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Re: acute low back pain
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Re: acute low back pain - July 12, 2004 1:27:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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I am still getting beat up, but that is ok...
Duffy wrote:
[QUOTE]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...[/QUOTE]John, you are speculating that manipulation would have caused the L4-5 disc to fragment (I am assuming you mean the disk not the vertebrae). I obviously did not evaluate you when you had this problem, but if I did and if you had at least 3 out of the 5 clinical predictors, I probably would have manipulated you and it probably would have helped you in the acute phase. The manipulation that I perform is not so forceful that I could cause a disk to fragment. I am fairly sure of that.
If I had an MRI report in front of me that showed a sequestered fragment hanging near a spinal nerve root, then I probably would not have manipulated you. Maybe.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 12, 2004 5:34:00 AM
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Jon Newman
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Bournephysio,
You stated: "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."
What I'm saying is that this current emphasis is misguided for the same reasons you mentioned.
"Manipulation involves descending modulatory systems" and "most of the resistance to glides you feel on testing is muscle tone anyway".
I would also state that there are many methods to enhance the descending modulatory systems and decrease muscle tone which don't involve freeing a fictitious stuck facet that I think I can not only find but hope to correct by forcing it back. To refocus, I don't deny that manipulation works, but why introduce false constraints into the problem?
I believe one of the descending modulatory responses is that when someone with back pain gets placed into a wound up position and then has their back cracked (maybe), it sends a very strong disconfirmation that their spine is fragile and needs to be protected. It frees them up to pursue movement. Manipulation may do this better than reassurance/education sometimes and sometimes not. Hence the subpopulation that benefits from manipulation. No facts to back up those statements though--just me thinking out loud.
Army, I don't think you are being beat up. In fact I bet you're an excellent therapist with excellent results or you wouldn't be so adamant in your posts. My posts are trying to challenge why you're an excellent therapist and I think it's because of the skills you aren't giving yourself credit for.
jon
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Re: acute low back pain - July 12, 2004 6:15:00 AM
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Diane
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Wow Jon,
Ditto your whole post July 12, 2004 09:34 AM.
Diane
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Re: acute low back pain - July 13, 2004 4:06:00 AM
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PTupdate.com
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Remember, we are talking about an acute injury treatment, perhaps even the same day or the following day.
The day I herniated, I had my colleague try a MET on me due to pain location. The following day, while obviously having an issue, I think someone would have been able to perform manipulation...bourneo, I dont' think pain and/or spasm would have been a block for that treatment, unless done by a really skilled person who knew what they were looking for (sorry, I feel you probably do, but most don't!)
Army, there is no way I would have had any MRI results at that phase. If a regular "Joe" patient, I would have not even recieved a return phone call from the family physician until the following day, let alone fill some med prescription or get an MRI.
However, you feel that manipulation would have helped me. How would it have helped? What biomechanical change would have been incurred to change the damage that was done?
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
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Re: acute low back pain - July 13, 2004 6:35:00 AM
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Alex Brenner PT MPT OCS
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Duffy wrote:
[QUOTE]However, you feel that manipulation would have helped me. How would it have helped? What biomechanical change would have been incurred to change the damage that was done?[/QUOTE]Good question, I wish I knew the answer because it would really help us all out in this discussion, including myself.
I would speculate that performing the manipulation would possibly free up some restrictions that you had during your exam thus allowing more pain free motion. I would then have you doing some exercises to help reinforce this new motion and get you through the acute phase.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 13, 2004 7:04:00 AM
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PTupdate.com
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Well, my primary restriction on day 1 was pain, probably from the tearing of the annulus and the initial nerve root trauma from the fragment and above level herniation. Day two was more tolerable, due to NSAID's, positioning, ice, and strong NMES.
Knowing what the problem was, (in hindsight), I still feel that what was done was the best option to relieve symptoms and prevent further irritation. How do we know the shear forces of the manipulation (vague term, as nobody is even describing what manipulation they would perform...Chicago Thrust, et al) would not have further herniated the more cranial disc?
