog.evidenceinmotion.com/]Evidence in Motion[/URL]. Another good read and something to think about.
[URL=http://blog.evidenceinmotion.com/evidence/files/does_technique_matter.doc]Does Technique matter?[/URL]
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Chris Adams, PT, MPT
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Re: Diagnosis and Palpation in Manual Tx - September 15, 2005 8:08:00 PM
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Alex Brenner PT MPT OCS
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Jeff,
I think we are finding out with research, like the document that Chris linked to above, that you don't have to know how to perform a ton of techniques to be effective. Personally, I use 3 maybe 4 different lumbar techniques on almost all my patients with LBP who I feel may benefit from manipulation. So with that, I feel a PT with a little background in manual therapy (and we all get this in PT school, some more that others) can go to a good 3-4 day course and come out of it feeling comfortable with a few "high dollar" techniques. In fact, I've witenessed it. As PTs most of us are really good with our hands, working with them every day, and so naturally it doesn't take much to learn these techniques.
Jeep mentions above about "risking well-being". Although the risk at the lumbar spine is very, very small I still think it is important for the therapist to learn when and who to manipulate. The great thing is that current research is telling us which patients most likely benefit from manipulation. That is what makes the Flynn and Childs studies so great. If we stick to the clinical prediction rule there is little risk and a great potential to get some back pain dramatically better in a short time. This doesn't take a 4 year degree and in my opinion can be learned very quickly.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 16, 2005 1:36:00 AM
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Jeep
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The study can only be interpreted(at most)to ascertain which patients responded/benfited from THIS(chicago)manipulation maneuver.
I also have questions regarding THIS(chicago) manuever. What is the provider moves?, what is the physics/biomechanics of what is supposed to occur with this move?, what is the target level? how is is changed patient to patient?
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