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Re: acute low back pain
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Re: acute low back pain - July 14, 2004 6:12:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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If I were to put you in a hammerlock there would be an immediate increase in your sympathetic tone as evidenced by a rise in your muscle activity, sweat gland activity and decrease in blood flow to the surface. Aside from pain (which would only occur if the arm were taken beyond your tolerance for the mechanical deformation produced-a variable range), you'd feel cold and the skin would display a visible pallor. This might happen well beyond the anatomy of the arm. To my knowledge, only one movement would reverse these findings and sensations-a movement that reduced the mechanical deformation in the nervous tissue of the arm. Can you think of another? If people move and experience and display the same sort of response (decreased muscle tone and warmth) I assume that a similar reduction in neural deformation is taking place, mainly because I can't come up with another reason for the change reported and seen quite easily with measurable increases in range and functional ability. I'm not talking about vigorous motion. These are often immediately present but not always. Is my reasoning flawed? Is the word "correction" inappropriate when describing a reduction in neural tension? Isn't that what happens when you come out of a hammerlock? Isn't this what happens when you shift about in your seat? Is that motion consciously controlled? Is it "corrective"?
Outcome data is fine, but a little logic might be useful to drive practice in the right direction as well.
Scott Oaks on this board was the one who suggested my course and maybe he has something to say here.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 14, 2004 6:24:00 AM
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PTupdate.com
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From: Pittsburgh, PA USA
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Army: I agree with you. If you are able to perform your own program, and get excellent results with minimal agitation, that is great. Others in this thread have not suggested they have this kind of success with manipulatino. Plus, if it becomes some "standard of treatment", then perhaps less skilled practitioners than yourself will be doing more harm than good.
This is where the problem that Barrett suggests comes into play. What Army does, most likely with great success, really cannot be based on cut and dry EBM. It may be a combination of his specific technique, the touch he has, how he communicates to his patient, and perhaps even the color of his wallpaper. Miss one of these ingredients in some RCT, and there may be failure.
Perhaps instead of alwasys following studies, we should also incorporate outcomes. If Army is able to provide stats that his method can improve function, reduce pain, etc better than mine, then I want to learn what he is doing and see if I have the same success.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: acute low back pain - July 14, 2004 6:55:00 AM
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Diane
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From: Vancouver, B.C., Canada
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Duffy,
[QUOTE]What Army does, most likely with great success, really cannot be based on cut and dry EBM. It may be a combination of his specific technique, the touch he has, how he communicates to his patient, and perhaps even the color of his wallpaper.[/QUOTE]Wholeheartedly agree.
Shill, I see nothing wrong with the word "correction" used generically by Barrett. I've heard the word used specifically by the manipulation people, to define a perhaps more sharply obvious post-pop set of expressed and observed changes in function.. maybe that's where confusion arises?
Another word that describes the same thing, a gradual rising tide of better function, a movment of the body closer to stress-free easy function, might be "restoration."
It was mentioned before by someone, that Army's patient population is of a certain type. I think it bears repeating that once out there in the general population comprised of members of all ages and (de)conditions with presumably less well-trained and obedient nervous systems/minds, even Army's presumably nice outcomes might decline.
Seems to me that the best candidate for a manip is a young healthy male mesomorph in a hurry, who contacts someone for help who has a similar physique. That would be the best "outcome" if you're looking for supportive data. The rest of us motley crew just get along (somehow!) by our wits and what we can put into our own minds and those of our equally motley patients, and elicit from their bodies.
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Re: acute low back pain - July 14, 2004 7:27:00 AM
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mcap56
Posts: 619
Joined: October 26, 2002
From: New York, NY
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Diane and Duffy:
Excellent points. I agree. Also, don't forget about the enthusiasm of the practicioner. I can honestly tell you that my results with the McKenzie method were the best as I was progressing towards certification. I was getting people better all over the place, including some who were about to have surgery. After certificantion and lot's of my own research, I wasn't as enthsuiastic about the long term effects. My success rate with it dropped significantly. I did however progress to what I thought was a treatment program with the best hope for long term benefits.
mcap
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Re: acute low back pain - July 14, 2004 7:54:00 AM
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Oaks
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From: Danville, Va
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(You go out of town for a few days and you miss the circus.)
