Re: Diagnosis and Palpation in Manual Tx

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Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 3:19:00 AM)
Addendum: We just don't know enough, researchwise, can we all agree on that? I do understand totally Jason and Army's arguments, to use what we know has been shown in a decent study. From what you say it's not that hard to learn either. But neither is S/CS and MET. I don't know about SC. Personally I am glad I'm not in a practice setting where I have to make the decision of which to use, or struggle to decide which to spend CE money on. Many of us are really financially constrained on CE funds. Reality bites.

Alex Brenner PT MPT OCS -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 6:50:00 AM)
Yogi, I will agree with you that we do not know research wise if strain/counterstain or simple contact really work. There is sufficient evidence research wise to show that manipulation works. When you and Chris say you would rather use S/CS and MET then you are saying that you would rather ignore what research shows to be the best evidence and perform something else you feel more comfortable with. That is fine but understand that you are using techniques that have less or no evidence to support them. To me, this would be ignoring what our profession is trying to move towards which is intervention based on best EBM. I am not trying to criticize; I am just calling it like I see it.

Diane -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 9:59:00 AM)
Army, 1. EBM includes clinical reasoning, and needs of the patient, also, last time I checked with Sackett.. not just what has made it through a hoop called RTC. 2. The profession is one thing. I agree it will move forward as you suggest it should. 3. The individual components of the profession are another thing, i.e.: the PTs, are using tools that have received RTC stamps of approval along with tools that haven't, yet, or ever, that work perfectly well in our individual niches. 4. A homogenized PT profession would be one that has ceased to have any adaptability. 5. Here's to evolution, at all levels. (Me, raising a toast.)

Jon Newman -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 10:16:00 AM)
Yogi, You make a good point that those who run studies will run what PT practice looks like if the only thing we base our decisions on is outcome studies. While it would be foolish to ignore outcome studies, it is not the only factor that enters into clinical decision making. Yogi and Chris, why do you use the techniques you use? Is the the theory behind it? Is the results you are getting?... Army, according to most accounts of EBM and its levels of evidence, systematic reviews rank at the top. Certain assumptions must be met as with any statistical procedure. Accordingly, manipulation does not seem to be superior to other treatments when viewed through these glasses. However, a certain subpopulation clearly does improve as demonstrated by Flynn, et. al. Do you manipulate anyone that does not fit this criteria anymore and do you use any other technique except the one in the study? If so, how do you justify your clinical decision? I'm not trying to cross swords with anyone here. I'm just curious. I think there are defendable answers to all these questions. One last question. Under what circumstances does EBM tell us what not to use? jon

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 10:36:00 AM)
Well, Army, I laud and respect your capability. There is one question that springs to mind. Do you get acceptable results on 100 percent of the pt's that meet the three of the five indicators? If manip. is not effective on 100 percent of those pt's., then do you go next to an indirect technique on the exceptions? Or do you possibly just think they were exceptions on the indicators? I have consistently stated on this board, I have not said don't use direct technique, manips. I have only, as above, argued for indirect treatment try first. Luckily for me, this is theoretical for me, in my setting. Diane, I'll join you in that toast.

Synergy -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 1:30:00 PM)
Hi Army! In your latest post, you stated that I'm ignoring what the research tells me. If performing a technique to 'move' a vertebra back in an optimal (functional) position is something other than manipulation, you are correct. Several of the patients I encounter may only have 1-2 of the criteria to manipulate and I usually tend to perform METs in lieu of manipulation. It's not a matter of being less 'comfortable' with manipulation. Are you more comfortable with it than I am? I would probably think so, simply because you've been practicing X amount of years longer than I have and your palpation skills most likely exceed mine. However, I don't perform METs in place of manipulation just because of being 'uncomfortable' with the technique. Theoretically, it makes more sense to me from a neuromuscular POV to use METs since they do involve the patients' direct intervention to 'move' the hypomobile segment into a more functional position. I will continue to believe this theory until it's disproven and despite whatever CPR says about manipulation. Please don't interpret the above to mean that I NEVER use manipulation. I love the results of both and I'm well aware of the CPR. I've been manipin' quite a few patients lately if they have at least 3 of the 5, but those that do not I use METs. I am a huge proponent of our profession's advancement! You may very well be calling it as you see it, but in my mind's eye it is synonymous with critcism. This is perfectly okay with me as I'm quite sure this goes on all the time here on these forums. I sure as hell don't mind it as long as it's constructive. :)

