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Re: Spinal manipulation and pregnancy
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Re: Spinal manipulation and pregnancy - July 27, 2006 3:08:00 PM
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steve
Posts: 470
Joined: May 14, 2003
From: Canada
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jbird,
I think you are actually contributing to the discussion now and I agree that with greater manipulation usage, the likelihood of an adverse event increases. With respect to a fused joint, my gues is if we were considering sacralization, the forces would simply be transferred to the nearest mobile structure based on the McGill studies on the specificty of manipulation (We localize the force to intended joint in the L-Spine about 50% of the time). In the thoracic spine I believe the number one reasons chiros are sued is due to rib fractures and certainly screening for obvious osteoporosis factors will decrease the likelihood of fracture. Again fused joints would most likely transfer forces to the nearest joint as we are accurate around 50% with respect to specificity in the thoracic spine. By all of this, I'm not suggesting that we attempt to manipulate fused joints but rather that manipulators have likely manipulated around a fused joint before and that the research on our ability to detect segmental mobility demonstrates poor reliability. One other subjective thought is that I work on the premise that the pop doesn't matter (Flynn) with respect to outcome so I'm not as likely to "Hit a joint harder" just to get cavitation.
With respect to c-spine manipulation, with unknown risk and no evidence that it is superior to mobilization, I choose not to practice manipulation for the cervical spine.
I believe Alex Brenner has published a nice case study on a patient with a unilateral sacralization and manipulation.
Lehmkuler provides a perfect answer for how to deal with manipulation and pregnancy so that the patient can make an informed decision.
Steve
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Re: Spinal manipulation and pregnancy - July 27, 2006 3:43:00 PM
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SJBird55
Posts: 2438
Joined: May 10, 2004
From: Michigan
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I remember reading Alex's article. It basically kind of substantiates that manipulation doesn't really "work" at the joint level, but that something else has got to be occurring. Of course, Alex didn't address that aspect, he just presented the results of his interventions and the outcomes achieved.
jbird, nice nick by the way... anyways, I believe the difference between chiropractors and manipulation and physical therapists and manipulation is, at least with the way I choose to practice and with what literature suggests, patients being manipulated by physical therapists are not being manipulated forever - in fact maybe 2-3 treatment sessions AND I believe Tim Flynn and Rob Wainner are the ones that say, "move it and move on." It really isn't point blank stated, but in my opinion, if a patient doesn't respond to manipulation after 2-3 attempts or 2-3 treatment sessions, the patient just isn't going to respond and there is no reason to continue. If the patient does respond, again, generally the patient doesn't generally need more than 2-3 treatment sessions because therapy is progressed to more active involvement and activities to increase function.
The question regarding long term benefit is a good one, but 6 months out is actually a pretty good length of time. The cost of physical therapy services and the substantially small amount of risk with receiving physical therapy services seem to be the relevent aspects that long term benefit just isn't necessarily worth the cost of proving the benefit. Long term results of 5-10 years seem to be more common after certain surgical procedures - but there is more cost with surgical procedures, hardware components have failure rates and there are more risks involved to the patient with surgical interventions.
What I really appreciate about clinical prediction rules and about what is being learned about outcomes with manipulation (even though it may be with subgroups of patients) is that I have a pretty solid base of who will respond, the degree of response and the time frame for that response.
I disagree with Diane and Nari somewhat because even though there may be science about pain, in my opinion there seems to be a greater amount of subjectiveness on the part of the clinician and vagueness in the approach they support. For me clinically I'd rather function in as much black and white as possible and have expectations and see them being met. In certain cases, the use of manipulation is "black and white." Why would I want to dink around through trial and error with patients to attempt to get a positive response? I also do not have a lot of comfort when anything is in the gray area. That's just me and my own personal quirk.
Nari... some of us have heard of Moseley... the problem is that it is difficult to obtain full text articles of his work. His work isn't generally published in the journals that we frequently have available through the APTA.
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Re: Spinal manipulation and pregnancy - July 27, 2006 4:14:00 PM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
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SJ
A good post. You have probably made an accurate assessment of Moseley's work not being available in the USA; much of it is in Pain journals and our own journals.
Pain physiology is in the forefront of research at present, and it is most definitely science-based. I have the feeling that the emphasis in the USA and other countries is on dysfunction, in other words, mechanical approaches to pain; it is different to some extent in the UK and here, where pain management is taken very seriously by PTs. As I said before, a different focus.
I can understand discomfort with grey areas, but they are the areas where great things can be discovered, and are being discovered. Phantom limb pain is just one aspect which has undergone a revolution in management. CRPS is another.
I think part of the problem, as suggested before, that many PTs like comfort zones and protocols, and some do not like such restrictions. In the end we all come up with similar results; it is the means that lead to discussions and a bit of furflying. That's OK too. Good for the neurons, mirror and otherwise.
Thanks for an evenhanded post!
Nari
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Re: Spinal manipulation and pregnancy - July 28, 2006 12:48:00 AM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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Nari,
You are correct about Lorimer Moseley. I take back my statement about the anecdotal evidence in relation to patient education and low back pain.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Spinal manipulation and pregnancy - July 28, 2006 9:07:00 AM
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ALICIAPT13
Posts: 95
Joined: December 12, 2005
From: North Syracuse, NY
Status: offline
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I think asking the patient whether or not she would like to try manipulation is a great idea... I would also have this on a signed plan of care from the MD before performing. But what I really want is to be able to say to the MD, your patients with LBP may benefit from spinal manipulation (depending on the CPR variables met). Then go from there...
Robert Wainner actually taught the course I attended and was unclear about specific contraindications... I REALLY like to have concrete contraindications for EVERYTHING I perform. So I was hoping someone somewhere out there could help me out... BUT I guess there isn't anything concrete. Which is understandable. Who would perform a study on the risks of manipulating pregnant women? At best there are some retrospectuve case studies.
Alicia
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