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Re: Should manipulation be taught in Entry Level Physical Therapy Programs?
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Re: Should manipulation be taught in Entry Level Physic... - May 16, 2004 11:04:00 AM
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satmad35
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Most DPT programs last only three years. Some schools offer a combined 3-3 BS-DPT which means they are doctoral level practitioners in only 6 years. I absolutely agree with adding a year worth of manipulation to these programs. Certainly taking 4 years to obtain the DPT would be resonable considering that most of our health profession peers take 4 years to obtain their clinical doctorate. I feel especially strong that universities with osteopathic medical schools should require their DPT's to have a year of training in osteopathic manipulation. If you believe in the osteopathic philosophy, it only makes sense. Furthermore, the more PT's that add manipulation into their regimens, the more success we will have with our patients as a profession.
As for cranial technique, it is not a silver bullet that cures everything. However, a skilled practitioner who knows when to use this modality can get very good results when appropriate. I have had great results using cranial technique when nothing else helps a patient with sacral problems. Thus, I respectfully disagree with my collegues here. I believe cranial technique is an excellent modality when used by a physical therapist skilled in its use.
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Re: Should manipulation be taught in Entry Level Physic... - May 16, 2004 6:25:00 PM
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mcap56
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The support and basis for CST is very, very lacking. I think our profession needs to evaluate it very carefully. I personally think it has no place in entry level education.
And again, although I don't disagree with manipulation in entry level programs, some of you are suggesting quite a bit of training for something that really could use more research substantiation. I hate to say it, but I have met far too many PTs who are incapable of performing a basic neurological evaluation on a patient with LBP. I have seen graduates from some programs where they barely spent any time in the lab and are incapable of even basic mobs.
Students need to master the basics first. Your point that manipualtion could be considered a basic technique is certainly a reaonsable. But....I think, with the limited time I get, there are other priorities. I will look carefully at my curriculum and reassess it.
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Re: Should manipulation be taught in Entry Level Physic... - May 17, 2004 2:22:00 PM
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Bournephysio
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Many different modalities have been discussed on this forum including manipulation, ultrasound and vax-d. The one thing in common all three have is some positive evidence be it physiological studies, biomechanical rationale, biomechanical effects, or rct evidence. CST has none of that. There is no rct evidence that it works. The physiological and biomechanical explanations are highly implausible (some are impossible). Reliability studies have shown that the reliability of palpating csrythm is consistent with a non-existent phenomenon. The only evidence we have is the opinion of some practitioners. This suggests that the most likely mechanism of action of cst is placebo. While I’m all for taking advantage of placebo in treating patients, a treatment whose only benefit is placebo does not belong in physiotherapy even in postgraduate education. Before cst is considered physiotherapy the evidence needs to be addressed. That ends my monthly cst rant.
As for the basics, there is absolutely no excuse for an entry level physio not to know how to perform a basic neurological evaluation, period. That is one of the stations in our national entry level practical exam. I think almost every manual therapy course which I have taken has gone over a screening exam. It’s done more as a review in more beginning courses and as an actual screen in the more advanced courses. Manual therapy is not a set of techniques. It is a philosophy of assessment and treatment that highly emphasises clinical reasoning (sometimes to a fault). It makes no sense to learn treatment techniques without learning when and when not to use them. Likewise, it makes no sense to learn a bunch of low priority treatments (e.g. how to nutate the left si-joint) instead of higher priority treatments (e.g. proper exercise prescription).
I am also very much in favour of learning pivms and mobs before learning manipulation. While pivms are derided for their lack of reliability (in many cases rightfully so), I strongly believe that they are essential for skillful manipulation. By that I mean a relatively targeted manipulation using a minimum of force. Many people just done have the motor skills to effectively and safely manipulate (especially necks), and need to be weeded out (or improve their skills) before they start manipulating patients.
Finally, manipulation is in the realm of expertise of physiotherapists. As such it should be taught be physiotherapists. Our development of manual therapy both from a clinical perspective and a research perspective is unparalleled. While I sure there is much we can learn from chiros and osteopaths (and vice versa), the primary teaching should be PT.
I doubt a two year program has enough time to learn manipulation ( I still don’t see how you can learn to be a PT over two years.) A 4 year dpt program should have enough time. Three years would be questionable.
Doug
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Re: Should manipulation be taught in Entry Level Physic... - May 25, 2004 9:35:00 AM
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Yogi
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When I was in school, we learned peripheral joint mobs, enough to be familar, then according to the job setting we gained experience or not. The spine elective class was taught Muscle Energy for the spine. Personally I've had two manipulations for a vertebral rotation, once as the massage class dummy for the ma. demo, which was a thrust during knuckling, and I didn't even know the instructor had done it until later, and again during the muscle energy demo. They were about two years apart, and the last one has laster 18 years. Personally, I think PT's should learn peripheral mob (alot more time than we spent) and Muscle Energy for the spine, and Strain/counter strain, and I think we should stay away from thrusts, unless we take classes with the D.O.'s. In fact, maybe we should see if the D.O. schools will give up the osteopathic manipulation curriculum to the D.PT schools, since it seems to be the rare D.O. that does manipulations, they don't have time since they are doing medicine. Dr. Wagner, opinion, Please?