steve -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 2:02:00 PM)
This arguement seems to be coming up quite frequently and there seems to be a variety of opinions on what classifies as EBP. Checking out the following link would be a very helpful way to establish exactly what it is: http://www.cche.net/usersguides/therapy.asp From the page: Table 1: Users' Guides for an Article About Therapy I. Are the results of the study valid? Primary Guides: Was the assignment of patients to treatments randomized? Were all patients who entered the trial properly accounted for and attributed at its conclusion? Was followup complete? Were patients analyzed in the groups to which they were randomized? Secondary Guides: Were patients, health workers, and study personnel "blind" to treatment? Were the groups similar at the start of the trial? Aside from the experimental intervention, were the groups treated equally? II. What were the results? How large was the treatment effect? How precise was the estimate of the treatment effect? III. Will the results help me in caring for my patients? Can the results be applied to my patient care? Were all clinically important outcomes considered? Are the likely treatment benefits worth the potential harms and costs? The following link provides a scenario as to why clinical reasoning that does not take into account evidence is subject to significant bias - I have seen Sackett's work regularly misinterpreted with respect to what clinical reasoning is - ie. an opportunity to forgo evidence and base decision making on personal feelings/theories. By the same token, I understand Jon's comment that EBP is not the only factor involved in clinical decision making; we should, however, be well aware that there are significant biases to making decisions based on previous experience. I think this ties nicely back into palpation and how a significant number of therapists depend on previous experience and subjective outcomes to identify it as an effective assessment tool. http://www.studentbmj.com/back_issues/0200/education/15.html Yogi, I'd place a good bet that Army gets about 92% success with the patient caseload he sees with 4/5 positive criteria. Steve

Alex Brenner PT MPT OCS -> Re: Diagnosis and Palpation in Manual Tx (February 25, 2005 8:09:00 PM)
Yogi, If a patient has 3 out of 5 I manipulate along with prescribing impairment based exercises, pnt education, reassurance etc., etc.. If they do not get better in a week or so then I may try something else but manipulation is almost always my first line treatment if the patient has at least 3 out of 5.

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (February 27, 2005 4:01:00 AM)
Did I hear my course, Evaluating and Treating Pelvic Joints" mentioned? I have read the posts. I will say that my treatment approach adheres to the "align the pelvic joints first" philosophy and that using the appropriate, specic muscle energy techniques is the most effective way to align the pubic symphysis and sacroiliac joints. Just like the other peripheral joints, the pelvic joints only move/malalign in certain directions, the pubs elevate (primarily) and the ilium malaligns posteriorly and also laterally. Each of the malalignments is associated with a specific posture fault, e.g. outflares--eternally hip/knee/maltracking patella, posterior rotations--scoliosis,shoulder (protracted/impingements on the opposite side of malalignment), elevated pubs--flattened low back,increased mid-upper thoracic kyphosis,straight cervical spine,distalized mandible/malocclution/ TMJ. I also believe that the pelvic joints cannot be manipulated into alignment, malipulations are best used to increase mobility (as P.T.s use mobilization). Palpatory skills are needed to assess extremity length differences (pubs) and assessing comparative differences of the asis's position (si) This can be done with the patient in supine. In fact, the pelvis jointd can be both evaluated and malalignments corrected in supine. You can also teach your patient to maintain their alignment using the Pelroll. The spine can also be ver effectively aligned using muscle energy once the pelvis is aligned. I'm beginning to sound like a commercial. I am also involved in studying the pelvic joints using 3D reconstruction software (VoxarBarco), which analyzes CT DICOM's. Hopefully this will prove that the pelvic joints move and muscle energy techniques are what moves them. Looking forward to your responses!

