Re: Diagnosis and Palpation in Manual Tx

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Synergy -> Re: Diagnosis and Palpation in Manual Tx (February 17, 2005 4:20:00 PM)
Being surrounded by experienced practitioners such as yourselves, I'm hesitant to post sometimes, but I'll give this one a shot. I would probably say that I am a biomechanist at heart, but I still involve myself with other approaches as well. I use on a daily basis techniques from Greenman, Johnson, Kaltenborn, and Mulligan to name a few. I also love the 'Butleresque' (nice FLA) style of including a neural approach (did a study for school involivng a stretching protocol for the median nerve with several Butler references). Like you FLAOrthoPT, I also love Greg and Vicki Johnson's IPA style of practice. Robert Friberg, PhD, PT, CFMT was my instructor at school for the majority of our manual techniques. I grew very fond of the IPAs approach. In response to the symmetry of the human body, sure...it's highly unlikely that we are even close to being 100% symmetrical, but as FLA said, our palpation skills should be able to differentiate something 'out of whack' (if you will) versus something that appears 'normal'. I have yet to take ANY con-ed courses for manual therapy (I'm a rookie and quite broke) but I do hope to one day receive my CFMT or another type of related credential to better myself as a manual therapist. Jason, could you please clarify what you mean by "...general techniques of mob, manip, MET, and others not aimed at a specific level or supposed dysfunction"? If I do happen to come across, let's say, a Type 1 restriction of T7-9 and after METs it appears to be resolved, is this methodology considered 'utterly useless'? I'm truly not attempting to be confrontational (and wouldn't do so here anyways with my limited experience), but rather just looking for the obvious: why did this resolve following the MET at these 'specific' level? The bottom line, in my humble opinion is that the ultimate goal is to facilitate movement, regardless of the approach.

steve -> Re: Diagnosis and Palpation in Manual Tx (February 17, 2005 5:06:00 PM)
Chris, You should have more confidence in your skills, to date your posts have been well thought. I've been practicing for almost 5 years so I'm relatively fresh myself. I took manual therapy courses out of school and found them very helpful with respect to giving me manual treatment tools but not a theoretical model with which to appropriately assess my patients. With respect to your question about why your specific treatment was effective, likely any manual technique particularly with respect to MET crosses multiple segmental levels. There is no danger in using this as your treatment paradigm as long as you realize that your biomechanical diagnosis has a significant probability that it is not definatively correct, that you recognize when there is serious pathology present or significant psychosocial issues and that you dont make your patient focussed on their segmental diagnosis. Steve

Synergy -> Re: Diagnosis and Palpation in Manual Tx (February 17, 2005 5:55:00 PM)
Steve, Thanks for the kind reply. I agree with you in regards to the METs crossing multiple segmental levels. They pretty much have to considering all the deep muscles and their various attachments to the spine. I recall a few of my friends saying they could isolate a single segment and its corresponding muscles to facilitate movement. To me, it didn't make much since anatomically considering that, for instance (correct me if I'm wrong), the multifidi traverse 2-4 segments. I have yet to (and don't plan on) make my patients feel as if their main problem is a vertebrae 'out of whack'. Again, thanks for the reply. I'm sure my confidence will improve as my skills improve as a therapist. My employer agreed the other day to pay for all of the required courses to attain my CFMT (Johnson/IPA). Needless to say, I'm excited. :)

nari -> Re: Diagnosis and Palpation in Manual Tx (February 17, 2005 6:44:00 PM)
Just as an addit; Ask your patient with the stiff and limited ROM in the neck, to elevate their contralateral shoulder as they rotate the head to one side. An extra 20-30 degrees is painlessly gained. I am keen to ask the biomechanics what their reasoning is here - jammed up joints,tensed muscles, extra ROM gained. Why? maybe it is obvious to all here - but the posts suggests it may not be.... Nari

JLS_PT_OCS -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 1:58:00 AM)
Chris- Thanks for your posts. The "utterly useless" part (i just love saying stuff like that) is the idea that the problem is localized to a specific joint in a specific way and that to correct it I must do a specific thing. The treatment techniques can work, but I just don't think they work for the reason we have been told that they do. That biomechanical model does not consider such things as the neuromuscular control of movement, and that seems to be some of what Nari alludes to above. I won't let my lack of understanding get in the way of using these techniques, but I will keep an eye open for other ways to explain their effects, and other things to use in conjunction. In your example, you have no way of knowing what the exact movement problem is, and no way of knowing that the technique you applied did what you thought it did. My link cited above helps to explain that issue. I am all for manual therapy experience, training, etc...but from what I have seen of EVIDENCE, fancy initials and tons of money spent don't seem to be a factor in outcomes. Most of the "education" provided in the manual therapy world seems to be about learning a system of evaluation which is probably of little value. As Barrett put it "palpatory exam techniques ... do not show us relevant pathology [but do] show us irrelevant assymetry and unreliable and misinterpreted motion restrictions." Perhaps there are experienced folks out there who have paid for the letters and feel a sense of betrayal about these statements, I don't know. In my experience and my discussions with experienced (several internationally-known) people has lead me to believe the important things aren't the biomechanics models but the critical thinking, problem solving, and repertoire of techniques in a manual therapy program. And perhaps there is enough of that to make a program of study worthwhile...