Shill,
I'm sure that if you make the minimal effort and expense to attend one of Barrett's courses, you may just learn something that will be helpful in your practice.
One thing that I've noticed on this post that goes beyond specific treatment technique, is how easy it is to critique anothers methods and brush them off as being invalid without really knowing the basis of that specific type of treatment.If any of us are going to progress as clinicians, we have to realize that our method of intervention isn't the only one out there, you do yourself and your patient an injustice when you only wait for information to be spoonfed to you, and don't do a bit of logical analysis on your own. I know it gets tough in the continuing education realm trying to weed through all the crap, but until you allow yourself to be your own filter for information, you may just be missing out on something critical.
Scott
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Re: acute low back pain - July 14, 2004 10:27:00 AM
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SJBird55
Posts: 2438
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From: Michigan
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Shill, I'm completely with you in regard to showing me the outcomes. Barrett hasn't done a darn thing to substantiate the outcomes he achieves using his technique. He hasn't collected data... nor does he probably use any functional outcome tools to capture the change that functionally occurs in his patients.
Diane, I did argue my view of generalizability with both Childs and Wainner. Wainner did agree that their population may be different than the general population - especially when I mentioned the average PF-10 scores my folks tend to have. I'm not working with a completely healthy population of folks. Mine tend to be functioning below normal for their age group. So, yes, there does need to be care in deciding how wonderfully great manipulation is - their population may not be the same as what some of us may be seeing on a daily basis. Wainner also didn't seem to get defensive with my comment on generalizability of their results.
Duffy... I would highly doubt that you are going to have any of us that frequently post mention how manipulation does bring great outcomes. The reason is simple - none of us are frequently doing it and I'd question how many of us are actually assessing our outcomes. I've made up my mind to include manipulation when appropriate with my patients. I'll be selective in who I use manipulation with, but I can't really argue with the evidence for the use of manipulation. I also have the luck of possibly being able to capture changes in my outcomes.... meaning, I've collected data for 2 years on what I do and what outcomes I achieve. I may have the ability to compare my outcomes in a couple of years. Will the use of manipulation change my outcomes? I don't know, but I know I can find out.
Diane... I just did one manipulation technique on one patient the other day. I'm treating her a post-op shoulder issue but she did have complaints of cervical pain that was not allowing her to sleep at night - and her neck has been bothering her for 2 months. I spent a little bit of time assessing her cervical spine and then it took me 3 minutes to do what I thought I needed to do... and viola - for over a week now she hasn't had any cervical complaints and sleeps without awakening secondary to cervical pain. She's not some big, tough guy - just an average woman.
Duffy, what Amy does is based on some good research. The Wainner and Childs stuff wasn't just with one therapist - they had more than one site and more than one therapist involved in their studies. Army said he had Flynn as an instructor - Wainner, Childs, Flynn, Bennett - those guys are all pretty much consistent with their techniques. I do firmly believe that the main thing that isn't captured in any research is the interpersonal skills of the clinicians. But - all that aside, the clinical findings weren't findings of one therapist.
And, Duffy, I completely agree with you. We should all be assessing our outcomes and talking the same language in regard to outcomes. The outcome tools are there to be used. In my opinion, an Oswestry score is an Oswestry score. For example, if I'm seeing patients with low back pain in the preferred practice pattern of spinal disorders (as described in the Guide) 6 weeks after initial complaint initially at a 65% disability and discharging them with a 20% disability in 12 visits over 2 months and your same type of population is coming in with a 50% disability and being discharged with a 20% disability in 8 visits in one month - well, heck yeah, I want to know what you are doing. Of course the next piece which would be difficult to capture would be to see if there was re-entry into the system for further treatment and also what the patients were functioning at 6 months down the road.
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Re: acute low back pain - July 14, 2004 10:28:00 AM
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SJBird55
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From: Michigan
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Oh... and I do have Wainner and Childs email address at work. They may actually be interested in this particular conversation. I'll let them know about it and if they are interested they can chime in their 2 cents worth.
