|
|
Re: MD's story on misdiagnosis: How Doctors Think
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 6:59:00 AM
|
|
|
proud
Posts: 944
Joined: March 22, 2006
Status: offline
|
Buddy,
I sent you a PM.
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 10:37:00 AM
|
|
|
TLB
Posts: 353
Joined: September 13, 2002
From: Arizona
Status: offline
|
[QUOTE] if they had 2 PTs and 2 DCs working there, how would that be any different from another hospital that had 4 PTs working there?[/QUOTE]The 2 PTs would be busy getting your hotpacks and e-stim ready for your patients and addressing you as doctor so and so, "is there anything else I can get you."
I keed, I keed
_____________________________
Todd
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 10:48:00 AM
|
|
|
SJBird55
Posts: 2438
Joined: May 10, 2004
From: Michigan
Status: offline
|
Buddy... ginger is in Australia. I don't believe that he has the same billing or procedures as we do in the states.
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 10:51:00 AM
|
|
|
steve
Posts: 470
Joined: May 14, 2003
From: Canada
Status: offline
|
Very interesting thread.
I think before we assume that orthopods are diagnostically performing poorly I would read the study comparing PT knowledge level with GPs and other physician specialists by Fritz et. al. Orthopods scored the highest. I would also suggest that much of orthopaedics diagnostically is "Murky water" where theories behind pain generators abound but gold standards for diagnosis are few. Think of one of the most common conditions - low back pain. We are just beginning to get evidence for reliable classification of nonspecific low back pain. I think if we were to look back at our ability to "Diagnose" as PTs or DCs that many of the patients are given explanations that lack reliability or a gold standard and are only a theoretical entity.
Even in the case where Dr. Groopman states that only one physician took the time and got the diagnosis "Right", how much do we actually know about the reliability of scapholunate instability as a diagnosis? A medline search of the term "Scapholunate instability diagnosis reliability" turns up two results. The surgery itself is also inconsistant with its long term outcomes.
With respect to the duplication of services Marc, I think based on what we are allowed to do in Canada, an evidence based physio and DC would practice in a similar manner because they would be making decisions based on the same body of literature. For some reason this similarity becomes a contention between the professions.
Proud brings up the point of how much training do you need to improve outcomes with manipulation and this should not be confused with mastery of manipulation. There is some pretty good research that being instructed for a very short period of time in manipulation with very specific criteria for manipulation can dramatically improve outcomes. I think this suggests that likely outcomes from manual therapy are not entirely influenced by the proficiency of the therapist performing the manipulation but rather based on specific patient characteristics identified through the examination. It may be that the master clinician has superior outcomes not based on his ability to provide an intervention competently but rather picking up on cues/patterns both consciously and subconsciously that guide how they will provide the intervention, if that makes any sense. It certainly begs the question of how many techniques are really required to obtain optimal clinical results with manual therapy and how much practice is needed before these techniques are employed clinically.
I would suggest both the PT and DC community have been guilty of placing too much emphasis on the technique of intervention rather than finding reliable indicators to identify who is most appropriate for the intervention.
Steve
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 11:34:00 AM
|
|
|
nari
Posts: 1568
Joined: November 14, 2003
From: Australia
Status: offline
|
Steve
Well said.
A technique is only as successful as the time taken to assess the person's characteristics, both physical and nonphysical presentations.
Nari
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 11:51:00 AM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Sorry guys, looks like I accidentally planted a bomb! BAM!
I appreciate how we have been able to keep the tone of this conversation respectful; it really shows our true colours as professionals and clinicians. Let me address some specific points that were asked
1) I was taught SMT in Year 1 at school (CMCC). I learned about 10 adjustments, mostly thoracic and lumbo-pelvic. I've heard now that its gone up to about 15 or so. Over the course of the 4 years, there was probably 100 different types of manipulations (extremity and spinal) that were taught. The more variety of adjustments you have in your tool bag to accomodate the patient the better. Life isn't one-size-fits-all, and similarly manual therapist should be able to modify/adapt their protocols to a given patient/case. Anywho, in Year 3 our technique class incorporated soft tissue training too, although most of my class took active release techniques before we entered clinic. STM is now taught in year one with manipulation.
