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Classification Scheme vs. Biomechanical model
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Classification Scheme vs. Biomechanical model - November 16, 2007 6:32:23 PM
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Crevidence
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< Message edited by Crevidence -- August 26, 2008 5:04:30 PM >
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RE: Classification Scheme vs. Biomechanical model - November 16, 2007 8:21:07 PM
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SJBird55
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I believe the reason that the classification system has evolved - beginning I think with Delitto's work - is because the biomechanical approach sucks. The biomechanical evaluative process is not valid or reliable. Of course, the therapists that have paid thousands AND those teaching the biomechanical approach are going to disagree because 1) those teaching want to make a profit and 2) those learning want to have and believe they have something of substantial value that elevates their qualifications.
With acute back pain, correctly classifying the patient leads to better outcomes per Cleland and Fritz and maybe Brennan. I believe most of the research has been directed toward acute low back pain - as opposed to subacute or chronic back pain. So, I would anticipate that as more research is done with more groups of patients, there may be a classification system rolled out that is time dependent (meaning as to when the onset of complaints occurred). I could be wrong, but I'm just guessing.
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RE: Classification Scheme vs. Biomechanical model - November 16, 2007 8:50:42 PM
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Kaden
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Why the need to always bash one approach over the other. I think they are best used together. One can use the classifcation system to put someone in the manipulation category and then use biomechanical skills to narrow down the segment.
Using biomechnical skills alone may not be all that effective but when used in combo with class. system can get good results. If someone meets the criteria for a lumbar manip I would like to think my biomechanical skills could narrow this to the lower or upper part of the lumbar spine, not just wack and hope I get the joint between T12-L5.
Many of the researchers producing the studies/research on class. system teach in manual therapy programs and universities that teach specific joint assesment - they have not abandoned the approach all together.
Also, much of the research that states PIVM reliability sucks and it is right it does suck. But I hope there are not manual therapists relying on one motion test, position test,etc then treating. If we use AROM in combiniation with intervetebral passive and accessory motion I think reliability increases.
....and like I stated above if combined with classification system, even better results.
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RE: Classification Scheme vs. Biomechanical model - November 17, 2007 12:14:51 PM
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SJBird55
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If I came off as arrogant, that wasn't my intent. The current published research does substantiate what I wrote... I was just more blunt and to the point about it. If something sucks, why would it survive? Money and pride...
When using the biomechanical approach, if there is no validity or reliability or even accuracy with the actual evaluative process, then reality is that the approach or theory has some major holes in it. If it has some major holes in it and the final outcome from using the approach has favorable results, then the question bears what actually occurred? What actually occurred probably had nothing to do with flexed/rotated or whatever spinal segments.
As can be seen from the clinical prediction rules, clustered findings from the evaluative process should be what leads clinical decision-making. In some cases, the ease of lack of ease of a PA movement... toss in a few provocation tests... toss in a few subjective findings and the mix of those findings add strength to the decision-making process. You also have to think that with the clinical prediction rules, the manipulative techniques aren't joint specific at all, but a general technique that does provide results with the subgroup of identified patients.
Crevidence, there is a recent paper out there that deals with acute low back pain, the treatment based classification system and the use of the classification system on occupational related injuries. In other words, this paper tested out the classification system to see if favorable outcomes occurred AND if it mattered whether patients were classified or not. For those with recent occupational back injuries AND when therapists did classify patients and perform a treatment based classification approach to care, the outcomes were better than not applying the treatment based classification approach. To my knowledge, I have not read any other article that actually put the treatment based classification system to the test to see IF the approach does work with patients with a greater length of time since onset of complaints.
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RE: Classification Scheme vs. Biomechanical model - November 17, 2007 1:58:24 PM
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Kaden
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Crevindence,
"pain provoking PA glides" to localize. This makes a big assumption that the painful area is always the one that needs manipulated.
SJBird,
I agree that the techniques talked about in CPRS are not specific but what about in clinical cases were they need to be. What do we do then if all we have are CPRs and general manipulative techniques.
A good biomechanical evaluation should also cluster findings from an evaluation to include subjective, motion tests, etc. just like those included in CPR.
Why is it always assumed that those using a biomech. approach palpate for dysfunction and then mob or manip. There is more to it than that. That is why I feel a biomechanical exam (including more than just palpation, PIVMS and PAIVM) combined with CPR gives great results.
