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Re: MD's story on misdiagnosis: How Doctors Think
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 10:38:00 AM
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nari
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From: Australia
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Quote:
No matter what we do, we interact with the nervous system at many levels.
Quite. The actual technique is getting less and less important, from where I'm viewing. Which is likely the reason why, back in the dark Cartesianesque ages, we got good results simply dealing out hot packs and general exercises.
Now...what happened to the diagnosis theme at the beginning of this thread? I can't add much to ginger's post on how things are in Oz; and if the day ever arrives where DCs are permitted into Aust's hospitals and clinics, it would benefit all to tolerate each other. If one profession disapproves of another, it is encumbent on administration to sort it out, not individual professions.
I would suspect that PTs make as many misdiagnoses as doctors, but it probably matters less, as long as any red flags are recognised and referred to docs. I have come across some amazing 'diagnoses' made by PTs who then launched into a complex program of rehab over weeks and weeks...when some correct education and communication with the patient resolved the problem/s within a few days.
Nobody gets it right or efficient all the time.
Nari
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 2:32:00 PM
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Marc Bronson
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From: Toronto
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Sebastian, Nari
I think we're pretty much in agreement, its just a matter of semantics. When I say technique is important, I'm simply referring to making the adjustment as comfortable and non-threatening for the patient as possible. The neurophysiological effects of manipulation that induces cavitation are likely to be different if you crush someone and they're in pain or if you're gentle it's a pleasant experience.
My 0.02c
Steve:
I agree that SMT is under-utilized for acute LBP. That's what the CCA has been saying for years. If you didn't perform SMT yourself, and you had an acute LBP patient, would you refer to a DC? I bet the majority of MD's and PT's would still say no despite the fact that DC's still do over 85% of the manips in Canada. Are you personally opposed to seeing DC's integrated into the health care system?
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 3:43:00 PM
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proud
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Marc said:
"...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...."
You being someone who is apparently a proponent of EBM, I find this particular part of your post interesting.
Marc said:
"...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...."
This also is suprising. As Steve indicated, the "pop" has been shown to NOT impact outcomes. And I would ask, why did you feel worse? Did you have back pain prior to the manip?
Marc said:
'...Motor skills, whether or not its SMT or sports require biofeedback to improve. I'm curious to hear your responses...."
Well sports is a highly intricate set of co-ordination skills involving all areas both centrally and peripherally. I just do not see sports as a viable comparison. Again you seem to be making the assumption that manipulation must be highly inticate and mastered in order to have great outcomes. The evidence is rapidly heading in the opposite direction. Keeping in mind that I have dedicated a fair amount of my time learning various "locks" etc( 10 years worth), I am still able to let go of all my notions and ego and submit that my outcomes appear to be the same with my non specific manip as it was when I attempted to "lock and isolate". Interesting to me for sure.
To be clear, as I stated before, I appreciate that we have oppossing views on the manip topic and I am not trying to be antagonistic. Debate is always worthy and not everyone will see eye to eye. The debate will go on until the evidence is unequivocal.
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 5:59:00 PM
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steve
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From: Canada
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Marc,
I agree with the common ground of making manipulation "A pleasant neurophysiological event" but still wonder if that is the result of years of practice or confidence and mannerism of the clinician.
Your other two questions are quite a leap from what I was discussing - would I refer to a DC if I didnt manipulate? Based on best evidence I would take 15 minutes to learn the lumbar spine manip that was 95% effective with novice clinicians. With respect to the neck I choose not to manipulate due to evidence suggesting no superior benefit over mobilization and no serious (Yet likely rare) complications.
Im not sure how DCs are not integrated in to the health care system in Canada anymore than PTs with respect to orthopaedic practice.
Steve
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 6:20:00 PM
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Marc Bronson
Posts: 113
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From: Toronto
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Proud,
First, I'll ask that you politely never question my adherence to EBM. I use the evidence to guide my clinical judgment. If all professionals were to treat strictly by the evidence, 80% of all procedures would be wiped out, surgeries included. Go check the evidence based medicine wiki to see the many limitations of EBM. I'm a proponent of it, but every system has its flaws.
Let me ask you a few questions:
1) Do you think the mechanism of SMT is neural? Do you think there are measurable, quantifiable neurophysiological effects?
