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Re: acute low back pain
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Re: acute low back pain - July 10, 2004 12:51:00 PM
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Alex Brenner PT MPT OCS
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MCAP wrote:
[QUOTE]....But you have hand picked a few studies and drew a conclusion. That is not adequate. There in absolutely no overwhelming evidence in favor of manipulation. And yet, there are so many presenting the evidence as incontrovertible.[/QUOTE]In your opinion, what would be adequate? What are you looking for?
In your previous posts you seem to treat acute low back pain passively, i.e. just giving reassurance and advice or a drug store hot pack and to have them follow up later. How did you come about this intervention? What was adequate enough that convinced you to apply this intervention to acute low back pain as opposed to something else?
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Re: acute low back pain - July 10, 2004 12:59:00 PM
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Jon Newman
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I'd like to chime in with my usual rhetoric on manipulation to see if someone has reflected on some of my interests.
SJ stated "and after the technique all you have to do is whatever functional test you did that determined you would manipulate"
I have never argued, nor will I, that manipulation helps decrease acute low back pain, or that certain subpopulations of acute low back pain sufferes may benefit more from manipulation than others. I will continue to ask, what is the theorhetic basis for it to work. The functional test that predicted success in the Flynn article above, is hypomobility of the spine at any level. What other functional tests are being used to determine which technique and why? The fact that manipulation works is interesting to me. But more interesting is the specialized decision making based on "functional tests" of the spine even though these types of test do not predict success with manipulation. This quandry needs to be resolved in my opinion before spinal manipulation is accepted by a broader audience. "It works" has been used for years without much advancement of why. My understanding is that teaching of manipulation continues to focus on the pathomechanics (fsr left, etc) of the spine that benefit from manipulative therapy even though this theorhetical premise doesn't seem to be holding water. I'm bothered by this (among many other unrelated things).
jon
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Re: acute low back pain - July 10, 2004 1:49:00 PM
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Alex Brenner PT MPT OCS
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Jon,
Tim Flynn was my professor in PT school and I remember in lectures and in presentations at recent CSM's that he states: "We don't really know WHY it (manipulation) works". However, we should not let this deter us from providing this intervention. He goes on to compare manipulation to the advent of aspirin. Early in time, before Christ, medicine men knew that if they had patients eat a certain leaf from a tree that it would cause a decrease in pain. They didn't know the exact mechanism or why it worked, they just knew from experience that it worked. Later, the Egyptians knew if they took the same leaf and grind it into paste and administered it as medication that it was even more effective in pain relief. Again, they did not know why it worked, they just knew that it was very effective. Later in time, doctors found out that the substance from the leave was asprin and if they extracted this from the leaf it was even more effective. Not until relatively recently, our lifetime, did researchers find out the exact molecular mechanism of how spirin worked to block pain receptors in our body. The same is true for manipulation. At this time, we do not know the exact mechanism of why or how it works, but we do know with experience and with research that it is effective. Just because we our unsure of exactly how it works, does that mean we should not perform the intervention? The early Egyptians didn't think so.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 10, 2004 3:25:00 PM
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Jon Newman
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Thanks Army for your reply,
Your aspirin analogy is interesting. I admit that I'm not a pharmaceutical anthropologist so be sure to take what I have to say with a large grain of salt. I would be willing to venture that the bark/leaves were believed to contain something in them that decreased pain. Another way to look at it is that they did not believe it was the shape of the leaf or the number of branches the tree had. Their basic premise of why it worked was correct but they could not prove it. They could prove, however, that if they used leaves of similar shape but not the same plant that they would not get the same results. They could also disprove "the number of branches" theory. If these experiments were done they would be forced to select a new hypothesis to explain their results. I'm suggesting here that manipulative therapists do likewise as evidence is mounting that using bony alignment (or other functional testing) does not predict success with the manipulation. So, to be clear I'm not suggesting that manipulation does not work, I'm saying it is not the "shape of the leaf" or "the number of branches" that makes it work. So why teach it that way?
jon
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Re: acute low back pain - July 10, 2004 3:34:00 PM
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SJBird55
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Jon, the functional tests weren't little spinal hypomobility tests - they were easily observed differences in movement that my 6 year old could notice a difference between. The functional tests sort of in a way do indicate some success with the manipulation - if the manipulation did something than supposedly there will be an observable change in movement patterning. For example - single leg stance or more ease with sit to stand. Something changed and that's a good sign. Believe it or not, Jon, no one mentioned evaluating the spine as fsr left and all the technical stuff like muscle energy.
