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Re: Mythbusters
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Re: Mythbusters - January 31, 2005 4:02:00 AM
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PTupdate.com
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Well, one must always use some judgement when performing MMT and noting what they see. According to Kendall, 5/5 is a contraction that basically cannot be broken. However, as SJ indicates, a post-op knee patient who is an athlete may present with 2 inches of quad atrophy, yet still cannot be broken by a weak PT (usually the ones that cheer for the Patriots), so in all liklihood, should not be listed as 5/5. Once this is done, it becomes hard to justify the PRE program.
But, weakness can present problems with certain activities, especially sports and weightlifting.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Mythbusters - January 31, 2005 6:17:00 AM
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Yogi
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SJ, Like Greg the lateral tracking of the PFPS makes a lot of sense to me, and when you can alleviate the pain by manually guiding the patella, doesn't that indicate the lateral tracking is the problem? However, I am coming to the idea that it is less a VMO weakness problem, that a VMO timing problem, it needs to contract at a specific point in the motion. Until I can figure out how to teach it the timing, I work on teaching it to contract period, by positionin the tibia laterally with the foot loaded laterally with weight (resistance) during the SLRs and extensor lag range short arc quads. Diane, good neural tension plug, David, if you ever read the forum, Thanks for bring neural tension out of the basement or closet or wherever it was hiding all those years.
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Re: Mythbusters - January 31, 2005 6:33:00 AM
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SJBird55
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Yogi, if it were completely a lateral tracking issue, why does tape that is applied in the completely opposite line of pull also alleviate symptoms? Why does tape that has no pull in any direction alleviate symptoms? There might be a proprioceptive component based on that research.
Duffy... LOL So, are you definitively stating that only PTs that cheer for the Patriots are weak PTs? I need just a bit of clarification. LOL
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Re: Mythbusters - January 31, 2005 6:46:00 AM
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bravocosta
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Hello Yogi,
Was taught that you could improve the "timing" of the VMO (ie- get it to contract very briefly before the other quad muscles to help medial tracking), not sure if this is what your referring to, or just getting it to turn on more during WB'ing. Been reading that since the Fem nn. innervates all the quad muscles, what we were taught in school and clinic doesn't make sense. Have stopped giving SAQ's for PFPS because of increased compressive forces of patella near endrange. Agree with MMT not correlating directly with function of legs.
Cheers.....Thomas
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Re: Mythbusters - January 31, 2005 6:59:00 AM
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dosrinc
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From: Bonita Springs
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Hello all, great thread
I would like to ask those that are palpating the anterior aspect of the vertebral bodies just what it is you are trying to learn from this? if you can palpate the vertebral bodies doesn't it make sense that you can also palpate the anterior aspect of the disc? I have never heard of anyone palpating the anterior aspect of the disc, am I missing something?
My favorite myth is exposed when you ask a PT student to measure ankle inversion and or eversion three different times on the same ankle and you get three vastly different measurements. I agree with the MMT myth as well.
Rick
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Re: Mythbusters - January 31, 2005 8:54:00 AM
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srcase
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I was wondering if anyone has looked at pfp functionally, like Gary Gray, PT in his Chain Reaction courses. He explains that lateral tracking of the patella is due to altered timing of the rotation of the tibia and femur from ground reaction forces up the chain from the foot. For instance, if the tibia is rotating faster than the femur into internal rotation (such as during knee flexion) the patella will be forced over the lateral condyle of the femur. The same is true if the femur is rotating faster than the tibia. Why would one segment rotate faster than others? It depends on the relative stiffness of the hip and subtalar joints usually. If a person lacks subtalar joint eversion and or dorsiflexion, when the foot hits the ground, more rotation most occur at joint above to make up for it. Or if the person has tight hip external rotators, they may lack the necessary hip internal rotation. Either way, it's a problem with the track, not the train, according to Gary Gray. And it is also most likely proprioception loss in the above mentioned joints.
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Re: Mythbusters - January 31, 2005 12:18:00 PM
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FLAOrthoPT
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amen...think globally, treat locally...you must look at the whole chain especially with pfps...thorough eval of foot and ankle and hip, and back for that matter....kendall has been disproven on so many occurrences, when they tried to extrapolate MMT grades from a primarily polio stricken pediatric population and guestimate what a health population would be able to do, a lot got lost in translation. I think just about every grade above a 3 can be disproven in a study with every muscle, it has already been disproven in a study for the gastroc and soleus, and i did a study soon to be published in JOSPT disproving the "lower abdominal" mmt as well, but it is merely obvious that anything over a 3 is very subjective...ok gotta go get ready to think of how I will console all those eagles fans who think their is the slightest chance they'll hold their own against the PATS...