I was always taught "above else, do no harm". The risk versus reward, especially for what my problem was, would not have been worth it. As someone earlier posted regarding 50% wanting to come back and hit the PT, those are odds that are not in my best interests (or the patients)
Perhaps we should ask the patient what they want. "Mrs Smith, I can do some mild things today to relieve you of pain, improve some movement and then tackle your problem in the near future, OR I can manipulate you. I don't really know what your problem is, and I am not sure what the manipulation will do, and there is a 50% chance you will hate me afterwards" I think I know which most patients would choose.
Duffy
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John M. Duffy, PT
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www.PTupdate.com
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Re: acute low back pain - July 13, 2004 7:32:00 AM
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Barrett
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How about asking manually what the patient wants to do instinctively? Consider Patrick Wall's suggestion about the "need state" that pain produces and the "consummatory act" of movement it evokes. (see more about this in the Bullypit) Clearly the patient has the best idea of what to do though they typically cannot choose this action consciously. Like the best diet, it should be chosen instinctively for the individual who is hungry, not as the end result of another's needs.
I doubt that manipulation "works" except through the good graces of luck as certain movements reduce the mechanical deformation responsible for the origins of pain. What's so mysterious about that? Instinctive movement performed by the patient actively doesn't depend upon this and, in my experience, never results in actual worsening of the condition.
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Barrett L. Dorko P.T.
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Re: acute low back pain - July 13, 2004 8:21:00 AM
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mcap56
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Isn't the instinct of most people in acute pain not to move at all? ....Something we are trying to work against?
mcap
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Re: acute low back pain - July 13, 2004 9:02:00 AM
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Alex Brenner PT MPT OCS
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Barrett,
Show me the science.
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 13, 2004 9:04:00 AM
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Alex Brenner PT MPT OCS
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Duffy,
You bring up excellent points concerning your case. Hindsight is ALWAYS 20-20.
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 13, 2004 9:25:00 AM
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Shill
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[QUOTE] How about asking manually what the patient wants to do instinctively? Consider Patrick Wall's suggestion about the "need state" that pain produces and the "consummatory act" of movement it evokes. (see more about this in the Bullypit) Clearly the patient has the best idea of what to do though they typically cannot choose this action consciously. Like the best diet, it should be chosen instinctively for the individual who is hungry, not as the end result of another's needs.
[/QUOTE].....Huh?
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Steve Hill PT
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Re: acute low back pain - July 13, 2004 10:04:00 AM
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Barrett
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mcap asks: "Isn't the instinct of most people in acute pain not to move at all?"
Not according to Patrick Wall in "The Science of Suffering." Isn't this man of sufficient stature in the scientific community to be taken seriously? When I quote his work does it make any sense to make fun of it?
At what moment does "acute" become something more than only the sensation of pain alone? When does the *perception* of pain kick in with all its concurrent messages about danger, fear and societal rules about appropriate expression? Half an hour? Six weeks? Do we need a definition of instinct here? Doesn't it play a larger role in protective and corrective movement than we ordinarily allow it? How is it that people recover without our intervention (happens all the time) except through their own naturally occurring processes and movement? Might we be more effective therapists if we understood more about this and got on board? Is it possible that therapists get in the way of this at times?
You want science? Read Engle's "Wild Health," Spitz's "Nonconscious Movement" or Wall's work after 50 years of study and clinical experience with people in pain. Check out Morris' "Illness and Culture in the Postmodern World." The science supports such thinking, but therapists seem to want a study proving that something "works" though this is neither the definition of EBM nor does it mean that the intervention was appropriate. If that's your idea of "science" you're never going to find it in the physical therapy clinic.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 13, 2004 11:34:00 AM
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Alex Brenner PT MPT OCS
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Barrett,
In your opinion, what is wrong with the Flynn et. al. 2002 study in Spine. "Clinical prediction rule..."?
