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Re: Spinal Manipulation on someone with a partial sacralization of the L5 vertebrae
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Re: Spinal Manipulation on someone with a partial sacra... - March 18, 2004 7:32:00 PM
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Bill Egan
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From: Newton, MA
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I have been following this thread with some interest. I am an ex-army PT, and I continue to utilize manipulation as an intervention as a civilian PT. I have heard all the arguments from PT's before about why we should not perform spinal manipulation. Of course, PT's should be comfortable with the interventions they chose to use. They should fit with their own personal belief system and model of patient care. That being said, there is quite compelling evidence for the use of spinal manipulation in acute LBP. Low back pain guidelines from multiple countries list spinal manipulation as a proven option for short term relief of pain in acute LBP. The reported risk is extremeley small. Thanks to Flynn et. al we have some idea as to what patient variables predict success with manipulation. A recent study by the same group in PT Journal reported on the patient variables that predict no benefit from manipulation.
If presented in the proper context, I do not believe that it causes patient dependence on passive care, or leads patients to believe they are out of alignment.
As Army mentioned before, manipulation is easy to perform and should be considered an entry level skill. If you have not been trained in this skill, and are interested in learning manipulation, I suggest you take the APTA sponsored course on the lumbar spine.
Bill
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Re: Spinal Manipulation on someone with a partial sacra... - March 18, 2004 7:50:00 PM
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Bill Egan
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From: Newton, MA
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Army,
I forgot to answer the original question...I would ignore this x-ray finding and make my clinical decision based on my examination. I'll bet he had at least 4 of 5 factors that would predict success with the technique you utilized. In my opinion, your choice was completly appropriate.
Bill
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Re: Spinal Manipulation on someone with a partial sacra... - March 20, 2004 5:26:00 AM
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j
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Joined: January 7, 2004
From: wi
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Hi Bill,
Before I ask my questions I feel compelled to reiterate that I accept that manipulation provides pain relief for some patients with acute low back pain. I agree that the risk for lasing physcial harm is minimal. My hang up is how PT's come to make their decisions and why it works.
I agree that Flynn et. al. have published an interesting study. But it is that very study that serves as a source of discord. Spinal hypomobility at ANY lumbar level and (normal)hip ROM are the only two anatomical exam findings that predict success in this study.
1. In theory should the one manipulation technique used in this study solve a hypomobility problem at ANY level?
2. If so are the other physical exam methods such as standng flexion, spring test, pelvic symmetry, to name a few, a waste of time?
3. What is the proper context to present manipulation and do you feel that this context is standard practice?
I ask this because certainly the patient needs to know why they are about to get manipulated and I'm curious what PT's tell their patients.
Lastly, I hold most if not all of my beliefs provisionaly. I am willing to change my mind as the overwhelming evidence I am exposed to suggests. I would be grateful if you exposed me to a few (please just a few) of your better references--the ones that help drive your manipulation practice.
Thanks, john
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Re: Spinal Manipulation on someone with a partial sacra... - March 20, 2004 11:31:00 AM
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Bill Egan
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From: Newton, MA
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John,
These are tough, honest questions and I won't pretend to have all the answers. Also keep in mind that most good research studies generate more questions than they answer.
1. The technique used in the study (called in some circles the Chicago technique,Flynn and colleagues call it the SI region manipulation) is very general. It was designed to "correct" an anterior inominant by locking the L-spine in neutral mechanics and thrusting the inom. posteriorly. But, I think you pretty much mobilize the SIJ, entire lumbar spine, and even the lower thoracic spine with this technique.
2. This is the best question, if this and probably most other technqiues have such a generalized effect, do we do away with half of our physical examination.
I would argue No for two reasons:
I: A thorough physical examination has been shown by itself to have a therapeutic effect.
II: The tests are still useful for clinical decsion making. The study by Flynn tested only one technique and used a change in the Oswestry score as the only outcome measure.
3. I'm not sure how other PT's present their manipulative procedures to their patients. Are there PT's out there emphasizing positional faults and malalignment? I would suspect so, are they wrong ? Are their patients improving ?
I explain to my patients that movement will improve their condition, and that the manipulation will assist them in moving better and with less pain.
Here is a link to one of the most recently reviewed LBP practice guidelines (Royal College of General Practicioners, UK). It contains all the references that found manipulation to be useful in acute LBP.
