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Re: to feel or not to feel
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Re: to feel or not to feel - August 17, 2006 4:47:00 AM
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SJBird55
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Statistical values seem to be all over the place with reliability of ability to assess segmental hypomobility.
From Cleland's text:
Maher - determination of posterioranterior spinal stiffness with 40 asymptomatic patients: first study ICC = .55; second study ICC = .77
Binkley - posterioranterior mobility testing with 18 patients with low back pain: ICC = .25
Hicks - segmental mobility testing with 63 patients iwth current low back pain: kappa value = -.2 to .26
Fritz - hypmobility at any level with 49 patients with low back pain referred for flexion-extension radiographs: pearson correlational coeefficient = 38 (I think there may have been a typo and it should be a .38)
Abbott and Mercer - segmental hypomobility testing with 9 patients with low back pain: passive accessory intervertebral motion has .75 sensitivity; .35 specificity; + LR 1.16; - LR .71; passive physiologic intervertbral motion has .42 sensitivity; .89 specificity; +LR 3.86; -LR .64
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Re: to feel or not to feel - August 17, 2006 1:22:00 PM
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ginger
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Nari
There is no doubt that effective mobs to spinal facet joints does impart a substantial altered recruitment pattern to both paraspinal musclulature and those within a myotome related to that nerve root. Or rather there is a normalisation of muscle behavior. It seems clear to me that a real time relationship is taking place between joint behaviour and recruitment patterns, both to muscles intimate and not to those joints. The link between them is of course a nervous one. By saying a CNS relationship , I'm a little concerned that an assumption is being made about brain function , rather than reflex acivity. How one would sort out which were which however , in the realm of a trial or of patterning with MRI or other imaging is not clear.
Worth the time and effort no doubt, but beyond my resources.
Yes there must be a nerve issue to be understood here , but my personal bias in in favour of reflex activity as a part explanation .
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: to feel or not to feel - August 17, 2006 1:31:00 PM
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ginger
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Rob , yes the effects are immediate, and an assumption that no inflammation were present is not supported by observation of the post treatment period. Where further resolution of both facet pain and referred behaviour continues for 48 hours .
By your comments I see you have already established a good relationship with your own mobilisation method and use it to good effect . What differences there will be between the best effect of your method and approach, compared to the continuous method would only be a trial away for you. I would be interested in comments from you should you choose to try the continuous method and do so without any other intervention.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: to feel or not to feel - August 17, 2006 3:50:00 PM
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rwillcott
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Nari mentioned:
"EBM is a guide for conscientious PTs; it is not a dictator. It probably is useful for identifying those PTs who may be extremely out of date or performing risky techniques; but I can't imagine there are many of those."
Unfortunately there are many PT's in my province and surronding area that are out of date. There are many within private practice that continue to treat with just hot packs, interferential and ultrasound for all conditions. Sounds crazy but it's the sad reality. That's why there are many of us who are pushing for EBM. I feel that as a relatively new PT I have to protect my profession and try to make up for lost ground by these PT's that have set physiotherapy back 20 years.
Rob
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Re: to feel or not to feel - August 17, 2006 4:01:00 PM
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ginger
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Rob , I too am aware of many physios in melbourne that are stuck with modalities and a range of minimalist interventions that offer very little of value. The phrase "I tried physio but it didn't work", is one I hear from patients who ultimately find their way to me by referral from friends and family I have previously seen .
It is saddening and maddening to think that the reputations of those with considerable skill and perserverance or skilled physios are sullied too often by these people. Wether they are out of date , as Nari calls them , or just not skilled in the first place is moot. It could be that for the want of professional credits being somehow tied to a program of continuing ed related to registration, we will continue to have these also rans in our midst.
I for one would shudder to be compelled to attend continuing ed ,encouraged yes, invited sure , but compelled ,no thanks.
Thoughts?
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: to feel or not to feel - August 17, 2006 4:27:00 PM
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proud
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Steve,
Your post today on this topic was brilliant.
Nari, although I appreciate your sentiments, I am afraid EBM IS the dictator. And I for one think it is about time.
