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Re: back pain case
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Re: back pain case - August 22, 2006 5:49:00 PM
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jboypt
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Sorry ginger. No good research exists that you can Dx anything with palpation. In fact, many good research articles exist reporting there is no reliability with palpation. I do support mobilization but, only after you understand the pathology and have at least performed pre-manipulative/mobilization testing. To just manipulate a joint without any understanding of a pathology is unethical and foolish.
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Re: back pain case - August 22, 2006 5:56:00 PM
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nari
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Sounds like a spondylolisthesis (what is with the "spondy"??)should be ruled out first. Energetic stuff causing symptoms like baling hay and racing around after a ball suggests some sort of instability; however, this is not certain.
Probably best to exclude defects first.
Nari
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Re: back pain case - August 22, 2006 6:03:00 PM
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ginger
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Your suggestion of lack of ethical standards is most likely driven by the same set of "lets get more data to satisfy the insurance company" that drives the exercise prescribers to stand well back from their patients.
It is only of concern to me that palpation has gotten some bad press, in it's apparent ( and incorrect)implication then of manual therapies, to somehow be tainted by the darkness of "unreliability" . Results draw the best picture John. Those who regularly see excellent results from mobs would no sooner abandon them than cut off their hands.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 22, 2006 6:45:00 PM
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ginger
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I regularly and successfully mobilise those with grades one and two spondylolistheses, with good results and nothing to suggest "instability " is any more involved as cause for their pain , than the much more likely combinations and cascades that are the aetiological normals in protective events.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 23, 2006 7:05:00 AM
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Sean Weatherston
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Ginger,
I won't disagree in the least that grade I and II spondylolistheses respond well to manual therapy and exercise.
I think the point with this young gentleman is the fear that something more serious is going on.
_____________________________
Sean Weatherston, PT, OCS, CSCS
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Re: back pain case - August 23, 2006 7:58:00 AM
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Shill
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From: Madison WI USA
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Ginger,
I know your thumbs are wonderful, but can you shoot a beam of magnetism out of them, capture an image on film, and then see what is going on? If the test is negative, then so be it. If he has a spondyloarthropathy, it is likely somewhat fresh, spondylolysis, not a congenital, or degenerative, but stable grade 1 or 2 listhesis. If you cram on him, and he has a bony defect, your retirement fund could end up in the pocket of his attorney. Not fearing litigation, just being smart. There are patients who do have bigger problems, and waiting to find out will not kill them. Sure it is (spect, CT, MRI) an expensive test, but they exist for a reason, and one needs to know when to NOT treat, and wait.
_____________________________
Steve Hill PT
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Re: back pain case - August 23, 2006 8:12:00 AM
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ragempt
Posts: 111
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From: linden, michigan
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Shill, i don’t think Ginger was going to perform a grade 5 manip!!! You know there is such a thing as performing a gentle mob and assessing outcomes both during and directly after the treatment.
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Re: back pain case - August 23, 2006 1:16:00 PM
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Shill
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From: Madison WI USA
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Rage, You may be right, but read some more of Ginger's posts, as he would be the first to admit that he mashes away at the joint.
Welcome to the forum by the way.
_____________________________
Steve Hill PT
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Re: back pain case - August 23, 2006 2:19:00 PM
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ginger
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Shill contrary to both visions of my thumbs as either mashers, crammers or having light or any other radiation beaming from them, I do as any trained sensitive user of thumbs as first line assessors would do, relate to feedback. Most of the time the best feedback will occur only after I've begun to mobilise. Do these joint structures move? , how?, do they cause pain with mobs? how much ? , are they responding to mobs? , like expected? not?. The movements I'm talking about Shill are just enough to push the skin off the average home baked rice pudding. Not the sort of mashing cramming litany of abuse it appears you think. Results , good results esre the normal, certainly including those situations where known structural abnormalities exist, including those where interpretations of "instability" are a feature.
Spinal protective responses are the ubiquitous element in spinal pain. The best we can ever do is to just apply whatever turns them off and keeps them off. Mobs do this very well indeed. They are safe, easy to learn and not requiring of magical super sensitive light emitting thumbs .
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 23, 2006 2:27:00 PM
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yarringtonpt
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It seems as though we are forgetting that this kid was able to play football, bale hay, etc. This is certainly more stressful to the spine than a grade I or II spinal mob, no? To ignore ginger's basic tenent of use your hands to evaluate and treat is foolish. I hope that we do not become a profession (with advancement of DPT, importance on radiology and pharmacology for PT's, etc), like medicine, that relies simply on diagnostic testing, or too heavily on diagnostic tresting, before we touch a patient. How many times have all of you been complimented by your patients for the thorough physical exam you gave them? I'm not sure how it is in Oz, Canada, the UK, etc, but in the US our patients are almost never given a good physical exam by their medical doctors.
I don't know if ginger's mobs would help this kid. But, would they hurt him? Would they not be both evaluative and possibly therapeutic? Would they be more stressful to the spine than baling hay or getting hit by a guy weighing 200 pounds in a football uniform? And , I don't get the impression that ginger just "mashes away". If he is true to his word, he probably gets tons of people better.