2) Patients have always reported that there is an immediate pain relief following cavitation as opposed to a delayed response with no pop. Sure they may both improve, but clinically speaking, an audible cavitation is usually means that immediate analgesia.
3) You don't think that clinicians can deliver bad adjustments and it have negative effect rather than a positive one? I felt worse because the guy but way too much, way too much torque, landed way too hard and essentially sprained my back. Before the adjustment I felt fine.
4) Are you suggesting that there is no neurophysiological difference between a cavitation and no cavitation? I'm hedging my bets that there is a difference, whether or not its clinically significant is another debate.
5) By being a more refined manipulator you can increase the safety/comfort of you manipulations, prevent iatrogenic complications, and can have even better outcomes. Proud, I've went through chiro school for 4 years, had probably 160 different people manipulate me and I can tell you right now with 100% confidence that there is a big difference in someone who does it well and someone who is mediocre. What is your personal experience with manipulation?
I appreciate your dedication to the evidence at all times, but if this was the case, how do you explain to the techniques that your peers use (skin stretch, ideomotion) that have no studies to back it up? Are your peers quacks? I have seen one RCT let alone a case study with this. What is your opinion regarding the statement absence of evidence does not equal absence of effectiveness? Why do you think SMT stuck around for 100 years despite everybody saying it was witcraft, placebo, and quackery?
For the record, I'm likely heading back to do my Masters and possibly PhD in 2008-09. I hope to be working alongside a little someone named McGill, like my classmate who is working with him right now. Please don't question my passion and dedication to science, the scientific method. You have to realize studying manual therapies in a reductionist manner will never yield unequivocal results. We're not studying half-lives of drugs; we're studying people interacting with people.
/end rant.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 6:52:00 PM
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ONstudentPT555
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When you refer to "skin stretch" are you talking about nerve mobilisation? I can assure you there is at least one good quality RCT that proves its effectiveness:
1: Man Ther. 2006 Nov;11(4):279-86. Epub 2005 Dec 27. Links
Slump stretching in the management of non-radicular low back pain: a pilot clinical trial.Cleland JA, Childs JD, Palmer JA, Eberhart S.
Physical Therapy Program, Franklin Pierce College, 5 Chenell Drive, Concord, NH 03301, USA. clelandj@fpc.edu
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 7:03:00 PM
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ONstudentPT555
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In my opinion the actual manipulation itself is rather simple to learn.. I learned all manips in about 15 mins except c-spine which I have not attempted. I think it takes more skill to be able to assess when it is helpful and safe to perform a manip..rather then the actual delivery of the manip itself. Manips can be a useful tool in a few cases but in most cases mobilizations are just as effective.
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Re: MD's story on misdiagnosis: How Doctors Think - March 22, 2007 7:06:00 PM
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Marc Bronson
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From: Toronto
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MIke,
No, I wasn't referred to clinical neurodynamics type testing. I'm literally talking about stretching the skin for pain relief. I'm not saying its bad; the neuroscience behind makes sense; but I was illustrating a point that not everything has an RCT behind it and we shouldn't automatically jump to conclusions and reject stuff when there is reproduceable, positive clinical benefits. I'm actually looking forward to Diane's study, in all honesty.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: MD's story on misdiagnosis: How Doctors Think - March 23, 2007 2:15:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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Marc, I'll try to address your "rant" (not really):
"1) Do you think the mechanism of SMT is neural? Do you think there are measurable, quantifiable neurophysiological effects?"
I think it's neurophysiological. "measurable" neurophysiological effects? Very likely.
"2) Patients have always reported that there is an immediate pain relief following cavitation as opposed to a delayed response with no pop. Sure they may both improve, but clinically speaking, an audible cavitation is usually means that immediate analgesia."
But the research shows that cavitation is NOT an essential aspect of manipulation effects. So, "clinically speaking" is at this time, trumped by stronger evidence.
"3) You don't think that clinicians can deliver bad adjustments and it have negative effect rather than a positive one? I felt worse because the guy but way too much, way too much torque, landed way too hard and essentially sprained my back. Before the adjustment I felt fine."
This has no other value than anecdotal. Of course there will always be people with "lead hands" who can crush an oak tree in adjustment/manipulation. But the evidence shows that the most "proven" manipulation, is a easily learned, very safe and simple technique. I bet there are people out there who can tell stories of PTs actually hurting patients with US.... That doesn't make US in itself in need of advanced learning.
