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Re: Is spinal manipulation working in the suspected area?
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 1:28:00 AM
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JLS_PT_OCS
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Barrett-
Our posts crossed in the ether....
I think your statement "I don't know what I'm doing exactly or why the result is so positive in such a case, and, in fact, I don't much care. But I have a study driving my choice of treatment, and that's how I practice." could apply to many of our interventions currently being used.
Manipulative therapy is not the only modality to be poorly understood, yet used with success frequently and to patients' benefit.
If I stuck only to interventions we truly understood -- what they were doing exactly and what changes they made exactly -- I don't think that would leave me with much. Maybe nothing. Even the exact mechanisms of proprioception approaches for ankle instability and muscle weakness are not fully understood, yet no one has raging forum discussions about whether to use them.
To borrow Jon's phrase, why this is the case is worth contemplating.
_____________________________
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: Is spinal manipulation working in the suspected area? - March 7, 2005 2:08:00 AM
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Barrett
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Jason,
Now I'm confused. If cavitation often occurs before the thrust, does this mean the cavitation is now somehow relevant? I have read here previously that it "wasn't necessary for a good result." If it isn't, what's the thrust for? What does it do to what that this extreme (in rotation) positioning doesn't?
I may not know exactly what tissue I'm affecting with my treatment either, but I *care* about such things. Aren't we supposed to care? Doesn't this drive further investigation? Armed with only a seemingly effective manuever and no real passion for rational explanation won't many simply abandon the search for meaningful practice? Does this sound like chiropractic to you?
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 2:20:00 AM
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Alex Brenner PT MPT OCS
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Barrett,
These are good points. I should be careful (no pun intended) with my "do not care" statements. I think what I mean by "do not care" is that I will not let lack of knowing "why" affect my choice of intervention especially if it has good evidence for its safety and utilization. I actually do want to know why but I am not going to hold back a good intervention because of this.
I am one who also believes that the cavitation is not necessarily needed but it is nice to have because I think it lets us know that something definitely moved. The thrust is needed to move the spine and/or pelvis whichever is the one that moves.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 3:32:00 AM
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Jon Newman
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Jan,
I don't think a big explanation is needed either. People come with the implicit knowledge of why manipulation works. Ask anyone you meet on the street why manipulation is performed on the spine and you will find very similar answers.
In fact if you re-read the posts here you will find why it presumably works and the explanation is essentially concordant with what you will hear from the average person. It leaves me wondering though if it is necessary. It just doesn't seem to be. That doesn't mean one shouldn't use it however; unless it can be shown to have other unintended negative consequences.
jon
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 3:43:00 AM
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SJBird55
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Christopher Powers addressed Barrett's concern in his editorial in JOSPT May 2003. I don't know if the link below will work... and I couldn't copy and paste anything because it was in adobe. The title was, "Priorities for Orthopaedic and Sports Physical Therapy Research: Assessing Outcomes or Understanding Mechanisms?"
http://www.jospt.org/members/fulltext/2003/may/May2003-Editorial.pdf
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 3:55:00 AM
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Diane
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Jon,
[QUOTE]It leaves me wondering though if it is necessary[/QUOTE]No more than any other form of placebo elicitation. [QUOTE]People come with the implicit knowledge of why manipulation works.[/QUOTE]On some level it has always been a people-pleaser. Which is probably why it persists as a modality. There will always be someone with that particular itch to scratch, and more than enough willing itchscratchers to help them out. Scratching itches doesn't really make them go away. How about understanding and getting rid, entirely, of the itch?
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 4:12:00 AM
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JLS_PT_OCS
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Barrett-
Good insightful points. I will again agree with Army that it is really not that I don't care, it's that I don't let not knowing get in the way of my using the tool. My cavalier "not caring" statement is more of an alternative viewpoint to those (not referring to anyone in particular) who don't use a good intervention because they are not personally satisified that it has been explained. It also shows that my first concern is a good outcome for my patients and speedy pain relief, and my (very distant) second is understanding the mechanisms of my care. I contribute of my time to forum boards like this and my money to professional organizations to assist in the understanding and research of such mechanisms. But that's not what drives my practice and not what my energy is devoted to day to day.