Eric
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Eric Yarrington, PT, MPT, OCS
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Re: back pain case - August 23, 2006 4:10:00 PM
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ragempt
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Junction13, funny im smiling your post is funny but do you know what a grade 1 mob is right? Remember bending the legs of a fly (Maitland)? if he can perform core exercises he can tolerate a grade one mob. Eric will you please explain to these people grades of mobilization? I suggest you listen to Ginger. Do you guys realize how aggressive football is?
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Re: back pain case - August 23, 2006 5:50:00 PM
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jboypt
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Ginger,
Explain what you mean by understanding a pathology (prior to adminstering mobilization) leads you to the conclusion that I stand back from treating patients? I am telling you that not all patients need mobilization/manipulation to resolve a pathology. And yes, subjective reporting of what you think the patient needs doesn't fly with third party payers unless it translates to functional progress...at least in America.
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Re: back pain case - August 23, 2006 6:25:00 PM
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ginger
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From: Melbourne Victoria
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several things John may appear to stand in the way of administering pain relieving manual therapies to one like the young footballer above.
Fear of doing harm
doubt about likely outcomes
concern about litigation
unwillingness to deviate from the doctors orders
lack of experience
lack of understanding of manual therapies
probably others I've not thought of.
However, were the therapist to have a method that , with skillfull application ,had proven itself , within the experience of the therapist at least, to be both safe and effective, much of the anxiety of doing harm , outcomes, litigation , etc would certainly fall away.
In my experience , doctors know zip about manual therapies, and here in australia at least are not likely to be used as a realistic reference for how to go about treatments.
Your culture is different, though I venture to suggest, nowhere near as amenable to a first class physio/patient constructive relationship .
Be that as it may, it seems the idea that all bases need to be covered by X-rays is only favoured here in Australia , by the chiropractors. I personally never use them. It is rare for those with the clinical appearance described above, for an x-ray to be ordered, even by a GP. I would consider this to be a waste of resources. This , particularly in the light of the likely best outcomes coming from safe , gentle methods like mobs.
To be swallowed up by the fear associated by your litigation prone US medicolegal system, driven in part by the insurance companies themselves , is a feature of a system we, here in australia , wish to completely avoid.
Wish you well.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 23, 2006 7:59:00 PM
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ginger
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From: Melbourne Victoria
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Ive got a place for you in my next tragicomedy peformance at the local amateur theatre production junction, as writer.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: back pain case - August 23, 2006 10:52:00 PM
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nari
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From: Australia
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Junction
Your satire is appreciated, because we Aussies love to laugh at ourselves. Problem is, it is not accurate - although multinational, for sure.
Never mind....
I agree with the points made by Eric. Perhaps there is a yearning for PTs to be doctors (medicos)in the USA. An XR shows nothing else other than nasties, and that is their only purpose if we are dealing with pain. Despite rumours to the contrary, XRs and CTs and MRIs cannot show pain. They can point to a possible cause for pain, but it is only a guesstimate and they are useful for exclusion of nasties only.
Some people live quite contentedly with a 1 or 2 spondylolisthesis, just as they do with "prolapsed discs". Some don't. Sounds, therefore that this bloke is probably OK to treat.
Wouldn't do McKenzie extensions, though...
Nari
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Re: back pain case - August 24, 2006 4:18:00 AM
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jboypt
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O.K. Ginger. You bit so I'll continue one more time for the rest of us to laugh. Not once did you answer any of my statements or questions. Your rhetoric is typcial of many elitist mentalities. Your first point was: Why don't you just put your hands on and mobilise these painfull joints till they improve? My reponse was you don't even understand what's going on and you want to push...poor idea. Who cares about insurance companies if you cause a fracture or progress a sinister pathology?
You then said I stand back from patients. Too bad you can't see that far from the island but, essentially I re-stated my first post to see if you give an intelligent response. Instead, your
last post attacked my culture: Your culture is different, though I venture to suggest, nowhere near as amenable to a first class physio/patient constructive relationship.
I only respond so the intelligent clinicians can see you for what you are. You make me laugh. By the way a thorough mechanical (skilled) assessment has more sensitivity than any diagnostic imaging or palpation. In truth, no research exists to support diagnosis of non-specific back pain except discography and mechanical assessment. Your magic hands lose every time.
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Re: back pain case - August 24, 2006 5:34:00 AM
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Shill
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From: Madison WI USA
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Lookie here - Real world examples of similar cases! Yippy!
J Orthop Sports Phys Ther. 2005 May;35(5):319-26. Links
Differential diagnosis of spondylolysis in a patient with chronic low back pain.Thein-Nissenbaum J, Boissonnault WG.