Let me ask you this...if you tore your ACL and went to 5 orthopeadic surgeons, would you expect the same dx and treatment advise from all of them? Of course you would.
As it should be for PT. If a patient has back pain, and sees 5 separate PT's, there is no need for 5 separate dx and treatment options( one guy says hyomobility, the other hyper, the next says it's a "pelvic assymmetry", and still the next says you need orthotics and a heel lift...)
The only reason that exists is simply because of our continued insistance on using unreliable assessment tools( i.e those clinicians that claim they can tell the type of hypomobility through motion palpation and then perform "special" mobilizations/manipulation.)
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Re: to feel or not to feel - August 17, 2006 4:28:00 PM
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SJBird55
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In the States, I think that the fee for service method of reimbursement is a potential factor in higher utilization rates of hot pack, ultrasound and electrical stimulation, oh, and toss in massage too... I did a trial of 90 days at a local clinic and was very disappointed in the therapist who owned the clinic. Honest to God, every single patient of his received ultrasound, hot pack and massage - for every and any kind of diagnosis. I parted ways because his philosophy of care just didn't mesh with mine... and then through the grapevine I heard he badmouthed me because I lost him money. Technically, what he meant was that I didn't charge 3 passive modalities on every patient. He used hardly any exercise and his soft tissue mobilizations were just massages. What a disgrace to our profession. He was doing what he did to generate more revenue. I do believe it was that experience that opened my eyes that not all therapists read literature and apply what they have read.
Really, ginger, you wouldn't attend a continuing ed course? I'm lost, why not?
proud... I didn't see your post... but yeah, isn't that irritating? One problem presented to 5 therapists will have 5 solutions with sometimes large variances in the solution. I guess that's the "art" aspect of what we do, but it has always bothered me that there are large variances in the care provided to patients that receive physical therapy services.
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Re: to feel or not to feel - August 17, 2006 4:39:00 PM
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FLAOrthoPT
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Proud, you wrote:
Let me ask you this...if you tore your ACL and went to 5 orthopeadic surgeons, would you expect the same dx and treatment advise from all of them? Of course you would.
As it should be for PT. If a patient has back pain, and sees 5 separate PT's, there is no need for 5 separate dx and treatment options( one guy says hyomobility, the other hyper, the next says it's a "pelvic assymmetry", and still the next says you need orthotics and a heel lift...)"
let's go apples and apples. Pain is not seen on an MRI like a torn ACL. If you go to 5 orthopedic surgeons with back pain, all 5 of them would diagnose you with something different. The difference is the PTs will maybe diagnose it as something different but we usually look at a functional cause rather than purely an anatomical cause. Therefore, we are much more likely to treat non traumatic back pain successfully, and really treat it at all, compared to an ortho surgeon.
This all being said, I do not get what your point of that post really means? Maybe more on target is if you came in with a really pronounced scoliosis i bet 5 of 5 therapists can accurately say which way the cruve goes...so what?
I think that if you see 5 therapists for a back problem I'd guess that while some of the names for what they Dx you with may be different, but most would be gearing towards the same impairments and treating fairly the same. That is, I do not think too many therapists are going to find a significant disc issue while someone else thinks it is a muscular issue, subsequently treatment will be very similar. That is what EBM is all about; identifying practice patterns and having some commonality of diagnosis and treatment, but it is never going to be the same reliability as ortho surgeons because we are dealing with sources of dysfunction that are often not measureable with current technology: be it neuromotor recruitment dysfunctions, peripheral nerve type entrapments, etc.
Ok I have stared at a computer too long today, night-
Ben Galin, PT, DPT, OCS
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Re: to feel or not to feel - August 17, 2006 5:01:00 PM
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ginger
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birdy , didn't say wouldn't , said didn't want to be compelled. Some course are crap simple as that.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: to feel or not to feel - August 17, 2006 9:44:00 PM
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nari
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Have to agree with ginger on cont ed, though it will become compulsory very soon, at least in my neck of the woods. It is just so difficult to sort the rubbish CE from the really useful, by just looking at blurb in the journal or newsletters.
