|
|
Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: Spinal Manipulation on someone with a partial sacra... - March 5, 2004 8:11:00 PM
|
|
|
Sam B
Posts: 73
Joined: August 6, 2003
Status: offline
|
Hi,
Might be interesting to know how many lumbar vertebrae this person has. Often six lumbar segments is the norm. The films are hard to read, other than the obvious anomaly. I'd be looking for reactive tissue sensitivity higher up probably.
Cheers,
Sam
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 5, 2004 10:10:00 PM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
Barrett,
Thank you for the input. Points taken, however, I would like to respond to a couple of your statements.
[QUOTE]Originally posted by Barrett:
manipulation remains a method of care with inherent problems many would rather ignore.[/QUOTE]
The above statment saddens me. I hope MANY would not ignore this. Manipulation has been clinically shown to be successful in the treatment of low back pain. Why ignore something that works or ignore clinical research? Isnt that why we do clinical trials?
[QUOTE]Originally posted by Barrett:
I've heard several thousand patients tell me they were made worse by it and for the most part the manipulator remained completely unaware of this.[/QUOTE]
Wow, thousands. That is hard to believe and hard to swallow. I can't think of anyone who I ultimately made worse with manipulaton. Some had some soreness the following day or were ultimately no better but I have NEVER made someone worse.
Football. When throwing a pass, what are the two bad things? Are they, 1) Interception (obviously) 2) drop the pass? Dropping the pass is not necessarily bad. You get 4 downs.
On a final note I would just like to say that manipulation is easy, it is an entry level skill, and I teach it to students (military and civilian) who come to our military hospital on clinical rotations.
Thanks everyone for their input. God bless our soldiers at war and those training to go to war.
ArmyPT, OCS
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 5, 2004 10:13:00 PM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
Sam,
This patient has 5 lumbar vertebrae and was asymptomatic everywhere except around the right side of the L5 vertebrae with some radiating pain around the PSIS region on the same side. Mobility wise all other vertebral levels moved well and were asymptomatic.
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 6, 2004 2:05:00 AM
|
|
|
Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
Status: offline
|
ArmyPT says: "Dropping the pass is not necessarily bad. You get 4 downs"
Perhaps the high level of football in Ohio has unduly influenced me, but here dropping a pass *is* bad. It's a waste of time, encourages the defense and reduces our confidence in the offense. Rather like a manipulation that has no effect.
I agree that manipulation is easy to perform and this is part of its seduction. The public (and many therapists) are easily convinced otherwise by others trying to appear highly skilled. It appears you aren't like this.
When I say "lucky" I mean you're lucky you didn't make the patient worse more than you're lucky they got better though this distinction is a little difficult to sort out in a business where our outcomes are so hard to determine. I think of listening to so many people over the past thirty years describe their response to manipulation and I must conclude as you do that it is a sad state of affairs. I know movement is necessary for recovery but long ago concluded that it is best achieved by the patient actively both from conscious or unconscious origins. Even if the research indicates that it may help, manipulation carries a risk I don't find acceptable and I am personally convinced other methods are safer and more compatable with self-care.
[This message has been edited by Barrett (edited March 06, 2004).]
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 6, 2004 8:27:00 AM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
Barrett,
What risks are there in manipulating the lumbar spine, especially after a thorough history and physical exam?
Catching a short pass and being tackeled in bounds, no time outs, when your team needs to desparately score with 30 seconds on the clock would be bad (it would essentially lose you the game). Dropping a pass knowing that you are not going to make a first down or get out of bounds would then be good. You still have a good quarterback with a good arm and 3 more downs.
Knowing when to manipulate and when not to is also important.
ArmyPT, OCS
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 6, 2004 11:13:00 AM
|
|
|
Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
Status: offline
|
ArmyPT,
Standing next to my computer screen I have two things: an action figure of Homer Simpson rearing back to throw a football and a Bobblehead Woody Hayes. I’m not making this up. Woody stands there stoically gazing ahead, his arms crossed, perfectly focused on the game he almost invented and Homer appears to be saying, “Go long!” Woody never goes for it.
