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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 9, 2005 1:55:00 AM
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january
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Jason,
The example you gave is perfectly out of context but you're so Cartesian! Why flu have such difference in its effects with a similar population? You're denying nocebo and placebo! You refuse that patients may have expectations which differ from yours!
There are now tons of papers saying that LBP is son of stress, poor lifestyle and lack of exercise. There are many papers saying that extension gives space to IVD. There are hundred good ones saying that flexion/sitting is first responsible of our "weak" back.
Just Move!!!
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 2:32:00 AM
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Shill
Posts: 1052
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From: Madison WI USA
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Barrett,
I leave out my name and email address for the purpose of avoiding SPAM. Not a big fan of picking through 400 emails a day to find the 5 that are not for herbal viagra. My first name is often posted, as it was in my post to you. It is Steve. Last name is Hill. PT in Madison WI. Id give you my phone number, but Im on the no call list. Dont much like telemarketers either.
I have read your essays, which are good, you are a talented writer, however, I am not enthused about searching for hidden meaning amongst them, in order to find what I am looking for.
True, your purpose in life is not to satisfy me, but you surely know that credibility and respect in the health care field, comes not only from opinion, but from peer review, and reproducable research. (Is the osteopathic journal article you mentioned available somewhere on your site, and if not, could you provide the title?) Thanks.
It amazes me that you are so quick to belittle those who disagree with you, as well as those who seek to learn more about your techniques. Surely a man of your intellect and experience recognizes that not everyone learns through prose. Reaching those who dont defines the true teacher.
I can read all there is about Melzack, et al, but I want to read about Dorko. He is the one who travels across the country teaching thousands. He is the pioneer of a "new" approach, apart from the "conventional" treatment methods. He is the ground breaker.
_____________________________
Steve Hill PT
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 2:38:00 AM
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Jon Newman
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Personally I see a number of people doing their best to reduce variation by having a coherent theory in which to explain what it is they do and not get distracted about what "technique" it is that got their patient better. For example, Jason and others often equate manipulation with pills and cures for what is wrong despite never knowing what is wrong or why manipulation works. It may just be that the manipulation part of the equation is more than is needed versus the wrong thing to do. Based on my apparently hallucinatory clinical experience it isn't. I have had 2 patients that fit the prediction criteria since this study has been published and both had 50% reductions in pain assessed upon presentation to their next follow up appointment. I had offered one person to see a chiropractor, gave him the study and his oswestry and FABQ results to take to the chiro. He declined and got better with what we did together. The other was fearful of manipulation and was outside the age range of the study. She got better too. This may have suprised her mother who gets manipulated regularly and finds that it works for her. And she's right, there is a study that proves it. Too bad for the others.
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 9, 2005 3:08:00 AM
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chiroortho
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Might I offer two thoughts for your comments?
First, when we manipulate spinal segments, we (at least some DCs) tend to think one-dimensionally. That is, when we apply a mechanical force (thrust), that force affects more than just the joint capsules. It also affects the overlying muscles, fascia and skin, not to mention the musculoligamentous attachments of the segments being manipulated. Any or all of this my contribute to the therapeutic effect, as opposed to attributing the effect solely to stimulation of joint capsule mechanoreceptors. One of the things I teach my conference attendees to do is to think 3-dimensionally, and to realize that there is much more to manipulation than simply applying a stretch to a capsule.
Second, if it is true, as some imply in posts here, that manipulation doesn't accomplish anything really effective or lasting, how do we explain the 92% rate of improvement of LBP that lasts at least 6 months that is effected by the recommended manipulative technique? Placebo? I don't think so.
Lastly, I take issue with those who propose that joints 'misalign'. I suggest that it is the function, the mobility of the joint, that is the primary issue. Vertebral joints allow for some normal 'play', and misalignments in my view are a myth. Some DCs draw lines on radiographs that note spinous process 'misalignments' of as little as one or two millimeters. This is a chiropractic concept that needs to be forever discarded. Our bodies are simply not that fragile, and I have never seen a perfectly aligned spine. Never.
_____________________________
Greg Priest, DC, DABCO
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 3:21:00 AM
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Jon Newman
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Greg,
You state, "Second, if it is true, as some imply in posts here, that manipulation doesn't accomplish anything really effective or lasting, how do we explain the 92% rate of improvement of LBP that lasts at least 6 months that is effected by the recommended manipulative technique? Placebo? I don't think so."