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Re: acute low back pain - July 14, 2004 12:49:00 PM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
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I'm certainly no expert, but I am under the impression that a meaningful outcome study would have to include a specific population of patients with an identical essential diagnosis treated in the same fashion over time and then questioned and tested in a reliable manner. Please note that I said *essential* diagnosis i.e. a description of the tissue at fault and a clear indication that it is troubled by a certain sort of lesion. "Fractured humerus" might do, as long as the sort of fracture was specifically within a certain parameter. A *nominal* diagnosis like, oh, I don't know, "backache" or "cervical pain" or "sciatica" hardly qualifies as an appropriate description of a problem ready for therapeutic intervention of a consistant sort (another aspect of a reasonable outcome study).
Without a relevant and accurate essential diagnosis to begin with, the collection of data means nothing though the effort itself might be fairly considered heroic and impressive to some. If the questions regarding recovery are posed to a patient in whom no essential diagnosis was ever made, well, all we've got is a bunch of numbers.
Perhaps there's a reason that outcome studies regarding painful problems with a mechanical origin are hard to find. For those same reasons I find it hard to trust those that might pop up. Heck, I wouldn't trust my own, and if that's the only reason to attend a course-then you shouldn't attend.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 14, 2004 1:59:00 PM
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Bill Egan
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From: Newton, MA
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Barrett,
I would agree with you to a certain extent. Trying to do an outcome study on a multifactorial problem such as LBP is a daunting task. With painful syndromes such as low back pain, it is impossible, except in about 15% or less of cases, to determine a medical/pathoanatomical diagnosis. What Flynn and other reserachers are doing is trying to find sub-populations of patients that respond to specific interventions. Most treatments will not work for all patients, yet this is how most therapeutic interventions are studied. The study by Flynn et al. was an attempt to identify responders to manipulation. This is part of a larger effort to develop a treatment based classification scheme for acute LBP. There are some flaws with this system, but I think it is a very valid and rational attempt to study physical therapy interventions for a wide-spread problem.
As a hypothetical situation, let's take your method of care and apply it to LBP. What patient characteristics do you think will predict a successful outcome with your technique? How do you know who is appropriate for your method of care?
Bill
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Re: acute low back pain - July 14, 2004 4:19:00 PM
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SJBird55
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From: Michigan
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Barrett, you don't have to have a diagnosis per say. All you need is to categorize or classify your patients using your own definition of your own created category or classification system. For some reason a lot of therapists seem to believe that every patient is too much of an individual, but I believe that there are enough commonalities between patients that technically there should be a way to identify various types of patients by categorizing or classifying them.
Or, heck, if you don't think you can do that - work it backwards like those doing manipulation research did. Do your technique on every patient but collect tons of data on each patient to then analyze what pieces of data were the most important pieces that would generally indicate success with your technique. I really think that the recent research on manipulation had a very logical and rational approach.
As I've said before, you've been doing what you do for a long enough period of time that even though you don't admit it, I still believe that you have some expectation or anticipated end outcome that you want patients to achieve and in your mind I'd also believe you have some idea in what timeframe you expect that anticipated outcome to occur. And, at the same time, you know what patients you do your techniques with, so I would also guess that you could provide a description of your population. The Guide isn't the best tool in my opinion for classifying or categorizing patients, but it is a good start - it just needs some fine tuning to be a bit more helpful when clinically describing patients. I'm saying this politely, so take it that way... but the bigger issue for you in my mind is your communication style. Yes, I do believe that you need to communicate in a style that isn't as comfortable for you in order to reach the majority of us in order for the majority of us to grasp what it is that you do that obtains the outcomes that you achieve.
By the time someone has a chronic condition (lasting greater than 6 months) I would actually question if the problems are mechanical in nature 100% of the time.
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Re: acute low back pain - July 14, 2004 4:28:00 PM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Bill,
I think we agree almost entirely. What I call nominal you refer to a multifactoral, and both are acceptable terms.