Also agree with Ben about different diagnoses from specialists - it is most likely there would be 5 different or vaguely similar diagnoses. A torn ACL is pretty standard, but back pain???? or neck pain?? I don't think they would differ much from PTs; and more often than not we are better at managing a painful condition, and we certainly know more about pain than they do. (Or, to note other posts, some of us do.)
Nari
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Re: to feel or not to feel - August 18, 2006 1:03:00 AM
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proud
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Yes I knew the ACL example would get spun around after I wrote it. Very true.
But choosing to focus on the "example" provided I think is missing the point.
We cannot continue to survive within the evolving EBM model when we do not have any consistency in BOTH dx and treatment. Imagine what an educated public would think of getting 5 completly different dx and treatments for the same problem. And trust me...the "end result" is NOT the same( some will dx Hypo while another Hyper...hmmmm?).
The McKenzie assessment is an example of a technique with reliability studies(Kilpikoski et al, Spine 2002;27 and Razmjou et al JOSPT, 2000.30(7). Not suggesting this is the gold standard but it is leading in the right direction.
Time to recognize these flaws and move from always finding ways to defend, to finding ways to prove...This I know we can do.
FLAOrthoPT,
Did you read my post on the importance of reliability, over in the Evidence Based Practice thread? I think you would find your answer about what I meant by this post in that.
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Re: to feel or not to feel - August 18, 2006 2:27:00 AM
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Jon Newman
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I think starting with sound theory is the place where consistency begins. At least that's how other sciences work. The theories I have in mind do not involve an ideal spine or posture or living in an ideal world where all exists in biomechanical perfection and deviation from this brings on clear and obvious suffering--and is therefore easily dealt with.
What's our primary presenting complaint? I need to shave some time off my box packing so I can be more productive--can you help me?
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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: to feel or not to feel - August 18, 2006 3:12:00 AM
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FLAOrthoPT
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just b/c mcckenzie is easy to study and has big pockets to fund research doesn't mean it is sound. most clinicians use a variety of techniques that change some with each visit based on respone from prior treatmnets and how the patient presents that day. This is why EBM is going to be hard to totaly incorporate into PT because EBM rates Random controlls as the highest form of research, but in doing so it says that PT environment is a controlled one. ut how oculd this be so when we are dealing with human subjects that are going about their daily lives inbetween treatments and are all bringing somethig different to the table even if they all actually had tennis elbow...none of them have the same scapular positioning, muscle diameter, blood flow, etc. It is very hard to pick one modality and isolate it and say this is EBM. It is a bit simpler with mckenzie b/c the tx approach is fairly a rigid one if x then do y, but still doesn't mean it is working because of the proposed theory. In fact, i think most people realize it does not work for the theoretical basis. EBM is great, i support it, i think at the very least we all need to think why are we doing something, and if the reason is because "that's the way I've done it for years" may be a signal to read some current literature and try something new and think twice about throwing every ankle patient in a whirlpool and every back patient doing mcckenzie, etc. Like I had said, I would highly doubt too many experienced manual clinicians...say 3 clinicians CFMT or COMT, and have them diagnose a clearly hypermobile joint, I'd wager all three would agree, not whether it is hyper on one side or hypo on the other, now there may be the debate.
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Re: to feel or not to feel - August 18, 2006 4:19:00 AM
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rv36116
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As far as McKenzie goes, if you do research and it proves to be valid, it means that there's money causing the research to be valid?
[QUOTE]In fact, i think most people realize it does not work for the theoretical basis.[/QUOTE]Who would be "most people" and are these "most people" trained and have "most people" had clinicals where they study with others who have been trained and consistently use the diagnostic tool and treatment?
I'm just waiting for PT's to quit hacking on McKenzie with no valid reasons other than their opinions or they try it once and give up after it doesn't work the first time after they take any back patient, give them the magical "mckenzies" (synonymous with 90% of PT's with the word "extension" for some reason), and it doesn't work.
Honestly, come on, quit the McKenzie bashing, that post was rediculous.