Lets not forget the weakness of a CPR and that is not all patients will fit cleanly into a sub group. Your patient with an instability of the lumbar spine may benefit most from specific stabilization exercise but thats not to say they can't also benefit from a mobilization or manipulation technique to adjacent segements as well, but the CPR would not take you down that pathway.
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RE: Classification Scheme vs. Biomechanical model - November 17, 2007 8:53:05 PM
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SJBird55
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Kaden, where is an example of a clinical case in a peer reviewed journal where clinical techniques have to be specific - where is an example of a specific technique put head to head with a more generalized approach? Where is a study that presents data on a subgroup of patients that requires a highly technical manual technique that is shown to be predictable and superior? Also the treatment based classification system is not a clinical prediction rule. The classification system discussed does seem to cover the majority of the patients seen in therapy except those in chronic pain with a highly sensitized nervous system or those with (+) slump testing or those with high levels of fear.
Crevidence - PM me with your email address and I'll send you a PDF of that study. Granted... I'd like you to really, really think about joining the ortho section though. :)
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RE: Classification Scheme vs. Biomechanical model - November 17, 2007 10:22:09 PM
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jlharris
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I'd have to agree with SJBird. The research shows us not only that manipulation need not be specific, it is not specific. Even if you are "targeting" a specific level, you may be getting the level but also a few above and below. I'm not saying to not try and be specific, but we all must understand we are not moving L2 specifically, if at all with you mob/manip.
The problem we faced with in the clinic is we have limited - in terms of supporting evidence beyond manip and stabilize - for our treatment based classification system. I believe it's the way to go, though. The biomechanical model has been around as long as US and both need to fade away for lack of consistent results.
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RE: Classification Scheme vs. Biomechanical model - November 18, 2007 1:42:35 PM
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steve
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A segmentally specific biomechanical model suffers from more than just poor reliability during assessment - Using PAs one researcher found that there was a "Bowstring" effect where movement occured throughout the lumbar spine during the technique. When a manipulation was tageted in the lumbar spine to a specific segmental level it was only accurate 53% of the time. Researchers have also found that there are global changes in muscle tone (Ie. quads, deltoid) with manipulation. In manipulation of the cervical spine, therapist chosen techniques had effective outcomes - equal to those patients receiving a manipulation directed towards a randomally generated segment.
The nice thing is that it probably doesnt matter if you use a biomechanical approach for patients fitting the CPR for manipulation - 95% will get better and if you want to attribute this high success rate to choosing a specific level go ahead. I think the biomechanical approach becomes problematic in that it typically under values components other than palpatory findings in clinical decision making. Hypomobility does seem to have a small place in our decision making process and hypermobility/instability seems to have a moderate to good influence in decision making but taken alone makes for poor clinical work.
Steve
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RE: Classification Scheme vs. Biomechanical model - November 18, 2007 6:34:06 PM
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Kaden
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Crevidence, I know you stated you are looking forward to my answer. If you want me to be the biomechanical defender that is not going to happen. I allready stated I use parts of both systems and too am not in favor of only using the biomechanical model.
Your original post wanted thoughts on the classification versus the biomechanical model and that is exactly what I gave you.
It was others who turned this into the biomechanical model must parish discussion. I agree the biomechanical approach has flaws and why I stated multiple time I use both approaches.
Maybe we should define "biomechanical model" b/c I feel some are making this out to be the osteopathic positional palpate and then mob or manip.
I am NAIOMT trained and taught to scan with subjective, ROM, MMT, neuro, etc long before performing any joint specific assesment. We cluster special tests with subjective and other finding to lead us down a pathway of treatment.
To me this is much like the classification system (maybe hasn't been validated in the literature yet with my specific scan I use) in which one takes a cluster of symptoms to lead them down a path of stabilization, manip/mob, etc.
So maybe we shouldn't be so quick to bash everyone not using a particular classification system.
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RE: Classification Scheme vs. Biomechanical model - November 18, 2007 9:48:13 PM
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Kaden
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When you say NAIOMT biomechanical exam, please elaborate. I was referring to the scans that are taught that I believe employ many of the tests and measures used in the classification systems.
...and have you actually taken the class or are just being taught by someone who has.
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RE: Classification Scheme vs. Biomechanical model - November 18, 2007 9:57:32 PM
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steve
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Good questions Crevidence, particularly clustering unreliable tests. I think there is good evidence that clustering tests with mediocre to poor likelihood ratios improves diagnostic accuracy (When put through clinical trial such as the CPR for cervical radiculopathy or identifying meniscus injury) but with respect to reliability I'm not as sure this is the case, particularly if a number of tests are used with unknown or poor reliability. When a number of tests are used and we aernt aware of their predictive qualities for identifying those with/without the disorder we are just left with clinical "Noise" that confuses our diagnostic ability as we will have some positive and some negative tests and not know what value to give to them.