Your football analogy is pretty good but reveals a lack of appreciation for “three yards and a cloud of dust.” I get a sense of the West Coast offense here and it violates the principles of conservative care. Woody felt that if every player did his job then a good running game couldn’t be stopped, and he was right. The risks surrounding manipulation are directly related to the fact that not everyone does their job, as I’m sure you know. Even if they do there’s always the risk of having a patient return to the doctor and say, “I’ve been worse ever since that therapist cracked my back.” True or not, who needs that?
Too often therapists use manipulation as an adjunct to care simply because it’s impressive or has the pizzazz so many traditional forms of treatment lack. They have been taught that facet joint stiffness causes pain or that muscular relaxation will often result from forceful movement. These ideas have a hold on our community but no longer on me. I guess that’s just the way it is.
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 6, 2004 11:52:00 AM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
Barrett,
Well put. I have a large grin on my face. Thanks for the advice and guidance. Go Buckeyes.
ArmyPT,OCS
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 9, 2004 4:50:00 PM
|
|
|
j
Posts: 74
Joined: January 7, 2004
From: wi
Status: offline
|
ArmyPT, I'm curious what exam findings led you to choose the manipulation techinque that helped this patient (versus alternate techniques).
Thanks, john
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 10, 2004 12:46:00 AM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
John,
On physical exam, I felt he was not moving well into flexion and right side bending due to the right sided low pain. He seemed to be restricted in his movements. He also felt hypomobile when I provided PA glides at L5-S1. Based on these findings and based on the fact he was no better with my previous intervention of activity modification and various mobility exercises I felt that manipulation would be helpful. I also quoted the Flynn et. al. article above (Flynn et al. Spine 2002;27:2835-2843)on manipulation and low back pain, which is a good study that shows that manipulation is helpful in patients with acute low back pain. I tried it and it worked this time. I am not sure if the lumbralization of the L5 vertebrae had anything to due with his pain and I am not sure if anything there moved when I manipulated him. What are your thoughts?
Army
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 11, 2004 12:34:00 PM
|
|
|
j
Posts: 74
Joined: January 7, 2004
From: wi
Status: offline
|
Army, let me start be stating that I am not questioning your treatment choice. I am simply seeking to understand how PT's make their choices. My struggle with manipulation is less with if it works than why it works. The study you referred to highlights my discord. My understanding (which may be wrong) is that many commonly used assessment procedures were used in this study, i.e. pelvic alignment, standing flexion test, spinal ROM etc. Yet none of them were predictably pathonomic. That is, some people who benefited from the manipulation procedure apparently should not have based on physical exam alone. And some may have benefited that should not have.
Those things that were predictive were mostly non-alignment findings. If my understanding is clear they consist of
1. score of fear avoidance scale
2. duration of sx
3. no sx distal to the knee
4. lumbar spine hypomobility at ANY level
5. Either hip with greater than 35 degrees of int. rotation.
Only 3 of the above needed to be valid to predict success from manipulation. Thus, if 1,2 and 3 were true, then manipulation was likely to work. Yet none of those address lack of range of motion, alignment, etc. This begs the question, "Why then does one assess and base manipulation choice on things like pelvic symmetry, standing flexion etc.?" It would seem that the success of manipulaton has less to do with fixing an alignment problem and more to do with some other reason; at least for this particular manipulation procedure.
My ability to express my thoughts is sometimes poor. Do you understand my discord?
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 11, 2004 11:42:00 PM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
J,
I understand your discord and I agree with you. I dont think we know. I dont look at pelvic alignment very closely anymore. The Flynn et al study is interesting. Especially, the findings that predicted success for manipluation, which you listed above. Those are items that many of us were not taught in school and that many of us are not currently looking at on physical exams. I also believe there are very very very few physical therapists who use spinal manipulation regularly in thier clinics. Hopefully this article will encourage more of us to learn and not be afraid to try lumbar manipluation. It is easy, effective, and should be an entry level skill taught to our students.