I wasn't making an argument that the cavitation is relevant (though I can see how I might have been giving that impression). My point is that the thrust part is often not necessary to acquire movement at some level. I use thrust manipulation because it has more evidence to support it than do other manual methods, such as mobilization or MET. Which I also use frequently.
Diane, I would argue that whatever manipulation's effects, (and there certainly is some dispute regarding what they are) it does on some level fix the need to be scratched. In fact, if I understand you correctly (please correct me if i'm not), you seem to be characterizing manipulation as a bandaid or temporary pain reliever that does not correct any underlying problem. At least there is some evidence (posted on this forum elsewhere) that manipulation may change some things such as muscle activation and spine kinematics. Hardly covering up the problem, in my opinion.
SJ posted an excellent editorial by Powers that shows the outcomes vs mechanisms debate in a world outside of manipulation, which is useful to show us that this issue is not restricted to this modality alone.
_____________________________
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: Is spinal manipulation working in the suspected area? - March 7, 2005 5:46:00 AM
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chiroortho
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[QUOTE]I may not know exactly what tissue I'm affecting with my treatment either, but I *care* about such things. Aren't we supposed to care? Doesn't this drive further investigation? Armed with only a seemingly effective manuever and no real passion for rational explanation won't many simply abandon the search for meaningful practice? Does this sound like chiropractic to you?[/QUOTE]Mr. Dorko,
I'll preface my brief comment by saying that I have developed a TREMENDOUS amount of respect for your expertise. Now, as to the ongoing quest for evidence for what we do as PTs and DCs, and I'll state this carefully, 'Best Evidence' or 'Best Practice' does not mean 'Complete Evidence', and unfortunately for those of us that utilize SMT the body of evidence for manipulation, while growing every day pro and con, is not totally satisfying. I'll be the first to admit that. I don't like to make the kind of comparison that I'm about to make, but there are many interventions in all aspects of medicine that are commonly utilized and even standard of care despite the fact that conflicting and incomplete evidence exists. Let me make it clear that this in no way is intended to imply that 'anything goes if you have one favorable study', but I hope you understand my perspective. And yes, I will concede that 'it sounds like chiropractic', to my shame.
Army, [QUOTE]I am one who also believes that the cavitation is not necessarily needed but it is nice to have because I think it lets us know that something definitely moved. The thrust is needed to move the spine and/or pelvis whichever is the one that moves.[/QUOTE]I totally agree.
By the way, would you post the Childs study again for me? I didn't find it. Thanks Captain.
Diane, [QUOTE]Scratching itches doesn't really make them go away. How about understanding and getting rid, entirely, of the itch?[/QUOTE]Why not do our best to get rid of the itch as well as the cause of the itch if we can?
Respectfully,
Greg
_____________________________
Greg Priest, DC, DABCO
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 6:45:00 AM
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Yogi
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Jan, to your original question, There was a study posted on another thread that showed poor correlation to the "isolated joint" and cavitation sounds during manipulation, which was used as evidence for not being able to isolate the segment. Relate that to Duffy's post above, which I agree with. Now we hear from some respected clinicians that the cavitation is probably not significant, in the spine, and which in another thread the concensus seemed it was not significant in peripheral joints either. However, the non-isolation study did not utilize MET, Strain/counterstrain, positional release, or any other techniques. My problem was that they assumed cavitation correlated to the segment pathology, and I agree with Duffy's quite sensible assessment, therefore it would not correlate, and was not a valid or useful study, in my opinion. A study to determine if cavitation relates to pathology (other than perhaps a hypermobile joint) was needed before making the assumptions utilized in this study. Therefore, I do not rule out yet that other techniques (mobilization, previously mentioned techniques, even other manipulatory techniques), may, in fact, do a suitable job of isolating the proper hypomobile joint in the correct segment.
We actually await more studies to answer your very good question.
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 7:18:00 PM
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january
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Hi All and thanks again for your patience and thoughtful replies,
Army
[QUOTE]it works because there was a good quality research study that looked at manipulation and exercise versus just exercise and found that the manipulation and exercise group did much better. The success of this group could only be contributed to the manipulation.[/QUOTE]This statement seems not logical since if the success = manipulation + exercise then I can't conclude that success = manipulation? The study shows only that success ≠ exercise but it is possible to have also success ≠ manipulation?
It would only mean that addition of parts is better than parts taken solely?
