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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 27, 2004 7:01:00 AM
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Jon Newman
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Army, thanks you for supplying the summaries...they are worth reading in their entirety for anyone who hasn't. These articles strive to define who will benefit from manipulation. These study designs are worth repeating with many of our PT interventions. For instance those who would benefit from McKenzie, or from spinal stabilization or from jumping jacks for that matter.
To those teaching, this information could be covered in a very small number of hours and thus there is no reason not to consider including it. However, it seems that while being manipulated is correlated with analgesia in a population with the summarized characteristics, none of those characteristics lead us to technique selection. That is the part that takes a lot of classroom hours but has scant evidence.
I have to admit to some suspicion that those are characteristics of people with low back pain who will demonstrate a dramatic improvement in pain with treatment in general. I remember during the APTA course that information was presented (not in the handouts) of someone doing their disseration on just that (proving my suspicion wrong). But I haven't seen it published yet. I'll keep my eyes open and if anyone know about it please educate us.
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 27, 2004 7:31:00 AM
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OAK
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Good points Army. The current mechanical dysfunction theories of the spine, while effective for technique instruction, do not hold up for all cases and should be taken with a grain of salt.
The real question when performing spinal manipulations should not be when to do them (one can always find a reason to do them) but when NOT to do them.
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Re: Should manipulation be taught in Entry Level Physic... - May 27, 2004 8:55:00 AM
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Bill Egan
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Jon,
The study you are talking about has been completed and the results support the clinical prediction rule. I believe the article was submitted for publication and is in review. Look for it soon. The preliminary results were published in the CSM abstracts in JOSPT.
Bill
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Re: Should manipulation be taught in Entry Level Physic... - May 27, 2004 2:34:00 PM
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Jon Newman
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Thanks Bill!
I've been waiting. It seemed to be a persuasive argument for the prediction rule being specific to manipulation versus therex. Now if I could find some peace with technique selection. Note that my preoccupation with technique selection carries over to other areas of PT also, not just manipulation.
jon
_____________________________
[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 27, 2004 2:51:00 PM
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Bill Egan
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Jon,
Specific technique or exercise etc. selection is more art than science at this point. Studies are underway, but this area of PT research is relatively new. I think as long as you are applying some sound clinical reasoning in addition to the latest and best evidence for what intervention you select, than you are doing pretty well.
Bill
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Re: Should manipulation be taught in Entry Level Physic... - May 29, 2004 8:42:00 AM
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CarolinaPT
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My two cents would be that manipulation should be taught in entry level programs as the efficacy has been shown, in fact one of the few techniques that has been shown to be valid. I would just stay away from some of the more difficult techniques such as vertebral manipulation which has been shown to be correlated with more associated risks. The basic thoracic, lumbar and peripheral manips should be taught though in my opinion becuase just as others have said, they are additional tools.
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Re: Should manipulation be taught in Entry Level Physic... - June 2, 2004 11:11:00 AM
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Dr.Wagner
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Carolina, while I think manipulation of the spine is a fantastic tool...it is not "valid" (usually validity is reserved for testing) You certainly couldn't get two DO's or DC's to agree on what manipulation actually does nor do two practitioners perform manipulations the same.
Virtually all research on manipulation is of poor quality regardless of literature. Lack of blinding, control, or sham provides problems.
But...therapy is an art, manipulative medicine is an art and certainly not a science...
I think there will be alot of resistance in the world of PT to push for manipulation, as this has always been a sticking point of the DC vs PT wars. I am very interested to see where this may actually lead...but I can tell you it takes constant practice to get good at spinal manipulation (muscle energy or HVLA) and it takes commitment (that is why so many DC's are fantastic at manipulation). As a DO and a PT I think I would have benefitted in therapy if I had learned manipulation...but then again, I probably wouldve manipulated anything I could get my hands on...and isn't that were much of the DC criticism comes from??