Army, neither Childs nor Wainner offered a reason for why manipulation works. They have no substantiated idea of why it works. I was actually quite impressed with them. They had no problem with just coming out and saying, "I don't know." I honestly don't mind paying a few hundred bucks to therapists doing research and being honest versus giving a line of BS.
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Re: acute low back pain - July 10, 2004 4:28:00 PM
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nari
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A brief addition:
Mckenzie works, but remains a hypothesis as far as I am aware.
There is some evidence creeping in to validate passive mobilisation (Maitland)
From those in the teaching and research business for PTs in Australia, the word is roughly thus:
'Two thirds of clinical practice should be EBP. The remaining third is empirical and based on experience..'
So there is leeway to practise what we individually think 'works'. The 2/3 bit, however, is a bit of a challenge...
Nari
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Re: acute low back pain - July 10, 2004 7:58:00 PM
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Jon Newman
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I've noted an error that I'm concerned about in one of my posts. I stated, "I have never argued, nor will I, that manipulation helps decrease acute low back pain, or that certain subpopulations of acute low back pain sufferes may benefit more from manipulation than others."
I should have written: I have never argued against the fact that manipulation helps decrease....
I doubt that will make a difference to most people but it was an important and significant distinction I thought I should clarify.
jon
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Re: acute low back pain - July 11, 2004 4:08:00 AM
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SJBird55
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Jon, manipulation wasn't taught the way you mentioned in the branches and leaves analogy. Childs and Wainner were actually quite vague about what side to treat... and actually said if it didn't help doing one side, try the other. I did find that quite unusual, especially since I generally do muscle energy kind of things and the comparison of how darn picky everything was supposed to be with muscle energy. But, I will admit, I never do the true muscle energy because from reading the literature I know that my assessment skills do not have reliability or at times validity, so I had the same philosophy in regard to muscle energy tecnhiques - if the way I thought was supposed to work didn't, I'll try the other side. (Which does sort of suggest that the basis for why I use muscle energy techniques may not be the true theory.)
Jon, I would bet that it will take a combination of high tech devices to explain why manipulation works. If you watch CSI, I would envision something that could capture exactly what is happening at 2-3 segments during the manipulative technique (like that CSI imaging they do to show the thought processes of where the bullet lodged itself). I'd guess the vascular system and the nervous system combined with some type of technology to assess weightbearing through facets combined with functional MRI to assess brain changes.
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Re: acute low back pain - July 11, 2004 7:22:00 AM
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Dr.Wagner
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Now, to prove your point...list the number of patients, the controls and the methods in each of those studies.
REMEMBER THIS IS ACUTE PAIN we are looking at NOT CHRONIC PAIN.
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Re: acute low back pain - July 11, 2004 7:25:00 AM
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Alex Brenner PT MPT OCS
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Jon wrote:
[QUOTE]I'm suggesting here that manipulative therapists do likewise as evidence is mounting that using bony alignment (or other functional testing) does not predict success with the manipulation. So, to be clear I'm not suggesting that manipulation does not work, I'm saying it is not the "shape of the leaf" or "the number of branches" that makes it work. So why teach it that way?[/QUOTE]Good question. In PT school I was taught by Tim Flynn SI joint cluster tests and palpation/alignment evaluation. And this was pretty much the way I practiced until I attended an advanced spine treatment course last year taught by Tim Flynn, Rob Wainner, John Childs, and Julie Whitman among others. In this course they had completely gone away from the original evaluation methods that was taught to me in PT school. Some therapists in my class were troubled by the instructors telling us they were not sure why manipulation worked. Many were also "blown away" when they suggested to manipulate the opposite side if the original side did not work. I guess as new evidence became available they changed the way they practiced and taught. The important thing is that the intervention really did not change from what I was taught in school, just the reason. I continue to palpate pelvic landmarkds during my physical exam but these findings do not help make my clinical decision of when to manipulate.