Ben
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Re: Mythbusters - February 1, 2005 3:24:00 AM
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Yogi
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SJ, yeah, I don't know why the timing is off, and some sort of closed chain work on proprioception might be better, the taping thing I don't know. But look, S. Case tells us a very smart fellow is looking into it. But, S., I'm thinking most are overpronated (which often is a result of lack of dorsiflexion). So, does Gary treat with an orthotic and heelcord stretches? Is there anything to be done about the proprioception? We need Gary on Rehabedge, remember, When the foot hits the ground, the s*** hits the fan.
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Re: Mythbusters - February 1, 2005 3:29:00 AM
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Yogi
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Bravo, yeah the femoral nerve does innervate all the quads, but it's controlled by UMN's. I tried selectively isometrically controlling contraction intensity of my VMO and VL and found it's not all that difficult.
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Re: Mythbusters - February 1, 2005 3:33:00 AM
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Yogi
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Oh, SJ, it's probably not completely a lateral tracking issue by the time we get to it. By then it's likely a chondromalacia issue, damage done.
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Re: Mythbusters - February 1, 2005 5:18:00 PM
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TKOPT
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Bravocosta.
Sorry so long to answer, I was on vaccation in ARUBA for a week and had 190 e-mails to answer or delete before I could "play."
I am as sure (whatever sure means)as I can be because of the anatomy. I know where the psoas is and when I think I am on it, I ask the patient to flex the hip ever so slightly and I can feel the muscle tense up under my palpation. Another way is to start the hip in flexion and have the patient slowly extend the leg causing eccentric contraction of the psoas so again you can feel the tension in the structure you are palpating.
The ITB is alot of thick tissue in the middle portion and distally but there is a good deal of muscle and mixed tissue more proximally. The TFL is part of that complex. Also, a good tissue mobilzation (deep massage) therapist can eliminate knots and ropey bumps all along the complex. AS a runner myself, I get these knots and ropeyness (sp?) in my old fart body and really appreciate having that area released.
I am an instructor of SI and pelvic dysfucntion courses (primarily Muscle Energy Technique approach)and it is difficult to do research when there are so few who can actually properly evaluate and treat these subtle but very anoying asymmetries. They would have to establish criteria for what constitutes and "expert" and that alone could take years before they even start the research itself. My practice is unusual in that I stake my livelyhood on correcting dysfucntion which has not been helped with traditional PT methodes, chiropractic, drugs etc. If I don't fix them, I am dead in the water (out of business)as I do not take insurance as payment in full.
I ask for a much higher rate of pay and if I don't deliver I am gonna have alot of pissed off people standing outside my office. It is true that these techniques take years to learn and master but I find in my classes that those who think I am off my rocker are the ones who just seem to get lost in the course. Not sure if they do not have the equipement to understand or if they just have a strong system of beliefe and have convinced themselfs that it is impossible. Yet every course we correct major problems in the students and they can appreciate the difficulty as well as the dramatic changes when done correctly.
I take no offense with your questions, they are excellent and if you don't ask you will take longer getting to your "truth."
Diane had a great line in one of her posts on another site and I even included it in my latest manual for Muscle Energy Techniques for the Thoracic, Cervical Spines, Ribs and Shoulders
"Give yourself a license to learn and allow new knowledge to continually interfere with your "education."
TKOPT
[URL=http://www.tomocklerpt.com]www.tomocklerpt.com[/URL]
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Thomas K.Ockler P.T.
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Re: Mythbusters - February 1, 2005 5:28:00 PM
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TKOPT
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Rick,
THe only time I palpate the anterior/lateral C spine is in looking for trigger points to treat with Counterstrain. Other than that I can't think of too many reasons to do it.
TKOPT
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Thomas K.Ockler P.T.
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Re: Mythbusters - February 1, 2005 5:35:00 PM
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Jon Newman
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I just came across this article. I think it illustrates the complexities of determining why things work, especially considering what we are charged to do.
I think it was Duffy who mentioned (in this thread) something about finding the truth in lies. Funny how different threads come together to form a web somtimes.