[URL=http://www.rcgp.org.uk/rcgp/clinspec/guidelines/backpain/index.asp]http://www.rcgp.org.uk/rcgp/clinspec/guidelines/backpain/index.asp[/URL]
Bill
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Re: Spinal Manipulation on someone with a partial sacra... - March 21, 2004 1:41:00 PM
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j
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From: wi
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Bill, thanks for the link. I did read it with some interest. It will take a bit of time for me to get the original text versions of some of the references on the list contained in the link.
By the way, I did attend the APTA course. Based on my posts I'm sure it would come as no suprise that I was largely disappointed. I'm hoping this forum is a more fruitful route to discovery (and cheaper). At the risk of perseverating I'm going reword my struggle with how PTs come about their decisions.
I feel the physical exam tests are not particularly useful for clincial decision making. Here's why:
1. My understanding is that most of the typical tests performed including those testing for hypomobility demonstrate poor reliablity, especially inter-tester. The ramifications of this, I think, are obvious.
2. In Flynn's research, physcial exam findings largely did not predict success from manipulation. I understand this was just one technique, but surely the physical exam findings that define an anterior inominant should have predicted success with this technique otherwise what are they good for? It seems that either the physical exam or the technique's intended use is flawed. How else could this be resolved?
I welcome anybody's thoughts here. I know I'm being redundant and this will be the last time I post this issue for a while.
thanks, john
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Re: Spinal Manipulation on someone with a partial sacra... - March 21, 2004 3:21:00 PM
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Barrett
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From: Cuyahoga Falls, Ohio
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John,
Maybe it's just me, but I had the impression long ago that this manipulation study revealed little interest in figuring out what might be causing the problem and instead focused on what seemed to relieve symptoms. These guys seemed to just give up on finding a reasonable theory of dysfunction and just tried a series of treatments hoping to find one that "worked" more often than others. The position of the pelvic bones tipped me off. Not only can't we see this reliably-Why would that hurt?
[This message has been edited by Barrett (edited March 21, 2004).]
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Re: Spinal Manipulation on someone with a partial sacra... - March 22, 2004 3:14:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Barrett,
I believe that Flynn argues that you don't necessarly have to know the “why” about back pain in order to make his subjects better. He compares it to the introduction of Aspirin as a drug to ease pain. When Aspirin (over a thousand years ago) was introduced they did not know the exact mechanism of why it worked. Did that mean that they did not prescribe it for pain? We did not find out until relatively recently the exact mechanism of how Aspirin works but yet it has been prescribed for centuries.
According to Flynn’s study this particular technique (Sacroiliac region manipulation or the Chicago technique-described in the latest issue of Physical Therapy) is effective in reducing acute low back pain. We don’t know why it works (that was not the focus of this study), but we do know it works and we she be using it in the clinic, even you Barrett. [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
Army
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Re: Spinal Manipulation on someone with a partial sacra... - March 22, 2004 5:13:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Yea, like I said, they don't know what it is exactly they're affecting or why that would be a good idea beforehand and they have in effect given up on trying to figure that out.
Not good enough.
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Re: Spinal Manipulation on someone with a partial sacra... - March 22, 2004 5:37:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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Barrett,
Not good enough for what? Not to try this technique in your clinic? What do you mean?
Army
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Re: Spinal Manipulation on someone with a partial sacra... - March 22, 2004 11:07:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Army,
Glad you asked. Check out the essay "No Deep Model: The problem of empiricism in alternative practices" [URL=http://barrettdorko.com/articles/no_deep_model.htm]http://barrettdorko.com/articles/no_deep_model.htm[/URL] It begins with this quote: "Empiricists are not equipped to recognise the loud signals of alternative medicine as false. A deep model of the physical world is essential for choosing hypotheses to be tested and for learning from failures. Practices of alternative medicine that do not fit even at the far fringes of the model should not be tested in humans. Our decisions on which practices to test and which to adopt should be based on three things: empirical evidence; our deep model of the physical world; and our commitment to the wellbeing of our patients."
From (Alternative complementary) medicine: a cuckoo in the nest of empiricist reed warblers E, Beilinson and Leonard Leibovici British Medical Journal 1999; 319:1629–32.
There are perhaps 2000 words in the essay but essentially the point is this-empiricism alone (seeing what works) is insufficient reason to promote any method. This is the mistake of the "alternative" community and it should not become ours. In other words, we should strive to do better by forming and defending a deep model of reality that leads reasonably toward methods of management, not the other way around. This is harder, of course. I figure we should try anyway.
