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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 8, 2005 6:34:00 AM
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Shill
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From: Madison WI USA
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Barrett,
I cant let it go either.
Wouldnt we all benefit from a published study, or for starters, a published case study regarding the specifics of your approach?
Why dont you just do it?
Sincerely,
Steve
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Steve Hill PT
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 7:03:00 AM
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Barrett
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The specifics of my approach have been described many times by me for years-hundreds of essays readily available for free, and in a peer reviewed journal of osteopathic medicine you'll find a description of its basic theory. I can hardly be held responsible for people not reading this or the published work of Elvey, Sunderland, Shacklock et.al. (See "the Analgisia of Movement" on my site)
I don't feel that I've failed in this regard, though my effort may not satisfy you. Speaking of that, do you have anything similar about your own practice? Is your actual name available somewhere?
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 7:15:00 AM
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JLS_PT_OCS
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Barrett,
The specifics of the homeopathic approach have been detailed as well. That is not an argument for efficacy, sir.
Are the references you cite above research on outcomes or specific processes using your delineated approach? Or merely general descriptions of pain theories, pathways, and the role of movement in general?
Your site is impressive as theory goes, and I enjoyed it, however it did not provide information or data that would cause me to change the way I currently practice. I can just see how your theories can apply to what I am already doing with movement.
For me to, for example, compare your approach to that of manipulation (assuming they are exclusive, it didn't seem they were), I would need a specific breakdown of your approach and or techniques, not some seemingly very general theory and practice discussions. Not that those are bad, they're not, it's just that it's opinion, not evidence, sir.
You clearly are an intelligent and reflective man, can you sort of see where I'm coming from?
Thanks for your willigness to discuss, especially considering all the forum hours all of us have logged by now...
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 7:30:00 AM
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Barrett
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From: Cuyahoga Falls, Ohio
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Jason,
Somehow I don't get the impression that calling me "sir" is somehow a sudden show of respect. I say this because you've never done it before.
Anyway, I have NEVER said that I provide evidence of efficacy and don't know why you would assume I am now saying such a thing. As for Elvey's work and the others, why not look at what they offer? In vitro studies of nervous mobility and intricate research regarding the physiology of neural response to mechanical deformation known to produce pain and consequent alterations in physiology might not be what you're looking for in order to guide practice, but as I've said before, it is where my thinking begins.
Ann Downer, the author of "Physical Therapy Procedures" was one of my instructors at Ohio State. She proclaimed many times, "This is a cook book, learn it well." It made me uneasy then and today it makes me nauseous.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 8:23:00 AM
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JLS_PT_OCS
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Barrett,
My use of the term sir is to ensure my intent is perceived as respectful, as typing contentious discussions cannot always convey what a face to face discussion would. I will dispense with it if it bothers you.
But I do wish to be courteous, although we disagree (not on everything as evidenced in other threads). I see no reason to be rude to anyone, and I carefully word my posts at times to not appear so. I do not think that rudeness would be productive.
I don't mean to say that you claiming evidence of efficacy. If that was your interpretation, let me clarify.
I am asking why you do not feel the need to provide any, given what I perceive is your disdain for other methods which have more evidence to support them.
I have read some of the material you mention, and I do find it interesting. I don't find it inconsistent with practicing EBM (in this case, manipulation for a certain subgroup of LBP cases).
It is my perception that you are using the work you cite as evidence that underlies your approach, which includes eschewing manipulation, and therefore EBM in this patient cohort.
That is my confusion.
I don't believe we can use the "every patient is different" thing as a shield to keep away critical thinking and EBM. I feel some people do that. I'm not sure if you are doing that, I'm just asking. Most patients, when I present them with a choice, are most interested in the most efficacious treatment, regardless of their personality quirks. Hence most of my patients receive in general very similar care. I could say that as easily with my ACL reconstruction and ankle sprain patients as I could for my spine patients.
I have yet to feel nauseous because of this.
Interested in your reply, thanks.
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 8:25:00 AM
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JLS_PT_OCS
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Heard a famous PT put the standardization thing a different way:
"When people say decrease variability in practice, everyone jumps to the conclusion that what is being advocated is cookbook clinical care. Instead, variability in care should be viewed as a spectrum where, on one end there is complete chaos with regard to assessment and treatment procedures and the other is strict adherence to an approach with almost complete predictability with regard to clinician behavior. What [many researchers] are advocating is addressing the chaos end of the spectrum, which is a pretty tall order from the looks of data related to physical therapy."
I don't have his permission to quote him so I won't use his name, but I thought he put it well.
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 9:11:00 AM
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Barrett
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Jason,
You say, "...you cite as evidence that underlies your approach, which includes eschewing manipulation..."