We are all so closely connected in how we practice; but sometimes it is the little things that make a big difference. My quest is to determine what are the truths that tie all our lies together.
Here the link:
http://www.csicop.org/si/9709/beyer.html
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: Mythbusters - February 2, 2005 1:05:00 AM
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SJBird55
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Jules Rothstein spoke of pretty much what that article states a few years back.
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Re: Mythbusters - February 2, 2005 4:48:00 AM
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JLS_PT_OCS
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TKO-
If you have so much success in treating chronic cases with your methods, where can I find your case studies or research? Would love to see them.
I often feel lost in this area and unsure of my current approach of palpation, motion testing, and assymetry to address what I think is pelvic/SIJ pain. That is of course, when my first line methods fail (manipulation, stabilization and strengthening exercises).
I think if your methods are as successful as you claim than I for one would LOVE to attend one of your courses. I think having some outcome data on this population along with your eval/treatment methods and theory would go a long way in advancing our profession. That is, if it actually works.
I'm not intending to be disrespectful, just skeptical, and I think if we tout something to be really great and it reliably produces results, (especially where so many others have failed) why aren't we publishing it?
If they do take years to learn and master then we should be studying the difference between an expert practitioner and a novice. Don't you think, sir?
I truly believe there is something to this (meaning treating pelvic motion and assymetry to address pain) because I have seen it with some of my patients. I don't doubt it sometimes works. But I am not sure why it sometimes works and sometimes does not. I am unsure if my treatment is wrong, or if my theoretical construct that guides my treatment is wrong?
Or maybe I just suck. That's definitely possible (some would say it is certain). :)
What do you think, and what type of biomechanical model do you use to guide your treatment?
Thanks.
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: Mythbusters - February 2, 2005 5:38:00 AM
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bravocosta
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Dear TKOPT,
Thank you for your viewpoints. Having wrestled with the whole SI joint thing for some time, appreciate your viewpoint. Research come across suggests poor interrater reliability between assessment of assymmetries and other research suggests that assymmetry in this region is a poor predictor of pain. That being said, have recently had several patients from falling down steps (things come in bunches) with sx not reproduced mechanically with L-spine motion but painful in this area without pelvic up/downslip. Am not suggesting there is not something to this SI joint thing, and quite possibly it is skill based as you suggest. "Expert" opinions on both sides make things even more complicated ie- "used to teach this stuff for years, but have long since stopped etc.." to "can be consistently assessed and effectively treated". Jason posts some excellent questions, and would look forward to hearing more of your thoughts on this. To quote Sebastian ("I am very opinionated and often wrong")
Cheers...Thomas
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Re: Mythbusters - February 2, 2005 6:01:00 AM
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KIDPT23
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How about those great, expensive machines such as the KIN COM or Biodex that can soo accurately test a patients strength, because isokinetic strength is so closely related to functional strength.
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Re: Mythbusters - February 3, 2005 5:41:00 PM
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TKOPT
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From: Willoughby Ohio
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Jason, Bravocosta.
It has nothing to do with sucking and everything to do with the correct instruction and years of practice. I sucked so bad at this stuff for the first three or four courses I labled myself a
"manual therapy moron."
I took hundreds of hours of courses
(over 800) in the non-manipulative manual therapies as well as manipulative therapies. Also took courses which were a complete joke. The major breakthrough for me came when I learned there was a treatment sequence when it comes to somatic dysfucntion. ONce understood, it streamlined my time and I became very efficient at the techniques. Jason, where do you live? I'll send you course info as soon as the new department is ready (two months estimate) I have two courses cuming up in April / May. One for the Cleveland Clinic and one for S.W. Genneral. Both in the Cleveland area but they are closed, just for those facilities.
As far as studies and reasearch, tell me who has time and tell me who I am trying to convince. The techniques take alot of time to learn and practice. Requardless , if the reaseach study showed a huge advantage to doing it my way, people still have to take years of courses and years of practice to get good at the techniques. The vast, overwhelming number of students just find it too long, too complicated and they don't like looking green in the clinic so they drop the techniques in favor of machines, hotfakes and ultrsham. Also, the biggest complaint I get when teaching is
"just when are we supposed to use the techniques if we have to see 4-6 paitents per hour?"