I hope that answers your question.
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Re: Spinal Manipulation on someone with a partial sacra... - March 22, 2004 3:09:00 PM
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Bill Egan
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From: Newton, MA
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Barrett,
I do not think we should make our decisions based on empirical data alone, either. I use the evidence to guide my clinical decisions and also encorporate the patient's values.
My question to you is: if you do not collect empircal data or do outcomes studies, how would you know if your theory or deep model of patient care is correct ? Many physical therapy interventions are rooted in scientific theory alone without any evidence to support them.
Bill
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Re: Spinal Manipulation on someone with a partial sacra... - March 22, 2004 3:44:00 PM
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Barrett
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From: Cuyahoga Falls, Ohio
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Bill,
Please note that empirical data *is* one of the three elements thought necessary for best practice. It is when it is used alone that trouble follows.
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Re: Spinal Manipulation on someone with a partial sacra... - March 23, 2004 4:28:00 AM
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j
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From: wi
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I know I said I would'nt post on this again but, apparently, I just can't help myself.
I agree that the purpose of the study was not to determine why manipulation works. My point is that regardless of the authors' intent, there are consequences to this study. The consequences are that if you accept the conclusions regarding certain people get better with manipulation, you must reject the use of provocation tests and tests of pelvic symmetry and mobility as useful in prognosis. These items were clearly considered and not retained as useful for clincal decision making as it pertains to manipulaion in this population. However, therapists are being instructed (even at the APTA "advanced clincal practice" series, taught by one of the authors) how to use special tests and bony alignment to select manipulation techniques.
I believe it is an example of confirmation bias at work.
john
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Re: Spinal Manipulation on someone with a partial sacra... - March 23, 2004 9:31:00 AM
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Alex Brenner PT MPT OCS
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John,
I have not read this study for a few months but if I remember this study said nothing about refuting or rejecting looking at pelvic/boney alignment. Those just did not "fall out" as predictors as to who would benefit from manipulation. Continue to look at this if you feel you are successful examining this way. I dont think the aim of the study was to change the way you do a physical exam. I do not remember anything in the conclustion that stated that you should abandon the assessment of boney landmarks. If you come to the conclusion on your exam that the patient may need manipulation, now you have an idea if he would respond favorably using the technique that they used. John, I use this technique almost daily. It is safe, effective, and easy to perform. Learn it, add it to your manual tool box and don't listen to Barrett.
Army
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Re: Spinal Manipulation on someone with a partial sacra... - March 23, 2004 10:07:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Army,
You're right. I don't know what I was thinking by suggesting we think at all before we treat. Tests proven unreliable, invalid and irrelevant should be done anyway, especially if they're on the form we are compelled to complete. Manipulation might help (according to the study) so it shouldn't be withheld. On top of that it's pretty cool to do and some patients really like the drama, to say nothing of the sound affects.
I think I'm done here.
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Re: Spinal Manipulation on someone with a partial sacra... - March 23, 2004 5:53:00 PM
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Bill Egan
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From: Newton, MA
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John,
I'll give it one more go here because I feel strongly that as a profession we underutilize this intervention.
The question of reliability may not be as simple as what we learned in our stats class. Who decided what constitutes "good" reliability ? Like anything else, not all realability studies are created equal. A test can still be useful if it has poor reliability. Read this editorial by Rob Wainner, it may change your thinking on this issue.
Reliability of the clinical examination: how close is "close enough" ? JOSPT. 2003;33(9): 488-490.
I would agree with Army in that this particular study did not invalidate all the examination techniques. I think it showed that this manipulative technique really is not specific to the SIJ. Also, manipulation has a large non-specific effect. As I stated before, the examination itself has been shown to be therapeutic. As Army stated, I continue to examine the patient according to a model that makes sense to me ( but no I don't look very closely at the alignment of boney landmarks). If I decide, based on my examination, to chose a particular manipulative intervention, I have the clinical prediction rule to help with prognosis of how this patient will respond.
John, your questions are good ones, and it shows that you are a reflective clinician. If you'd like, e-mail me and I can put you in touch with Tim Flynn. He may be able to provide you with other answers.
Barrett, I think things have gotten a little out of hand. I hope you don't harbor resentment towards Army or myself. I think with communicating this way, things can get a little misconstrued. I'm sure you, Army, and myself could have a lively discussion about manual therapy over a few pints. I know Army would be game for that.
