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Re: Diagnosis and Palpation in Manual Tx
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Re: Diagnosis and Palpation in Manual Tx - October 20, 2005 3:19:00 AM
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JLS_PT_OCS
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Jon-
I don't think they are going as deep as "hypermobile needs to be stabilized, and will improve, hypomobile needs to moved, and will improve."
It's merely used a way to direct treatment, and only one part of a multiple-step process. I don't believe they have addressed the biologic rationale for the use of the palpation test, only that it is useful in directing treatment.
If you're looking for a model that deep here, I believe you are bound to be disappointed. I just don't think we're that far along yet. But slow progress is being made.
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 - October 20, 2005 8:59:00 AM
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steve
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I'd agree with Jason, although we may not be completely sure why something works (And I am generally skeptical when people give me lengthy biological mechanisms for why a treatment wroks), we can still use it if it is proven through sound research to be effective.
Steve
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Re: Diagnosis and Palpation in Manual Tx - October 20, 2005 11:47:00 AM
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nari
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Steve
Are any of us completely sure why something works?
I doubt it, when it comes to the brain/body that is in a constant state of flux.
And even if we did find that approach A is sound and effective, it still won't 'work' for all our patients - the physicists are still looking for the theory of everything; they haven't found it yet and it may not exist in the sense that we can understand precisely the dynamics of neurophysiology - but in the meantime, we can only use what we reasonably know.
And I do know of PTs who mobilise the hypomobile segment and stabilise the hypermobile - as though there is an established normative value for the spine's segmental mobility....it is all very biomechanical thinking.
Nari
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Re: Diagnosis and Palpation in Manual Tx - October 20, 2005 3:13:00 PM
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Jon Newman
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Now wait a minute. What on earth is someone stabilizing when they are doing stabilization exercises? What are people mobilizing or manipulating when performing those procedures? It would seem to me, in these CPRs that vertebral mobility is the only biologic determining factors for selecting the technique. For example, acuteness does little to explain explain why someone would pick manipulation as a therapeutic procedure but hypomobility would.
Here's some examples of some other CPR's (I've been checking these out lately) and the one thing that they seem to have in common is that indeed the variables in the rules seem to make sense (to me). What do you think?
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15827908&query_hl=1]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16086720&query_hl=3]link 2[/URL]
I think one is obligated to accept that you are mobilizing a hypomobile facet or stabilizing a loose one if you don't come up with a better explanation (considering Occam's razor and all).
jon
ps I agree that one does not need to have an understanding of biological mechanisms when they have a study to tell them "it's ok, it works--a barber could use it with confidence. It helps to have a biological rationale of what to do if you're going to do something other than that.
jon
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Re: Diagnosis and Palpation in Manual Tx - October 20, 2005 9:08:00 PM
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steve
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Actually Jon I choose to use the CPR on the basis that they have research to back that they work. A plausible biological rational would be nice but not necassary as there is a significant possibility that any biological rational I work from is wrong. This is based on the fact that 85% of low back pain has no identifiable cause that can be proven (Or disproven) and that the best that we can do at present (With scientific certainty) is identify subgroups based on reliable testing. These subgroupings get us no further in determining biological rational except serve as a starting point for further research. This all stated, I certainly have my own theories as to why some subgroups respond to specific treatments but I also feel that these theories need to be in a constant state of flux, changing as new evidence arises.
Steve
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 2:18:00 AM
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Barrett
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Steve,
I think the focus on cause rather than origin when it comes to painful sensation keeps many clinicians from progessing, both in terms of understanding and management.
The former is defined as "a thing that exists in such a way that some specific thing happens as a result." Given the complexity of life (to say nothing of our biology, psychology, physiology and anatomy), isn't this virtually impossible?
The origin of something, defined as "the source from which anything arises; the first stage of existence," translates to the neurophysiologic fact that nociceptive firing only takes place in the presence of sufficient chemical irritation or mechanical deformation (leaving out central pain for the moment). The contribution of one or the other can be determined fairly easily with some questions, a little provocation and/or some medication.
The physiologic signature of various tissues when involved is known, and with a certain amount of certainty we can direct our care appropriately if we don't try to figure out what led to what (as in cause) but instead dealt directly with the origin.
It seems to me that the confusion and disagreement among so many of us dealing with a common condition like backache will persist until we attend first and foremost to origins and not causes.
For me, this has changed everything.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 3:44:00 AM
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JLS_PT_OCS
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Jon-
I don't think the carpal tunnel CPR criteria necessarily make any more "sense" than the one for Manip or the proposed one for Stability exercise.
For example, one of the CTS criteria was "shaking of the hand to get relief" - I don't understand what makes sense about that and why it would make me think median nerve entrapment at the wrist and not lots of other things. When I touch something hot, I shake my hand, too.