Well, of course. I don't manipulate my patients because of my past experience with such care. This experience included fabulous success at times-as far as I could tell. For me, this was not enough once I had one too many experiences with angry patients and furious physicians. If you've not yet had this happen consider yourself lucky. In civilian life I doubt this luck will hold, but I'm no psychic. By the way, this response had nothing whatsoever to do with the forcefullness of my technique or my bedside manner. Patients aren't always what they appear to be. I imagine you'd agree with that.
The evidence I cite encourages the use of movement but I can't see how it encourages the use of manipulative technique. I conclude that manipulating people with an abnormal neurodynamic makes little sense and that active movement of a certain sort would be a better idea, to say nothing of the decrease in the side-effects I mentioned. This includes those patients with all five of the prediction rule findings. I admit they aren't really a part of my practice.
The evidence is what makes me conclude that every patient is different, it isn't an excuse I use to avoid critical thinking. On the contrary, a lack of critical thinking among those who use "recipes" is what *I'm* complaining about.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 9:31:00 AM
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Bournephysio
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I am quite amazed that many people here are reverting to a pseudo-biomechanical models when it comes to explaining/arguing for or against manipulation. People have made arguments that they use other techniques to “align vertebrae”, or that general manips won’t effect the hypomobile segment. The question that started this thread assumes that we need the forces to be absorbed at the right joint. I think we need to take a step back away from this pseudo-biomechanical model and take a look at what is probably really happening.
I’m using the term pseudo-biomechanical models because most of them are not only based on top notch biomechanical research but also large jumps in logic and even physical impossibilities.
Evidence from many different areas has lead me far away from a strictly mechanical model of the effects of manipulation but first lets look at how manipulation can work in a purely mechanical model.
Lets say we “find” a hypomobile or misaligned joint. What are the possible mechanisms making this joint hypomobile or misaligned? Meniscoid entrapment: makes sense and a manipulation could free it mechanically but it is hard to believe that every joint whose mobility was improved by manipulation was a meniscoid entrapment. Capsular adhesions/scarring: a single manipulation would have to have the force to tear through connective tissue adhesions/scarring. Sounds painful and not very likely. Muscle tightening: a straight mechanical model again would involve tearing of the muscle. How about osteophytes? Do you think we can break these off with a manipulation?
The only thing that makes any sense to me that would so quickly free a “hypomobile” or “misaligned” joint is a decrease in muscle tone caused by some sort of mechanoreceptor input. If mechanoreceptor input will decrease the muscle tone there is no reason to believe that this mechanoreceptor input necessarily has to come from the affected segment.
What is a “hypomobile” or “misaligned” joint? As a manual therapist and a biomechanist, I do believe that there is clinical value in some of these mobility tests especially for the neck. Many times I find hypomobilities I’m not so sure about. Those I could be imagining but often I find joints that are obviously “hypomobile.” I find it hard to believe that I am making these up. The question is, I’m I really finding hypomobile joints? To answer this we need to look at how we are testing. Usually the testing involves pushing through muscle tissue through to the bone. The bone on the segment we are pushing as well as segments above and below (and their respective joints) will have to resist the force (note that this probably precludes us from “gliding” the joints the way we were taught we are). The decrease in resistance we feel can be in any of these. I believe that the most likely candidate is the overlying muscle tissue. I also believe that those finding spinal malalignments are most likely finding differences in muscle properties, not actual malalignments.
Is the improvement in general range of motion due to segmental improvement of range of motion? It may lead to some improvement but I think it is more likely that the mechanoreceptor stimulation directly leads to pain reduction which allows the subject to move further.
Can we be certain that a manipulation did not effect the targeted joint? In certain instances, I think we can. A roll down thoracic manip does not involve any forces through the neck (except for some muscle activity). I think we can be pretty certain that a mid tspine manip will not manip the neck. However a study has been quoted here suggesting that tspine manips can help neck pain. In my experience, you can get an immediate improvement in cervical joint mobility after a thoracic manip. This can not be due to a direct mechanical effect.
The above model contains plenty of speculation but I believe that it is much more consistent with the literature than any of these pseudo-biomechanical models. There is very little evidence supporting bone out of place models and for the most part they don’t make much sense.
Doug
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 1:20:00 PM
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Jon Newman
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Doug,
Really, you're amazed? If no other theory of why it works is forwarded then the only thing left to discuss is the one that has been being used for a long time.
Thanks for doing your part. But watch out, what your doing is NOT EBM.
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: Is spinal manipulation working in the suspected area? - March 8, 2005 1:20:00 PM
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Synergy
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Hi Doug!
Can you please postulate on why immediate improvement in cervical mobility after a thoracic manipulation cannot be due to a direct mechanical effect?