2) I agree 100% with Steve's post. Our diagnosis professor, an MD, said that error rate of clinical diagnosis is likely close to 50% for all professions. Without the help of imaging, labs and the expertise of other professionals, clinical diagnosis is a misnormer and should only really be clinical impressions at best.
3) With respect to Proud's point, I fail to see how the principles and neuroscience behind motor learning of a skill would not apply to SMT. For example, if someone has been playing squash for 4 years, and then someone one weekend decides to take up the game, would you assume that the new player is "better" or even "equal" to in skill/mastery than the more experienced one? After all, squash is all only about hitting a ball between lines right? Sounds easy enough? Steve hit the nail in the head, mastery is where it's at. And Sebastian is totally right, if he's being doing SMT since I was 3 years old, I can pretty much guarantee he's a better adjuster than me. But, as a whole, I think its a stretch to say that the profession of PT is equally adept at using SMT as the DC profession, at least at this point in time. There will always be exceptions, and since my class at CMCC was the first class ever with more females than males (90 vs 70) it's going to be interesting if these physically smaller women can get the required speed/force to manipulate some of the bigger guys. That's another ball of wax entirely, I suppose.
I think that our respective professions are at a cross-roads. What is the difference, clinically, between a PT that does SMT ("chiropractic?") and a DC who does STM and general exercises? My patient asked me this the other day saying what the difference was and I was hard pressed to answer it carefully. I work with PT's, DC's and RMT's and I frequently refer to our PT for a complete rehabilitation programme and defer to his expertise. He's recently referred a few patients to me for my expertise which is manual therapies. It's a two way street.
Another point that I think is worth mentioning is that a lot here seem to think that manipulation is definitely non-specific. Are we referencing my professors, Ross and Bereznick? How many studies have come out to support this? I was a subject in that study. It said that lumbar SMT, generally was non-specific, (46%) but as you moved cranially specificity increased. I also remember that there was one DC there who had 95% specificity with his adjustments and fittingly enough, he was the best technique tutor. The DC that adjusted me was a relatively new grad (3-5 years out) whereas our Dr. Ruhr had 25 years+ experience.
The point is, that specificity of SMT to the lumbar spine is never likely going to be a cut and dry thing. Some manipulators are more refined than others, some patients may be cavitate much easier than others and you "zipper" them, on so on.
Ginger:
I don't pass off myself to be a "Dr" other than a doctor of chiropractic. Optometrist, and dentists are also doctors and yet you don't hear anyone asking them to drop the the Dr. from their business card. I have 8 years of university education, which is universally considered the academic threshold to be able to use the title. Also, although I only clinically deal with NMSK issues, I still have a lot of "medical" knowledge from all the non NMSK diagnosis classes I took. If you can honestly tell me that your training included hard core "medical" sciences and could confidently know what lab tests to order forliver pathology, for example, (ALP, AST, GGT, etc..) than there would be true duplication.
To be 100% honest with you, the CMCC programme positions us to be some kind of MD-PT hybrid --we are manual therapists first and foremost, but also have a lot differential diagnostic skills in non MSK. I'm not advocating that I'm like a MD, I'm not, but Proud's implication that I'm essentially redundant and useless in the big picture is unfair.
Anyways, sorry for the long winded reply, I hope I haven't stepped on any toes, I'm not trying to.
Marc.
PS: Have you guys read the study whereby SMT has an anti-inflammatory effect? Was done by my immunology prof at school. JMPT, Jan (I think) 2006. Injeyan et al. Good stuff. PM me if you would like to see it.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 11:56:00 AM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Sorry guys, looks like I accidentally planted a bomb! BAM!