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Re: Should manipulation be taught in Entry Level Physic... - June 3, 2004 5:35:00 AM
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Yogi
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Thank you Dr. Wagner. Good points. You still didn't address whether manipulation should be taught in entry level programs. There still seems to be a problem in the labeling of mobilization vs manipulation, it seems to me. How about this as a solution, everyone. Teach familarization with the mobilization and manipulation techniques, direct and indirect, in entry level programs. Since these are all MPT programs, that should be feasible at this time. As Dr. Wagner says, it takes practice to develop skill. So, PT's that expect to be DPT's should be expected to have more expertise and skill, so they should have additional classes and opportunity to develop greater expertise and skill. This teaching of all the techniques may help alleviate Doc.'s point about overusing a single technique, the least invasive technique necessary could be utilized. I would have liked to have had more opportunity in the Bs. program to have learned more manual therapy techniques. I think the real question may be, are the present MPT students learning more manual therapy than I did? It seems logical that they should. The Canadians learned alot more than the US PTs when I was in school, so I know it was possible, it just wasn't what the school(s) wanted to teach. I did feel somewhat shortchanged once I met and learned some from a Canadian therapist. Luckily I knew a DO that specialized in DO manipulation, and so I had someone with expertise to refer to. The benefit of that is he was medically trained as well and could find medical conditions such as an iliacus cyst that otherwise would have gone untreated at worst, and not for a long time at best, had I not referred. Here's a salute to all the DOs.
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Re: Should manipulation be taught in Entry Level Physic... - June 3, 2004 6:10:00 PM
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CarolinaPT
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Sorry, valid was the wrong term, but what I meant by it is that there is more evidence out there for manipulation vs some other techniques which are just as widely used, if not more. Poor quality studies or not, they are still better evidence than we have for some other techniques. AS far as a lot of practice is needed to become proficient in the techniques, I fully agree, but you have to start somewhere.
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Re: Should manipulation be taught in Entry Level Physic... - February 1, 2005 5:36:00 AM
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JLS_PT_OCS
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Hard to believe that we are still having this discussion, given the evidence available for manipulation in the literature. It truly shows that the problem in the PT profession isn't lack of evidence, but lack of willingness to use it to guide treatment.
I think without question that manipulation is an entry-level skill. It is a simple procedure that has an extremely low risk in the lumbar and thoracic spines, and the technique cited recently for acute back pain can be taught in about 10 minutes.
It is expected behavior among PT students rotating through my clinic. They can no more choose not to manipulate the appropriate (see prediction rules elsewhere) patient than they can choose not to provide strengthening exercise for their ACL patients.
Personal treatment philosophy never enters into it. It is a simple matter of what is proven and what is not. You can not choose to avoid doing something that is proven effective and even think that you are providing optimal care. Indeed, the data to date state somewhat unequivocally that if you choose not to manipulate an appropriate patient, you are deliberately providing suboptimal care. That is exactly what we want entry level students to NOT provide.
I would second and support opinions about chronic pain patterns, yellow flags, etc. They definitely give me due pause with many patients.
I think it is ridiculous to consider that mobilizations must be taught before manipulation, or that in order to use manual treatment methods, you must learn some theory underlying your care, or some unproven biomechanical model (osteopathic or otherwise) that guides your treatment, or get some certification or a long term training program, or an additional year of manipulative training....such ideas are simply ridiculous, foolish and have no basis in evidence. NONE.
There is no evidence to support the contention that a lot of practice or experience or skill is required to successfully perform this procedure.
It is a psychomotor skill like any other.
What is the argument against teaching this immediately to any and all PTs and PT students you know?
1. Risk? It's more risky to plop them on a treadmill for risk of a cardiovascular event.
2. Skill? The aforementioned manipulation in the decision rule can be learned from watching the video and practicing on a collegue in 10 minutes.
I teach PA students that technique all the time and they use it with success in primary care. And yet they have no manipulative therapy experience and wouldn't know these terms: ERS, FRS, Grade I-IV, PIVM, mobilization, etc. They don't have FAAOMPT, CertMDT, COMT, or XYZ after their names, either.
I'm not implying that manual therapy training and certification is not of benefit, just that it is not "required" to be successful.
I remain unconvinced of any argument whatsoever that would serve to disinclude this procedure from entry level programs.
If you are a professor, and you don't have "room" for this in your training programs, then you need to drop something that is unproven to MAKE room. I suggest you drop the PIVMs and accessory spinal motion training first. That should leave plenty of time to discuss evidence based care and at least one manipulative procedure, proven to be beneficial.
When are we as a profession gonna wake up and smell the coffee??
Shouldn't evidence and demonstrated effectiveness ALWAYS trump any other issue of any type?