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 13, 2004 12:04:00 PM
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Barrett
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I have always been troubled with the procedure of manipulation itself because of its lack of specificity and the unlikelyhood that it has the desired effect on the connective tissue it proposes to have. Having taught alongside Paris, Mennell, Grimsby, Kaltenborn and others I can reasonably claim to know something about the method.
Until we know what happens during manipulation itself I don't think we can reliably say it has any relation to outcome, and since so many other factors are ignored, autonomic state for one, Flynn's study will always fail to mean anything to me.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 13, 2004 5:35:00 PM
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nari
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At this point, sifting through the data in the posts on this thread, there does not seem to be much( NOT any) evidence that the patient is involved with a decision-making process regarding this bit of manual therapy or that bit - and as all aspects of manual therapy seem to work to a degree, it probably does not matter much what is done....
People in acute, early, spinal pain can and do move, albeit with fear and trepidation, and, in our trained eyes, with abnormal posturing - I see it as a duty to give them permission to move as they feel OK with (all red flags noted), and they will consciously opt for their best bet with verbal guidance; we have to address that fear, not that joint/muscle.
I agree with Barrett -
Nari
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Re: acute low back pain - July 13, 2004 10:28:00 PM
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Alex Brenner PT MPT OCS
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Barrett,
How do you define Evidenced Base Medicine or Evidenced Based Practice?
Army
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 14, 2004 4:09:00 AM
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PTupdate.com
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I am not all that sure that what Barrett would do is that much different than either mcap or myself...basically finding positions or activities that reduce painful deformation. I don't think Barrett means he helps the patient find this position and tells them to lie like that for a week, and mcap probably facilitates movements based on those positions/motions found to be relieving.
Army: You may have success at what you do, and don't necessarily need EBM to continue. However, your situation may be different than one in private practice (I am assuming you are actually in the Army, at a base, etc). I have more PT clinics surrounding me than there are gas stations. I cannot afford or risk the high rate of aggrevation and patient dissatisfaction that can come with manipulative therapy in the acute phase, except certain instances. I already get too many ticked off persons fleeing a chiro for this reason. If I can improve them passively at first, gain their confidence and restore some mobility, then I can manipulate and get more aggressive, if even necessary.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
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John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: acute low back pain - July 14, 2004 4:36:00 AM
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Alex Brenner PT MPT OCS
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John,
How about the other way around? You are using EBM and manipulating people making some great changes in acute pain in short time. Then you start making a name for yourself, you start rising above the other clinics nearby as the guy to see for acute low back pain. Just a thought.
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Alex Brenner, PT, MPT, OCS
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Re: acute low back pain - July 14, 2004 4:47:00 AM
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Barrett
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Army,
Google the subject and then start a new thread. You'll find that without exception the experts define this in several ways extending beyond RCTs and will acknowledge that RCTs are most reliable in pharmacology, not when employing the kind of comprehensive management we are obliged to provide.
John,
You've watched me work, though briefly, and I assume you recall that the movement elicited came from the patient and not me. Correction was evident in the physiologic response more than the immediate relief of pain. This type of management agrees with Wall's assertions about the ways humans respond to pain instinctively. Take a look at the middle of page 150 in his last book. Coercion, including manipulation or any other sort of passive movement, no matter how gentle, is not something that would predictably assist in this process.
I asked a number of questions a couple of posts ago. Any answers out there? Still dumbfounded?
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 14, 2004 5:49:00 AM
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Shill
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Barrett
You noted [QUOTE] Correction was evident ... [/QUOTE]Correction of what?
Certainly you must have some outcome data, regarding functional improvements in the patients that you see. This is the kind of material that might put me in a seat, as you are "coming to a theatre near me" in the not so distant future.
Maybe I will need to see first hand what it is that you talk about. Maybe it will change my mind. Maybe.
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Steve Hill PT
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