steve -> Re: Diagnosis and Palpation in Manual Tx (February 27, 2005 5:50:00 AM)
Roger, Thanks for taking the time to respond. It would seem you are well educated and have taken a great deal of time to create/learn this theoretical model. During this time I'm assuming that you read one of the 15 odd studies that indicate that palpation of movement is unreliable at the sacroiliac joint, be it for a single test or a combined test. What is your arguement for continuing on with this palpation even though there is so much evidence to the contrary? What type of evidence would you have to be presented with in order to rethink your theoretical model - something like your own research study failing? Looking forward to your response. Steve

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (February 27, 2005 8:01:00 AM)
Steve, Thanks for your response. I also agree that palpating movent is not reliable. Testing movement between vertebral segments, for example, is very subjective because there may be pelvic joint malalignments causing spinal posture faults that could be impacting your findings. A posterior rotation of the ilium, for example, tilts the base of the sacrum to the opposite side, which in turn laterally deviates the entire spine, the spine also rotates around it's longitudinal axis,then compensates back in the opposite direction. In other words, causes a scoliosis. This scoliotic spine has much less mobility than a spine that is properly aligned. Trying to assess pelvic joint mobility is time wasted. The pelvic joints, because of the shape of the articular surfaces will only move in specific directions. These movements cannot be forced/manipulated, but can only be moved using the approprite muscle energy techniques. They can be passively moved. For example, if you passively stretch your patients hamstings (SLR) you will malalign the sacroiliac joint (posteriorly rotate the ilium). Besides, it is more important to align and stabilize the position of the pelvic joints----unlike the peripheral joints where movement and stability is important. Like I stated in my previous post, I am currently working on a research project being supported by Voxar/Barco 3D reconstruction software to objectively measure movement of the pelvic joints. I have successfully aligned the body landmarks of the pelvis, spine/body, but I have not proven that the muscle energy techniques I use actually move the joints. I welcome your response.

ericm -> Re: Diagnosis and Palpation in Manual Tx (February 27, 2005 9:23:00 AM)
Roger, welcome to the BB. "These movements cannot be forced/manipulated..." "They can be passively moved" Where do you really stand on this? "it is more important to align and stabilize the position of the pelvic joints" Important for what and how do you know clinically when you've achieved this? Do we actually know to what extent supposed pelvic malignment faults exist in the general population and is there any correlation with reports of LBP? Thanks, Eric

BRuchin -> Re: Diagnosis and Palpation in Manual Tx (February 27, 2005 2:54:00 PM)
Roger, It is my understanding that before doing any kind of vertebral palpation, the therapist must first assess the body's bony landmarks and make sure that the body is in alignment. I use the Grimsby Pyramid that Rick discusses on the first page of this discussion. It is a very systematic, logical flow to move through an evaluation of the spine and extremities to be able to come to some type of conclusion as to what the problem is. Palpation can be very effective, even though it is subjective and has not shown very good intertester and interrater reliability. I do not have that much experience as a clinician as I graduate in May from PT school, but I do believe that when I assess a patient and treat them for what I believe to be the problem and underlying cause of their complaints, using a systematic approach works very well and can be retested by another therapist and followed to find the same results. I use what some call x-ray vision and try to imagine what the body looks like, kind of like in CSI on TV. So if i think that a patient is not properly aligned, there are some movements that I will know to be restricted or movements that will not be "normal", but they are not normal because of something else causing it, not that area. In the case of your example if a SI is malaligned, I would expect the lower lumbar spine to not move as one would if the SI was aligned. But I would not treat the lumbar spine as the primary cause of the patients complaints, I would treat the SI causing all the other problems. that is what the evaluation approach leads me to. With me being in school, I did my research on the evaluation of the spine, specifically a manual therapy evaluation of the spine. I take 4 of the many well known manual therapists, Paris, Grimsby, Maitland, and McKenzie; summarize their evaluation methods, compare and contrast, and then develop one master evaluation based on all four of theirs to be able to perform an evaluation that hopefully will be very reliable. Thus far, it has been. Bryan

steve -> Re: Diagnosis and Palpation in Manual Tx (February 27, 2005 5:14:00 PM)
Bryan, "Palpation can be very effective, even though it is subjective and has not shown very good intertester and interrater reliability." Could you explain this comment, it seems to contradict itself. If something is unreliable it it has no validity so how can it be effective? Roger, You obviously have a different method than the standard pelvic assessment. So what is your method for assessment if you do not use palpation? Is there any research on these methods and what were the results? Steve

