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Re: who's going to do the manipulation?
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Re: who's going to do the manipulation? - October 3, 2006 4:15:00 PM
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jlharris
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Nari, my sincere deapest apologies. No disrespect meant. See what happens when you make assumptions? Someone as insightful must be a man, right?? Again my apologies.
Reminds of how people respond to my wife profession. This is the general conversation:
them: So what does your wife do?
ME: She's a Resident surgeon at such and such
them: Oh, what is she going to be? A nurse?
ME: No, a SURGEON, aka a doctor
them: Oh, isn't that exciting for her
lol, even her husband can't get past making the same assumptions.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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Re: who's going to do the manipulation? - October 3, 2006 4:28:00 PM
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dfjpt
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[QUOTE]If I read your post correctly, you are indicating that you achieve the same neurophysiological effect through "smaller" less dramatic techniques. Well I am suggesting where is the documentation on intervention effect?[/QUOTE]Stay tuned, maybe some day there will be. Meanwhile I'm in no rush, in that interventions that are non-mesodermal, that are based on good science, and are non-disruptive to anything in the body except bad motor output (i.e. no danger of tissue damage) to me are less likely to need the same degree of persuasion.
[QUOTE]If you choose to employ "smaller steps" in the face of current best evidence, I have to ask why?[/QUOTE]We've been through this already. I'd rather do something easy that requires complex thought/reasoning, than something byzantine that requires no thought/reasoning.
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Re: who's going to do the manipulation? - October 3, 2006 6:21:00 PM
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srcase
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I'm sorry proud, but sometimes you sound like a broken record:
[QUOTE]If we have a technique with documented outcomes, then this is a higher "level" of evidence than your clinical experience. According to sackett:
“Evidence Based Medicine (EBM) has been defined as “the conscientious”, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” David Sackett et.al “Evidence Based Medicine: What it is and What it isn't” BMJ 312 No. 7023 (1996). [/QUOTE]If you read further in that citation:
"Evidence based medicine is not "cookbook" medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. Similarly, any external guideline must be integrated with individual clinical expertise in deciding whether and how it matches the patient's clinical state, predicament, and preferences, and thus whether it should be applied....
"Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. To find out about the accuracy of a diagnostic test, we need to find proper cross sectional studies of patients clinically suspected of harbouring the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow up studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes the evidence we need will come from the basic sciences such as genetics or immunology. It is when asking questions about therapy that we should try to avoid the non-experimental approaches, since these routinely lead to false positive conclusions about efficacy. Because the randomised trial, and especially the systematic review of several randomised trials, is so much more likely to inform us and so much less likely to mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm. However, some questions about therapy do not require randomised trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been carried out for our patient's predicament, we must follow the trail to the next best external evidence and work from there."
(emphasis mine) Diane is working from the standpoint of basic sciences of embryology, neurophysiology, and neurobiology. This is not "bad" practice, but more scientifically-based than most PT practices taught in our entry-level program, IMHO.
Sarah
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Re: who's going to do the manipulation? - October 4, 2006 12:28:00 AM
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nari
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Whew, this thread moves fast...
Jason, no problems at all. You are not the first person who assumed I was male. I think that is because my name is not uncommon in India and the Middle East/Far East. I'm not at all offended... a name is a name is a name...and I am second generation Aussie with cranky Irish and English ancestry.
Re your post where you felt insulted by me...I never intended to imply that you personally use massage , US, etc etc. It was not a personal criticism; I was speaking broadly about PTs in general, and I avoid as far as possible acting ad hominem. Doesn't serve any useful purpose. So, apologies if you inferred it was a kick at you.
Great timing with the post, Sarah. Working from sound first principles has to be OK; cannot see why it could not be.
Nari
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Re: who's going to do the manipulation? - October 4, 2006 1:15:00 AM
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proud
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Sarah,
I wonder why you emphasised this:
>>>>>And if no randomised trial has been carried out for our patient's predicament, we must follow the trail to the next best external evidence and work from there.">>>>>.