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 12, 2004 11:41:00 AM
|
|
|
j
Posts: 74
Joined: January 7, 2004
From: wi
Status: offline
|
Army, I am sure there are many reasons why few PT's use manipulation. For me, it is because it is not part of my belief system. It would be easier to swallow if manipulation would be presented as a modality to reduce acute low back pain in people with low fear avoidance scores. Instead, manipulation is presented as a method to fix a stuck or malaligned joint and fixing this malalignment is neccessary for pain relief. Yet the theorhetic clincal presentations of these stuck/malaligned joints fail to predict the success of the technique used to treat the problem.
If manipulation is to be taught more routinely (perhaps it is now) in school, how should it be covered? Should the extensive special testing and movement observations be used to choose techinque, or just the elements in the prediction rule?
I'm interested in your thoughts because my own are always bugging me.
Thanks, john
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 13, 2004 11:59:00 AM
|
|
|
Synergy
Posts: 592
Joined: March 11, 2004
From: Texas
Status: offline
|
I'm a fairly new grad, please feel free to retort b/c in the long run it helps me grow. I've had several LBP patients that I've manipulated/impulsed and I've gotten good results. I never end it there though. I usually follow those techniques with METs and PNF diagonals for increased stabilization around the joints. From what I've seen, you can't treat the lumbar segments without looking at the sacrum, i.e. checking the arthrokinematics, etc. In my limited experience, those two go hand go hand in hand and depend on one another for proper joint movement. Anyways, just my 2 cents *cha ching*
Synergy
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 17, 2004 11:38:00 PM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
[QUOTE]Originally posted by Barrett:
...Even if they do there’s always the risk of having a patient return to the doctor and say, “I’ve been worse ever since that therapist cracked my back.” True or not, who needs that?
[/QUOTE]
Barrett,
I recently took the time and read through most of your writings on your web site-Simple Contact and now I understand why you are against manipulation. I am also embarrassed to say that I had never heard of you or this technique until I came across the rehabedge forum.
I am not sure which is worse, having a patient go back to the doctor and tell him that "I am worse after the therapist cracked my back" OR having the patient go back to the physician and tell him "I am no better and some weird guy layed his hands on my back and did some voodoo stuff that I didn't understand." Which would be worse for your credibility?
I am sure that if I tried to use simple contact on my 215 pound Infantry Airborne Rangers, I would get the above response. Who needs that?
You make it sound as if when I manipulate a spine I am jumping off the top ring rope into their back. Many times just placing the patient into a position I can obtain a cavitation and a desired result; with no force.
ArmyPT, OCS
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 18, 2004 3:30:00 AM
|
|
|
Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
Status: offline
|
Army,
I think you’re on thin ice here. Regarding my work you seem to be of two opinions-you’re “embarrassed” that you hadn’t previously heard of it and you presume I come across as a “weird guy.” I’m confused, and, it seems, my explanations about neurodynamics, the reflexive effects of handling, ideomotor activity, Simple Contact and the relation of these things to manual care for painful problems leaves you unmoved. That’s fine, I can live with that.
There are a few things you don’t know yet about practice out in the world that may become clear one day. Let me give you a head start. 1) It is impossible to control what every patient says to the doctor about the care you provided and, no matter what you do, there will come a day when you hear it described in the worst possible way. This shouldn’t happen too often but you might as well prepare yourself because it will. 2) Assuming that anyone’s size or what they do for a living will tell you much about what they’re going to need in the way of care or what they’re able to understand is a rookie mistake, and prejudicial views such as this lead to all kinds of trouble that a little time and thoughtful conversation can avoid. I’m the size you describe and every bit as tough (my own opinion) but this has never hindered my intellect. 3) You’re unlikely to ever find a referral source who actually cares at all about what sort of thinking you do, and very rarely one who pays any attention whatsoever to the procedures you use. Ignorance and indifference, not opposition, is what you’ll find. Unless of course there’s some monetary consideration.
For the most part my patients say my care is gentle, immediately effective and makes sense to them. Sometimes they think I’m an idiot. This will never, never change.