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (February 28, 2005 1:45:00 AM)
Dear Eric: A couple of good questions. When I say the pelvic joints cannot be manipulated into position I am saying that the articular surfaces of the sacroiliac joints are shaped in such a way ("hills and valleys") that movement can only occur in certain directions, just like the other synovial /peripheral joints.Their joint anatomy dictates the direction, type and amount of movement. These joints can be passively manaligned. For example, bending forward to touch your toes will malalign the sacroiliac joint because you are moving the ilium on the sacrum in the movement plane of the joint. Manual manipulation to restore the joint's alignment does not work, but using a combination passive stretch movement/muscle energy technique, the joint realigns easily.The same holds true for outflares. The sij can be malaligned passively, but a muscle energy technique is used to restore proper alignment, not manual manipulation. To answer the second question I would say you know the pelvic joints are aligned when after using the proper MET's, the asis's are of equal height and equadistant from the pelvis' midline for the sacroiliac joints and the extremity lengths are equal (pubic symphysis). But aligning the pelvis is only the first step. You must also align the sacrum, spine, head, correct the muscle length and strength imbalances, normalize the spinal joint/peripheral mobility/motion etc., In other words manually normalize the musculoskeletal/joint system that has been adversely affected by the pelvic joint malalignments. Thanks!

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (February 28, 2005 2:05:00 AM)
Dear Steve: First of all, I evaluate and treat all the pelvic malalignments with the patient in supine. I use palpation in the sense that I compare asis heights, compare asis distance from the pelvic midline for sacroiliac joint malalignments, as well as compare extremity length differences for pubic symphysis malalignments. I do not examine them in sitting, standing, have them move or do any mobility testing. I also look at the imaging studies which helps clarify/support/adds to my assessment. Thanks!

Yogi -> Re: Diagnosis and Palpation in Manual Tx (February 28, 2005 2:22:00 AM)
Roger, thanks, to all the naysayers on SI, When asymetrical ASIS's are symetrical after treatment, and the pain is less or gone, why are we argueing SI treatment? It works that way, despite us not knowing the percent of back pain that is actually SI. As I've mentioned before, diagnosis (problem finding) is "treat your best guess, and if the treatment works, the diagnosis was correct (the problem was corrected)". The studies help with the guessing, but the guesswork will always remain. That may be why Barrett thinks we should all watch House. Chris, Army, yeah sometimes a lot of this board discussions seems like critiscsm, but actually I think it's not. I think all of us realize it's actually presenting different viewpoints, and all of us enjoy that or we wouldn't be here.

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (February 28, 2005 2:29:00 AM)
Dear Bryan: I am not familiar with Ola's Grimsby's Pyramid. I have taken a course from him and even hosted him for a course, but that was many years ago. He was an excellent teacher and I thoroughly enjoyed learning from him. I will comment that I think a systematic approach is a very good idea.

Bournephysio -> Re: Diagnosis and Palpation in Manual Tx (February 28, 2005 4:28:00 AM)
Roger, Thanks for posting on this site. I have a few technical questions before I comment further. 1. Why did you choose CT over another technology such as MR? 2. I am not familiar with the software so excuse me if I'm wrong but it appears to be just a 3D visualization software. How are you measuring SI joint angles? What coordinate systems are you using and how are they located? 3. What is the accuracy of this technique? Thanks, Doug

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (February 28, 2005 11:49:00 AM)
Dear Doug: Thank you for your question. We are choosing to use high speed/thin slice CT DICOM's because we want to get clear bone images/landmarks to help ensure accurate measurements. You are correct in that the Voxar software will allow us to view the pelvic joints, but it will also (hopefully) help us establish the correct anatomical landmarks/ planes to measure the movements.We have not totally established these measurement markers yet. As far as the accuracy, I have no idea,but assume we will have several trials before we perfect it. Thanks again! Roger

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