I appreciate how we have been able to keep the tone of this conversation respectful; it really shows our true colours as professionals and clinicians. Let me address some specific points that were asked
1) I was taught SMT in Year 1 at school (CMCC). I learned about 10 adjustments, mostly thoracic and lumbo-pelvic. I've heard now that its gone up to about 15 or so. Over the course of the 4 years, there was probably 100 different types of manipulations (extremity and spinal) that were taught. The more variety of adjustments you have in your tool bag to accomodate the patient the better. Life isn't one-size-fits-all, and similarly manual therapist should be able to modify/adapt their protocols to a given patient/case. Anywho, in Year 3 our technique class incorporated soft tissue training too, although most of my class took active release techniques before we entered clinic. STM is now taught in year one with manipulation.
2) I agree 100% with Steve's post. Our diagnosis professor, an MD, said that error rate of clinical diagnosis is likely close to 50% for all professions. Without the help of imaging, labs and the expertise of other professionals, clinical diagnosis is a misnormer and should only really be clinical impressions at best.
3) With respect to Proud's point, I fail to see how the principles and neuroscience behind motor learning of a skill would not apply to SMT. For example, if someone has been playing squash for 4 years, and then someone one weekend decides to take up the game, would you assume that the new player is "better" or even "equal" to in skill/mastery than the more experienced one? After all, squash is all only about hitting a ball between lines right? Sounds easy enough? Steve hit the nail in the head, mastery is where it's at. And Sebastian is totally right, if he's being doing SMT since I was 3 years old, I can pretty much guarantee he's a better adjuster than me. But, as a whole, I think its a stretch to say that the profession of PT is equally adept at using SMT as the DC profession, at least at this point in time. There will always be exceptions, and since my class at CMCC was the first class ever with more females than males (90 vs 70) it's going to be interesting if these physically smaller women can get the required speed/force to manipulate some of the bigger guys. That's another ball of wax entirely, I suppose.
I think that our respective professions are at a cross-roads. What is the difference, clinically, between a PT that does SMT ("chiropractic?") and a DC who does STM and general exercises? My patient asked me this the other day saying what the difference was and I was hard pressed to answer it carefully. I work with PT's, DC's and RMT's and I frequently refer to our PT for a complete rehabilitation programme and defer to his expertise. He's recently referred a few patients to me for my expertise which is manual therapies. It's a two way street.
Another point that I think is worth mentioning is that a lot here seem to think that manipulation is definitely non-specific. Are we referencing my professors, Ross and Bereznick? How many studies have come out to support this? I was a subject in that study. It said that lumbar SMT, generally was non-specific, (46%) but as you moved cranially specificity increased. I also remember that there was one DC there who had 95% specificity with his adjustments and fittingly enough, he was the best technique tutor. The DC that adjusted me was a relatively new grad (3-5 years out) whereas our Dr. Ruhr had 25 years+ experience.
The point is, that specificity of SMT to the lumbar spine is never likely going to be a cut and dry thing. Some manipulators are more refined than others, some patients may be cavitate much easier than others and you "zipper" them, on so on.
Ginger:
I don't pass off myself to be a "Dr" other than a doctor of chiropractic. Optometrist, and dentists are also doctors and yet you don't hear anyone asking them to drop the the Dr. from their business card. I have 8 years of university education, which is universally considered the academic threshold to be able to use the title. Also, although I only clinically deal with NMSK issues, I still have a lot of "medical" knowledge from all the non NMSK diagnosis classes I took. If you can honestly tell me that your training included hard core "medical" sciences and could confidently know what lab tests to order forliver pathology, for example, (ALP, AST, GGT, etc..) than there would be true duplication.
To be 100% honest with you, the CMCC programme positions us to be some kind of MD-PT hybrid --we are manual therapists first and foremost, but also have a lot differential diagnostic skills in non MSK. I'm not advocating that I'm like a MD, I'm not, but Proud's implication that I'm essentially redundant and useless in the big picture is unfair.
