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Re: Diagnosis and Palpation in Manual Tx
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Re: Diagnosis and Palpation in Manual Tx - September 23, 2005 9:01:00 AM
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UTDC
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I appreciate it Jason, I can use all the help I can get!
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Re: Diagnosis and Palpation in Manual Tx - September 23, 2005 11:55:00 AM
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Shill
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From: Madison WI USA
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This is the thread that wouldnt die!!!
To make it go a bit longer, lets go back to the title of it, and deal with the fact that other than with acute LBP, we dont have a great lot of information as to when to manipulate. Sure, we can go with what we think might be stuck (or whatever) with motion palpation and joint play, but hanging our hats on such an unreliable tool is a bit scary to me. When do you all decide to get crackin' in the non acute situation?
Steve
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Steve Hill PT
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Re: Diagnosis and Palpation in Manual Tx - September 27, 2005 2:11:00 PM
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Jon Newman
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Chester: It's quiet out there
Marshall Dillon: Yea, too quiet
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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 28, 2005 2:02:00 AM
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Sebastian Asselbergs
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President Bush, what are your thoughts on "Roe vs. Wade"?
Well, I don't particularly care HOW people get out of New Orleans....
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Mundi vult decipi
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 3:03:00 AM
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SJBird55
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Manipulation was never in my belief system, mainly because of my fear, combined with patients having no control, combined with the horror stories of the techniques described to me.
I only use manipulation if it fits the clinical prediction rule for LBP. I did take the time to educate myself about both my belief system and my fears and did take a course with Wainner and Childs and Bennett. I don't know what other therapists do, nor do I know what chiropractors do... but I do know that it was stupid of me to have the beliefs that I did regarding manipulation - it isn't scary and what they taught especially for the cervical spine to me wasn't extreme at all and the forces were directed to a joint not to the whole available ROM of the cervical spine.
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 3:35:00 AM
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Alex Brenner PT MPT OCS
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I like this thread, probably one of my favorites of all time on rehabedge.
Jon has been waiting in the background, licking his chops, for whoever will attempt to answer this one first.
It is funny how the manipulators have avoided answering this one. Of course, of all of the regular contributors on this website as manipulators we are in the minority. Is it just Jason and I?
[QUOTE]Sure, we can go with what we think might be stuck (or whatever) with motion palpation and joint play, but hanging our hats on such an unreliable tool is a bit scary to me. When do you all decide to get crackin' in the non acute situation? [/QUOTE]I do my best to follow the clinical prediction rule when it comes to manipulation. Of course acuity is actually one of the best of the clinical predictors but you can still use the prediction rule to help guide your decision to manipulate on sub acute and chronic patients. I also use the FABQ to decide who to crack and who not to. If they have a FABQ great than 19 I almost always decide not to manipulate for obvious reasons.
The CPR sometimes is fuzzy on some patients. In that case I rely more on my physical exam to drive my clinical decision to manipulate. For example, if they are having pain over the right side around L4-5, and they have limitations in forward flexion and left side bending I may try an opening technique aimed at the right L4-5, 5-S1 region and then immediately retest those motions looking for improvement in quality and quantity of movement.
I don't think there is much evidence behind this one, but I like it when a patient says "Man, if I could just get this thing to pop." or "It feels like it needs to pop". If I hear this, they are gettin' popped. And actually most respond pretty well. Maybe that could be the 6th clinical predictor.
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Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 3:51:00 AM
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Jon Newman
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HI Alex,
If I'm licking my chops it is only because I'm a theory junkie and Shill's question had theory written all over it. I learn a ton from picking through the mechanism of action, the clinical reasoning, the big picture, etc. Manipulation works. All that's left is to explain its workings.
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 28, 2005 4:08:00 AM
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Barrett
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Alex,
What if the patient who has ALL the predictors lined up perfectly also harbors a desperate fear of being "popped" but remains silent about that? Maybe this hasn't happened to you yet. In my experience, once you've "popped" them, any consequent increase in their symptoms, no matter how unrelated, can easily be blamed on that procedure. I'm not suggesting this is fair.
I predict that one day your trust in what the patient says they need will be tempered by a few experiences to the contrary. Showing you what they need is another matter.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 8:54:00 AM
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JLS_PT_OCS
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Barrett-
I agree with the point I think you're driving at, (please correct me if I'm wrong) in that many people have a fear of passive movement they can't control directed at a painful area by another person they may not trust, whom they probably met just a few minutes ago.
