Joined: October 3, 2000
From: North Woodmere, NY USA
Hi everyone, Joint mobilizations seem to be widely used manual technique to improve ROM and decrease pain, yet there does not seem to be a substantial amount of research surrounding the ideal amount of force generated for proper and effective performance. Is this a technique that physical therapists acquire with time, and are the forces generated consistent between therapists. I have come across some research using biofeedback for teaching the skill, but how much force is enough? Does anyone have any resources that can give me some more insight? Thanks.
Joined: January 30, 2001
From: hong kong SAR
Personally, i think it is quite hard to give out a standard formula things to say how much force is required for a certain technique, since manual therapy basically is heavily based on the tactile sense of the therapist; the therapist assess the degree of bind or resistance present and then give the appropriate force to elicit the comparable symptoms carefully. Besides, the forces needed is different among individuals and also among individual joints.
Joined: July 29, 1999
From: Cuyahoga Falls, Ohio
A piece of advice, remember when you are eventually allowed to handle others that the materials of the body vary in their response to force and may alter that from moment to moment. While it is perfectly possible to calculate accurately the amount of force necessary to do damage (forensic pathologists know this), how much pressure must be exerted in order to gain a therapeutic effect is another matter.
Joint mobilization, which I spent several years teaching and virtually never use today, supposes that the technique isolates the appropriate connective tissue in the desired way. That would be nice of course, but I doubt that it's often true. When you move another passively they have a great deal to do with what eventually happens and what kind of effect endures. I've come to the conclusion after nearly thirty years of doing this that it is what the patient *learns* that matters, and your role as a therapist is more appropriately described as a witness than a manipulator. This is not to say that handling others shouldn't be an integral part of your care, just that assigning something like pounds per square inch to therapeutic effect won't really help you understand what you really need to know.
Joined: October 3, 2000
From: North Woodmere, NY USA
Thank you both for your replies. Barrett, I definitely see your point because it is quite obvious that different amount of forces are applied from joint to joint. I also feel joint mobilizations are dependent upon condition/situation, and patient response. For this reason, I agree that we cannot put a definitive number on the amount of force that is needed for therapeutic effect that will be correct in all situations. I guess my question more lies in a therapist's ability to "know" how much force they are applying, and reproduce that force with reliability during upcoming sessions. I would think that our spatial/ tactile awareness is not automatically on target after learning this technique in school. Have you found any teaching techniques that have been particularly effective when teaching the skill of joint mobilizations to your students? I guess I am just seeking ways to back up one of our treatment modalities with some research. (Who knows, maybe even expand upon the existing research before some health insurance companies consider manual therapy "unskilled") Thanks again.
Joined: February 9, 2000
I would agree that as I go on in my career I use joint mobilizations less and less. Better for my body and probably for the patient [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] I think that therapists try to force joints far too much. If you look at the biomechanics of soft tissue and the tissue creep and stress relaxation phenomenon - joint mobilizations don't seem to be in line. However, they have been proven effective in some situations. There was a study recently that compared shoulder PT with and without Joint mobilization. The joint mobilization group demonstrated increased strength and better outcomes. I can get the cite if you need it. Now the question that begs to be asked is.....did the mob group get better simply because someone was touching them. Don't know. Some one should compare mobs with some kind of touch thing to see if there is a difference. In terms of other studies, there is an overwhelming amount of evidence for the efficacy of manipulation in accute low back pain. This has been restated by the AHCPR, the UK and NZ guidelines. Of course, manipulation is to be used for pain control mostly. It doesn't seem to have any affect beyond the first four weeks and on the overall outcome. So you see this is a complex issue. If you are who I think you are don't get ready with the hippocrit lablel because I stood in front of your class and taught you joint mobs [IMG]http://www.rehabedge.com/forums/frown.gif[/IMG] Remember, I said they were to be used sparingly and in very specific situations [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG] Later, Marc
Joined: October 3, 2000
From: North Woodmere, NY USA
Hi Marc, Me...give you a hippocrit label. No way! If anything, you taught us more about the importance of having research to support our treatment techniques. I might have come across the article you mentioned in my search. I found one about the effect of joint mobilization for comprehensive treatment of shoulder impingement syndrome (JOSPT July 1998). If there is another one, let me know. As far as the question regarding whether it was simply "touch" that helped the patients get better, I don't really know. I can say that I just completed my affiliation at a clinic where the therapists did utilize alot of joint mobs and manual stretching techniques (when applicable, of course). Does this now make me an expert?- Not really. The patients did repeatedly show decreased pain, increased ROM, and increased functional ability upon discharge. I would like to think my hands had something to do with it. Remember, I am still a student... eager to make everyone "better". I did come across some other articles regarding joint mobilization education and clinical use, efficacy of spinal manipulation/ mobilization, etc., so I will let you know if I have any more insight. Thanks for your reply. Keep in "touch"
Joined: November 25, 2004
thank you chris for mentioning this topic. I think that mobilisation comes with experince over years. For 8 years in this profession I noticed that the more education you give to your patients , more better results you will get accordingly.I do agree with Barrett.