Anyways, sorry for the long winded reply, I hope I haven't stepped on any toes, I'm not trying to.
Marc.
PS: Have you guys read the study whereby SMT has an anti-inflammatory effect? Was done by my immunology prof at school. JMPT, Jan (I think) 2006. Injeyan et al. Good stuff. PM me if you would like to see it.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 12:55:00 PM
|
|
|
ginger
Posts: 660
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Marc , good morning, The physiotherapy courses in both new zealand and australia do include aspects of pathology, histopathology, so called medical baselines etc ,very much the same as is so for chiros here. The direct comparisons in terms of years spent at university don't work between our systems here and yours however. We have a four year degree , which in contact hours is the equal of those for a five year chiro degree. My concerns about the doctor tag is that it is confusing for the public and sets a tone of one upmanship that is not helpful to chiros as a group. When the decision was made to adopt this title in Australia , there was a certain amount of " well, if you won't allow us into hospitals , we''ll just be doctors too , nyaa nyaa".
While this remains so there is very little likelihood of the current system admitting chiros into public hospitals as participants.
Our degrees are very similar in baseline sciences, also similar in the periods spent aquiring manual skills. Physios do get a much wider spread of patient types to learn from and ultimately treat as students.
Our professsions are different. There is no doubt from my contacts with hospital based physios that MSK skills vary enormously. There are plenty I would not employ, many who belong , as it were, in rehab settings, others who flog old ideas and outdated methods knowing no better.
The willingness I percieve in yourself Marc to explore and consult, to reach out and consider alternatives I have seen very rarely in Aussie Chiros. Many it seems are locked into the subluxation/manip paradigm , which serves their bank balances while not serving their clients .
I'm happy as an individual to work shoulder to shoulder with any therapist who displays your kind of appreciation and open mindedness. I have no therapeutic secrets I won't share, we all benefit when the community gets together and talks plain english about the what, the how and the when. I look forward to further considered comments from you .
Cheers
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 2:10:00 PM
|
|
|
proud
Posts: 944
Joined: March 22, 2006
Status: offline
|
Marc,
I am not really sure but I think you missed the key points in Steve's post( Steve can clarify if I am wrong). I gather from his post that he was NOT suggesting mastery over a "technique" is paramount but rather mastery of the clinicians ability to digest the information and apply the appropriate technique based on characteristics. Nothing to do with mastery over a technique. Honestly virtually none of our techniques really require mastery. The mastery is knowing when to apply what technique.
I gather it is your impression that manipulation requires extensive time and mastery to be effective? Squash requires much much more of our human body than manipulation. I fail to see the similarities there but I do understand where you were heading. I disagree but that is a philosophical difference and we are both not going to change on that so....respect.
Secondly, with regards to duplicity of service, although I am a PT and feel strongly that PT's are heading in all the right directions for excellence in NMSK dx and management, I would not claim PT's have or deserve that title as things stand now. The competition from evidence based DC's is healthy and if events unfold such that they emerg as the superior provider then so be it. And certainly both can be excellent at the same time.
But at the end of the day, as someone involved in healthcare, I see far too many flaws with how NMSK is currently managed. Just too many hannds in that cookie jar to manage things effectively. I stand by my feeling that the starting point to remedy this problem is to identify one acountable professional expert. From there standards within that profession can be established and regulated. I am certain that this is what the future will hold.
Thirdly, with regards to your question regarding specificity, a great article was written by Peter Huijbrets et al on this topic with literally tons of references. Not sure how you could get a copy.
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 4:01:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Proud,
I appreciate your response and hear where you are coming from. Clinically determing when/who/what time SMT is of prime importance, but it's my hunch that as the mechanisms of SMT become better understood, the more broad it's delivery will be. Until that point I will still use for spine-related NMSK issues on a case by case basis, however as the paper by Injeyan et al. suggests, there is potentially a lot more benefit to SMT than simply pain relief, improving ROM and decreasing muscle spasm. Ironically enough this almost validates some of the wellness claims by the fringe elements within my profession, but I do not wish to open that pandora's box for now.