I was speaking about the fact that we have a higher level( from PHSPT's link on level's of evidence). Child's study.
I am adding: Basically, I agree with the definition provided of EBP/best practice. But dfjpt implied that her "smaller steps" accomplished the same goal. When evidence is lacking, then clinical experience cannot be discounted. When presented with an approach that is documented to be effective, then why avoid it in favour of "clinical experience? Sarah, I think you missed the mark on that one.
dfjpt, have you read the Childs study? There is nothing "complex" about the manipulation described. Really simple.
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Re: who's going to do the manipulation? - October 4, 2006 2:59:00 AM
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Sebastian Asselbergs
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I HAVE to say this: the following quote "there is a neurophysiological effect. That is not placebo." shows a possible reason for misunderstanding. Placebo effects ARE neurophysiological effects. ANY therapeutic intervention has neurophysiological effects through psychological/cognitive involvement.
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Mundi vult decipi
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Re: who's going to do the manipulation? - October 4, 2006 3:08:00 AM
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avalon
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Proud,
There is studies saying that [URL=http://bmj.bmjjournals.com/cgi/content/full/308/6928/577]Nothing[/URL] is a very good solution.
In that case, rest is the "normal natural" solution.
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http://www.somasimple.com
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Re: who's going to do the manipulation? - October 4, 2006 3:27:00 AM
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proud
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Sebastian,
This is true. Studies have shown that. Thank you for the clarification.
I was referring to the term razzledazzle that was used...I think that term was used inappropriately in the case of the neurophysiological effects of manipulation. That is all.
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Re: who's going to do the manipulation? - October 4, 2006 3:36:00 AM
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Shill
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Nari,
You had a great statement with " To me, it propagates the 'out of place' myth and that is a very difficult concept to alter in patients' thoughts. However, most of us will try to alter that concept." I completely agree. 1000%. Changing the patient's perspective on this is absolutely necessary, but does the one at a time method reach enough people quickly enough to set the record straight, and stop this nonsense that something is out of place?
How do we get this message out on a larger scale?
_____________________________
Steve Hill PT
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Re: who's going to do the manipulation? - October 4, 2006 6:07:00 AM
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dfjpt
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Proud, if hands-on and muscle energy technique (badly named contract relax) applied to various sections of back that appear to not move on acute LBP patients counts as manual therapy, then yes, I do manual therapy. I never crank/thrust/suddenly rotate or jump on anyone's acutely painful back,ever. Ever. I have no personal or political interest in keeping such a tool "safely" in our PT hands (in Canada, at least in BC, it's never been out of our hands in the first place).
There seems to be no lack of chonic pain patients coming in to my practice who've been manipulated by various designations of human primate social groomers, and it didn't seem to do the job. Of course, that was before Childs' study that LIMITS the group upon which manipulation should be performed..
Proud, to follow up on Sebastian's point, what exactly do you see happening that you would term a neurophysiological effect? Just curious.
Shill, you win the shiny toaster for getting the bit about the importance of deconstructing memes. :)
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Re: who's going to do the manipulation? - October 4, 2006 6:34:00 AM
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proud
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dfjpt,
For one, I have never jumped on someone's back. I never crank, or "suddenly" rotate. Have you heard of premanipulative holds?
You did manage to skirt my question about why avoid the technique with the evidence right there. Actually muscle energy is more complicated than the lumbo-pelivic manipulation described.
As for your question. I think the article posted provides some insight. But I gather yours is a leading question? Why don't you tell me?
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Re: who's going to do the manipulation? - October 4, 2006 7:23:00 AM
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dfjpt
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Proud, [QUOTE]Have you heard of premanipulative holds?[/QUOTE]Frankly, no. Is this something someone came up with last week?
[QUOTE]You did manage to skirt my question about why avoid the technique with the evidence right there.[/QUOTE]Check out the article in Avalon's post.