And you make a good point about increasing symptoms and the subsquent blame game that is likely to surface. I think that issue is as true for extremity problems as for spine problems.
I think Alex and I are kind of on the same page when it comes to this stuff, in that we are sensitive to people who might not do well after the procedure because of a heightened emotional state or fear beliefs(and the FABQ is a great way to help spot that).
I explain the procedure and what I'm going to do, I even pre-position some people and get a feel for their comfort level before I give the thrust (which if you've seen the video, is rather gentle and firm rather than aggressive).
This helps assuage the discomfort of most patients who are nervous. For those that don't seem comfortable, I move on to another method.
I have had patients for which I have done manual therapies of all kinds, who c/o an increase in symptoms. This is always temporary and resolves well with time. If my clinical "spider sense" tells me that a patient is likely to not do well with manipulation, regardless of what the CPR tells me, I don't manipulate that person. This is usually those with heightened fear avoidance type beliefs or an over-emotional presentation, but who still managed to score low on the FABQ.
I don't think it is correct to infer that those of us who use manipulation simply haven't had enough patients c/o increased symptoms to consider abandoning the practice. I've had my share of people who said it didn't help or made them worse temporarily, probably about as many as the literature predicts, which is a very small number. The published and documented risks for lumbar manipulation are extremely small. Those persuaded by this level of risk to not perform these techniques (not referring to anyone in particular) must also be consistent with their interpretation of the risk and therefore not do other things with patients which have similar or larger levels of risk, such as use of hot packs or doing any cardiovascular conditioning, for fear of burns or sudden cardiac death. Were these same PTs to work as a physician for one day, and not give NSAIDs for a patient in acute pain due to fear of GI events (much more common and serious than manual therapy side effects)?
I think that most civilian PT clinics see a lot of folks who are more chronic and who have many of the factors (esp fear-avoidance beliefs, and other factors for chronicity like litigation, compensation, etc) that indicate less likely success with manipulation (or with any treatment, for that matter). I think Alex and I probably see more acute stuff than most people in the non-military PT world, and this can color our view a bit as well. If it seems we are pro-manipulation, some of it may just be that we see way more people who fit the CPR criteria, statistically speaking.
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 28, 2005 10:03:00 AM
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Barrett
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Jason,
I find nothing in what you've said to argue with. Bummer.
I especially like the way you make the point that risk is present no matter what you decide to do. My solution to that problem is to "do nothing," I guess. Not that that doesn't get me into plenty of trouble as well.
Still, we press forward, often at the head of the pack. I think of myself not as a running back outrunning the defenders-I'm more like a pullin' guard.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 3:51:00 PM
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Shill
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Alex, Jon, Jason, Barrett, SJ, (and even Sebastian, that was a good one!)
Thanks for the replies.
I just wanted all your thoughts on this.
Excellent points all.
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Steve Hill PT
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 5:58:00 PM
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Jon Newman
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Here's someone trying to establish the why behind manipulation:
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15626991&query_hl=12]link[/URL]
It doesn't do much regarding technique selection, not to mention that the study was on cats. I thought this was important
[QUOTE] In general, the mean instantaneous discharge frequency for all 6 afferents increased abruptly as the duration of the impulse approached 100 milliseconds. An increase in loading magnitude (33% vs. 66% vs. 100% body weight) did not appear to systematically affect the discharge from the 6 low threshold mechanoreceptors. [/QUOTE]jon
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 8:28:00 PM
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Alex Brenner PT MPT OCS
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[QUOTE]All that's left is to explain its workings.[/QUOTE]Jon, you and I will probably not be around to see this.
By the way, is there a USB cable running from your brain to the internet. Amazing where you find these links so quickly and appropriately.
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Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 28, 2005 8:55:00 PM
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Alex Brenner PT MPT OCS
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Barrett,
As always you bring up such thought provoking examples. Jason, as always, brings up excellent points that I usually can not add to.
I too use my "manipulation spidey senses" to see whether or not the patient is game to manipulate. I get better at this as time goes on. If I see any type of reluctance then I go on to something else. I also spend a good time explaining the procedure and technique to be used. If after explaining the technique and I see the patient make a Billy Idol rebel-yell-curled-lip-face then I also move on to something else.
With all due respect, in the pictures I have seen, you are built more like a pulling tackle. I would not want to catch you but rather just get out of the way.