Regardless, I am optimistic that there can be peaceful, complementary and productive co-existence amongst our professions, even when the extended class/advanced status arrives. There are only 2 chiro schools in Canada and 14 PT schools, so I really don't see how much of a threat we could ever really pose. I have access to U/T libraries so I'll track down the Huijbrets paper. Thanks for the reference.
M.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 4:18:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Ginger,
Thanks for the comments. I'm confident that my generation of chiro's from Canada are much more like myself, --middle of the road, team players, however it's easy to get on the defensive when your profession has historically been attacked from all sides. I'm hoping Canada continues to raise the bar and high ground for DC's, and their role in mainstream health care, but I accept the fact that we could always be on the outside looking in. For the record, I have a few classmates in Oz right now and they are very well received by the DC's down there as we have a reputation of being very good clinicians. Regarding subluxations and stuff, is that the norm in the teachings at RIT and Macquerie or is that simply a product of a bygone era or schooling at another country (NZ) which still adheres to the subluxation model. Shame.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 4:40:00 PM
|
|
|
ginger
Posts: 660
Joined: February 26, 2005
From: Melbourne Victoria
Status: offline
|
Marc, I do realise this has gone off topic , but it is so refreshing for me to have a conversation with a chiro who is not attached to the same old subluxation story. It is beyond my ken to know the current status of chiro teachings here in any detail , but from what I hear it seems subluxation theory is still the basic framework taught to undergrads here.
It may take a generational change to shift that.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 5:20:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Ginger,
I agree with the generational shift... It's going to take a bit of time for my generation to supplant the older guys who seem to cling for dear life to that model. In fairness though, a lot of them use the 'word' subluxation but they mean it as synonym with vertebral joint dysfunction and are not implyiing that these 'subluxations' cause organic disease. I would say that they are more wellness inclined (meaning SMT prone) than grads from my era, but there are a few studies now which suggests that maintenance SMT can prevent exacerbations/recurrences of LBP. I think the author is Descarreaux in JMPT.
I was thinking of starting a bulletin board similar to this and SS primarily for DC's but manual therapists in general but I don't have the financial wherewithal at this point to do it. For now, we are kind of stuck in the abyss, but it would be nice to find an educational forum on the web we could call home and give a voice to evidence-based chiropractic practice. The 'other guys' get too much airtime!
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 5:35:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Ginger,
I agree with the generational shift... It's going to take a bit of time for my generation to supplant the older guys who seem to cling for dear life to that model. In fairness though, a lot of them use the 'word' subluxation but they mean it as synonym with vertebral joint dysfunction and are not implyiing that these 'subluxations' cause organic disease. I would say that they are more wellness inclined (meaning SMT prone) than grads from my era, but there are a few studies now which suggests that maintenance SMT can prevent exacerbations/recurrences of LBP. I think the author is Descarreaux in JMPT.
I was thinking of starting a bulletin board similar to this and SS primarily for DC's but manual therapists in general but I don't have the financial wherewithal at this point to do it. For now, we are kind of stuck in the abyss, but it would be nice to find an educational forum on the web we could call home and give a voice to evidence-based chiropractic practice. The 'other guys' get too much airtime!
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 5:53:00 PM
|
|
|
proud
Posts: 944
Joined: March 22, 2006
Status: offline
|
Marc,
Just a couple of points:
1. 14 PT schools but I would guesstimate that one third of the graduates go on and work in MSK. And even less 'specialize' in orthopeadics. Many hospital based PT's are forced into rotational positions such that they become more a generalist rather than a specialist. I think this is what you are witnessing in that T.O. hospital. Of course it is possible for a hospital based PT to become specialised orthopeadically, I have known a few and they are awsome. But it's more rare. So the numbers in terms of delivery of >EFFECTIVE> NMSK care is lower than it would seem based on 14 schools.