I didn’t characterize your technique in any fashion whatsoever, I said the patient would (see explanation above). For the record, a study done at Lackland AFB and presented at the sections meeting demonstrated that “no audible pop” (the cavitation you refer to) was correlated with the success of manipulation. (“Audible pop from high velocity thrust manipulation and outcomes in patients with low back pain” Childs et al)
One more thing. My patient load isn't special in any way.
[This message has been edited by Barrett (edited March 18, 2004).]
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 18, 2004 5:56:00 AM
|
|
|
OaksPT
Posts: 124
Joined: November 19, 2003
From: Va
Status: offline
|
Holy crap, did hell freeze over, Barrett and SJ have somewhat of a concensus.
Seriously though ARMY,
Let me first state I have military experience( 4years USMC, but not as a PT)so I understand where you are coming from, and have been there myself as far as treatment choices. Very orthopaedic based, love the sports med/acute injury clientelle who respond well to manipulation. But as SJ stated, the civilian population is very much different than the Military/sports medicine population. Even disregarding the litigious element, what I see as themain difference in the two populations is chronicity and accountability. Population A(military/sports med)usually(not always) are presenting with an acute traumatic event. Population B (civilian world, the other 95% of patients you will run into after military service)tend to be passive and markedly uneducated about there own body, and expect us as professionals to do something to them, and really don't want to be responsible for what they are feeling(pain). This is why people love to see their chiro's, want to get a prescription, or ready to get sliced at the 1st onset of something they perceive as abnormal.But when we take the time to educate our patients some of them start to listen(although it is a shot in the dark)and want to be involved in their own treatment, and want to be able to know how to deal with their "pain" for the next time it arises, and I'm not talking about just a list of exercises.They want to know preventative techniques, to be able to self-correct at the first sign of a return of symptoms.
I too several years ago, when 1st reading Barrett's stuff, lumped it into the same category as cranial sacral/ and MFR. Just keep an open mind, and realize that you can keep learning for the next 25-30 years, or you can repeat what you know now for the next 25-30 years.
Well that's my ramble ,
Scott
Wow Barrett and SJ have a concensus(sort of)
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 18, 2004 3:47:00 PM
|
|
|
Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
Status: offline
|
I've never said I was typically the "last chance" for my patients. If you think I said that in some other manner than just saying it there isn't much I can do about that. I see all kinds of people with all kinds of pain, acute and chronic.
All this "game" stuff goes right past me.
|
|
|
|
|
Re: Spinal Manipulation on someone with a partial sacra... - March 18, 2004 6:30:00 PM
|
|
|
j
Posts: 74
Joined: January 7, 2004
From: wi
Status: offline
|
Regarding risk:
I believe manipulation is risky. Not for the reasons most people probably first consider but due to a subtly sinister problem. People with low back pain come to MD's and subsequently to PT's (MD's optional in the army, I understand) not knowing the actions that help them toward recovery. They are usually susceptible to suggestion in this situation. They may bring their own notions of how to fix themselves but more on that later. My understanding is that the manipulative therapist will perform a thorough examination of the ways spinal motion is limited. They will educate the patient that they have discovered the problem and the solution is to manipulate the back, to realign it. Of course, exercises are prescribed to prevent this from happening again. But it is the manipulation that they will remember in the future if they have back pain again.
Thus enters the patient who either directly had manipulation or heard from a friend that it works. They feel sure that their back pain is due to an alignment problem. After a thorough exam, I'm sure some alignment problem will indeed be found. The cycle continues.
I doubt that a manipulative therapist says, "Well you have a high oswestry, a low fear avoidance and short duration back pain, therefore I'll try this one technique that is predicted to help you." Thus the risk is that the patient feels his alignment "problems" are the source of his pain despite a lack of evidence for this. The risk is sinister because it instills a belief system that alignment is the cause of their pain, that we can accurately assess it and fix it. We do not know, for sure, the cause of their pain, we cannot accurately assess their alignment problems and we don't know if we can fix it because we cannot accurately assess it. It is risky to propogate beliefs that we cannot prove. On the other hand sometimes risk takers win. I do think it is a good short term buisness maneuver. Chiropractic sure has had a go of it.
john--sorry for the long post
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.141
|
Printable Version
