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Re: Diagnosis and Palpation in Manual Tx
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Re: Diagnosis and Palpation in Manual Tx - September 30, 2005 4:02:00 AM
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JLS_PT_OCS
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Steve,
No, haven't done Barrett's course. Had to miss it when he was down here last time. Hoping to catch him next time.
Though you don't manipulate the Cspine, you do do lower velocity mobilization, right? Given the efficacy in the literature, there's no reason to think that avoiding Cx spine manipulation is detrimental to your outcomes.
I think for most of my career I have relied more on global range of movement to determine where to start manual therapy, and the motion/static palpation stuff just never seemed to pass the common sense test to me.
I am trying something new with my neck pain patients. Instead of trying to feel their segmental mobility and plan treatment areas from that, I am just doing translatory mobs to their entire lower Cx spine, and some MET/mob for their OA/AA if needed. Ever since I read this article...
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12782973&query_hl=1
...I wondered if it even mattered which segment I was workiing on. If the mechanism of manual therapy has anything to do with the general things we've discussed (neural effects) then I suppose it wouldn't matter if we were a few segments "off".
Therefore why am I supposed to do motion palpation again?
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 30, 2005 4:24:00 AM
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Barrett
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Jason asks, "Therefore why am I supposed to do motion palpation again?"
Good question. Why does Shirley Sarhmann continue to look at standing posture? Though she admits never having seen a study connecting it to pain, she "can't imagine" not looking at it.
Google "meme" today and you'll get 52,900,000 hits. You'll find in there the reason we stick with things that we've always done; things that comfort us, rationalize our behavior, justify it and, ultimately perpetuate it in the face of all evidence to the contrary. The progression of science has always been dependent upon each individual's ability to see through this tendency and then consciously alter behavior and belief, even in the face of ridicule from those we respect.
Good luck stopping the motion palpation during exam. It was easy for me, and I taught thousands of therapists to do this in the 70s. I'm not sure why I let go of it without an internal battle.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Diagnosis and Palpation in Manual Tx - September 30, 2005 4:46:00 AM
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Yogi
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Sebastian, great horse line. I just read it. You think horses might take you where you don't want to go, try mules.
Jon, great find on the cat study. That's why I liked the dual degree thing for a Doctorate, other knowledge fields could be applied to PT concerns. This time it was a DC-cat surgeon-neurophysiologist. Great.
This could point to a tone inhibiting effect from manipulation, which then points to the same mechanism as Ginger's mobs and Strain/Counterstrain. Probably SC, too.
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Re: Diagnosis and Palpation in Manual Tx - September 30, 2005 5:07:00 AM
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JLS_PT_OCS
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I think for people to let go of things, they have to consider the weight of evidence and their personal approach to knowledge to be more valuable than their personal experience and their training.
As I'm sure Barrett could tell me, this is a lot harder than it seems.
I think there are people who tend to be more reflective in their lives and in their practices, and who have had instilled in them somehow more of a respect for evolving knowledge and new paradigms than in their experience and training.
I find many people who have "grown out" of certain things in their lives (for example, people who have a different feeling about religion than the way they were taught) understand this pretty well. Getting them to see the same concept in different circumstances is difficult sometimes.
But as my wife says about things "Once you REALLY think about it, you can never go back."
Once you really start to challenge those paradigms of thought and listen to the evolving research, you can never really go back to teaching people to find ERSs.
Maybe the reason Barrett let go of motion palpation so easily was that he realized this and knew in his heart it was pointless to do other than what he did. He knew it was over, so he let it go without concern.
Buddhism has much to say about this sort of thing, as many of you may already know.
I can think of other things in life that are like this (remember the Vegan thread?) but they have little to do with physical therapy...
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 30, 2005 12:13:00 PM
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samuelmagnus33
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The toughest part about letting go is when you finally believe you found something that works and is true based on your application of this truth over the test of time.
We must let go if we wish to continue to evlove and transform in our thoughts and in our practice.
Maybe the best thing we could do for our patients is to teach them how to recconect with their innate instincts, teach them healthy living practices, and set them free.
However, we must first be willing to do the same.
Samuel Mielcarski, PES,DPT
Homo Fructus
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Re: Diagnosis and Palpation in Manual Tx - October 4, 2005 7:07:00 AM
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JLS_PT_OCS
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Thanks, Jeff, I just came from there to post here. I see you beat me to it!
Awesome.
Here's the comment I left on Evidence in Motion:
"Well, as harsh a critic as I have been in the past on the motion palpation style of assessment in manipulative therapy, I think this is an encouraging study.
My question is: how was the PA mobility assessed?
Was it a straight PA mobilization type movement through the spinous processes as I think it is, or was this hypomobility determined by palpation and attempts to categorize movement or positional differences between facet joints?
I think many manual practitioners will be happy to see a role for palpation, but I want to clarify whether we are speaking of general mobility or of motion-palpation style ERS/FRS dysfunctions. The differences and resulting implications are very important."
*************************************************
So if we are using general ROM and general PA mobility measures to guide manipulative therapy of the Lx spine, that seems a good thing. It is worth noting that the palpation was not of facet joint position, and that the data seem to indicate that those with hypermobility in one location should NOT treated with manipulation, even to segments not judged "hypermobile".
I don't think this study really ends the debate, but it sure helps clarify the role of palpation (a minimal, basic amount of it) in the overall management of LBP. I wonder how this might apply to other regions?
Any other thoughts on this study?
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 - October 4, 2005 12:27:00 PM
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steve
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Jason,
The study is based on the data collection of those patients who participated in the CPR for manipulation in the Annals of Internal Medicine. I am not surprised by the findings and they suggest that there is SOME predictive value to passive mobility testing but that when it is combined with other factors (ie. Pain below knees, Work/fear avoidance) it becomes much more relevant to determining outcomes for clients. I think the problem arises when we are using overly complex movement models that are based on special senses of touch that can be achieved through guru instruction.