2. Pain has so many interesting facets. Modulating pain results in some suprising effects both peripherally and centrally. But that is a whole other area for discussion. Check out the EIM blogs under the "pain" header for some interesting debate.
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 7:04:00 PM
|
|
|
drbuddy
Posts: 429
Joined: July 30, 2005
From: Pennsylvania
Status: offline
|
Marc,
I onced asked a professor at NYCC how we can possibly advance chiropractic when many of the oldtimers cling to the subluxation (one cause, one cure) theory, and of those it is impossible to reason with them.
His answer... "One funeral at a time". Quite a morbid answer, but probably also the right answer.
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 8:00:00 PM
|
|
|
steve
Posts: 470
Joined: May 14, 2003
From: Canada
Status: offline
|
Marc and Proud,
Proud is right - I was trying to point out that the mastery is in appropriate patient selection for the intervention based on reliable research. The number of techniques and the complex models upon which to apply them are typically based on faulty theoretical models that have been unable to adapt to changing evidence on why spinal manipulation is effective.
Marc, with respect to specificity, you point out that manipulation is effective (And probably most of the other manually and even verbally driven interventions) due to neurophysiological changes. If changes occur secondary to neurophysiological effect(I believe Walter Herzog and Tony Wright have dne significant research in this area) doesnt that suggest that the intervention will be multisegmental in its very nature? I would also add that the significant research identifying our inability to identify monosegmental lesions and further research identifying that we are not accurate to a specific segmental level with manipulation as further evidence to discredit specificity of treatment. There have also been a couple of interesting studies that compared randomly generated manipulation versus therapist chosen technique and level - all patients significantly improved although there were no differences between the two groups.
I have a suggestion for you Marc - try a George Kastanza "Opposite week". Identify what you believe is a specific lesion and then manipulate the opposite side or a couple of levels above or below. The results may surprise you.
Steve
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 8:41:00 PM
|
|
|
Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
Status: offline
|
Steve, Proud (real name?)
I agree that mastery of determining the application is important (the clinical science) I'm also saying that mastery of delivery is equally important (the clinical art) Let me further explain.
1) the more you manipulate, the safer your manipulations get. Your motor skills, in terms of velocity and force get highly refined. You also learn to know, instinctively even, what is going to cavitate and what itsn't. You adjust accordingly. (Pun kinda not intended). The end result is a safer adjustment that is patient specific.
Technique matters, guys. Do those here who use SMT clinically also receive it, either for clinical benefit, maintenance, or just practice? Do you not feel that it's clinically important to be on the receiving end of the treaments you're providing so you get a better understanding and appreciation of it? Motor skills, whether or not its SMT or sports require biofeedback to improve. I'm curious to hear your responses.
Trust me, I've been crushed by some bad adjustments in in chiro school, and although I cavitated "pop", I felt worse than before the adjustment. SMT applied correctly will have a positive therapeutic/neurophysiological effect. Performed incorrectly, it will be detrimental. An analogy could be that Wayne Gretzky and Dave Sememko were both hockey players, but no one would question who was the most effective once he mastered the game.
Regarding specificity of manipulations at monosegmental joints, I can tell you from personal and clinical experience that the more cavitations the greater the therapeutic effect in terms of immediate pain relief. By specificity I'm implying a specific amount of force at an area that that hypomobile segment(s) acts as fulcrum. The neurology of the spinothalamic pathway and allows that nociceptive signals can enter segmentally and 2-3 segmentals above/below. Hence SOME pain relief even if you miss your target. The descending inhibitory system is involved too, which is also why you can get a more global than segmental neuromodulation of pain. So, the study makes sense, but I don't think the right question was asked and more pertinent data obtained.
It wil be interesting to see studies looking quantifying, an extent, the neurophysiological effects of SMT as a function of number of "pops/cavitations." I wouldn't be surprised if there's a strong correlation and I bet this is found within the next 2-3 years.