If not, then why not?
Jason.
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Should manipulation be taught in Entry Level Physic... - February 1, 2005 7:09:00 AM
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Alex Brenner PT MPT OCS
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Wow, this is everything that I have attempted to articulate on this forum in the past year in just one post. Outstanding!
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Alex Brenner, PT, MPT, OCS
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Re: Should manipulation be taught in Entry Level Physic... - February 1, 2005 8:17:00 AM
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steve
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Jason,
Very well said, why cant we get the rest of the physiotherapy community (Researchers and post graduate educators) thinking on this level? It just seems to be common sense and would benefit patient care greatly. Perhaps your post would sit even better in the "Myth busters" on the open forum.
Steve
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Re: Should manipulation be taught in Entry Level Physic... - February 2, 2005 6:06:00 AM
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OrthoSam
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Hi all,
I teach a University based DPT program as well as a post-professional manual therapy residency.
There is a huge difference between highly skilled manual therapy with manipulation as only one of the treatment modalities, and undergraduate manipulation education.
The APTA's manipulation task force has created a fairly comprehensive manipulation education manual, as a frame work for manipulation education. The manual provides extensive objectives for the learning of contraindications for manipulation, as well as indications.
I would make this point in favor of learning manipulation. If it is learnt at an undergraduate level then students understand that it is part of their practice when they graduate. That's all it is. The manipulations are so basic and simple. There is no real cervical rotatory component with the techniques. Graduating students now feel like it is an optional technique that they can learn, but most really never incorporate it into orthopedic practice. If graduating students realize it is a skill that is indicated, just like joint/soft tissue mobilization and exercise, then they will realize that they can then learn more to become proficient at it.
Most if not all instructors teaching at Universities know that manipulation is used infrequently, and should be learnt in a guided/ mentorship type manner, to become skilled at it (as most of them are fellowship trained)
Anyway, that is my impression of the type of manipulation training.
Keep in mind that manipulation is only one technique in the armada of other techniques available to newly graduating PT's. Manipulation has to be part of the whole rehabilitation package and not a lone technique.
Cheers,
Sam
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Re: Should manipulation be taught in Entry Level Physic... - February 8, 2005 1:23:00 AM
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JLS_PT_OCS
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Sam-
How does your University program approach the teaching of manipulation?
Why do students feel as if it is an optional technique they can learn, and not a required one?
Is it a requirement for all students to learn some type of manip/mob, do they demonstrate basic competency, etc...
Thanks for your input.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Should manipulation be taught in Entry Level Physic... - February 10, 2005 8:54:00 AM
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USAPT
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Army,
I'm assuming manipulation and mobilization are synonymous in this matter? I was taught by Stanley Paris and his consensus is that the two are the same. That thrust are the differentiation. Obviously, I agree with you that manip [should be taught in entry level schools. That is not to say a recent grad with those skills is anywhere near knowing what exactly they are doing. Just like ther-ex and other PT skills, it takes CE courses and most of all, experience.
Take the basics and pursue adv courses to perfect techniques. That’s what I'm doing. I'll be honest, I don't use everything I learned from Paris but at least I was taught the principle of why and when to use it. That's my 2 cents:)
-Jason
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Jason, PT
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Re: Should manipulation be taught in Entry Level Physic... - February 11, 2005 6:14:00 AM
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JLS_PT_OCS
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Jason,
I would agree with your generally accepted definitions of manip/mobs.
The great secret of manual therapy techniques seems to be that there is no secret.
At least to speak of the one for acute LBP, it requires neither experience nor a great deal of skill to use, we have seen that a new grad's level of skill with this one technique has nothing to do with effectiveness.
Food for thought...
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Should manipulation be taught in Entry Level Physic... - February 18, 2005 2:16:00 PM
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mcap56
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Wait...........
How did we get to the point where manipulation is the gold standard of spine care? All I have seen so far is that it is proven to provide a short term benefit. NSAIDs also have evidence of short term efficacy. When I look at the list of characteristics of patients who may respond to manipulation, it looks to me like a group of patients who would do well no matter what intervention they were given.
We can not have a debate about manipulation in entry level programas without an honest debate about the research. A lot of the reserach is really, really poor. And, the bulk of it seems to inidcate a short term benefit only.