"4) Are you suggesting that there is no neurophysiological difference between a cavitation and no cavitation? I'm hedging my bets that there is a difference, whether or not its clinically significant is another debate."
You said "an audible cavitation is usually means that immediate analgesia" in point #2. It seems you have already made up your minds that there IS a clinical difference. My response is the same as in point #2.
"5) By being a more refined manipulator you can increase the safety/comfort of you manipulations, prevent iatrogenic complications, and can have even better outcomes. "
LArgely, this is likely correct. So far, no real evidence of "new" practitioners being more hurtful to pts than experienced ones. If and when that is proven, I will be the first to take it to heart.
I agree that RCTs are not essential for techniques to make sense. It takes solid theoretical underpinnings, it needs to fit the laws of physics, it needs to do the least harm and risk to the patient.
_____________________________
Mundi vult decipi
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Re: MD's story on misdiagnosis: How Doctors Think - March 23, 2007 2:46:00 AM
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proud
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Marc,
I PM'd you in response.
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Re: MD's story on misdiagnosis: How Doctors Think - March 23, 2007 9:48:00 AM
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Marc Bronson
Posts: 113
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From: Toronto
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Sebastian,
I think we are mostly in agreement. Except for the point regarding the immediate analgesia (in acute back pain) with cavitation. And, I'm only going with what the patients report at the time. Whether or not they pop, they both seem to improve. Maybe it's entirely placebo-conditioning with cavitations, maybe not. I would be a good outcome study at the least. I too agree that there's no way around explaining the therapeutic effects of any intervention without acknowledge the role of the nervous system.
Mike/Steve
I guess the issue I have, and it may be more of an ego/personal thing as well as an academic one, is that you can truly learn the art of manips in 15 min. I sure hope you don't tell your patients that. Well, I learned how do to his yesterday for the first, and of course, there is a rare chance of cauda equina syndrome, disc herniation and more common stuff like exacerbating your back pain and possibly strain/sprain injuries.
Would you feel that it would be OK if I claimed I learned a good chunk of physiotherapy in 15 min? Why would you not refer to someone's whose expertise in manual therapy trumps yours and could be more clinically effective. I refer to our PT for advanced rehabilitative protocols after I've done the basics. I defer to his expertise. I even refer to our RMT for more generalized body work.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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Re: MD's story on misdiagnosis: How Doctors Think - March 23, 2007 10:56:00 AM
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steve
Posts: 470
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From: Canada
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Marc,
I certainly wouldnt pigeon hole DCs into only practicing manipulation but I can understand how the statement that a manip can be learned in 15 minutes would be threatening to any PT/DC who had spent a significant amount of time mastering the technique. I'm not suggesting that only 15 minutes should be devoted to learning the technique but rather we de-emphasize the number of techniques and the emphasis on form and focus on reliable identification of appropriate patients. Sure, its nice to have mastery of the motor skill but irrespective of how skilled you are, if you manipulate every patient that walks through your door (Not directed at you personally, just an example) you will have suboptimal results and patients will not be given the best care. If it makes you feel any better, I frequently say the same thing about exercise - there is no evidence that we can identify appropriate isolated contractions of the TA or multifidus and even if we could there is no evidence that specifically training these muscles leads to superior outcomes.
It seems a common theme that there is increasing complexity and specificity of any intervention we provide. Before you know it there accreditation courses, costly courses and books by Gurus. Often, I believe this complexity arises from adapting the techniques to fit the entire orthopaedic population without considering that there may be just a small population that will actually respond to the treatment.
Steve
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Re: MD's story on misdiagnosis: How Doctors Think - March 23, 2007 12:23:00 PM
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Marc Bronson
Posts: 113
Joined: January 13, 2007
From: Toronto
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Steve
Great post. I think that should about cap it. Well done folks, no one got banned and no flame wars!
How about a new threat dedicated to finding some universal truths/principles/theories in treatment though, regardless of the population.
I'll start it off, hopefully we can get some kind of consensus that draws on both academia and clinical knowledge.
_____________________________
BSc (Hon), DC, Dipl. Med. Ac. CSCS
Integrative Manual Medicine
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