Unfortunately, most of the clinicians who use this approach are more certain of their diagnostic abilities than those basing tests on substantiated research. They identify a syndrome that is untestable against a gold standard and based on the fact the patient improves (Although it may be due to natural history of the condition, patient expectation etc.) attribute it to a correct diagnosis and treatment.
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RE: Classification Scheme vs. Biomechanical model - November 18, 2007 11:19:36 PM
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Kaden
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Crevindence, if you feel that strongly then why are you learning it and why don't you question the "guru" and give us all on this post his or her info.
Can you elaborate on the classification system for the cervical spine - i am not as familar as with the lumbar spine. I will search though.
Keep the dialogue coming. Like I say I am fully willing to come to the other side but like the dialogue about the two systems.
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RE: Classification Scheme vs. Biomechanical model - November 19, 2007 11:24:03 AM
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Kaden
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I asked about the CS b/c I knew there was not a classication based system yet. I like where the research is going on classifcation system but can we hold off the "banish the biomechanical model" talk, except maybe in the lumbar spine. Without the biomechanical model we don't have another approach to treat CS, TS, shoulder, wrist...do i need to go on.
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RE: Classification Scheme vs. Biomechanical model - November 19, 2007 1:05:20 PM
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SJBird55
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There is a proposed treatment based classification system for the neck out there. It hasn't been fully tested.
Kaden, I never said banish the biomechanical model. I don't believe there is as much value in that model based on the research that is being done. (The main value is to those teaching it for monetary reasons and for those involved in certification for the pride/bragging rights.) If you choose to use it, you can, but there is quite a bit of bunk to it with regard to the spine - based on research. You didn't address my questions with regard to research indicating the value of the biomechanical model....
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RE: Classification Scheme vs. Biomechanical model - November 19, 2007 1:21:31 PM
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Kaden
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SJBird,
I wasn't trying to single you out just making a point that it doesn't yet work for all joints so lets hold off criticism if there is not a better option to treeat CS and TS. As far as your question regarding research on the biomechanical model - I can't argue - there is very little. I think this is two fold
1) Hard to do specific biomechanical research and as allready pointed out not all that reliable.
2) Many teaching this model are not doing much research with I agree is a problem
I use the classification system for lumbar patients. I was just saying that until there is a better option for other joints lets hold the criticism.
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RE: Classification Scheme vs. Biomechanical model - November 19, 2007 1:42:49 PM
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SJBird55
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So, explain to me again the value in a system that has been around for quite some time that doesn't have supporting evidence.
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RE: Classification Scheme vs. Biomechanical model - November 19, 2007 2:16:51 PM
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Kaden
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I am not trying to justify value. I agree that the lumbar classification system is great but until you present me with another option to manually asses at the joint level then that is what I am going to use.
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RE: Classification Scheme vs. Biomechanical model - November 21, 2007 1:32:44 PM
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jesspt
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The direction of the last few posts begin to get at the crux of the matter regarding treating patients with thoracic pain (and to some extent cervical pain) - what do we do when confronted with a lack of evidence to support the use of the interventions we have at our disposal? Do we send them out the door? Personally, I think that few of us would take that approach.
Also, there is some decent evidence to guide us in treating the cervical spine. Deep cervical flexor retraining has been shown to be helpful, as has thoracic spine manipulation in certain instances. If I'm remembering correctly, there has also been some work done attempting to quantify what characteristics are found in patients who benefit from cervical manipulation.
We can all throw stones at some of the traditionally taught treatment paradigms that lack any type of sound theory or outcomes research. It sounds like Kaden recognizes the limitations of the biomechanical model. It is probably far more helpful to the participant of this forum to discuss what interventions that we choose when there is a lack of evidence, and why we choose them. For instance, SJ, you seem to be an opponent of the biomechanincal model (and for full disclosure, I am as well). What approach do you take during both assesment and treatment of the cervical spine?
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RE: Classification Scheme vs. Biomechanical model - November 21, 2007 4:26:02 PM
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Kaden
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Jess,
Well said. You are right, I do fully recognize the limitations of the biomechanical system. I too would like to hear responses from the likes of crevidence and SJ Bird as to what they do in treating a population of patients lacking solid assesment credibility in the literature.