[QUOTE]Have you read the Flynn et al Clinical Prediction Rule study and the follow on validation study by Childs et al that were referenced in the other thread that you read? What do you think about those?[/QUOTE]Not completely, sorry.
[QUOTE]Do you think your patient even knows what that means or even knows where that is on his or her low back?[/QUOTE]Yes! They come with tons of XR and MRI and have beliefs based upon these diagnoses! They say : “It's my L5 that's hurt”. Being imprecise is just a risk to say “I don't know what I'm doing but I'm an expert!”
Barrett
[QUOTE]It wouldn't be right to say they were spinal structures since so many others may be involved.[/QUOTE]I agree so why are we limiting our reasoning to bones/joints?
Jason,
[QUOTE]I usually say something like "no one knows what really causes back pain.[/QUOTE]I can't have a such comment since patient seek, too often, for a definite diagnose. Saying that may let them with a taste of lack of knowledge from our own?
[QUOTE]it does on some level fix the need to be scratched.[/QUOTE]Is it impossible to search the responsible structures?
Yogi
[QUOTE]Therefore, I do not rule out yet that other techniques (mobilization, previously mentioned techniques, even other manipulatory techniques), may, in fact, do a suitable job of isolating the proper hypomobile joint in the correct segment.[/QUOTE]Perhaps is it time to understand that the riddle is certainly more complex than we thought?
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 9:07:00 PM
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Alex Brenner PT MPT OCS
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Jan,
You should really get a copy of the study and read it. Also, there was a huge thread pretty much dedicated to the validation study of the CPR study. Maybe you could read through that to understand where I am coming from.
I think this particular thread was some kind of rehabedge world record for postings and Dr. John Childs the lead author of the validation study gets involved during the thread and answers a lot of questions.
http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?ubb=get_topic;f=1;t=000508
Good luck,
Army
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Is spinal manipulation working in the suspected area? - March 7, 2005 9:34:00 PM
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Alex Brenner PT MPT OCS
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Greg,
Here is a link to the Annals of internal medicine and the Child's et al study.
http://www.annals.org/cgi/content/abstract/141/12/920
I think I have an electronic copy of the full article that I can email you.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 12:38:00 AM
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january
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Thanks Army,
Reading this looong topic was interesting but brings water to my side: (It is quite impossible to digest a such intelligent thing in a single post)
[QUOTE]Similarly, attempts to identify patho-anatomic causes of back pain have been entirely unsuccessful, and likely account for why the management of back pain in the 20th century was a "medical disaster" (Gordon Waddell), leading to millions of dollars of unnecessary imaging studies that in many cases cause more harm than good.[/QUOTE]1/ That's quite true but it may clearly tell us that the content of the aerobic/strengthening group is a child of this disaster and perhaps, its content is inappropriate to cure LBP? In that case, the manipulation group will ever “win” the battle!
2/ Is it a good advice to exercise a lumbar region which is suffering? It is clearly known that LBP induces often a fear of movement and this fear is perhaps a good predictor of failure in this group.
3/ I'm using “the simple pelvic tilt” to relieve common acute back pain and its works marvellously but I do not use manipulation. :rolleyes:
4/ I saw that the study was made over military employees. Can we generalize military population versus a civil one? I'm not sure! :confused:
5/ The most strange thing is that Doctor Childs is also a trainer of manipulation's courses? There is no most faithful preacher that the one of his church?
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 1:01:00 AM
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JLS_PT_OCS
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Jan,
I have completely abandoned the search for an anatomic cause or lesion in low back pain, as have many of the researchers in the field.
Patients actually like that I don't have an answer, and the quicker I get them off the "what's my diagnosis" topic, the more we can focus on their future: rehab through active motion, strengthening, and function.
RE: your points above...
2. Yes, it's a good idea to exercise a lumbar region which is suffering, as it is an ankle, knee, or shoulder. Exercise rehabilitation was our bag, or so I thought. There is much evidence to show the benefit of early mobilization and movement for most musculoskeletal problems.
3. Would love to see your data on the pelvic tilt method for treatment of low back pain. I don't use that method myself because there are many other methods (including manip) with evidence to support them. Perhaps there are other ways to produce the size of effect that manipulation did in this study, but I haven't seen any yet.
4. It was in a military facility, including active duty personnel, family members, and retirees. Actually a good cross-section of any typical outpatient clinic.
