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Re: Diagnosis and Palpation in Manual Tx
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Re: Diagnosis and Palpation in Manual Tx - September 16, 2005 4:10:00 AM
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UTDC
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Jeep,
According to Julie Fritz, PT, PhD- one of the primary authors- it was the sacroiliac joint that is affected by the manipulation.
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Re: Diagnosis and Palpation in Manual Tx - September 16, 2005 4:54:00 AM
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JLS_PT_OCS
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Jeep,
Like Jeff said, the theoretical movement occurs primarily at the SIJ.
But like all other manipulative techniques (see previous citations) there is no real specificity to level or joint AT ALL. We are all fooling ourselves if we think we are moving bone A on bone B to reduce movement problem C. Whether we call them subluxations, somatic dysfunctions, or ERS/FRS dysfunctions, we're not able to be very specific at all in the technique.
I have a good deal of experience with the Chicago technique, and find more often than not, there are multiple cavitations in the Lx spine as well as the sometimes deep "thunk" that is (once again, theoretically speaking) the SIJ cavitating. The cavitations usually happen on the "opening" side of the spine (ie the side that we are sidebending away from).
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 16, 2005 5:39:00 AM
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UTDC
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[QUOTE]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.[/QUOTE]Alex,
For the most part I agree with what you say here. What I was trying to say is that I still feel biased toward the fact that supervised experience is a significant factor in outcomes. I fully realize that this point of view is not supported by the literature thus far and is merely my opinion.
So what about the study on the million $ roll vs Chicago?
Jeff
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Re: Diagnosis and Palpation in Manual Tx - September 17, 2005 3:17:00 AM
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Jeep
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[QUOTE] Like Jeff said, the theoretical movement occurs primarily at the SIJ.
But like all other manipulative techniques (see previous citations) there is no real specificity to level or joint AT ALL. We are all fooling ourselves if we think we are moving bone A on bone B to reduce movement problem C. Whether we call them subluxations, somatic dysfunctions, or ERS/FRS dysfunctions, we're not able to be very specific at all in the technique. [/QUOTE]I must disagree. Much can be done to influence specificity---------most importantly the skills and proficiency of the manipulator, which include choice of selection of a particular maneuver for a particular presentation, patient positioning(eg. locking out segments you do not want to move), the developed palpatory sensitivity of the provider(eg. end feel)and clinical experience in the delivery(eg. depth of thrust, line of drive- {anatomy knowledge very important here} etc.). There have been many times when I have chosen what segment and reason I want to address, chosen my method, carefully set up the patient, but could tell, unless I "cranked" on it, it would not respond as I intend(I am not a "whaler"). So I go back and re-evaluate---- choice of method, positioning, contact etc.) So while, IMO, chiropractic adjusting may not be as specific as some debate, it is/can be a lot more specific than you have been led to believe.
[QUOTE] I have a good deal of experience with the Chicago technique, and find more often than not, there are multiple cavitations in the Lx spine as well as the sometimes deep "thunk" that is (once again, theoretically speaking) the SIJ cavitating. The cavitations usually happen on the "opening" side of the spine (ie the side that we are sidebending away from). [/QUOTE]Yes----- I would expect a cascade of cavitations with this maneuver- from the SI to thoracics and perhaps even a few lower cervicals, and also the shoulder. Sorta akin to what is known as a "master cervical"(UTC and Chirortho will smile at this!) Two broad contacts at either end of the C-spine and "crank"!. The result is loud, multiple cavitations. You can learn it in about 30 min. Does that mean you are now a qualified manipulator? Does that mean you have any idea what you are doing? Does getting "multiple cavitations" infer a good manipulation? Does that mean you should ever use it on someone? My answer to all above is a huge "NO".
You may find the discussion of this maneuver interesting. http://www.chiroweb.com/ubb/open/Forum1/HTML/000654.html
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Re: Diagnosis and Palpation in Manual Tx - September 17, 2005 7:11:00 AM
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Bournephysio
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Jeep, first don't ever think that you are getting an accurate view of physio from chiroweb. Neither Wags nor Drew seem to know much about manual therapy in PT. Manual therapists in Canada generally think of these "non-specific" manips as the realm of Chiropractic not physio. We are "taught" to be very specific with our mobs and manips.
Chiro manips have been shown not to be specific (McGill's study in particular). The mechanics of any manip is almost total conjecture. We base our mechanics heavily on the work of people like Panjabi. Great work but relies on osteoligamentous spines with applied pure moments. There is very little good 3D mechanics of the spine in-vivo for normal movements and none that I know of for manipulation.
