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Re: Look at this validation study guys, worth reading!
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Re: Look at this validation study guys, worth reading! - January 11, 2005 9:17:00 AM
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steve
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Diane,
Give yourself some credit, there is tons of evidence to back neuromatrix theory of pain.
Steve
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Re: Look at this validation study guys, worth reading! - January 11, 2005 9:36:00 AM
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Diane
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Steve, you're right, I said that wrong. I should have said, I'm a non-manipulator and therefore probably always will be treating sub-optimally, working...etc. There is evidence to support the theoretical constructs, but not many studies done in PT ranks specifically, at least not yet, unless you know of some?.. maybe the right questions haven't been asked yet. Lorimer Moseley is an exception, a pain researcher/PT, and exceptional...but he's the only one I know about.
Anyway, still want to know John's thoughts on the matter of persistant pain and any connection that might have to a history of having had manipulation over the years.
Regards,
Diane
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Re: Look at this validation study guys, worth reading! - January 11, 2005 3:25:00 PM
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Jon Newman
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Hi John,
You're right; I was confused when I first posted that original question. I thought, as SJ did at one time, that the non-manipulation group was instructed to move their spine (like the manipulation group) versus stabilize it. As Duffy stated, it probably wouldn't change the results but it's too bad that the experiment was structured this way because we can't know, "weak argument" or not.
I think you are correct in stating that people can feel justified in performing manipulation on this group of people. Although, if we're honest, people seemed to be justified to do it on just about anybody without frank contraindications. Your study is particularly helpful in pulling in the reigns a little. However, I would think that, as a researcher, your ultimate question is to ask why manipulation works. If it didn't work at all, I think we would have abandoned it by now don't you? So the "if" question is a bit uninteresting, at least to me. While I'm sure you would never dismiss the "why" question, I get the feeling from your posts that you're downplaying it, favoring the "just do it" approach.
I think that the manipulation treatment offers much more than the other group. Specifically, it offers, in a psychological sense, to fix something. It requires that you touch the patient and move them in a way to correct what is wrong. I think it is too bad that the other group did not perform ROM and other forms of manual care.
I was thinking what it might be like to participate in an experiment like this...I have back pain and go to see my MD. Is an offer extended to me to participate in a study? What am I told and what do I read at this point? Do I sign something?
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: Look at this validation study guys, worth reading! - January 11, 2005 4:28:00 PM
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Randy Dixon
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Diane,
You say that you will "never" be a manipulator. Is this despite any evidence that shows it to be effective and safe? If so, why would you choose to NOT do something that has been proven to help your patients in addition to what you are doing now? Is it a matter of simply not believing the evidence is sufficient, or is it philosopical or...?
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Re: Look at this validation study guys, worth reading! - January 11, 2005 5:05:00 PM
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Jon Newman
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Steve and Doug,
I was just re-reading something that you both noticed as a characteristic of what I think you both feel is helping the patient. Specifically, a softening of the patient's muscle tonus post manipulation. I've also seen that same characteristic, but without the manipulation part. Perhaps there is something here worth exploring. Perhaps, if your "technique" can produce this change in quality (grossly observable and subjectively confirmed--not likely measurable except for its allowance for improved ROM or decreased pain) then you are on the right path. I would be willing to bet many therapeutic approaches in the context of caring are able to help bring about this important change. Not that softening is the only characteristic we're after but I'm noticing a unifying quality among the numerous approaches to patient care. It also seems relatively easy to explain on a gross level what is happening.
Of course our expectant role in care giving is to know how the story ends before it begins; we'll see if that's possible.
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: Look at this validation study guys, worth reading! - January 11, 2005 6:48:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Hi Randy,
[QUOTE]You say that you will "never" be a manipulator. Is this despite any evidence that shows it to be effective and safe? If so, why would you choose to NOT do something that has been proven to help your patients in addition to what you are doing now? Is it a matter of simply not believing the evidence is sufficient, or is it philosopical or...? [/QUOTE]It has to do with personal preference. I like soft tissue work a lot more. I did learn a few 'popping' techniques over the years, but never developed any great fondness for doing them. Philosophically I am a neuronut, more interested in all the nerves that live in soft tissue and slide through fascial layers, and how they're doing. Plus I really am concerned about inadvertantly increasing pain or decreasing pain threshold with manip, because it happened to me. Anecdotal, I know, study of one... It took a long time and a very different sort of treatment for my formerly perfectly asymptomatic T spine to get over being addicted to the crunch and come back to something approaching comfortable extension on its own again. I had gotten so I 'needed' that little HVLA intervention for my back to feel completely painfree. I must not have been someone who fits John's subgroup of good candidates!