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Re: Should manipulation be taught in Entry Level Physic... - May 25, 2004 9:49:00 AM
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Yogi
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Addendum: Satmad 35, I agree with you on everything you said. I was against the MPT requirement, and I don't see from my admittedly limited contact with MPT's that the entry skills are any more or better. I hope I'm wrong on that. A D.PT from scratch in 3 years?, I thought a Master's was 3 years. What are we thinking? Two or three years probably for an experienced Bs.PT. Let's not cheapen degrees. A Doctorate should carry a lot of prestige, because of the effort and learning it signifies. Disclaimer: should be no offense taken, opinions are only opinions, not facts.
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Re: Should manipulation be taught in Entry Level Physic... - May 25, 2004 10:18:00 AM
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p.glynn
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I think we all agree that learning mobs(1-4) is an integral part of any entry level PT program. The majority of the time the manipulation is simply the high velocity, low amplitude thrust added. This would not excessively add to the teaching time. Review of the indications and contraindications may take slightly longer however my opinion is that we can spend less time on many of the modalities currently included in the curriculums. As previously mentioned we have few proven techniques for acute low back pain, manipulation is beneficial hence we should be teaching it. The university is the ideal controlled evironment to learn this. Problems may arise when individuals are learning from books and improperly trained CI's.
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Re: Should manipulation be taught in Entry Level Physic... - May 25, 2004 1:38:00 PM
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Yogi
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Strain/counterstrain is safe and effective sub-acute or chronic, really acute and severe might need need pain treatment first, or would it. I mentioned peripheral mob, I'm not familar with spinal mobs except central posterior anterior vertebral pressures, and I've never done them as a treatment. If there's no malignment, what is the thrust for? If there is a rotation, why not use safe(r) MET or strain/counterstrain. The D.O.'s have, I think, Types 1 and 2 manipulations. I am not convinced the thrust type belong in entry level curriculum. Although I think a D.PT (in manual therapy, at least) should know them and be able to use them in a treatment progression only if really necessary. So, educate and convince me, or: cure my ignorance, if that's a better terminology.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 1:52:00 AM
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Alex Brenner PT MPT OCS
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Hi Yogi. There is overwhelming evidence for the safety and effectiveness of manipulation for the treatment of patients with low back pain and the risks of manipulation are very low, provided patients are selected and assessed properly. The most recent evidence that we have in the literature for the effective treatment of acute low back pain is manipulation. There is more current evidence for the use of manipulation than in strain/counterstrain. We owe it to our patients to provide evidence based treatments and we owe it to our students to teach them the tools they need to treat spine pain. Yogi, if you go to the APTA Hooked on Evidence web page and do a search on "manipuation" you will find several excellent research articles on the effectiveness of manipulation on spine pain. You should read these.
[QUOTE]Yogi says " ....really acute and severe might need need pain treatment first..."[/QUOTE]Yogi, this is actually when spinal manipulation has been shown to be most effective-the acute low back. In my opinion students should be learning this. Just my thoughts.
ArmyPT
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Alex Brenner, PT, MPT, OCS
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 4:10:00 AM
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satmad35
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Yogi, thanks for your thoughtful posts! One area in which I have a different view is your idea that it might be good for DO's to give manipulation to the DPT's. I think that we would do best simply to learn osteopathic techniques within our scope to better serve our patients and to collaborate with osteopathic physicians. It would be foolish for DO's to give up manipulation as they use it much more broadly than we could to treat other diseases outside our scope. Having graduated from a university with a osteopathic medical school, I simply wish the PT program had added in more osteopathic manipulation to allow me to better collaborate with the DO's.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 4:44:00 AM
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Jon Newman
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Hi Army, I might as well give my two cents here. I think manipulation should be taught in PT course work. But I am curious how it would be presented. I understand the theorhetic frame work and believe the theory is worth considering and that it is easily taught and discussed. Would the instruction in PT school be limited to "general" manipulations for treatment of the condition of acute LBP? Or would instruction extend to technique selection... why choose this way of manipulation versus that? Is there good evidence that the decision algorithm used produces superior effects than mis-manipulating? Are there significant consequences to mis-manipulating? I'm sure the answers are known to the satisfaction of society or they wouldn't be in such common pratice.
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: Should manipulation be taught in Entry Level Physic... - May 26, 2004 5:25:00 AM
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Yogi
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Thanks Army. Good thinking Sat, you're absolutely right, my suggestion was tongue in cheek to make exactly the point you articulated so well. I don't do much ortho work, as you all can tell. By the way, I know what PAVP is, what is PIVP, also, from another thread, ULNTT, and TOS. Thanks.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 7:43:00 AM
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p.glynn
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Jon,
I think that's a great question and it will be interesting to see how the programs introduce the decision making process. Researchers such as Flynn are certainly trying to pull together criteria to determine who may or may not benefit from manipulation i.e. acuity, pain beyond the knee etc. But the techniques are still "regional", does this mean that we just have to get the joint moving? I think from a teaching standpoing this approach would be simple however incomplete. As you perform more and more manips you begin to see patterns as to who would benefit, do we upglide, downglide etc, however as most things this decision algorithm is a work in progress.