Steve
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Re: Diagnosis and Palpation in Manual Tx - October 4, 2005 4:46:00 PM
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Jon Newman
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As usual, I have some questions. First, a technical question to those who test this sort of thing regularly: I thought when one encountered a hypomobile segment that quite frequently there is hypermobility in nearby segments. Is this common? And based on the classification scheme used in the study how would these people be classified?
I do have a concern that no reliability testing was done with the clinicians when evaluating this specific component of the physical exam. While it is contented that segmental mobility testing could be a reliable technique, it does not state that these clinicians were in fact reliable with the technique. I appreciate the argument that in combination with other tests/measures that this type of testing adds to the clinical picture and thus reliability is less important. However, that is not what is going on in this particular analysis.
This brings me to another question. This was not actually a new study per se. It was a post hoc analysis of an existing study. I think that this is not the first post-hoc analysis of the referenced study but I could be mistaken. My question to anyone is, what happens to the generalizability or the power of the analysis with subsequent post-hoc analyses? Intuitively, it seems like it shouldn’t matter but I seem to remember that it does in some way.
Thanks for bearing with me.
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 - October 5, 2005 1:50:00 AM
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SJBird55
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Jon, Cleland's book addresses reliability of clinicians with various aspects of the physical exam.
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Re: Diagnosis and Palpation in Manual Tx - October 5, 2005 1:56:00 AM
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Jon Newman
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SJ,
I'm glad for that and actually plan on getting that book, but what's your point (or his point)?
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 - October 5, 2005 2:00:00 AM
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SJBird55
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My guess would be that if they didn't state their reliability, then I'd assume it might be similar to what Cleland found in literature. I'd mentally just extract that information.
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Re: Diagnosis and Palpation in Manual Tx - October 5, 2005 4:56:00 AM
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JLS_PT_OCS
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Steve-
Agree completely.
Jon-
I haven't read the full text of this study yet (it's in my "to be read" pile) but I feel certain they addressed the reliability issue.
I know this is an ad hoc analysis of the CPR study, and I think that's a good thing.
I am not sure how they handle someone who is judged to have both "hyper" and "hypo" mobility in the Lx spine. I wonder if they addressed this issue in the study somewhere.
I am not aware of the pheomenon you suggested about hyper segements next to hypo ones. That has not been my experience, for what that's worth.
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 - October 5, 2005 7:52:00 AM
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Barrett
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Jason,
Hypermobility adjacent to hypomobility (as an adaptive response) was one of the first things I learned from Paris in '73.
As far as I know, he still teaches this whether or not it's ever been demonstrated.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Diagnosis and Palpation in Manual Tx - October 6, 2005 3:19:00 AM
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JLS_PT_OCS
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Interesting. I'll query the folks on Evidence in Motion to see how they addressed people with segments judged to be both hypo/hyper.
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 - October 6, 2005 3:35:00 AM
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JLS_PT_OCS
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Here are particulars of the palpatory procedure and the reliability:
From the study, page 1746 of Archives of Physical Medicine and Rehabilitation Vol 86:
"With the elbow and wrist extended, the examiner was instructed to apply a gentle but firm, anteriorly directed pressure on the spinous process. For each spinal segment, mobility was graded as normal, hypomobile, or hypermobile. A separate judgement was made for earch spinal segment of the lumvbar spine (L5-1). Examiners were instructed to base their judgment of mobility on the anticipation of what normal mobility would feel like at the tested spinal level for the particular patient being examined, and in cmoparison with the mobility detected in the spinal segment above and below. Each subject was then categorized as to the presence of hypomobility or hypermobility. IF hypomobility was judged to be present at any level of a subject's lumbar spine, the sugject was categorized as having hypomobility. If hypomobility was judged not to be present at any level(ie, all elvels either normal or hypermobilie) the subject was categorized as not having hypomobility. A second categorization was made for earch subject with respect to hypermobility. Subjects were categorized as having hypermobility present (ie, a judgement of hypermobility was made for at least 1 lumbar level) or not having hypermobility (ie all segments judged either normal or hypomobile). We have examined the reliability of these categorizations in previous studies of patients with LBP. Kappa values for judging the presence of hypomobility have ranged between .13 and .30, with percentage agreements between 59% and 78%. For judgements of hypermobility, [kappa] values have ranged between .18 and .48, and percentage agreements between 76 and 77%."
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 - October 6, 2005 3:37:00 AM
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Lukey
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Jason,
This is a very common idea in osteopathic manipulative models also.
Luke
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Re: Diagnosis and Palpation in Manual Tx - October 6, 2005 5:09:00 AM
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JLS_PT_OCS
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OK everybody, here it is from page 1750:
"Because of the difficulty in identifying a particular level of the lumbar spine, and the questionable need to do so, we chose to categorize subjects without regard to level. This did result in a small percentage of subjects (2%, n3) categorized as having both hypermobility and hypomobility. We cannot draw any conclusions on the best intervention approach for patients with LBP judged to have both hypomobility and hypermobility simultaneously"
I for one, am surprised that the number of people judged to have both was as low as 2%, given the reliability information.
Interesting stuff, for sure.
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 - October 6, 2005 5:09:00 AM
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JLS_PT_OCS
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BTW, the full text of the article is available on Evidence in Motion.
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 - October 6, 2005 8:31:00 AM
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steve
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Yikes,
I wouldn't trust those kappa levels, they are the more important statistic, identifying percentage agreement between raters while take into account chance (Ie chance of agreement on heads or tails on a coin flip is 50%, kappa would take this into account). Both ratings would be considered very poor.
Steve
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