[QUOTE]Actually muscle energy is more complicated than the lumbo-pelivic manipulation described.[/QUOTE]Maybe it is, but it leaves the locus of control with the patient, a very important factor in prevention of future chronic pain states, that the patient's pain be "self"- resolving, that they keep their own motor output locus of control.
[QUOTE]As for your question. I think the article posted provides some insight. But I gather yours is a leading question? Why don't you tell me?[/QUOTE]I asked you first, on this thread. I told you what I thought on another thread (adherent nerve root I think) awhile ago. Your retention seems lacking. I answered that the dorsal rami were implicated neurodynamically (to refresh your hippocampal homunculi). But I want to know your own definition of "neurophysiological."
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Re: who's going to do the manipulation? - October 4, 2006 7:42:00 AM
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steve
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Just a quick note on Avalons study on low back pain and a 90% resolution within a 2 week period, there was no follow-up beyond 90 days. I'll have to check my reference but there are two good studies with cohorts of patients finding about 70% of patients continued to experience symptoms over the next year. Incidentally, these higher episodes of reoccurrence corespond with the long term data (6 month)found in the Childs study for those patients not treated with manipulation and the Jull and Hides study for patients not treated with stabilization exercises over the course of a two year follow-up.
The literature suggests doing nothing leads to higher rates of disability and pain.
Steve
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Re: who's going to do the manipulation? - October 4, 2006 7:51:00 AM
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proud
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dfjpt,
1. Pre manipulative hold is not new.
2. Avalon's post is nothing new. LBP does resolve through natural process's. However, it is known to have high recurrance rates. The childs study has shown long term results...
3. Muscle energy as I know it is therapist generated so how does that leave the locus of control with the patient? I do agree with you however on locus of control. Which is why some of the McKenzie principles have clinical value.
3. Well, I am not one for interpreting other experts research with my own spin( eh Junction). But dorsal horn inhibition? Or:
Neurophysiological processes have also been used to explain the underlying effect of SMT [13,21-23]. Specific to the purposes of this study, SMT has been theorized to affect spinal joint and muscle spindle mechanoreceptors, activating low (A-beta) and high (A-delta, C) threshold afferents [7]. This afferent input converges on the spinal cord with the potential to inhibit dorsal horn cells involved with transmission or amplification of nociceptive input. In this scenario, SMT's underlying effect would be as a "counter-irritant" stimulus to peripheral nociceptive input received by dorsal horn cells [7].
In the case of manipulation...
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Re: who's going to do the manipulation? - October 4, 2006 8:14:00 AM
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dfjpt
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[QUOTE]Muscle energy as I know it is therapist generated so how does that leave the locus of control with the patient?[/QUOTE]The patient is required to make a bit of a motor effort, consciously.
Neurophysiologically, things happen at every level, proud. No doubt things are occurring, as you suggest perhaps, at the levels you suggest they happen at... But there's another whole spectrum of afferent input that is being disregarded here, because of the mesodermal fixation still operant in the minds of mesodermalists. It's like they can't conceive of afferents that have nothing to do with joints or muscles, such as the ones in skin, or the actual physicality of nerves as tissue that live their lives in tunnels that feed them but that can also tighten round them/pull relative to them for periods that are long enough to deoxygenate them. What of the nocioceptive noise from this? What of the possibility of allieviating this? It seems to never register on mesodermalists' mental radar.
And here we still are out in the periphery, not even into the brain yet where as Seb pointed out placebo is also a neurophysiological effect.
It strikes me that mesodermalists' minds can only deal with specific bits of info, and that they have cognitive hemineglect. Which produces more (ahem) "science" that moves us all along farther into more cognitive hemineglect. It makes me roll my :rolleyes: and :p (there is no "barf" smilie here, this is all there is.)
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Re: who's going to do the manipulation? - October 4, 2006 9:13:00 PM
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avalon
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[QUOTE]I'll have to check my reference but there are two good studies with cohorts of patients finding about 70% of patients continued to experience symptoms over the next year[/QUOTE]Check it out! 70% really? I was told that it was less than 5%.