Why wouldn't placebo have a lasting effect in conditions where there is no detectable pathology? And what's wrong with placebo?
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 9, 2005 3:36:00 AM
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JLS_PT_OCS
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Ah, yes, the Cartesian argument again.
I either completely ignore what evidence is available in treatment of my patients and do whatever suits me, or i'm a mechanistic robot PT.
Sad that there are only two points on that line.
It seems that any credible discussion of EBM use among some PTs may never progress beyond paranoid fears of cookbook treatment, anecdotal evidence, personal treatment tastes, and demands for unrealistic mechanistic explanations of any intervention before embracing it.
What's thatI see? I just let that stone roll downhill, past me.
I'm done pushing.
Greg, do many of your colleagues in Chiropractic feel the same as you do regarding alignment issues?
I realize this may be an unfair question, as in the interest of full disclosure I had thought PTs were scientific minded and respected evidence in practice before I came to RehabEdge. Shows you what I know.
Perhaps I'm living in a kind of dreamworld?
_____________________________
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 3:54:00 AM
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Yogi
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Greg, right, spinous proscesses can not be concrete landmarks. But with localized pain to pressure, and malalignment, I would want to be able to localize treatment to that segment, in acute care, because I would want better than 50 percent pain reduction at six months, right?
Doug, you constantly impress me. I do think that misalignment of bony landmarks occurs, and that causes pain in a joint, and that realignment will alleviate the pain. I can say that from treatment done on myself. It was a simple grade 5 mobilization to a transverse process.
But I agree that the muscle, due to a central mechanism (pain modulated reflex), is the difference in muscle properties you refer to holding the malalignment. If that is truly the case, manipulation (affecting the joints) may be needed only if treatment to the reflexive muscle hypertonus (spasm) is ineffective. As I've mentioned before, that boils down to the old pain spasm pain cycle. In my opinion, treatment to the hypertonic m. is most effectively Strain/Counterstrain. Unfortunately, there is no one dedicated enough to S/Cs to duplicate the Childs, et al study yet. If I was seeing that type of clientele, I would learn the Flynn manip, and use it if needed, as a last resort (as I always used any other Grade 5 mob.)
Jan, pelvic tilts and clocks are particularly effective in affecting tone, (NDT mobs, is how they were taught) and even in non-symptomatic people really increase spinal flexibility.
Got to go, Thanks again Doug, for your well-reasoned and articulate posts.
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 4:45:00 AM
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Bournephysio
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Jon: subluxation theories (at least for the spine) have been discounted since before I was a PT. Likewise neural theories such as endorphin release have been proposed since before I was a PT. These are not new.
Integrating current research and clinical experience to develop new theories and testable hypothesis may or may not be ebm but it is definitely Science.
Nari, I haven’t forgotten your reference. I haven’t had time to read it. The effects of mechanoreceptor input have to be central. I think it most likely a combination of spinal and brain but almost definitely brain.. There is also evidence from Wright that mobilization has its effect through central serotonergic pathways.
January: “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.” Don’t forget that these patients received spinal stabilization exercises after the course of manipulation and rom exercises during. Manual therapy research has almost always shown temporary benefit. There is a strong trend in current studies that manual therapy with exercise is much more beneficial than either alone. I would say the trend is so strong that it would be pointless to do a study with a pure manual therapy treatment.
Greg: “It also affects the overlying muscles, fascia and skin, not to mention the musculoligamentous attachments of the segments being manipulated.” Exactly, the response from these has to be from mechanoreceptors whether they be joint receptors, muscle spindles, golgi tendon or what have you but it is a mechanical stimuli. I should have clarified that considering manual therapy’s fascination with joint mechanoreceptors. I believe that some of my course notes have a couple of pages on joint receptors and a paragraph on spindles.
Thanks Yogi and Sebastian.
Doug
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 5:40:00 AM
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Diane
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I'm being a fly on the wall... I think a bit of sense is being made here.
A chaos treater, who considers all layers when treating, outermost ones first..,
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 6:42:00 AM
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Jon Newman
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Thanks Doug,
I agree.