I am undecided in this debate. However, I object to the way the evidence is presented. When the proponents stand up and tell everyone that manipulation is absolutely consistent with best care evidence, they are not being thorough or even truthful.
I would urge everyone to read expert panel reviews and to take the time to see what researchers say about manipulation - not just the manipulators!!!!!!!!!
Here is how Nachemson assess the literature: There is strong evidence that manual therapy proviceds more effective short term pain relief than placebo. There is moderate evidence that manual therapy is more effective than usual care for short term pain releif. There is limited and conflicting evidence of any long term effects.
I don't understand the context of this debate. Since when are we seeing these supposedly acute spines in the clinic anyway?
The real issue in spine care is what provides a long term effect and what will reduce recurrence over the long run. We need better ways to predict who will suffer long term severe pain and disability. We should be intervening in the subacute phase to provent progression to somehting more serious. I don't know how manipualtion accomplishes this goal.
Why must PT always borrow from other professions. Where is the out of the box thinking? If I were starting a clinic I would stongly consider teaming up with a cognitive behavioral psychologist who is experienced in dealing with pain.
Again, manipulation may be a useful part of entry level education. But why don't you go to the latest new grad or student at your clinic and ask them to explain the relationship between psychosocial factors and low back pain. See what happens. Ask them to explain what actually causes radiculopathy. How well are they performing their neurological scans? Are they medicalizing the patient and reinforcing the diagnosis? Does manipulation play into medicalization? There are so many factors to consider.
mcap
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Re: Should manipulation be taught in Entry Level Physic... - February 18, 2005 2:28:00 PM
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nari
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mcap
Well said! Especially your last paragraph!!
Nari
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Re: Should manipulation be taught in Entry Level Physic... - February 18, 2005 2:56:00 PM
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Jon Newman
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mcap,
Are you some sort of rabble-rouser?
I do find it interesting that the hallmark of EBM is a systematic review of RCT's (except when it comes to manipulation). So far, when tighter and tighter controls are used to study manipulation, the fewer and fewer people seem to benefit in a manner beyond other forms of therapy.
Obviously more research is being done. Eventually enough will be done to run a systematic review. Who knows what that will reveal?
As far as teaching, I'm not sure what will be taught. This was essentially the point of Barrett's "thoughtfulness" post. What is it that is being taught? Is this segment of the curriculum going to take longer than the video on the internet?
By the way, I have a whole thread on prediction of outcomes. I'm not sure if anyone noted any trends regarding who doesn't get better.
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... - February 21, 2005 8:06:00 AM
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JLS_PT_OCS
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Ugh, back running in circles again...
Here we go again...
I guess this will help me phrase this argument in shorter and shorter terms until at last, I have it down to a science.
Mcap, no one said it was gold standard or the only option...why does this always happen in this debate?
Every time someone mentions the strong evidence supporting the use of manipulation, the retort is always:
1. It's not the only tool (I never said it was)
2. What about long term effects (good point, those who manipulate care about these effects and attempt to address them as well)
3. There's no evidence it's the best (boy, this has been beat to death...if a clinical prediction rule established in a randomized controlled trial that has since been validated isn't enough evidence for you, then you must not treat any patients, because no other treatment is as strongly backed)
4. Systematic reviews - they are statistically flawed in lots of ways, this has been covered in depth elsewhere. Jon makes a good point about SRs, in any SR, the tighter the controls, the fewer people benefit from ANY intervention...they regress to the mean of no change.
5. "why do we have to borrow from others..." What profession owns manipulation? No one does. Therefore, we are simply using a tool that others use also.
6. We don't see these acute spines in our clinic... I see them all the time in the military, and anyone who treats spine pain would generally anyway. Think of the recurrence and incidence of this problem...it's astounding...
Why this issue has so much resistance is beyond me... if a treatment for ankle sprain had this kind of support, all of us would use it without even thinking twice... when will evidence trump our personal opinions and approaches?... from the looks of it, maybe never...
Use of this modality in a treatment regimen does not mean that 600 other things aren't also done... if anything was funny about this debate here, it was that everyone seemed to agree on everything... the one difference being that some would use this tool and others would not... if this is indeed a tool, surely it should be taught to our students.
As we've covered, it doesn't take long to learn, can be used easily and provides impressive results, above anything else currently known.
OK, that's enough for now...
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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