I do agree with you and with Nari when you bring the point that most people hear the word "Stabilization" exercise and assume a necessarily biomechanical problem or hypemobility that is being "stabilized". However, the most recent research in this area, including the stabilization CPR (indicating higher fear avoidance predicted success) leads us to believe that there is a cognitive-behavioral and educational component of the stability exercise that is going on.
I think that this "hypomobility" found that leads to success with manipulation could just as easily be excessive muscular resting tension causing mechanical deformation than to some kind of joint-related stiffness. Certainly we could make a theoretical case for manipulation helping both for the "muscle resting tension causing pain" theory as well as the "stiff joint causing pain that needs to be moved" theory.
Likewise, we could easily make a case for stabilization exercise based on the "hypermobility of the spine needs stability through muscles" theory as we could for the "excessive mechanical deformation, fear of movement, and pain sensitization" theory. We could argue that stabilization is an efficacious treatment based on either theory. I'm not sure which one Occam would approve of, as either or both seem equally plausible to me.
Barrett-
Love the origin vs cause thing. Very insightful. I'm going to steal that and use it with students. Thanks.
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 - October 21, 2005 3:56:00 AM
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Barrett
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You're welcome.
This is the first lecture I gave at every course and ordinarily the class grows very quiet if they realize how much this should color their practice. For others, this bit of information remains forever irrelevant. I think that this is because causation is, to them, comforting in some way. After all, it's much easier to stand there and blame another for their inappropriate behavior than to simply deal with its consequence and move toward solution.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 4:13:00 AM
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Jon Newman
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The fact that shaking does relieve their pain is a sign that the pain is primarily neural in origin. For example, I wouldn't imagine that shaking a fracture or ligament tear would relieve pain. When you shake your hand after a burn is your pain gone until you touch something hot again? I imagine not if you had a burn sufficient to cause a chemical irritation secondary to cell lysis. I think hand shaking typically provides relief until the hand is placed in a compromised position again. In advanced cases there is not much tolerance to mechanical deformation and the tingling comes easily.
Additionally, the shaking is specific to the region of the problem (hands). If the mechanical problem was the neck, perhaps movement there would change the pain.
Who teaches people to shake like that anyway?
jon
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 5:05:00 AM
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JLS_PT_OCS
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Jon-
I see your point about shaking being localized, but I thought all pain was neural in origin. What about shaking says "median nerve" to us?
In any case, I think the CPRs can apply and make sense in several situations where the theory behind them is different.
For both those CPRs, I can (as my anatomy instructor used to say) "make it make sense".
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 - October 21, 2005 5:15:00 AM
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Jon Newman
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Shaking doesn't tell us which nerve. The distribution of symptoms, etc tell us that. Shaking just implies that mechanical deformation or intermittent ischemia are the primary contributors to the sensory experience.
I've not argued that CPR's aren't useful, especially when someone fits the criteria. The problem comes in when someone doesn't fit the criteria (i.e. the majority of the people I see in the year). Understanding how the predictors contribute to the picture simply enhances my clinical reasoning. Without understanding this, there is no reasoning. I'm not attempting to discredit a prediction rule, I'm trying to understand it.
jon
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 6:37:00 AM
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Diane
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[QUOTE]I thought all pain was neural in origin[/QUOTE]Technically, yes.. everything in the body is innervated so the brain can track it subcortically. My understanding of pain that arises from the origin of pathology irritation is that the "cause(s)" default to processes coming from inside some other tissue, not nervous tissue, bothering nervous tissue nearby; I.e., a tumor, pressing against and finally triggering cascades of mechanoreceptors that finally are outputted to the conscious awareness part of the brain as pain. (Isn't it true that the conscious awareness part is often/usually the last to know when there's a 'true' body problem? i.e., pathology) I.e., one of Shacklock's examples, destruction of the vasa nervorum in the arterioles of the feet by the processes of high blood sugar in diabetics, leading to neuropathic pain due to starved nerves.
Usually movement will do nothing to help this sort of pain.
Usually movement WILL help the "other kind", the mechanical deformation kind, using Barrett's nice succinct dividing tool. And that's how we can tell them apart. Usually. Almost always. OK, virtually always.
Any kind of pain that is strictly from mechanical deformation (not to say people can't have two origins in the same body sometimes) will decrease and the nervous system will produce WESS.. warming, softening, surprise and effortlessness, as the sensory reward for relieving the mechanical deformation. If the pain becomes completely manageable by doing this, it is/was simple mechanical deformation pain. If it doesn't, look harder smaller deeper.