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Re: to feel or not to feel - August 18, 2006 4:20:00 AM
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proud
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FLAOrthoPT,
Never suggested McKenzie was "sound". Just that it can be applied with reliability. They move from that foundation to the study by Long etal in Spine 2005...Subgroups have better outcomes.
Also...the experienced manual clinicians you identify in fact do not have reliability( I will find you studies).The ability to palpate such movements seems to rely on our knowledge of how the segements move. The coupling pattern they like to quote( ie RR coupled with RSB etc) is inconsistent between individuals( I think Huijbrets etal), making it even more unlikely that any reliability can exist.
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Re: to feel or not to feel - August 18, 2006 10:14:00 AM
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yarringtonpt
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ginger:
I'm not sure I am responding to your view on continuing education courses properly. But, I know of many therapists trained in the States feel compelled to attend continuing education courses because of the extreme generalist approach to PT taught in many US programs. Mine was certainly a "do a little good (no harm) for a lot of different conditions" approach; at least that is how we all felt when we graduated. Lots of theory, science, etc, but not enough in the way of manual thechniques, pain, or depth of things like PNF or NDT. I could go on.
You then get out of school not being totally confident in manual skills and revert to what you know, or what seems to work,or what is simpler, or waht is easier; i.e. modalities and exercise.
I'm not certain that treatment along these lines is entirely profit driven, although it does occur.
Food for thought: should PT education evolve (or devolve, depending on your view point) into clinical residencies in areas of specialization like medicine. Then, there may not need to be so much good and bad continuing education??
Nice tangent. Sorry if I've strayed from the jist of the thread.
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Eric Yarrington, PT, MPT, OCS
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Re: to feel or not to feel - August 18, 2006 11:47:00 AM
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rwillcott
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Rob PT:
I agree with you about the misconception PT's have about McKenzie. Many think that it is simply prone extensions. When this fails they abandon McKenzie and conclude it does not work. If you were to ask these therapists if they addressed the lateral component they look at you like you have two heads. Often times the patient is shifted in standing and the PT doesn't pick this up. Also, some patients respond to flexion. Yes, flexion is part of the McKenzie approach. And even more crazier, some patients have an adherent nerve root that needs to be addressed that is a subclassification of the McKenzie system. If these PT's would simply take the time to read Robin McKenzie's text.
The study that proud mentioned by Audrey Long et al is a great example of how determining the direction of preference with the McKenzie system is crucial. Here is a link to an abstract:
http://www.aptei.com/library/viewReport.jsp?report=245
I believe that any system that sub-groups back patients is the right approach. Much more effective than performing PIVMs and PAVMs and simply guessing that there is a hypo or hypermobility that is causing the patients symptoms.
Rob
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Re: to feel or not to feel - August 18, 2006 1:31:00 PM
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dosrinc
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Ben,
I recently participated in a study comparing joint mobility grades between raters who all have quite a bit of experience and education and early results are promising in the high correlation between rates to pick up a hyper vs. hypo mobility, disparity continued to occur in determining exactly which level was different than the rest, hope the results will be published eventually, I for one, continue to utilize joint mobility assesment during my eval and treatment despite what the research says about it because I know it is a useful tool that helps to direct my treatment towards positive outcomes.
Rick
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Re: to feel or not to feel - August 18, 2006 1:34:00 PM
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dosrinc
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The funny thing about "Mckenzie therapists" is that they assume that the rest of us dont also include direction of preference as a useful piece of information in determining treatment plan, the big difference I see is that it is not the ONLY factor we use to determine the way we are going to treat.
Rick
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Re: to feel or not to feel - August 18, 2006 1:37:00 PM
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nari
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Rob (willcott)
I'm curious - if so many PTs 'do' only prone extensions, why do they ignore all the other facets (pun aside) of the McK technique? He certainly developed a huge array of possible approaches, including management of headaches.
The premise behind the theory is arguable re the 'relocation of the NP' and that sort of mechanical thinking, but for the right category of patient, the techniques work well.
I haven't done a McK course, but back in the 1980s we read his book/s and did group sessions as inservices.
So why do PTs persist in just one small aspect?
Any ideas?
Nari
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