5. Dr. Childs does teach manipulation courses, but surely that does not change the strength of evidence or quality of study that has been presented and validated. My family doctor is an instructor at a residency program but that doesn't make me cast doubts as to the medication he gives me. Even if he wrote the study. Evidence is just that, objective.
Thanks.
Jason.
_____________________________
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: Is spinal manipulation working in the suspected area? - March 8, 2005 1:33:00 AM
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january
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Jason,
There are scientific people who are searching and need a logical explanation for our modern diseases. Treating consequences is sometimes effective but caring the causes is ever better and opens the way of prevention.
It is incredible that we accept, so easily, more and more idiopathic illeness as a fate!
I do not forget that almost half of our population is suffering of back problems and the trend seems in augmentation. This is a disaster and shows our inability to find a long lasting treatment or a complete recovery. We are just “stabilizing” their states.
Early mobilization if only effective if you consider the patient's tolerance (pain).
Thanks for the clarification about army population. I was improperly restrictive about the sample.
I didn't want to start a comment about probity and objectiveness but I saw last week some studies saying that surgery was better for sciatica but one of these “objective” paper was made by surgeons who opposed “aggressive PT” to surgery outcomes! And the other didn't mentioned anyway PT cares, just surgery as the best solution.
There is some “productivity” is many “peer” reviewed papers for now?
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 1:50:00 AM
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JLS_PT_OCS
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Jan,
I agree that we need to be researching the causes. That's part of what professional membership dues do. But seeing as how no one has figured it out as yet, it would seem best to focus on what we "can" change, and as a clinician, not a researcher, that's where my focus is.
I think you bring up good points about the overall state of spinal pain treatment today.
Thanks for the discussion.
J
_____________________________
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: Is spinal manipulation working in the suspected area? - March 8, 2005 3:40:00 AM
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chiroortho
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Army,
Thanks for the reference, but when I read it I realized that I actually had it already and thought that you were referring to a different article.
Thanks again anyway,
Greg
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Greg Priest, DC, DABCO
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 4:32:00 AM
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childsjd
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I am not going to get involved in a detailed discussion here, but this has been a fruitful discussion emphasizing the need for standardization of care processes based on the evidence. The point has been made well by several here and I agree - we should not let the absence of mechanistic evidence paralyze our ability to provide evidence-based care. Our patients don't want to wait on the "why". Frankly, that answer may never come.
There was a paper published in the most recent issue of JMPT showing that manual therapy practitioners are all over the map when it comes to the approach they use. Of course, this is not surprising in light of the approach advocated by some in this forum that emphasizes the supposed ability to detect subtle nuances in a patient's presentation that should be matched with a specific treatment approach. Surely the wide variations in practice reported in this study can't all be attributable to our supposed "expertise" in detecting these patterns, most of which are figments of our imagination. The only reasonable possibility is that the decision-making strategies used by many manual therapy practitioners are not informed by the evidence, but rather their long held biases about what works best "in their hands".
"Cookbook" medicine is not a dirty word. Informed by the evidence, and permitting our ability to integrate decision-making in light of our patient's preferences, a "recipe" to care for our patients is exactly what evidence-based practice is all about.
John Childs
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 5:38:00 AM
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Barrett
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Can't let it go.
You say, "The only reasonable possibility is that the decision-making strategies used by many manual therapy practitioners are not informed by the evidence, but rather their long held biases about what works best "in their hands"."
This is no more true of those for whom you seem to hold such contempt than it is than it is for those who insist that "what works" should be done no matter how senseless.
The question addressed elsewhere here-a discussion you chose not to enter-is the significance of sensible practice. Again, you state that results are all we need to consider for competent practice. Both are necessary, and though you choose not to read the literature surrounding another approach, this does not mean that the "bias" of other practitioners is unwarranted or a "figment of their imagination." There are a variety of methods to be sure. Is this because those of us who don't follow your protocols are that stupid, ignorant and fanciful, or is this situation a consequence of the variety of responses seen in the human body to a single provocation?
You seem to think that pain always arises from tissues able to respond predictably to forces and time. This simply isn't true, and as long as that's the case a "recipe" isn't going to work in all cases.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 6:27:00 AM
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JLS_PT_OCS
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John, glad to see you are still out here reading.
_____________________________
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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