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 9, 2005 7:06:00 AM
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january
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Jason,
Saying that you're a Cartesian guy is not pejorative but just means that you seem to have squared ideas and definite values in your replies.
Maybe you're missing something??
I said that I'm not doing manipulation because I'm not trained to and because in counterpart I'm using a kind of Strain/Counterstrain technique that seems more effective as Yogi told us. The choice was easy for me: use a technique that I do not know or use the one I know that seems less aggressive.
Doug, just added some words!
[QUOTE]Greg: “It also affects the overlying muscles wired to brain, fascia wired to brain and skin wired to brain, not to mention the musculoligamentous attachments wired to brain of the segments being manipulated.” Exactly, the response from these has to be from mechanoreceptors wired to brain whether they be joint receptors wired to brain, muscle spindles wired to brain, golgi tendon wired to brain or what have you but it is a mechanical stimuli wired to brain. I should have clarified that considering manual therapy’s fascination with joint mechanoreceptors wired to brain. I believe that some of my course notes have a couple of pages on joint receptors wired to brain and a paragraph on spindles wired to brain.[/QUOTE]
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 9:39:00 AM
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JLS_PT_OCS
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Jan,
I'm not offended. As others can attest, this label has been tossed my way before. It doesn't bother me. Depending on the opinions of those who toss it, I consider it a compliment.
And thanks for using the word "pejorative" in a sentence, don't see that too often.
:)
It is the overwhelming opinion of researchers in our field that there is significant evidence that tells us what is effective for many patient complaints we treat. My "values" and "ideas" seem as "squared" as practioners and researchers believe the evidence to be.
It is now becoming clear to me that there are many people who will willfully disregard this evidence, for a variety of reasons. I think my fervor in attempting to debate the issue was matched by my astonishment that anyone could or would take such a position in the face of such convincing evidence. Now, I have just plain run out of fervor as the reality of the issue begins to descend upon me.
My astonishment has changed to disappointment, and my fervor has changed to acceptance.
It has truly been an education for me, for I thought everyone else was trained scientifically as I was, and paid as close attention to evidence as I did, and modified their treatment approach in response to new evidence as I did.
I really thought I was nothing special in the Physiotherapy world. So I guess in that way, it's been a happy discovery that I seem to be on the cutting edge. Still being convinced of my own mediocrity makes the cutting edge seem a bit duller than I had hoped it was, in our profession, at this time in history.
My "wired to brain" values and approach still are the same: most effective treatment for my patients.
Sometimes such wires need to be cut, and the beauty of EBM is that it sometimes cuts them for me, and replaces them with new ones. The problem in my view is with those whose wires remain protected from this process.
Clearly I cannot add anything further to the debate, as to restate my points seems like a waste of others' time.
I thank everyone for the debate and their time and effort.
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 9, 2005 12:39:00 PM
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Barrett
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Before Rehab Edge, before the Internet, heck, before disco died, I spent years working alongside Rocabado and Paris, I taught many courses with Grimsby and Kaltenborn, I went to Canada and treated patients in Fowler’s clinic, sat for hours with the late David Lamb and argued about the significance of small upper cervical motions. Every week I get a personal letter from Joe Kahn, the father of electrotherapy and my good friend.
I do not practice in the same way that any of these giants in our profession do or once did, and, take it from me, none of them practice as the others do.
Still I never heard any of them suggest that there was something fundamentally wrong with the thinking in any of the others. I never heard anyone say that others were “unscientific,” they didn’t look bemused at other’s ideas, shake their heads and conclude that they were hopelessly deluded and should just be ignored-and none of these men said that they were somehow “ahead” of the others, they just worked constantly to know more.
They understood the individuality of the patient in their hands and they respected the fact that their hands were attached to yet another individual with a unique perspective. They shared a passion for providing better care and little else.
Remembering this, I almost yearn for disco.
_____________________________
Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 1:20:00 PM
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nari
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Barrett
It also reminds me of something the scientist John Gribbin wrote at the end of a book - and these guys are of a high calibre with respect to research EBP...
Can't recall his exact words, but his colleagues and 'gurus' and he himself work in the field of science because they love its adventures, sense of discovery and something like serendipity; they considered it a nuisance to 'have to publish', but were in the field for the love of it, not for its stolid purpose of proving someone else is wrong and they are right.