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Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - September 29, 2005 12:55:00 AM
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Randy Dixon
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I wanted to ask Jason and Alex why they use the CPR to screen their patients? It may seem obvious. I presented this question with John Childs, at first joking but later seriously. With the CPR you can find the pt. population that manipulation will be the most effective for, but they are not the only ones that it is effective for, those with 3 positive CPR signs, or even 2, may still get some benefits. So by using the CPR and 4/5 signs you get a "hit" ratio of 80 out of 100. With a 3/5 signs, let's say 50/100 and 2/5 a 30/100. By including the lower scores your hit rate goes down but more total people are helped. If you feel the technique is safe and since it is only a one time, 5 minute procedure why not expand it's use.
In other words, I think the CPR is more useful for research than for clinical decision making where you want to give every patient the best treatment and chance rather than have the best numbers. Why is that wrong?
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Re: Diagnosis and Palpation in Manual Tx - September 29, 2005 2:14:00 AM
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Jon Newman
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[QUOTE] Jon, you and I will probably not be around to see this. [/QUOTE]I don't know. Much of its workings seems to be explained by current pain physiology, don't you think?
Although it also seems that our current understanding of physiology suggests that manipulation may not be necessary. I've made the analogy before that I think it is like eating (willow) bark versus taking aspirin. Both work for what they do.
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 29, 2005 3:28:00 AM
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JLS_PT_OCS
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Barrett-
After all we've been through here on RE, it seems we can't muster even a raucous disagreement lately. Perhaps that's progress. :)
I really must get to your course. Coming back down to Fairfax VA area soon I hope?
Jon-
If we were manipulating cats, then I think that study has promise. I don't even want to get started on the issues of animal experimentation here, but if the Cox-2 debacle did not show how pointless and possibly dangerous animal research is, then surely it will continue despite it's lack of applicability.
I have never manipulated my cat, and after reading and thinking about it, I am beginning to think the fact he never needs it has a lot to do with what Barrett says about ideomotor activity and mechanical deformation. Also, it's hell to get him to be still long enough to measure his hip rotation for the CPR! He also has difficulty holding the pen when I ask him to take the FABQ. :)
Randy-
Good point. I don't think we should infer that using the CPR implies that I only consider it when I have 4 or 5 out of 5. I think for any patient who has a painful lumbar spine and loss of movement, manipulation is on my list of options. I use the CPR to help guide me and try to establish priorities, but I see what you mean about the concept of "just trying it" since the risk/benefit ratio is rather good. I don't use the CPR to exclude people, just to help me see likelihoods. I have used the technique to good effect on many people who have had 2 or 3 factors also, but predictably, not as good success rates. Funny how that worked. :)
Steve-
Anyone with loss of motion and/or pain is a candidate for manual therapy, in my opinion. Who, where, what grade, etc is up to the clinical exam, patient presentation, and priorities. Like Alex, I use the global range of movement to help me decide where to start. I don't do static or motion palpation or anything like that. I give therex that reinforces the manual techniques in terms of motion directions. Does that help?
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 29, 2005 4:43:00 AM
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Sebastian Asselbergs
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Jason, with regards to animals and manipulation: riding horses are often 'forced" to move a certain way - this may be why they are such frequent patients of chiro and PT attention in the racing circles. If they were allowed to move the way they wanted to, no-one would get very far, or waaay too far with them - but never really where the rider wanted to go. LOL
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Mundi vult decipi
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Re: Diagnosis and Palpation in Manual Tx - September 29, 2005 4:03:00 PM
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Shill
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From: Madison WI USA
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Jason,
Im with ya on the ROM loss for a means of applying manip. I really dont use manip much on the population I see, which is never Acute by definition. I will use it, and on those I have, it does indeed help. And yes, all the answers do help. I dont find the manips very difficult to perform at all, and I think you have to really be a buffoon to screw up a lumbar or thoracic manip. C-spine is quite a bit trickier, and therefore I wont go above C7-T1. Thats my comfort zone. BTW, Im going to Barretts' course in October. Have you done it yet?
Steve
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Steve Hill PT
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Re: Diagnosis and Palpation in Manual Tx - September 29, 2005 4:32:00 PM
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Jon Newman
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From: Amherst, WI
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Shill,
If it's at all possible, I'd love to try to get down there and meet with you and Barrett (assuming he's up for that). I work that day so it would have to be a dinner.
jon
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