I am concerned about manipulation addiction, nervous system entrainment, and patient dependence in the short term, and increased sensitivity of the nervous system long term. I'm pretty convinced just by having been in this biz for 35 years that manipulation is overkill for the nervous system for most people.. pain relief can happen through so many other interventions. Slow handling. Education. Positional release. Neural gliding. Etc. Why beat up on it? If there really is this subgroup that John has determined actually "need" manipulation as opposed to the many many other subgroups that don't do so well, and its use will be limited, I'll be happy. Then ways might be found to make that pool of patients ever smaller.
$.02,
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Re: Look at this validation study guys, worth reading! - January 11, 2005 7:07:00 PM
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steve
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Jon,
I've queried the same thing - I think likely most manual techniques, be it manipulation, mobilization, massage, fascial release, neural gliding provide the central nervous system with feedback that in turn allows tone to be decreased. This tone certainly is measurable through EMG as Doug points out.
Steve
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Re: Look at this validation study guys, worth reading! - January 11, 2005 7:29:00 PM
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ericm
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While this top down approach to, as someone put it "validate beliefs" about a treatment is well meaning, I can’t help but question its usefulness. Let me see if I can explain, I hope this make sense.
We could take the same population of patients as used in this study and perform the same tests but instead assigning them to manip vs non-manip groups we could give one group red smarties and the other green smarties. If the smarties were administered with all the sincerity and ceremony that is appropriate to such an innovative treatment there is a good chance the group taking the green smarties would have a significant reduction in their back pain :p . This would validate the use of green smarties for anyone who likes to use them and even allow them to predict who will benefit the most from taking green smarties. This would be fine if all we had in our toolbox were red and green smarties. What about the yellow smarties, or the blue ones?
The alternative advocated by Barrett, Jon and Diane in this topic could be thought of as looking at the problem from the bottom up. Wipe away all traditional treatment options and start with a clean slate. You have to then look deeply at pain and its causes and from this level of understanding simple logic dictates what the treatment will look like. My experience in going through this process does not direct me to manipulation, or green smarties for that matter.
Even though we all may view this problem from different vantage points, none of us can doubt each others sincerity. I’m quite sure we all participate in this form of discussion in order provide the best treatments possible for our patients and a step in any direction must be considered as progress. I just feel privileged to read along.
eric
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Re: Look at this validation study guys, worth reading! - January 12, 2005 3:28:00 AM
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Jon Newman
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Hi Diane,
You stated: "Why beat up on it? If there really is this subgroup that John has determined actually "need" manipulation as opposed to the many many other subgroups that don't do so well, and its use will be limited, I'll be happy."
I'll be happy too. My critical questioning is to try to help answer if this subgroup actually "needs" manipulation. I think it is a great study in general. The whole point of reading any study is not only to get what happened but to try to explain why it happened. At least that's what I'm thinking when I read stuff. Without this approach one could use this study to justify not performing a physical exam at all. Take a history, fill out some questionnaires and if these things check out get your manipulation right? I know that this is not being advocated but rather an extreme (but probably too common) use of "evidence" to guide practice. That said, when statements like this are made: "Bottom line is that the failure to use manipulation for at least these patients with back pain is likely synonymous with providing suboptimal care unless someone can demonstrate otherwise", we are in danger of stating that manipulation is better than everything for this patient population, when it was only better than walking and pelvic tilts. It is overgeneralizing the conclusions of the study.
Also, consider this reading:
http://www.butterfliesandwheels.com/badmovesprint.php?num=38
I hope if I ever publish anything that I have the courage to come on a public forum and answer critical questions to the best of my ability like John.
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: Look at this validation study guys, worth reading! - January 12, 2005 6:13:00 AM
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bravocosta
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Greetings to all,
I have a basic question not directly related to manipulation per se, but what good evidence do we have that exercise within the first 2 weeks of an acute episode of LBP has a positive affect on outcomes ? Can search for the reference, remember reading a recent comprehensive study in Australia that concluded that exercise in the first two weeks of an acute low back pain episode actually prolonged pain and recovery time versus advice and a pamphlet with recommendations. Is it possible that sometimes less is more ? Need to read the study, but food for thought.