I think implementing this sequence in clinical reasoning puts the horse back in front of the cart. As Barrett and Jon have said, it stops the deluge of confusion regarding a plethora of possible "causes" and threats to the patients' frontals about "damage" or "unstable" things that might be "torn" or still "unhealed" after double digit months have gone by. It's all good meme management/basic mental housekeeping. We don't treat insurance companies, we treat patients.
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 9:46:00 AM
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JLS_PT_OCS
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Jon-
I didn't think you were trying to discredit a CPR. You ask good questions, as usual, I just don't think that they have any clear answers, in the PT version of the "big theory of everything".
I think, from a clinical reasoning standpoint, that the CPRs can make sense even if you use different theories to make sense of them. Therefore similar patients, who may not exactly meet the rule, can be treated with those interventions (in this case manipulation and stabilization exercise) and you can expect good improvement.
I am reminded of the manipulation CPR. Remember even if someone only had 1 out of 5 criteria, you still could expect 46% of them to be 50% better in a week via Oswestry score. So they needn't be acute patients or anything like that at all. Even though many of our patients might not fit a CPR exactly, they have enough criteria present that, at least for me, the choice of treatment is fairly straightforward.
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 21, 2005 10:52:00 AM
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Jon Newman
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I've heard it stated that we can't all be right. So while there may be many ways to explain our observations some are worth getting rid of. A lack of looking into it because we have a rule to follow is a behavior that renders us technicians. Why do you suppose no one seems courageous enough to make a claim?
"Never trust the artist. Trust the tale. The proper function of the critic is to save the tale from the artist who created it."--D.H. Lawrence
jon
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 1:32:00 PM
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nari
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There is a thread on NOI about a very sorry tale of woe for one person whose doctors went searching for a cause, thought they had found it on the imaging piccy, and rendered the unfortunate person into a shambles of an existence.
Searching for a cause at the neglect of big picture thinking can land therapist and patient in a muddle of reasoning.
Certain rules are obligatory; others are there to stifle creativeness, as I think jon is saying. Sorting out the mandatory rules (eg don't kill the patient) from the others must be a bit of a nightmare.
I think rules are set up to save the patient from malpractice, and also to standardise clincial reasoning for a number of reasons, one of which is research. Unfortunately, the curiousity factor, as Diane suggests, suffers; and we do become technicians rather than creative thinkers.
Hypotheses, the spine of scientific research, become fluffy and undesirable to pursue, because of rules. A safe clinical practice, such as SC, can still augment the less safe procedures, if one wishes to jump on joints in some way. I agree with Diane, that SC, given the appropriate criteria, is the first port of call; after that, localised Rx is probaly needed - if SC did not 'work' for a particular patient, for whatever reason.
Nari
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 3:33:00 PM
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Jon Newman
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Nari I'm not saying that the few CPR's in PT are to stifle creativeness. I'm just trying to make sense of them. I don't think I'm unique in trying to make sense of things although I am beginning to wonder.
I've behaved the same way with regards to Simple Contact believe it or not.
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 21, 2005 8:33:00 PM
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nari
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jon..
I didn't think you implied that at all...I did!
And trying to make sense of something is the trail to discovering important things, so keep trying.
Before the SC course, I was trying for months to visualise what actually occurs after touch and the nature of the ideomotive response...and it didn't happen.
Now I know and it's impressive. Visual realisation makes all the difference.
Nari
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 9:05:00 PM
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Randy Dixon
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Nari I'm not saying that the few CPR's in PT are to stifle creativeness. I'm just trying to make sense of them. I don't think I'm unique in trying to make sense of things although I am beginning to wonder.
I've behaved the same way with regards to Simple Contact believe it or not. -JON
You still don't see the difference in thought processing in the different groups. To you, and to me for that matter, the WHY is what is important, the WHAT mainly just supplies the clues. Both are important, but we place them in different priorities.
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Re: Diagnosis and Palpation in Manual Tx - October 21, 2005 9:06:00 PM
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Randy Dixon
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I forgot the ? in the first sentence.
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Re: Diagnosis and Palpation in Manual Tx - October 26, 2005 10:01:00 AM
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steve
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Sorry for the late response.
Barrett and Diane, I think your comments have much merit and certainly the focus on "Cause", "Unstable", "Damaged" etc has led to increase patient fear, medicalization and ultimately centralization of pain.
Jon, Looking to make sense of things is a very important component of what we do as therapists, but by the same token not required to use outcome based studies to guide our treatments. As Barret comments on the complexities of life and how we may be unable to be certain of the specific cause of injury, likely the same applies to our treatments and why they are effective. As always, balance between the two is important and it may be that how comes first the why or vice-versa.
Any other thoughts?
Steve
Steve
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