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Re: who's going to do the manipulation? - October 4, 2006 9:19:00 PM
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avalon
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And I was told that fear was the main factor of recurrence. Fear has nothing in common with manipulation.
PAIN 2003 Sep;105(1-2):371-9.
Fear of movement/(re)injury, disability and participation in acute low back pain.
Swinkels-Meewisse IE, Roelofs J, Verbeek AL, Oostendorp RA, Vlaeyen JW.
Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands. swinky@xs4all.nl
Fear of movement/(re)injury and its associated avoidance behavior have shown to be strongly associated with functional disability in chronic low back pain. In acute low back pain disability, the role of pain-related fear has received little research attention so far. Measures of pain-related fear such as the Tampa Scale for Kinesiophobia (TSK) are increasingly being used in primary care. The aim of the present study was: (1). to further investigate the factor structure of the TSK in a population of acute low back pain (LBP) patients in primary care by means of a confirmatory factor analysis (CFA); (2). to examine the relationship between fear of movement/(re)injury and disability, as well as participation in daily and social life activities in 615 acute LBP patients seen by general practitioners and physical therapists in primary care settings; and (3). to examine whether disability mediates the association between pain-related fear and participation. CFA, and a subsequent explorative factor analysis on the TSK revealed a two-factor model. The factors consisted of items associated with 'harm', and items representing the 'avoidance of activity'. Both constructs were significantly associated with disability and participation. Additionally, and in contrast to what is often observed in chronic pain, disability, and to a lesser degree participation, were also associated with pain intensity. Finally, the association between pain-related fear, pain intensity and participation was indeed mediated by disability. The results suggest that early on in the development of LBP disability, the successful reduction of pain-related fear and disability might foster increased participation in daily and social life activities.
PMID: 14499456 [PubMed - indexed for MEDLINE]
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Re: who's going to do the manipulation? - October 5, 2006 5:08:00 AM
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touchiba
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Have you considered the effects of manipulation on muscles spindles and GTO's? Also, neurophysiologically, do you think an HVLA maneuver might fire off different afferent pathways versus mobilization?
I dont have any definitive answers, but I have my theories.
-HVLA fires off larger/faser afferents, and through the pain gate theory, inhibit the pain fibers (I need to refresh my knowledge, I once knew all the different types of fibers. I think they are type 1A and C fibers)
- HVLA has an inhibitory effect on muscle spindles and GTOs, which has been shows to 'quiet' muscles as shown on needle EMG. Higher velocity and lower duration moves had a greater inhibitory effect.
I'm not so sure how much can be attributed to psychological influences. I dont tell any of my patients that something is 'out of place', yet they seem to benefit from the procedure.
Someone mentioned that it might be counterintuitive to manipulate someone with acute low back pain. I would say it depends upon their presentation. Is the area very sensitive and 'inflammed'? Was the MOI traumatic? Is it painful to even set them up in the pre-manipulation position? If so, then I probably wouldnt manipulate either. However, there are many patients who have acute low back pain that present differently that do respond well to manipulation.
If you're not comfortable with manipulation, don't use it. From reading the literature and my personal experience, I find that it is very benficial when added to the other things mentioned such as advice, exercises, etc. We all develop our style and way to deal with various presentations.
If we wanted to be critical of different methods using the literature, we could do so for many procedures. How about specific exercises? General exercise does just as well, so maybe people should just see personal trainers for their problems. You and I know that's probably not best for people, but do you see my point? Then again, maybe people would do just as well for low back pain seeing a personal trainer verus a PT. Who has the guts to do that study? Proud, maybe just as skilled versus unskilled manipulation makes no difference, I'm sure it probably wont matter who is teaching the exercises. Heck, maybe none of us are all that special and we should go back to when PT and DC school was a 2 year program.
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Re: who's going to do the manipulation? - October 5, 2006 6:22:00 AM
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Jon Newman
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Hi Proud,
I don't think that study is a sound refutation what BT DC is suggesting.
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