How would you design a fair study given I am the only PT in the clinic. If you audited my charts and saw my number of visits to pain free and contrasted them with the conventional or traditional PT practices, a great disparity would be seen but is this evidence?? Would it classify as acceptable reasearch? Hell no. Doing these techniques is much different from doing ultrascam at 1.5 watts /cm sq over the supraspinatus. So the design of the studies would be a real killer. STill I am open to what you would find acceptable. I see 8 patients a day and spend 1 hour, one on one with every patient. I dare say this is also a major contributer to my outcomes. So who else can spend that much time??
Your points and concerns are real and are well taken but how would we do a study?
I propose you come to a course, hang around for a day or two after to watch what i do, review my charts and report back to the forum.
What? don't have time? can't get away? I always offer PTs to come and spend time in the clinic and see what I do and listen to the patients subjective comments but very few take me up on it. Many Therapists in my area have done this and even bring their patients into see me. This is best as they can get involved with the actual treatments but is a big time commitment for the visiting therapist.
I take no offense by your questions, they are fair and from the gut!!
Much about these techniques has been published, my manuals are available ony with the courses, but many books cover the subject well. If more people did this stuff and were good at it, it would indeed go the long mile in advanceing the profession. BUT...when our colleques are seeing 18-30 patients per day, working for corporate practices whose only motto is income-income-income and outcome is a dirty word, or getting into bed with doctor owned, lawyer owned clinics, how can our profession be advanced? Having been an administrator for hospital for my first 11 years I can personally attest to the abuse of the therapists...I was one of the abusers.
Again, thanks for the questions and commments I welcome a study design if you can come up with it.
Interestingly enough, I have never seen Osteopaths do a study about what you propose. And ****, they invented the techniques. Go figure.
Sorry so long folks.
Bon Dia
TKOPT
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Thomas K.Ockler P.T.
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Re: Mythbusters - February 3, 2005 8:29:00 PM
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Alex Brenner PT MPT OCS
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Thomas,
I think I am with Jason on this one. I really would feel that my highly coveted CEU money would be better spent on a course that has some evidence behind it. I would be very reluctant to spend it on a course like yours and others that advertise all over Rehabedge.
[QUOTE]I took hundreds of hours of courses(over 800)in the non-manipulative manual therapies as well as manipulative therapies. Also took courses which were a complete joke.[/QUOTE]What do you mean you dont have time? Here is the time your are seeking. If you have time to conduct these courses on the weekends and to go to over 800 hours of continuing education then I would think you would have time to at least write a case series or one single case study for publication in a peer reviewed journal.
Maybe I am missing a lot of good continuing education but I really feel my money is better spent on courses/techniques that have peer reviewed evidence.
Just my thoughts.
Army
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Alex Brenner, PT, MPT, OCS
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Re: Mythbusters - February 4, 2005 1:25:00 AM
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SJBird55
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Thomas,
Yes, do a study just like you said. Yes, it classifies as research. If you classify your patients, have a way to tell what you do (and it can be general) and report your outcomes with standardized measurements with valid and reliable tools how is that not research? You are only one clinician... but if you get it published and other clinicians read it, especially those that CAN do randomized controlled trials - let them do that part. Plus, if you do a study of what you can do and it gets published, other therapists can read your study and if those therapists know their outcomes and know they suck compared to you, well... the current skeptical ones will not be skeptical and will sign up for your courses. And, in my opinion, using a rationale that osteopaths haven't done it is a poor excuse; just because they haven't done it, does that mean it's right, does that mean it is acceptable, does that mean they are correct?
When I first graduated with my MS, I never considered anything about the continuing ed course I took - if it sounded good, I went or wanted to go or tried to go. But... now... unless I've read something in peer-reviewed literature and what I've read seems to be something that would be valuable for the population that I treat, I don't sign up for any old course any more.
To be honest, when a therapist says that they spend 1 hour with every patient, for some reason that sets off a flag in my brain. It makes me wonder and it makes me think. What we do should not be preset, what we do should have a patient-centered approach, and the quality of what we do should not be tied into how many patients we see in a day. That's just my opinion though. I could be wrong - the only aspect of my belief that has been published, peer-reviewed and stated in literature is the patient-centered aspect.
ArmyPT, I went to a course by Great Seminar years ago and it was very evidence-based. That was about 7 or 8 years ago. I was first introduced to standardized measures through that course. And, if I recall, I believe it was the first course that I went to that actually had references and bibliographies listed for each section of the course discussed. I thought I saw Great listed somewhere here.
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