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Re: Look at this validation study guys, worth reading! - January 12, 2005 9:58:00 AM
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Bournephysio
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Well, I’ve finally read some of the study. It looks very well done and blinded pretty well. The only possibility of bias is the one Eric mentions but this is really reaching. The differences between the groups are not minor. Also remember that there are two important studies. The first is the study that developed the rule; the second is randomized control trial testing the rule. These are based on different patients. The chances that both would support the rule are not very good. In my opinion, this is a really strong study design. Also remember that the authors believe both treatment options to be effective and it is highly probable that some of the treating therapists believed that stabilization would be more effective.
Eric, Lets say we build a treatment from the bottom up. What do you have to do to see if it actually works? You have to do an rct then you are stuck with the same problem you are complaining about. You can not just use logic to determine that a treatment will work because there are undoubtably variables that you did not account for in your theory. You probably have also misinterpreted the relative importance of variables and their interaction. It’s a great way to generate hypotheses, but those hypotheses still need to be tested.
“My experience in going through this process does not direct me to manipulation, or green smarties for that matter.” That shows you why many great discoveries are found by accident.
As for suboptimally treating. a good example (from another thread) is eccentric training for tendinopathy. There is evidence that eccentric exercise is effective at treating tendinopathies. There is no evidence that eccentric exercise is any better than concentric exercise for treating tendinopathy. I can come up with pretty strong biomechanical arguments for why there should not be any difference between concentric and eccentric exercise and the only arguments of why there could be a difference are considerably weaker. So how do I currently treat tendinopathies: with eccentric exercise. It would be “suboptimal” to do otherwise not because I know one is better than the other, but because I know one works but I don’t know that the other works.
Jon, I think that your Jan 11, 8:05 post corresponds with my thoughts quite well.
“Even though we all may view this problem from different vantage points, none of us can doubt each others sincerity. I’m quite sure we all participate in this form of discussion in order provide the best treatments possible for our patients and a step in any direction must be considered as progress. I just feel privileged to read along.”
Well said Eric.
Doug
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Re: Look at this validation study guys, worth reading! - January 12, 2005 10:39:00 AM
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Randy Dixon
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My question is one I thought had already been asked but I'm unable to find it again.
If the manipulation is non-specific, and the production of cavitation is the result of manipulation, wouldn't a person who self manipulated (popped their back) also be able to get the same benefits? Many people, probably most people are able to do this.
I think I remember reading a study by McGill that suggested a difference in reflex response between manual manipulation and that done with a device, do you think that is relevant to the effect?
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Re: Look at this validation study guys, worth reading! - January 12, 2005 3:14:00 PM
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Bournephysio
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Oops, I was wrong. Therapists and patients were blinded on how the patient fit in with the rules. Eric, The bias you mentioned is not possible with this design.
Doug
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Re: Look at this validation study guys, worth reading! - January 12, 2005 3:38:00 PM
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Jon Newman
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Hi Doug,
I think your point is at the heart of EMB thinking right now. Here is a link provided by Matthias on the NOI site:
[URL=http://bmj.bmjjournals.com/cgi/content/full/329/7473/1053?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1105024100282_11770&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=329&firstpage=1053&resourcetype=1]http://bmj.bmjjournals.com/cgi/content/full/329/7473/1053?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1105024100282_11770&stored_search=&FIRSTINDEX=0&s ortspec=relevance&volume=329&firstpage=1053&resourcetype=1[/URL]
(Sorry for the ridculously long link but I don't know how to make it small.)
I want to make it clear, if I haven't enough already, that this is a good study and as the title of this thread states, worth reading.
Clinical decisions are definately colored by the context they are made in. For example, I'm sure surgical decisions require some degree more proof than a theory. Although the theory is where the idea for the surgical procedure comes from in the first place. PT's have more wiggle room for decision making than surgeons typically.
As you know, there is more to clincal decision making than just a research report or your clinical experience would be worthless and your ability to use rational thought can be shelved. I think more accurate than "suboptimal treatment" would be to argue the use of "suboptimal evidence". They are not one in the same if you think about it.
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: Look at this validation study guys, worth reading! - January 12, 2005 3:45:00 PM
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ericm
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Doug, point taken.
Eric
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Re: Look at this validation study guys, worth reading! - January 12, 2005 4:31:00 PM
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childsjd
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Diane:
I appreciate your candor about being a non-manipulator but find it unusual that you would be so willing to ignore evidence that suggests a particular treatment in a specific group of patients is highly effective. It's like a physician saying that they don't use antibiotics to treat an ear infection. The bottom line is that there is no data to suggest that soft tissue mobilization techniques or other strategies that you mentioned can generate 50% improvements in disability in such a short period of time in this subgroup of patients. You state you are more interested in the the patient's underlying nervous system. I would suggest that our #1 focus should be to ameliorate our patient's pain and disability, rather than adhering to a belief system that still largely hinges on theoretical constructs with little basis in clinical science.