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 1:59:00 AM)
Jason, question about the cavitation study, does cavitation relate to the location of the pain? The study only shows it doesn't relate to the target.

JLS_PT_OCS -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 2:27:00 AM)
Chris, I wouldn't worry about posting here, you have enough intelligent things to say to hold your own, you're a smart guy, don't be afraid to show it... In response to Chris's very fair question about what I mean re: general techniques... Cx spine: PAs at spinous or transverse area, translational mobs with pnt's head in my hands, AA/OA mobs, METs with rotation or sidebending while treating several segments. Tx spine: same except for translational and AA/OA (for obvious reasons :) ) plus manip/mob in prone or supine, sometimes sitting. Lx spine: PA mobs, sidelying rotational mobs/METs/Manips, supine "SIJ" Chicago technique I use all these techniques and I attempt to find an area of symptoms, but at far as choosing which technique to use, I kind of use their ROM as much as any mobility assymetry to guide me. For example, if someone has Lx pain and loss of ROM in flexion, if EBM and the Chicago manip (one with the rule) doesn't work... i will try some sidelying rotational mob/MET/manip for improving flexion ROM, reassess and go from there... What I don't do is look at them in sitting/ prone /prone on elbows trying to decide if I am seeing an FRS R or ERS L or whatever. I just move everything in the vicinity and go from there, "Move it and move on" as Flynn says. I am sure, as many others have stated, that it is not just about joint movement, but some neuromuscular effects as well, so why wouldn't I want to spread that out in the painful area? Especially as an introduction to exercise?? I have heard Chiros speak of the "Flying Five" manipulations done on every patient. While I won't comment on the truth or lack thereof of that statement, it does point to an example of experienced manipulators choosing general techniques over specific ones. So, there, my cards are on the table...

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 3:43:00 AM)
Jason, we discussed cavitation (peripheral joints) on another thread, I didn't get the idea they were pertinent to anything. Enlighten me, someone, per the study link and my previous post. Thanks.

JLS_PT_OCS -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 3:47:00 AM)
Yogi- good question. I think some of Childs/Flynn's research about the chicago technique showed that cavitation was not related to the efficacy of the technique. That is certainly consistent with my experience as well. Patients like them, but I frequently reinforce that they are neither necessary nor indicative of anything therapeutic. I think the most important things manual therapy does - pain modulation, motion improvement, neuromuscular effects, etc are completely independent of the "pop" noise... Other ideas?

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 5:33:00 AM)
As I recall, that's pretty much what Army, and others thought, but my point was if that is so, the the specificity study is pretty much irrelevant, right? I respect your (and the others) experiences, although it seems couinterintuitive, but I think we would need a better way to compare in a study than a cavitation location. Gee, I wonder how similar to chiro we will end up. I had wondered in the past few years just how joint specific chiro is, at least with osteopathic I thought I knew it was specific. Therefore, to my mind, more likely to be effective. There was always the old (perhaps urban myth) idea that chiros would treat repeatedly forever once someone started. (We, of course, only needed partly forever.) No offense, Greg, just my thoughts.

chiroortho -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 5:37:00 AM)
None taken. That's what forums are for.

JLS_PT_OCS -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 7:59:00 AM)
It is my understanding that those who use the osteopathic method feel the techniques are VERY specific. DOs I have spoken with and PTs trained in this method (from what I can gather, most are) really are trained to hunt for assymetries and motion restrictions and attempt to correct them. That was my question about methods taught in Chiro schools - I wondered if the same thought process and model was used. From what I can gather, it really depends on the school you go to, and there are subsets of schools of thought contained in most Chiro programs that approach things differently. I don't want to put anyone on the spot, and given all the bad blood there is between our professions, I understand if there is reluctance to discuss in detail. And really, I think these diagnostic models do give you a paradigm of thought when approaching things...when the general manipulative techniques fail, how do you know what to try next? I think that it is helpful to have a "worldview" off which to base your next step, I just don't think the best approach is first to dive in and start pushing, looking for an ERS... Yogi, your comment on the study seems true to me... if localization can't be proven, then certainly the cavitation issue is moot...