Faculty Associate, Department of Orthopedics and Rehabilitation, Physical Therapy Program, University of Wisconsin-Madison, USA. thein@surgery.wisc.edu
STUDY DESIGN: Resident's case problem. BACKGROUND: A 26-year-old male sought physical therapy services via direct access secondary to a flare-up of a chronic low back pain condition. The patient complained of recent onset of lumbosacral joint pain, including (1) constant right-sided deep-bruise sensation, (2) intermittent right-sided sharp stabbing pain, and (3) constant bilateral aching. The patient's past medical history included a hyperextension low back injury while playing football at age 17. Physical examination revealed (1) deep pain with palpation over the right lumbosacral joint region, (2) sharp right lumbosacral joint pain with 1 repetition of active trunk backward bending, and (3) a marked increase in pain and joint hypomobility with right unilateral joint assessment at the L4 and L5 spinal levels. DIAGNOSIS: The examining therapist referred the patient for radiographic evaluation due to strong suspicions of a pars interarticularis bony defect. Lumbar plain films, oblique views, revealed an L5 bilateral pars defect, leading to a diagnosis of a longstanding bilateral L5 spondylolysis. DISCUSSION: Patients with low back pain often seek physical therapy services. Identification of pathology requiring examination by other health care providers, leading to patient referral to other health care practitioners, is a potential important outcome of the therapist's examination. This resident's case problem illustrates the importance of a systematic examination scheme, including a thorough medical screening component that led to a patient referral for radiographic evaluation. The resultant diagnosis, although not representing serious pathology, did impact the therapist's patient plan of care.
PMID: 15966543 [PubMed - indexed for MEDLINE]
and another
Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school and college football players: a prospective study.Iwamoto J, Abe H, Tsukimura Y, Wakano K.
Department of Sports Medicine, Kitasato Institute Hospital, Tokyo, Japan.
BACKGROUND: Low back pain is a common presenting symptom among players of American football. In Japan, however, skeletal disorders in football players, including low back problems, have been rarely studied, and management to prevent skeletal disorders has not been established. STUDY DESIGN: An epidemiological study with prospective observation. METHODS: The authors analyzed the relationship between lumbar spine abnormalities viewed through radiographs taken during the preparticipation physical examination, and the incidence of low back pain during a 1-year period in 171 high school and 742 college football players. Abnormalities assessed were spondylolysis, disc space narrowing, spinal instability, Schmorl's node, balloon disc, and spina bifida occulta. RESULTS: High school players with spondylolysis had a higher incidence of low back pain (79.8%) than those with no abnormal radiographic results (37.1%). College players with spondylolysis, disc space narrowing, and spinal instability had a higher incidence of low back pain (80.5%, 59.8%, and 53.5%, respectively) than those with no abnormal radiographs (32.1%), and college players with spondylolysis had a higher incidence of low back pain than those with disc space narrowing and spinal instability. CONCLUSIONS: The results of the present study suggest that an abnormality such as spondylolysis is the most significant risk factor for low back pain in high school and college football players, and that disc space narrowing and spinal instability are also significant risk factors for low back pain in athletes with greater athletic activity such as college football players.
PMID: 15090397 [PubMed - indexed for MEDLINE]
So are those of us who feel he needs further radiographic evaluation paranoid?
Im going to go with no.
_____________________________
Steve Hill PT
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Re: back pain case - August 24, 2006 7:35:00 AM
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SJBird55
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From: Michigan
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Nice job, Shill. I was going to comment that high schoolers with back pain need to have the pars defect/spondylolysis ruled out because it is a decently frequent finding with kids with low back pain that persists, especially in contact sports. I just couldn't remember where I read the stuff.
If I'm treating kids with back pain that doesn't resolve as would be expected, I usually do recommend that pars defect/spondyloysis is ruled out.
Ginger, what I'd be willing to bet is that if you did try to do continuous mobilization on the football player would be the continual feel of guarding/tension and a lack of a painfree response. I'm not really sure that you'd actually cause a ton more damage, but I highly doubt that you'd get a typical response to the treatment you prefer. I'm quite sure your hands would tell you something wasn't normal. So, I do tend to agree somewhat with you that our hands are important and we can and should use them. I recall years ago that I had a patient referred to me from a general surgeon for "shoulder pain." I remember that first visit deciding that I was very sure that the patient didn't have any shoulder pathology, but instead had something wrong in the cervical spine. My hands didn't like what they felt. My hands couldn't do the job I was trying to do. I'm just very glad that I am gentle and not terribly forceful because the guy had a cervical fracture. He had been thrown from his tractor in an auto accident and somehow somewhere someone missed the fracture. He was 3 weeks post accident date when he came to therapy with a diagnosis of shoulder pain. And truth be told, what I felt with my hands is what made my clinical decision that he had something going on in the cervical spine.
Ginger, what tends to be the best treatment approach in the above type of condition is immobilization or bracing and elimination of the contact sport.
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Re: back pain case - August 24, 2006 9:47:00 AM
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ragempt
Posts: 111
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From: linden, michigan
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ok so you send the patient to the doc and the x ray is negative and then the MD says is PT helping? the kids says I feel no better and then she/he discharges him from football and PT. welcome to America or at least my small town.
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Re: back pain case - August 24, 2006 9:54:00 AM
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ragempt
Posts: 111
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From: linden, michigan
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Nari, I wouldnt do a McKenzie extension? why not? what if he felt better in prone. couldn’t you have him assume an on elbows position? what if he said Im pain free in this position? my point is dont stereotype based on possible dx. if you walk slowly step by step you may be surprised.
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