From what we know of the mechanisms of manipulation, it is quite possible that specificity is not that important. This brings up other possibilities. Maybe general manips with multiple cavitations are better. We don't know. How much skill is actually needed. I agree that alot of these "specific" manips take more skill. Is that skill needed. My personal belief is that general manips are probably fine for the lumbar and thoracic spine in most cased but that safety is alot better for specific manips of the cervical spine. This is also one of the main reasons I won't give up pivms and paivms. I think that good hands are needed for more "specific" cervical manips.
We clearly need a lot more research into this area.
Doug
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Re: Diagnosis and Palpation in Manual Tx - September 17, 2005 2:39:00 PM
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Jon Newman
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I thought cavitation was largely unimportant in determining success with manipulation. Am I wrong about that?
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 17, 2005 6:07:00 PM
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UTDC
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Jon,
There are some differing findings on this subject, however the best and most recent research indicates that cavitation is not a factor.
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Re: Diagnosis and Palpation in Manual Tx - September 17, 2005 10:29:00 PM
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yves
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From: Nanaimo, Vancouver Island BC Canada
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Hi folks:
After many years in private practice, and manipulation, I have returned to the hospital and just came off the Rehab floor.
In the last two months, I have had two patients early 50s, one with occluded right vertebral artery at the C2,3 region, and the other patient had a congenital narrowing of one vertebral artery of 25% of normal diameter.
AS Jim Meadows once said, if two people who manipulate daily, after 20 years, one of them will kill somebody, then I am glad after seeing these two stroke patients that I no longer wish to manipulate the neck.
You might as well drive on a Saskatchewan road and eventually you will hit a deer.
I am too old to live with this stress anymore, and was too young to know better when I was manipulating daily.
Regards
yves
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Re: Diagnosis and Palpation in Manual Tx - September 17, 2005 11:54:00 PM
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Alex Brenner PT MPT OCS
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[QUOTE]Does that mean you are now a qualified manipulator? Does that mean you have any idea what you are doing? Does getting "multiple cavitations" infer a good manipulation? Does that mean you should ever use it on someone? My answer to all above is a huge "NO".[/QUOTE]Jeep,
You are seeing it from a Chiro stand point and me as a PT, naturally. My answers to your questions are similar but with different rationale. Does this mean you are a qualified manipulator? I am not sure what you mean by this but no one comes out of these short courses thinking that they are now a "qualified manipulator" but they do come out feeling confident that they can administer a few "high dollar", safe techniques, that they can immediately apply to patients in their clinics.They also develop a foundation to which to build their manual therapy skills from. PTs are not coming out of these courses believing they can start cracking necks and low backs on every patient they see. Does this mean you know what you are doing? This is a great question because, truly, we do not exactly know what happens when we manipulate a spine. If you have read the Childs and Flynn studies they admit in the documents that they don’t specifically know which lumbosacral level we are manipulating. If you were to ask them, which I have, they would say that it doesn't matter. We have theories just as Chiros have theories as to what happens but when it comes down to it, we just don’t know. Please tell me you don't believe that you are correcting a misalignment or you are adjusting something (subluxation). Does getting "multiple cavitations" infer a good manipulation? I agree with you on this one. No. Current research shows that an audible pop is not necessary to achieve benefit with manipulation. There was a Flynn study published not too long ago that found these results. I don’t have the citation right away but can get that for you. Does that mean you should ever use it on someone? Absolutely. Current research shows a high level of evidence that this technique is effective for a certain subgroup of people with low back pain.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 18, 2005 10:21:00 AM
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UTDC
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Arch Phys Med Rehabil. 2003 Jul;84(7):1057-60. Related Articles, Links
The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain.
Flynn TW, Fritz JM, Wainner RS, Whitman JM.
US Army-Baylor University Graduate Program in Physical Therapy, San Houston, Texas, 78234-6138, USA. timothy.flynn@cen.amedd.army.mil
OBJECTIVE: To determine the relationship between an audible pop and symptomatic improvement with spinal manipulation in patients with low back pain (LBP). DESIGN: A prospective cohort study. SETTING: Two outpatient physical therapy clinics located in military medical centers. PARTICIPANTS: A cohort of 71 patients with nonradicular LBP referred to physical therapy. INTERVENTIONS: Participants underwent a standardized examination and standardized spinal manipulation treatment program. All patients were treated with a sacroiliac (SI) region manipulative technique and the presence or absence of an audible pop was noted.Main Outcome Measures: Subjects were reassessed 48 hours after the manipulation for changes in range of motion (ROM), numeric pain rating scale (PRS) scores, and modified Oswestry Disability Questionnaire (ODQ) scores. RESULTS: An audible pop occurred in 50 of the 71 subjects during the manipulative procedure. Both groups-those who had an audible pop and those who did not-improved over time in flexion ROM, PRS scores, and modified ODQ scores; however, there were no differences between groups (P>.05). Nineteen of the 71 (27%) patients improved dramatically (mean drop in modified ODQ, 67.6%). In 14 of the 19 dramatic responders, an audible pop occurred. However, the odds ratio (1.2; 95% confidence interval, 0.38-4.04) suggested that the occurrence of a manipulative pop would not improve the odds of achieving a dramatic reduction in symptoms after the manipulation. CONCLUSION: There is no relationship between an audible pop during SI region manipulation and improvement in ROM, pain, or disability in individuals with nonradicular LBP. Additionally, the occurrence of a pop did not improve the odds of a dramatic improvement with manipulation treatment.