Also, lets keep in mind that the cervical, thoracic and lumbar spine have different mechanics and unique anatomy properties which means non-specific in one area of the spine doesn't necessilary mean non-specific in another. My adjustments in the cervical spine seem to be much more specific than the lumbar spine. And they have to be, too, especially considering the delicacy of the C0-C2 area.
I've also read that study on c/spine manips at a random level, but we need a bigger body of evidence to state conclusively that this is so. Besides, the number of cavitations within a given manipulation might be clinically relevant as it seems to be and this is another avenue for research. This is where skill again becomes potentially relevant.
Also, no need for Opposite week. I don't claim to be specific in my lumbar manips, but I do claim they are almost aways therapeutic, rarely ever iotragenic., Plus, there is increasing ease and finesse in the application of SMT as I mature as a clincian. I don't always adjust the SI in pain, I go by my clinical findings, osseous, non-osseous, movement/stability impairments, guidance from the evidence and so on and make a decision if/when/where to adjust provided informed consent is given.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 21, 2007 9:36:00 PM
|
|
|
steve
Posts: 470
Joined: May 14, 2003
From: Canada
Status: offline
|
Marc,
I dont disagree that there is a certain skill level that improves with practicing manipulation of soft tissue techniques. I believe we do improve our ability to manipulate with ease and apparent comfort for patients. What I am questioning is how much it influences outcome when compared to the ability to appropriately select patients. I also question how many techniques are needed.
I have seen the random generated technique study twice now with the same results. Also consider the Childs clinical prediction rule study had 95% success rate when manipulating patients meeting the rule with a single technique that theoretically targets the SI joint. Josh Cleland then used the prediction rule with a side lying lumbar technique in a consecutive case series of patients positive on the CPR for manipulation and had a 95% success rate. This may not be a huge body of evidence but four studies is suggesting something...
With respect to the more cavitation the better comment, the only two studies I have seen in the literature on manipulation with or without cavitation suggest that cavitation has no influence on outcomes (Tim Flynn did one of the studies and the other authors name escapes me). In my experience, patients and clinicians put far too much emphasis on "The Pop" as an indication of a manipulation that will be effective.
All this may seem a little nitpicky but this emphasis on a multitude of techniques, specificity and skill mastery has been detrimental to the physiotherapy community using manipulation as an appropriate intervention. Despite evidence that spinal manipulation is highly effective for acute lumbar spine pain, it is underutilized because of safety concerns and self doubt about competency to perform manipulation. Non reliable palpation is used to identify a segmental pathology by the "Skilled manual clinician" and unfortunately can serve as a red herring as we can identify joint stiffness on virtually every patient that walks in through our door. The monosegmental theoretical model is then often given to a patient as the reason for their pain and in the patient with high fear avoidance/anxiety chronic pain it serves as a real pathology that they can attribute their pain to.
I would argue that although mastery may in fact improve outcomes this has yet to be demonstrated and is actually contradicted in the research. I would also say the same for the C-spine specificity - clinically, it feels as though I can be more specific to an area and palpate a given area more acurately and this would make sense based on the amount of soft tissue in the region.
Steve
|
|
|
|
|
Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 1:49:00 AM
|
|
|
Sebastian Asselbergs
Posts: 1206
Joined: September 29, 1999
From: Barrie, Canada
Status: offline
|
Just a quick note Steve. Yes I think that our ortho group is mired in the mystery and minutae of specificity in manipulation....Yet, recently had a presentation from them, focusing on the need to recognise that NO MATTER WHAT WE DO, we inteact with the nervous system at many levels. And that the "type" of manual interaction was less an issue than the careful evaluation...
Quite a departure...
_____________________________
Mundi vult decipi
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
 Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.125
|
Printable Version
All Forums >> [RehabEdge Forum] >> Open Forum >> Re: MD's story on misdiagnosis: How Doctors Think 