I have to chuckle too, because this thread is like deja vu from a previous discussion on manipulation on this forum. The exact same issues arise. I guess they never were resolved.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 11, 2004 7:41:00 AM
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Alex Brenner PT MPT OCS
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Dr. Wagner,
How about this? Have an open mind, go against everything you believe. Take the next 10 patients that come into your ED with acute low back pain. Be sure they have at least 3 out of the 5 clinical predictors for success for manipulation and perform a manipulation on their back using the same technique/procedure that Tim Flynn uses in the article that I posted above. Be sure to use Oswestry before and at follow up to measure your outcome. Report your findings here when you are done. If you need a copy of the Oswestry, I can email it to you.
In the mean time, I will gather the information that you requested. I included the ONE article on chronic low back pain because the investigators found that the earlier they performed the manipulation the better the outcome.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 11, 2004 8:39:00 AM
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rodgere
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Army, yes I would love to talk about your specific manips. from an educational standpoint. I only recieved a responce from you so maybe we should talk directly Rodgere@chartermi.net
Rodger
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Re: acute low back pain - July 11, 2004 8:48:00 AM
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Dr.Wagner
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That is nice in theory, but I propose this...
Do not do manipulation and provide the least expensive treatment, time, rest and return to movement and see if outcomes are different.
I have been surrounded by manipulation articles all my professional career, none have been advocated in the ED with great reason, acute low back pain that presents to the ED has never been shown to be more effective...look at the BMJ and Cochrane reviews data.
While I think your treatment plan on healthy army personnel overseas is fantastic, taking a 50 yr old, fairly immobile, unhealthy, overweight female that doesn't want to move...then forcing manipulation on them less than 24 hours after injury...is an automatic predictor of failure.
The TYPICAL american LBP patient is an overuse, deconditioning, multi teired injury pattern...not something you seen in your population.
I have seen SUCH success and compliance by education, guided movement, rest and NSAIDS then referral when spasm has calmed down...an article with 10 patients from the European Journal of Physiotherapy ain't gonna do much to change the serious clinicians mind (journal made up for effect).
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Dr. Wagner DO
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Re: acute low back pain - July 11, 2004 11:59:00 AM
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mcap56
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Army:
The approach I advocate is exactly consistent with the evidence and best practice. Have you seen the most recent lit reviews and practice guidelines? Have you been through Waddell's book? There are so many subacute and chronic patients that would benefit from PT, why the rush to treat so many acute patients at 40-100/visit (just a guess). Would you advocate an acute patient taking a series of pills that cost as much as a few PT visits? Again, I am not insisting that manipulation doesn't work but you need to be able to consider both sides of the issue.
mcap
-mcap
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Re: acute low back pain - July 11, 2004 12:50:00 PM
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Jon Newman
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Army,
You state: " I continue to palpate pelvic landmarkds during my physical exam but these findings do not help make my clinical decision of when to manipulate."
I have no doubt that those finding do not indicate to you when to manipulate but I am willing to bet they determine how you manipulate. If so, then you still subscribe to the logic that the spine has a pathomechanic error that needs to be corrected by manipulation. And that you can accurately determine what that error is with papation of bony landmarks and special tests. It is interesting to note that teachers of manipulation are now willing to admit they don't know how it works but then continue to choose manipulation techniques using these tests and palpations as if they understand why manipulation works. I mean why else would you choose one technique over another unless you thought that it would fix the problem better? Why would you go through the gymnastics if you truly didn't think you knew why it worked? Why would it work if you manipulated the "wrong" (now known as the "other") side? In fact, if back pain is truly pathomechanical and manipulation is so good at correcting accessory motion and you did choose the wrong side, shouldn't that make things significanly worse and more painful? Yet, we speak of the technique as entry level and virtually harm free (which I believe it is). I think researchers are wasting mental energy trying to prove that manipulation works. That mental energy would be better spent working on theories of why it works. And then testing those theories.