I remember listening to a presentation of Flynn's study at a national convention and feeling rather disappointed because the authors seemed to have abandoned any hope of figuring out what they were doing or why. As you point out, they were only trying to pick out the patients that were most likely to respond favorably to their intervention, and they didn't speculate upon the actual effect of the intervention beyond the patient's report of pain relief. I don't think many therapists realize that this was the nature of the outcome study done by Flynn. It certainly doesn't contain a theory of dysfunction we'd like to prove correct in any way. In the end, it doesn't "prove" much of anything other than the fact that movement can reduce pain of mechanical origin-sometimes, maybe. We already knew that.
When I hear people talk of spreading pain, perversions of sensory function, alterations in symptoms with position and use and the consequences of sympathetic increase I assume they have a problem with their neurodynamics and that's the essential diagnosis I go after. When I see their lower quarter(s) in internal rotation while supine this reinforces my thinking. I go after this with Simple Contact because I'm convinced that their own instinctive correction is the best way to resolve this problem. Usually this works out, sometimes not. As you said, their nominal diagnosis is multifactoral, and I'm simply unable to account for all of that.
Thanks for asking.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 15, 2004 4:02:00 AM
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Jon Newman
Posts: 1707
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From: Amherst, WI
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This topic seems to have developed into something I would normally expect in the bullypit!
I think the most recent installment of "Bad moves" on butterfliesandwheels.com offers food for thought and has some relevance to the thread as it is currently developing.
http://www.butterfliesandwheels.com/badmovesprint.php?num=43
Enjoy, 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 15, 2004 4:27:00 AM
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Shill
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From: Madison WI USA
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I think discussions like this are the reason I didnt major in philosophy.
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Steve Hill PT
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Re: acute low back pain - July 15, 2004 5:53:00 AM
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Barrett
Posts: 967
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From: Cuyahoga Falls, Ohio
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Ignoring philosophy, disliking it, dismissing its presence in practice or claiming it is beyond your understanding is probably not going to have any significant effect on your career if you're a mechanic or a machinist. This, of course, is because the car or machine doesn't feel anything and will always respond exclusively to the laws of physics and quite predictably so.
Doing what we do to whom we do it doesn't offer us this luxury.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: acute low back pain - July 15, 2004 10:11:00 AM
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mcap56
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From: New York, NY
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There are several, established classification systems for LBP. They are suitable for reearch and have been used many times over. The problem is multifactorial in origin but it doesn't mean research is impossible. Far from it.
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Re: acute low back pain - July 15, 2004 10:46:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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Barrett,
The wrestling reference is kind of funny. I really dont see you putting a hammerlock on anyone, as you would be coercing them to move in ways that are not inherent to them.
It all boils down to having different philosophies on how to treat. You have yours, I have mine, Army has his. Everyone has their own. Some are based on research and experience, some are based on experience, and some are based on other things.
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Steve Hill PT
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Re: acute low back pain - July 15, 2004 2:18:00 PM
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nari
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From: Australia
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A quick addition:
Philosophy is one thing, sure, but anyone who treats in a physiotherapeutic sense (ie physical only)and forgets/ignores basic tenets of psychology and basic CBT (which we all know about to a small extent) is missing out on some EBP and is denying patients a more effective treatment plan.
Physiotherapy is a science - but there is art in it, certainly with manual therapy, and a purely physical approach to s & s is cutting ourselves short in our duty of care.
Nari
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Re: acute low back pain - July 15, 2004 3:57:00 PM
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Diane
Posts: 1507
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From: Vancouver, B.C., Canada
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Nari,
[QUOTE]Physiotherapy is a science - but there is art in it, certainly with manual therapy, and a purely physical approach to s & s is cutting ourselves short in our duty of care.[/QUOTE]Ditto that.. the only time we would be purely "physically" theraputic is if we were treating cadavers. Otherwise there's a live person to deal with in that body, usually conscious.
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Re: acute low back pain - July 15, 2004 5:36:00 PM
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PTupdate.com
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From: Pittsburgh, PA USA
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I have to agree, especially with mcaps previous statement on our overall enthusiasm and attitude. I would bet we all get quite a few of our patients better simply because of what we said/explained/described that educated and comforted them. All the other stuff we might have done ended up being nothing but profit!
There are times that I am so comfortable with what I see on the first visit, that with an apprehensive or unsure patient, I bet them $100 I will take care of their problem, and I have not had to open my wallet yet (lest the moths escape)
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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