Thanks!
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Chris Adams, PT, MPT
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 7:12:00 PM
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january
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Hi All,
As pointed out in the last replies, the question was to know if manipulation worked “where” we diagnosed it. This strict bio-mechanical model was, of course, just a start to push readers to theorize about some illogical facts and physical impossibilities.
I didn't wanted to say that manipulation was or wasn't effective. It wasn't the question. I was just asking for discussion and information but I'm not a manipulative PT.
About recipes and cookbooks:
Is it possible to apply a recipe over all patients? If I agree that EBM is a necessary thing, I must remember that statistics are only computed values coming from different and unique patients. The average value show a common comportment of the sampled population but the general rule must be adapted back to fit an individual.
We are functioning in a similar way but we are not identical human beings.
So... I agree with Barrett, knowing a recipe is a good thing but the menu has to be done, just in time, since the patient is unique and ingredients differ all the time. Applying a recipe in the same way is a good chance to have an average value as EBM computed it but lets intelligence away and considers PTs as simple manual workers without brain.
Doug,
You're on the right track!
Acute back pain shows often these common clues:
Stiffness,low mobility, tight muscle and loss of ROM but they are governed by pain that is a brain response.
Jason,
Why a simple pelvic tilt may work?
1/ engage lumbar region to move in flexion and extension.
2/ relaxes muscles.
3/ change patient behaviour about movement.
4/ regains mobility.
5/ regain extension is a key issue in many lumbar problems.
Chris,
We have to see a patient in a more bigger picture and you may see that a local problem is embodied in a complex person.
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 7:58:00 PM
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nari
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I did post a study that demonstrates a central pain mechanism in manipulation but it fell into a black hole...
I agree with january.. the only possible explanation is pain relief from a brain/central response. The same may apply to mobilisations of any kind...if we reject the 'bone out of place' idea, then what is left?
EBM is fine, but does not take into account the subtle and not so subtle nuances of the individual patient with individual problems...and it is here that we have so much difficulty objectively recording changes pre and post-Rx.
Nari
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 8:07:00 PM
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steve
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January,
I think that your statement about evidence-based practice is a little off the mark. It is not about decreasing our ability to think, obviously with the plethora of research available it requires intelligence to identify the best research and use it when it is clinically applicable. Evidence based practice gives us another avenue to evaluate clinical scenarios that attempts to minimize biases and gives us a more objective viewpoint from which to make clinical decisions. Basing treatment solely on previous experience and "expert" clinician advice is subject to significant bias, not that it does not have its own merit and is often the starting point to research studies. Ultimately EBP is an attempt to provide treatment for a patient that is most likely to be effective. For example, in the prediction rule for low back pain the authors have taken a group of individuals with specific measurable qualities and applied a specific treatment to them that I can easily perform in the clinic with good confidence that I am going to improve most (92%)patients significantly more than if I didin't apply the technique. Are you oppossed to using EBP in this type of scenario and why? Is this what you refer to as cook book?
Steve
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Re: Is spinal manipulation working in the suspected area? - March 8, 2005 8:44:00 PM
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january
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Steve,
I said I agreed with EBM but if I'm not a manipulative PT it is only because I wasn't trained to manipulation. Some years ago, I was asking myself if I needed a such training. Now, I will clearly say, No. For many reasons (here two of them):
1/ The most effective technique is the one which uses the least “force” from our part.
2/ The best one is the one that is clearly understood by the patient.
So, I prefer active and responsible patients who have a chance to learn something with us.
About statistics;
I do not know much about stats but I thought that all population fits a Gaussian curve when the sample is enough high. Saying simply that induces that the endings of the curves have low rates. Scientists may call these patients refractory or high sensitive. Actually I do not know a PT/medical study where central average is 92% in a normal sampled population. Reading the references cited, it was clearly stated that the difference was very low six months later. Thus you initial 92% had fused as ice.
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 12:02:00 AM
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childsjd
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The resistance among some to further standardize our care is fascinating to me. Practice variation can be viewed as a spectrum. Complete chaos is on one end, with strict adherence and total intolerance for variation on the other. I am simply arguing that many in our profession are practicing far towards the chaos end of the spectrum.
I have posted a quote from a colleague of mine, Julie Fritz that explains the issue quite nicely.