Back to the aspirin analogy. I'm sure long ago, people stopped trying to prove that it works. They focused instead on how/why it works. It is because of this focus that we now know how/why. There is a reason manipulation has been around for so long and the main focus is still "Does it work?"
jon
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Re: acute low back pain - July 11, 2004 6:01:00 PM
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PTupdate.com
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3 years ago I fragmented L5-S1 and severely herniated L4-5. In the acute phase, I pretty much looked like an SI dysfunction...no radiculopathy below the buttock, no positive SLR, etc...I was in that 2-3 day latency phase. To have been manipulated at this juncture probaby would have sent the L4-5 the same way the L5-S1 went. I am glad I focused on some more simple things, common sense based on experience, and ES. Oh yes, someone back in the first page mentioned that ES does nothing for acute pain. I beg to differ...A strong dose of interferential stim at borderline tetanic contraction gave me a good day of relief and improved sleep. The only thing that ended up helping more was a Medrol dose pack, which certainly has more risks than ES.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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Re: acute low back pain - July 11, 2004 6:30:00 PM
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Jon Newman
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I feel I should apologize for my rant. I've gone off topic. I'll try to be more constructive. There are some commonalities among many of the posts as to what to do about acute low back pain. Everyone on this forum likely does an educational segment to try to set the stage for success and to decrease risk of fear avoidance behaviors (versus adaptive avoidance behaviors). Everyone tries some form of movement that decreases the person's pain (manipulation, muscle energy, every day living movements, etc). Some mention modalities and meds.
My recommendation is use education, choose the movement techniques that make sense to you, modalities and meds as your patient seems to believe and listen to the patient's story. And don't stop questioning your approach.
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: acute low back pain - July 11, 2004 7:43:00 PM
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Bournephysio
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John: I'm willing to bet that manip couldn't be performed on you without powering through pain and/or spasm (both no-nos). Do you think that's correct?
Pain relief of one day won't show up in an rct looking at any length of followup. Speaking as a patient would you give up your one day of relief knowing that it didn't have any long term benefit?
Jon: Positional testing has been out of vogue for a while. Currently, there is more emphasis on joint restrictions eg a facet won't flex or extend.
There is a fair bit of evidence on how manual therapy might work. You can see some evidence I posted on the CAMT site:
http://www.manipulativetherapy.org/camt.php?page=lit-lit-ifomt
I know Herzog and McGill have both done research on mechanisms of manipulation. Some brief results:
chiros can't localize a manipulation. As big of a proponent as I am for PT manipulation I doubt we can either.
Manipulation has a multisegmental effect
Manipulation/mobilization involves descending modulatory systems (seratonergic and noradrenergic) and is sympatoexicatory.
Add to this experience from master clinicians that you can manipulate the wrong joint but still improve mobility of the target joint.
In view of this evidence it is not suprising that you can get an effect by manipulating the other side (besides the fact that you can't move one facet and keep the opposite side still.)
In my view most of the resistance to glides you feel on testing is muscle tone anyway. You manip the joint, the tone and pain goes down. Glides are improved as well as rom and other functional tests.
Wagner. You might want to read the other posts before you reply. There is a consensus that you don't force a manipulation on anyone.
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Re: acute low back pain - July 12, 2004 1:18:00 AM
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Alex Brenner PT MPT OCS
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Alright, I am getting beat up here, but that is ok...
Dr. Wagner wrote
[QUOTE]I have seen SUCH success and compliance by education, guided movement, rest and NSAIDS then referral when spasm has calmed down...[/QUOTE]Where is the scientific evidence for this? How is what YOU have seen better than a scientific research article showing an intervention that demonstrates 50% reduction in an outcome measure?
Come on man, show me the science.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 12, 2004 1:23:00 AM
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nari
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jon:
Well said.
Bournephysio:
You say: 'positional testing has been out of vogue for a while'...
The key word is 'vogue' - favourite methods go in and out of fashion. Manipulation was taught at undergrad level in some Aust states in the 50s, but it has never been hugely popular here and is only a post- grad course.
McKenzie was very vogueish in the early 80s but is less so now as other options come into the circle.
We have such a wide choice of methods now, and with all of them, whether it is facet,ligament, disc, muscle or fascia, it probably does not matter too much what we choose, and in the end we will end up with what we are most familiar with, and has some evidence behind it. nothing will ever be shown to be 100% or 90% successful - there are too many factors to consider when you treat a person with pain...
Nari
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