I too employ TS manipulation and DNF strength with these patients, and was why I was trying to point out that those of us using a biomech. approach don't just throw evidence out the window. I choose to incorporate it into my current assesment and treatment techniques.
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RE: Classification Scheme vs. Biomechanical model - November 21, 2007 5:54:19 PM
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SJBird55
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Gonna put me in the hot seat, huh? ;)
My mind always thinks in terms of treatment based classification systems (if X is found than do Y). X is always generally more than one variable, but a collection from the subjective portion (which I do heavily weigh and a few things from the assessment process). The cervical spine is no different. I have always classified patients into treatment based classification systems even before the "rules" were written. It's nice seeing what is being published and having more specific guidelines than I had in my head mentally. I was taught the convex on concave crap and the flexed, rotated, mutated crap... I never, ever practiced it. It went out the window as soon as I walked out the door with my degree - I couldn't feel any of that crap. I refuse to spend a single dollar on any of that type of training because I do believe it is there to financially improve someone's or an institution's financial well-being AND I don't desire to undertake the training to give me an elevated status professionally (especially when I don't believe the evaluative process has any merit). And, as the research is being pumped out, I'm actually feeling happy that I didn't fall prey to the lack of my manual evaluative abilities in feeling/sensing all the bunk.
I tend to take more of a patient-centered approach. I let the patient tell me quite a bit on their perspective... I tend to spend a lot of time educating and discussing and answering questions... I tend to spend a lot of time problem-solving with a patient. In particular with patients with back pain, I tell them when to worry - I give them the symptoms that should cause them to seek action and get to the hospital. I spend more time on a medical systems review. I think the biggest key to what we do day in and day out is the personal communications and the personification of each patient's situation with what the patient desires. I'm also upfront and honest about the strength of my findings and the options available for the patient. I tend to often say that research doesn't assist with why something works. I offer them my thoughts, but tell them it's just my thoughts. I keep their home exercise programs so simple that I know they can do them and the home exercise program always has a bent toward some activity the person wants to do OR I communicate that there is a sequence to the path the patient decided to take and I need focus at X to progress to Y and I want to progress to Y on such and such a date. I use muscle energy, I use manipulation, I use mobilization, I use stabilization, I use PNF at times (depends on what the patient needs to do), I use balance/proprioception, I use strengthening, I use activities to specifically target a functional deficit area of value to the person.... I tend to begin with manual interventions and back off generally within 3-4 visits and tend to move into something active and do graded exposure. I don't use myofascial, I don't use craniosacral, I don't do skin stretching :) and I don't do ideomotor stuff (even though I see something of weak evidence has been published), I don't use electrical stim (one condition - post-op ACL or TKA - if atrophy and control and huge extensor lag, then the person gets a rental unit to do a few times daily), I don't use ultrasound. The way I practice today is quite a bit different than I practiced 5 years ago. I have a library of articles on my "stick" that I have organized... and with every patient, I can define the research in peer-reviewed literature that is assisting me with treating the patient. In fact, I go as far as sending a nice little introductory letter to the referring physician and provide 3-5 current references that will be the major rationale for the interventions provided. When something better comes out, I ditch old preferences that I thought were of value and I alter my recommendations to patients. Time is money... my goals are to always be time efficient and to keep the high quality assessment procedures within my evaluation and swap things out when something better comes along. The biomechanical approach has a value more in how the patient's system responds to our hands and to manual movements - be it at joints, muscles or nerves. I measure and analyze the results achieved in the clinic and in areas that I'm not so happy with, I change. I remeasure and reassess and see if the results improved.
I have the low back down pat where I am actually quite happy with my overall results - from a function perspective, from a pain perspective and from a utilization perspective - I'm not sure how low one can go in regard to utilization, but overall I'm happy. I have more problems with treating the shoulder. I do okay, but I could be better... we need a better classification system for that region. It's fine to talk about the thoracic spine and the cervical spine, but if you look at the patient population that you serve, I'd be willing to bet that #1 = back pain #2 = shoulder or knee and #3 = shoulder or knee and then #4 would be neck pain. My outcomes are not where I want them for patients walking through the doors with a shoulder condition/complaint. I thought they were, until I saw the numbers and I know they can be better. The reason I know they can be better is because, unlike the low back, I do not have a consistent, well-defined classification system that I use. I'm not sure if it's the tests and measures that I use evaluatively or if I'm missing something subjectively or if I'm just overwhelmed with too much information and not honing in on the truly relevant pieces of information.
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