Bill
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Re: Spinal Manipulation on someone with a partial sacra... - March 23, 2004 6:00:00 PM
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j
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From: wi
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Army, regardless of the aim of the study, the consequences of its finding are what they are. Since you don't have access to the article, allow me to provide evidence for my statements. From the article:
1. "Individual variables from the...physical examination were tested for their univariate association with the reference standard using independent sample t tests for continous variable and chi2 tests for categorical variables. Variables with a significance level of P<0.15 were retained as potential prediction variables; a more liberal significance level was chosen at this stage to avoid excluding potential predictive variables."
2. "Among the speical tests for SI dysfunction, only the compression-distraction test was retained in the predictive model, although positive findings were more common in the nonsuccess group." (This is a particularly salient point since the manipulation procedure is designed to correct SI dysfunction.)
3. "Similar to other studies we were unable to show acceptable accuracy for any individual tests proposed to identify SI dysfunction. Furthermore, we found that the reliability of these tests in a population of individuals with LBP is less than optimal...However, by considering other variables and combining findings, we were able to develop a clinical prediction rule that may be useful for assisting clincians in classifying patients as likely to respond to this manipulation technique."
I also took the time to re-read the subsequent Flynn, et. al. article classifying those who don't benefit from manipulation. While the uselessness of the special tests were only hinted at in the original article, the follow-up was (suprisingly) more direct.
1 "One reason for the lack of association for many of the tests may be the inability to obtain reliable measurements...We believe, however, that poor reliability may not be the sole explanation for the lack of association for the tests. Several tests that yielded data with acceptable reliability failed to show any relationship to the outcome of manipulation. Another explanation for the lack of utility of many of these test may be related to faulty theories underlying their mechanisms."
Take some time to re-read my posts and I have been steady with my question despite a lack of response to my answer. Bill and Synergy did make an attempt. You will also see that I spoke of the risk inherent to manipulation and the risk is especially brought out in Synergie's post: "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." The (likely erroneous) belief system of how manipulation works has been propogated.
p.s. "With the gift of listening comes the gift of healing."--Catherine de Hueck
john
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Re: Spinal Manipulation on someone with a partial sacra... - March 23, 2004 10:01:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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John,
These are great questions and comments, I can not answer them for you. Why not direct these questions towards the researchers. That is why they include thier email addresses at the ends of the study. I know LTC Tim Flynn (he is at Regis University now) personally, he is a good guy and will do his best to answer your questions.
Barrett, sorry for any hard feelings, I definetly would like to talk to you and Bill about it more over a friendly pint. In fact, I am close enough to Ireland that we could get a REAL pint if you guys are game.
ArmyPT, OCS
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Re: Spinal Manipulation on someone with a partial sacra... - March 24, 2004 5:19:00 AM
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j
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From: wi
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Thanks Army and Bill for directing me toward Flynn's e-mail. I currently feel my issues regarding the utility of the more commonly utilized special tests have been addressed through Flynn's follow-up article, Factors related to inability of individuals with low back pain to improve with a spinal manipulation, Feb 2004, journal of the APTA. Army, since you know him personally perhaps you could tune him into this thread. He can add to everone's knowledge base that way, not just my own.
It seems that this study really is not new information regarding the dubious utility of selected physical exam procedures, but rather one more study agreeing that these special tests are of low/zero utility in selecting treatment intervention. Citations in the article supporting these assertations go back to 1991. Now if they would just quit teaching those special tests as important in making treatment choices, especially at courses purported to be advanced clinical practice courses based on the evidence.
With the publication of the latter article, word may get out that a manipulation advocate is willing to down play current/standard examination methods in favor of other, less commonly used, examination methods in order to put the method of manipulaton on slightly more solid ground. This would be a step in the right direction toward a better understanding of manipulation's place in therapy.
john
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Re: Spinal Manipulation on someone with a partial sacra... - March 24, 2004 10:47:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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John,
As much as anybody I appreciate what you've said here. The comments about the dearth of exam methods that are worth much deserves a thread of its own and I may start one if someone doesn't beat me to it. In the meantime "The End of Evaluation?" on my web site has some ideas you might find interesting if not actually heretical.
As I've said before on this board, not knowing to whom I'm speaking because of their hesitance to reveal their identity is still something I struggle with. I hope you'll consider using an actual identity sometime.
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