That should be what we are about.
Nari
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 6:26:00 PM
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Randy Dixon
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Jason,
I agree with most of what you say on this forum, I even agree with a lot of what you say on this subject. There is a point I want to bring up though. You say that you feel you are on the cutting edge because you practice what you consider to be EBM. In my opinion, your entire argument has been that you are NOT on the cutting edge, that you are following the well trodden path with proven outcomes. I would argue that those who are following other paths, CBT and neurological influences are closer to the cutting edge. The burden on them is to prove that not only do they have theory but that those theories hold true in practice.
I believe Dr. Childs makes a good point. We can't compare techniques if we don't present evidence of efficacy. Currently, manipulation and stabilization exercises are the only two techniques which have known efficacy. This doesn't make them the best, only the best known and documented. They can now serve as a baseline to compare other approaches to.
I believe in research studies and constant reassessment of what we do, but over time I have seen many good studies and best practices change over time, then change back. This is true in all fields, not just PT. I have also seen overwhelming personal experience contradict what the research says. You can either choose to ignore everything you think, feel, and see, or you can choose to believe the research is flawed or in error. Usually I try to reconcile the two.
An example, when I was 18 I took over the family gardening from my Dad. He told me not to plant the cucumbers near the cantaloupes because they would cross. Well, I checked it out and found out that it was an old wives tale. The two plants aren't even in the same genus, much less the same species. It was a FACT that they couldn't cross. So after relentlessly teasing my Dad about being a superstitious Okie, I planted them together. I got Cucaloupes.
My Dad never said a thing, but I would sometimes catch him looking out at the garden and chuckling.
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 7:03:00 PM
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Synergy
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This thread seems to have taken a different route since my last post. The latter posts have dealt more with why some opt to abstain from EBM secondary to either a 'comfort zone' issue or 'lack of knowledge/training' rather than provide their theories for the efficacy of spinal manipulation (or lack thereof). Being a new grad in this field, I cannot see why some of us here won't attempt manipulation, in light of recent evidence (i.e. Childs CPR).
I'll perform any technique if I feel it's been proven to provide good results to a patient population. Sure, I still maintain that I employ various other techniques, but if I find that a patient of mine fits 3/5 requirements for manipulation, that's exactly what I'll do, barring any contraindications of course. :)
This debate has been ongoing on other threads and I imagine it will continue to do so. It is our nature as 'scientists' to explore any and every domain necessary to come up with what we think is a valid theory or technique to improve a patients condition. It appears to me that Child's study has done just that and some here won't so much as bat an eye and give it a shot or admit that it truly is effective.
Being so wet behind the ears, I suppose I am more malleable than most here and I'm trying to get and remain on the 'right' path (whatever that may be). EBM is seemingly the narrow path, but it will be the one I choose to follow. :)
Enjoyed your example Randy! :D
_____________________________
Chris Adams, PT, MPT
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 7:09:00 PM
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steve
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Randy,
Absolutely brilliant post.
Steve
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 7:31:00 PM
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Alex Brenner PT MPT OCS
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[QUOTE]My astonishment has changed to disappointment, and my fervor has changed to acceptance[/QUOTE]Jason,
This is where I currently am too.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 7:33:00 PM
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nari
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Randy
I endorse what Steve is saying above.
I do not like to feel limited to any two procedures and cancel the other ones with good outcomes, but without evidence.
That, to me, does not equate with better practice.
Nari
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Re: Is spinal manipulation working in the suspected area? - March 9, 2005 7:48:00 PM
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january
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Randy,
I enjoyed your reply
and Chris, definitely, it wasn't the question about EBM where we agreed all (with some variations) but an unique question about the localisation of effect, semantic and science.
The definition of spinal manipulation is simply inaccurate since it was affirmed, there, that we haven't any proves that confirms a movement/change of the suspected joint/structure. Nobody brought a proof in that way (but it is quite impossible!)
The other debate was about pragmatism and science.
1/ if a technique works without a theory then future adaptations are difficult.
2/ if a theory works, without a study, then the theory fits the facts, even not yet validated and remains adaptable and doesn't mean that it is inneffective!
The pure pragmatism is far from science since it doesn't bring a theory to explain the results.
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