"If we have no 'standard of care' then we cannot possibly hope to determine if a new model of care, new evidence, some new 'thing' represents an improvement on the standard of care. If tomorrow someone describes a new widget that is proposed to be the best thing ever for patients with LBP and radiculopathy – and even if that description includes expected clinical outcomes, it would be difficult to determine if it really represented an improvement because it would be terribly difficult to presently define – 1) what is current 'best practice' for these patients, and 2) what are the anticipated outcomes of care when large numbers of patients receive 'best practice' care. Every time standardization is mentioned (doesn’t matter which group of medical professionals you are talking about) an immediate concern that gets voiced is innovation will be stifled. The irony of the situation is that exactly the opposite is true. Standardizing a process of care invites critical analysis (more likely with actual data) of how good the results are, what types of patients don’t seem to respond, and what alternatives may exist. When an alternative is identified and attempted its value (or lack thereof) can be quantified against the standard. Without some standard of care, a new alternative is just one more thing thrown into the mix and its relative contribution is very difficult to ascertain.
On the grand spectrum of standardization - - variation we are way, way, way far from the precipice of over-standardization – but we have lived comfortably for a long time as a profession in the morass of being overly variable."
Based on some of the wild and fanciful ideas expressed in this forum (not the least of which is referring to one's personal essays as some level of evidence), we have a long ways to go before our profession could ever be accused of being overly standardized.
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 12:10:00 AM
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childsjd
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One additional point on this idea of practice variation. Practitioners who advocate what appears to be an infinitely detailed and individualized approach commonly use the “patient values and preferences” mantra to support doing whatever they wish. I rarely meet a patient whose “values” or “preferences” conflict with what the evidence suggests is the most efficacious approach.
Although we certainly do not have all the answers, the problem in our profession is no longer a lack of evidence. It's a lack of its integration into practice, especially amongst some who suggest with a degree of seriousness that decision-making based on essays is equivalent to decision-making based on well done randomized trials. My experience has been that there is little hope for these practitioners. Our profession should abandon their ideas altogether (other than perhaps reading for pure entertainment).
John
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 12:47:00 AM
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JLS_PT_OCS
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I think I have reached the pure entertainment stage.
It is allowing me to smile and relieving me of the need to push Sisyphus' stone uphill anymore.
Though my keyboard appreciated the mileage.
J
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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: Is spinal manipulation working in the suspected area? - March 9, 2005 12:47:00 AM
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Sebastian Asselbergs
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John, I am not going to wade into this debate too deeply, but I have to point out that your contention that "I rarely meet a patient whose “values” or “preferences” conflict with what the evidence suggests is the most efficacious approach." - puts you in a rather unique place. It is as unscientific a statement as you accuse Barrett of making.
I value your research highly; it doies not take away from the need to continually examine the deeper models for human movement dysfunction. Please note that I have NOT taken Barrett's course and HAVE moved through the (old) Canadian orthopaedic system. Reading about little issues such as brain modelling, pain behaviours, skin ligaments, cognitive processing, breathing, motor learning, and oh yeah: ideomotor motion, etc etc. have made an impact on my practice.
It does not hurt to look at that stuff more closely. I realize that time is an issue for all of us, but when we deal with core issues such as pain, we cannot leave related materials unread.
And John, please do not mistake the use of the words "specifics of my approach" for a claim of evidence of effectiveness - you state: "(not the least of which is referring to one's personal essays as some level of evidence)" .
Doug, well put.
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Mundi vult decipi
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 1:11:00 AM
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january
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John,
Perhaps I'm a son of Chaos and it is sure that I resist to some authority but I'm in standard practice since 20 years and because the PT treatments aren't limited, fortunately, to spinal manipulation, I keep the choice to choose the best available “recipe” available in my therapeutic arsenal.
I'm not a “marionette” in the hands of my patients. I do not treat “flesh an bones” as you stated but human beings equipped with brains. I learnt that that collection of cells was also responsible of their problems and they had a chance to modulate their health by this mean.
I agree that manip works rapidly in acute back pain, but I'm not sure that brain learnt something! I'm not sure that patient learnt to avoid the cause of their back pain.
We are a community of “mad car repairers” and our “blind patients drivers” are coming to us saying: “Hey, man, my car is out!” and we are systematically replying “Don't worry, guy I take it in charge!”
I think that is time to learn to these “blind drivers” to simply “drive” their cars and give them a "guidebook".
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 1:38:00 AM
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JLS_PT_OCS
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Given the state of knowledge about the causes of back pain (ie we have no idea), the concept that I could actually teach a patient what to do or not to do to avoid back pain smacks of egotism.
I hope when I go to my family doctor for a sinus infection, he doesn't say that he won't give me an antibiotic because my brain won't learn anything about how to avoid the infection in the future. I would think that would make him a quack. Especially since the causes of both are equally uncertain, and established treatments for efficacy exist for both, notwithstanding "reasons why it works".
But here I am pushing that stone again...
We seem to go around and around with the same arguments...
I just need to step aside and let that stone roll downhill...
_____________________________
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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