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Re: Diagnosis and Palpation in Manual Tx - September 18, 2005 12:59:00 PM
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jma
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Here is another article:
"Relationship between an audible pop from high-velocity thrust manipulation and outcome in patients with low back pain.
Childs J, Flynn T, Friz J
JMPT, in press
Results: The occurence of a pop id not improve the odds of achieving a successful outcome (50% or greater reduction in the Oswestry)."
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Re: Diagnosis and Palpation in Manual Tx - September 19, 2005 6:17:00 AM
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JLS_PT_OCS
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Jeep-
I don't think I can improve on Alex, Jeff, and jma's contributions too much.
I left Chiroweb long ago, and find nothing worthwhile in returning. I know Drew must see a point in going there and discussing, but this Sisyphus has long since stopped pushing that stone.
I understand your point of view about manipulative skill and specificity. I understand that the points I am making and the research I am posting goes against everything both of us were taught in school. However, there is a revolution afoot here in the evidence for and use of manipulation in the care of patients. I really can't argue your points with you, as there is significant research in peer-reviewed literature to refute them already. If you don't accept that, then I don't think we can go any farther.
No one knows "what they're doing" with manipulation. No one knows what happens, why it works for some and not others, etc etc. Just because I learned it in school doesn't make it right. I would think that applies to anyone and any school -- PT, DC or DO.
Now that literature is refuting much of the backbone of theory in manipulative therapy, many people who spent countless hours pursuing various techniques of evaluation and diagnosis are very threatened that much of it appears to be for naught. I can understand why you might be upset.
That does not change the importance, usefulness, or basic facts of this or any other manipulation.
I do agree that there may be a role for skill and experience, especially in the cervical spine, but that is purely conjecture at this point. I hope to see more research on this in the future.
Thanks.
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 20, 2005 5:45:00 AM
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Bournephysio
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I think that there is still some controversy over whether or not cavitation will effect the response. Its is definately not needed for an effect. Most of the Csp manips I've been taught were designed to follow the joint glide and thus aren't supposed to pop. The study UTDC quoted has 0.38 and 4.04 in the 95% confidence interval. Both would be very clinically significant. The in-press article will be interesting.
If cavitation isn't important, it will make determining what is important for effective manipulation even harder to figure out.
Doug
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Re: Diagnosis and Palpation in Manual Tx - September 20, 2005 7:07:00 AM
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Jon Newman
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Doug,
Perhaps the answer will eventually be that manipulation isn't even necessary to be effective in a similar way that eating the bark of a willow tree isn't necessary for fever reduction (although it does work).
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 20, 2005 9:00:00 AM
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Shill
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Yes Jon,
But if that very same willow tree falls in the woods when no one is around, does it make a popping noise?
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Steve Hill PT
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Re: Diagnosis and Palpation in Manual Tx - September 20, 2005 9:33:00 AM
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Jon Newman
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Well Shill, I don't think it does make a sound if no one is there to hear it. Regardless, even if someone was there to hear it they probably couldn't figure out which tree in the woods made the sound in the first place.
jon
_____________________________
[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 20, 2005 2:46:00 PM
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jma
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Many of the studies incorporate manipulation and exercise coupled together rather than alone. The coupled one had better outcomes.
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Re: Diagnosis and Palpation in Manual Tx - September 21, 2005 6:14:00 AM
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JLS_PT_OCS
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Good point, JMA.
Who's best qualified to provide that? Oh, yeah.
:)
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 22, 2005 6:14:00 AM
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UTDC
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[QUOTE]Who's best qualified to provide that? Oh, yeah.[/QUOTE]Why Jason, that would be us chiropractors of course! ;)
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Re: Diagnosis and Palpation in Manual Tx - September 23, 2005 1:13:00 AM
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JLS_PT_OCS
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I know, Jeff, I was just setting you up, buddy!
:)
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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