Jon Newman -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 1:40:00 PM)
While the following may be a contentious question, I do think it is a legitmate question and worth asking. Would testing vertebral mobility be considered a form of palpation? Does it lead to a diagnosis? jon

Synergy -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 6:52:00 PM)
Jason, thanks for the insight! :) With all of my patients suffering from lumbar pain and loss of ROM, I too look at bothersome positions, but I still attempt to find ERSs/FRSs and the like. Maybe I'm not seeing the forest for the trees, but in my opinion, the model I use (more biomechanical than anything else) also includes neuromuscular control of movement. Maybe I'm way off track, but segmental restrictions are theoretically driven by facilitated muscles surrounding the segment(s) in question. Is that not neuromuscular control, even at it's simplest definition, or is it blatantly considered biomechanical? I will usually attempt a MET before ever trying a manipulation. Correcting a segments position in relation to it's partners above and below via a neuromuscular approach seems more functional to me than a manipulation. However, manipulations put less stress on your body(the clinician) than do METs and they are typically faster techniques. If METs can essentially retrain the segment's surrounding muscles to become more aligned/symmetrical (I'm sure I'll take heat on this) and provide that segment with greater stability secondary to proprioceptive feedback, then why perform manips. in lieu of this theory? Both manips. and METs purport to establish motion in a hypomobile segment(s) which is the ultimate goal, but they differ vastly from one another. Jon, In my opinion, yes and yes, but the latter is a bit tricky. It can lead to a positional fault/diagnosis, but the patient may be asymptomatic. I seem to be rambling so I apologize! It's late and my 4 1/2 month old is crying. Maybe daddy needs to place her in prone prop position in search of an ERS dysfunction. :)

Diane -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 7:15:00 PM)
Ditto Chris here, except that I will allow that no matter how fancy one thinks one is about isolating segments, one is likely "treating" more than just one with the contraction one asks the patient to make. Perhaps only the L5 can be truly "isolated", in that it's movement is larger than the rest, 5 degrees I heard, compared to 1 or 2 for the rest.. Apart from MET I know of no good way to get the patient to access 'control' (however feeble) of axial musculature. All other ways, exercise etc, the patient ends up working their overlying broad lats/traps. With MET e.g. for L spine they contract overlying lats too, but at least the therapist can take them into eccentric stretch right away after a contraction and progressively lengthen lats out along with whatever "fish muscle(s)" (axial) underneath went temporarily off line. I don't do motion palpation for MET, I just look to see which level to target. MET is forgiving enough that it really doesn't matter, as long as you are in the vicinity of the non-moving segment, it will help/ the brain will take advantage of the input/ the brain will restore correct movement output.

Synergy -> Re: Diagnosis and Palpation in Manual Tx (February 18, 2005 7:29:00 PM)
I think the beauty of an MET technique is that it directly involves the input from the patient as opposed to a passive technique, i.e. HVLA thrust. I will admit that my knowledge of the latter is lacking, but if I may opine, mechanoreceptors somehow play a HUGE role in letting the segment(s) realize "Hey...this is where you belong." Both METs and manipulations involve a neuromuscular / neuromodular effect, directly and indirectly, respectively.

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 22, 2005 5:16:00 AM)
No, Jason, the point was, that if cavitation is moot, then how can it be used as a criteria for localization?

Alex Brenner PT MPT OCS -> Re: Diagnosis and Palpation in Manual Tx (February 23, 2005 11:40:00 PM)
Interestingly, last week I received an email from Rehabedge advertising the below course. It would be interesting to have one of the instructors from this course comment on the thoughts expressed in this thread. It would be good to see the other side of the coin. Evaluation and Treatment of Pelvic Malalingments The Florida Physical Therapy Association approved this course for physical therapists. Malalignments of the pubic symphysis and sacroiliac joint are explained and clarified using 3D animations. You will learn to evaluate the pelvic joint malalignments by physical examination and by interpreting imaging studies (CT/MRI/radiographs). Time is spent in the hands-on laboratory aligning the pelvic joints and correcting the body posture and musculoskeletal faults associated with the pelvic joint malalignments.

Barrett -> Re: Diagnosis and Palpation in Manual Tx (February 24, 2005 12:47:00 AM)
Army, I agree. Maybe someone can invite them specifically. I'm betting we get nothing. Silence in the face of questioning seems their only defense. If I'm wrong, those who claim palpation is reliable need to speak publicly in a forum like this to prove that.

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 3:04:00 AM)
Chris, I'm impressed with your rationale for MET, and I like your treatment sequence, it's what I've argued for previously. Neuromuscularwise, I also argue for Strain/Counterstrain, followed by MET if needed, or Strain/Counterstrain after MET, if needed, with thrust as a last resort. I am not articulate enough apparently to convince, and no one has done the studies to compare, but my guess is, is anyone did, both of those techniques would drop into Flynn's et al studies just as effectively as HVLA, and we'd have clinical indicators for them just the same as the HVLA technique. Respectfully, Barrett, Simple Contact may shake out with just the same result also. That's my hypothesis anyway, from a vague neuromodulation theory.

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