Yogi,
I believe PIVP would be passive intervertebral motion, I've seen it written PPIVM passive physiological intervertebral motion and PAIVM or passive accesory intervertebral motion. ULNTT = upper limb neural tension test and TOS = thoracic outlet syndrom.
Paul
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 7:59:00 AM
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OAK
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Most experienced therapists will know that while spinal mobilzations have there place, one can only get so far with them, and that clearly spinal manipulations are the superior technique.
If manipulations are not taught at entry level therapists will be forced to learn them on their own, which is a real tragity.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 8:58:00 AM
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Yogi
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Paul, thanks. I had a senior moment on TOS, PIVP I had learned as PAVP, but the brachial plexus tension test I had not learned or heard of before. Very helpful. Thanks.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 9:24:00 AM
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Yogi
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Back to spinal manipulation in the curriculum, I would rather see a sequencing of teaching and use beginning with the indirect techniques, which I do believe work well on acute spinal injuries, then to muscle energy as a direct technique, and lastly to direct thrusts. Everyone seems to be leaning toward HVLA manipulation. I guess if Chiros can be entry level with it in two? years then how long should we add to PT school for it? Yes, the more techniques in the tool box, the better. Just sometimes a rubber mallet works better than a sledge, even though they can do they same thing sometimes in the hands of a skilled mechanic. I would be leery of only providing a sledge to my mechanics.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 9:52:00 AM
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OAK
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In a perfect world it would be nice to be able to start with spinal mobilzations, practice them for a few years and get good sense of joint endfeel. Then spend several more years learning the anatomy of the spine and nervous system and then slowly learn spinal manipulations.
Unfortunately Physical Therapists are not the only practitioners that manipulate so the above path is not always practical.
Since competion is fiece nowadays between professions and within professions alot of Therapists are not willing to spend the 10 years it takes to go through the regular orthopedic manipulative system and opt to learn these techniques in an informal system. For liability issues this is a disaster.
Why not graduate all therapists with the same skill levels?
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 10:01:00 AM
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Yogi
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Oak, well then, we'll have to go to DPT entry level, won't we. That's another thread I may start sometime.
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Re: Should manipulation be taught in Entry Level Physic... - May 26, 2004 1:19:00 PM
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Yogi
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Oak, in reality, there has not been any homogenity between PT programs, so no one graduated at same skill levels, or even the same exposure to skills.
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Re: Should manipulation be taught in Entry Level Physic... - May 27, 2004 4:31:00 AM
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Shill
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Quick question here.
When manipulation is taught, what are the proposed indications for its use that are also taught?
My point is, if taught for purpose of aggressively mobilizing a hypomobile joint, to potentially encourage different movement patterns, great. With this I can agree.
If it is taught that we are realigning or "correcting" misaligned joints, here I run into a problem. This places our treatment intent in the same already disproven category as correction of "subluxation" like problems that probably dont exist.
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Steve Hill PT
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Re: Should manipulation be taught in Entry Level Physic... - May 27, 2004 6:01:00 AM
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Alex Brenner PT MPT OCS
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Indications for Spinal Manipulation from published literature.
-Based on a meta-analysis, DiFabio (DiFabio R. Efficacy of Manual Therapy. Physical Therapy 1992; 72:853-864) reported the following characteristics of patients with LBP who were likely to benefit from manual therapy intervention:
a. Duration of current episode less than one month;
b. Acute onset;
c. Pain free at least 6 months prior to the current episode;
d. No history of previous manipulation or surgery;
e. No evidence of systemic illness, structural deformity, or loss of strength or muscle stretch
reflexes;
f. Not pregnant; and
g. Were not receiving payments nor involved in litigation related to their condition.
-Flynn and colleagues (Flynn T, Fritz J, Whitman J, Wainner R, Magel J et. al. A Clinical prediction rule for calssifying patients with low back pain who demonstrate short term improvement with spinal manipulation Spine V 27 (24) 2835-2843.)found in a recent trial that subjects who had the following examination findings responded with dramatic success to manipulation (successful response to manipulation defined by a 50% reduction in Oswestry score in less than 5 days):
a. Fear Avoidance Behavior Questionnaire work subscale score <19;
b. Duration of symptoms 15 days or less;
c. No symptoms distal to the knee;
d. Lumbar spine hypomobility at any level;
e. Either hip with greater than 35 degrees of internal rotation.
Patients with 3 or more of any of these findings have a high likelihood of dramatic success.
These subjects had severe LBP with Oswestry scores > 30 but did not have significant sensorymotor loss. While the 3 or more findings predicted dramatic success, patients with fewer findings may respond more favorably than the passage of time. An ongoing clinical trial is attempting to validate these findings.
Shill,
Biomechanically I don't think we know what exactly is going on when we manipulate a spine. But recent clinical trial research shows that it is efficacious. This is what was taught to me in PT school and in my opinion what probably should be taught in all PT schools. Not a subluxation model or a misalignment model, which like you said is unsubstantiated.
Army
_____________________________
Alex Brenner, PT, MPT, OCS
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