Also, the evidence is much less clear regarding the effectiveness of manipulation for patients with chronic pain. There are a few studies, but generally speaking, it probably should not be the focus of the treatment plan. This is another discussion for another day, but many of these patients have significant psychosocial considerations (ie, depression, fear-avoidance beliefs, pain catasrophizing, etc.) that act as obstacles to recovery. Until we appreciate that not all pain is physical and amenable to relief from our "sophisticated" ideas about taking care of the patient's nervous system, we will fall far short of providing optimal care for our patients with chronic LBP. Finally, although I certainly don't advocate repeated manipulation (not for fear of danger, but simply becuase the evidence suggests that less is just as effective), I am unaware of any evidence to suggest some sort of adverse effect from repeated manipulation. Hope this answers your question.
John
John
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Re: Look at this validation study guys, worth reading! - January 12, 2005 5:38:00 PM
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Jon Newman
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Hi John,
Your ear infection analogy is not quite on target. The use of antibiotics has predictive validity AND construct validity making a much more compelling case for the use of antibiotics. That said, it is very nice to finally have a study in PT that demonstrates predictive validity of one of the treatment options we have to offer people. We need more studies like this and it sounds, from your previous posts, that they will be published soon.
I would love to see an effort at studies examining construct validity even though I understand that construct validation, in its entirety, will likely be elusive when it comes to treating painful conditions.
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: Look at this validation study guys, worth reading! - January 13, 2005 2:10:00 AM
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Barrett
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As some of you might imagine I've a lot to say about the discussion so far and will probably do so eventually. As someone who manipulated patients daily for the first five years of my career, trianed others to do so and spent time in the clinic and the classroom with therapists who must be considered foremost in the discipline (Paris, Mennell, Kaltenborn, Grimsby and others), I'm just wondering this morning if a certain "side effect" of manipulation has ever been experienced by those here advocating the regular use of this sort of manual care.
It is this: After your treatment the patient returns to the physician and says, "Ever since that therapist cracked my back I've been much worse." Please note that the patient's veracity and motivation here is a non-issue in that such things vary wildly and we have no way of controlling them. I'm wondering if this has ever happened to anyone else and, if so, how they handled it.
One more question for the John. How much knowledge do you have of the work of Elvey, Sunderland, Breig, Butler or Shacklock? Of course there are many others who've studied and written about the nature of nervous irritation not amenable to manipulation but altered via other means. Does any of it meet your standards?
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Look at this validation study guys, worth reading! - January 13, 2005 2:50:00 AM
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childsjd
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Barrett:
I continue to be amazed by the willingness among some in this forum to give substantial credibility to anecdotal stories about one's "experience" or an event that occurred in "my patient". The minor "side effects" (ie, increased soreness) from manipulation are almost always transient and resolve within 24 hours. This has been repeatedly demonstrated in many studies looking at this issue. The primary "side effect" in the subgroup of patients we found who get manipulated is a substantial decrease in pain and disability.
I have very little knowledge about the the work of the names you mention becuase they very infrquently (if ever in some cases) have published anything in the peer-reviewed literature. Barrett, just because someone has the gift of persuasion or a fancy idea, that doesn't make it synonymous with the truth. I don't mean to get too personal here, but much of the teaching that you and others espouse lacks any resemblance to evidence. Albeit I believe well-intended in most cases, there are many gullible therapists who fall for these fanciful treatment paradigms that lack any credibility whatsoever. Barrett, where is your evidence to support anything that you do.
I challenge you to cite here even one paper published in the peer-review literature (indexed in Pubmed) that offers more than just some esoteric theoretical construct to support. In other words, where are your clinical studies? Your name is auspiciously absent from Pubmed. Not everyone has to publish in the peer-reviewed literature, but those on the "leading edge" of the profession have a reponsibility to teach from an evidence-based framework. Until you do, your efforts will remain on the fringe of practice and be ostracized by the vast majority of practitioners who understand what evidence is and what it is not. In some sense, I apologize for being blunt here, but unfortunately gentle persuasion rarely overcomes a mind that has brainwashed by false teaching.
John
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Re: Look at this validation study guys, worth reading! - January 13, 2005 2:54:00 AM
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childsjd
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Jon:
You are suggesting that understanding mechanisms is essential to make decisions about treating patients. Again, this is just not true. If it were, many millions of patients would not have benefited from the analgesic effect of asprin simply because we didn't know how it worked.
John
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