Joined: March 1, 2004
This is an interesting thread from a while back that I have not read until recently "revived" by raheeb boy. Thanks.
[QUOTE] from MCAP concerning mobilization...Remember, I said they were to be used sparingly and in very specific situations.[/QUOTE]This quote was from Feb 2001. I assume MCAP is a professor at a PT school somewhere and manipulation was taught as a technique that should be used sparingly. It is interesting now that much research shows us that manipulation is effective for low back pain but it is very under utilized by PTs (this is a common thread throughout this month's issue of JOSPT!). I hope that more PT schools are teaching manipulation as an entry level skill and that more students are learning it and using it. It is one of the few treatment options that we have for low back pain that has been shown to be effective.
In my opinion, we should all get over the "I don't know what is happening to the tissue, therefore I won't use it" mentality.
I hope ChrisPT2B is now a PT and is manipulating spines in his clinic.
As one of my professors used to say, "Move it and Move on."
Just to back what ArmyPT was referring to Read this article in JOSPT. 32 (5) 5/02 192-3.
we were given this article as part of our syllabus before every class in school..I guess the president of our university felt the article was important..I didn't get the significance of the article until recently...I have been practicing for ~ 2 years...good reference Army PT.
In my opinion, Joint mobilizations/manipulations, which I feel to be synonymous are just a tool in our tool box, and when used in the correct context can be very useful for the spine and extremities.
As far as grading the depth of your technique, I agree with Barrett, to a certain extent....The contact factor of a skilled clinician on a patient is therapeutic in itself, however with increased amounts of depth into the given tissue, may and most likely do result in stretching of the joint capsule for instance...
We also have to consider the stress-strain curve when dealing with biological tissue....we can take advantage of this curve when applying or mobilization/manipulation techniques (for our intended purposes)
**Barrett: I would like your input on my response I respect your point-of-view
Joined: April 25, 2004
From: Amherst, WI
I have some basic questions that may be appropriate to ask here.
When mobilizing or manipulating, is it typical that one would attempt to move the joint into the restricted region? That is, if I can't side bend right very well, would the strategy be to make my joints move in such a way that I segmentally move into right side bending?
Is the restricted motion usually the painful motion?
Why is stretching a joint capsule a good thing? I thought that may hurt based on my interpretation of some of the research I've read.
I don't understand the particulars of how we are taking advantage of the stress-strain curve when using mobilizations/manipulation.
During the physical examination, if we find a patient to be limited with RSB..upon active ROM testing we still have to look further...how does the patient respond to Passive RSB (if we take the slack off of the upper trapezius, does their ROM increase ?? )...this may be suugestive of a soft-tissue restriction...upon passive intervertebral motion testing we can get a better assessment of what the facet joint are doing...and if you can really get the patient to relax, you can get a good assessment...we have to examine what actually is restricted...is it that the L side is not gliding superiorly or the R side of the segment is not gliding inferiorly...in other words , where is the restriction..it may be both L & R
As far as "is the restricted motion usually the painful motion?"...based on my education..."stiff joints are not painful"...so I tend to use pain response as a guide, however I will not mobilize/manipulate based on pain...i should restate that i may mobilize just for a "gating-effect", but not for the intent of freeing a restricted segment..i hope this helped a bit.......and always remember, this is just my point-of-view
Joined: February 14, 2003
From: Madison WI USA
Some questions I have on mobilization and manipulation. We have all seen the articles and studies for it, as well as against it. Who do we believe? How do we decide who to believe?
I like the systematic reviews because someone else has done the digging, and the evaluating of the quality of the studies used to determine efficacy. Heres one.
Cochrane Database Syst Rev. 2004;(1):CD000447.
Spinal manipulative therapy for low back pain.
Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG.
Department of Guideline Development and Research Policy, Dutch College of General Practioners, P.O. Box 3231, Utrecht, Netherlands.
BACKGROUND: Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain. OBJECTIVES: To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened. SELECTION CRITERIA: Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage). MAIN RESULTS: Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results. REVIEWER'S CONCLUSIONS: There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.
So again I ask, who do we believe? I suspect there are a multitude of answers.
Joined: March 1, 2004
I had this same conversation with a collegue of mine. It boils down to this. These authors are the very same that came out and praised manipulation a few years earlier. In this Cochrane review, they totally ignored patient classification and treatment systems. We know that all back pain is the not the same and to treat all as the same, and then draw conclusions is doomed from the beginning. This was the problem with all the studies in the past, we can't look at LBP as a single group. The proof for classification based systems is mounting favorably. In fact, there is an article coming out in 22 Dec 04 Annals of Internal Medicine by Childs, et al that addresses this specifically. This same study from Childs et al was presented at a major conference that included those same Cochrane authors. They have since back stepped on their views and are due to make a public statement to such. Not sure when that is coming out. Believe what you want, but I feel the evidence is there.
Joined: July 29, 1999
From: Cuyahoga Falls, Ohio
I appreciate your asking my opinion. Evidence of effectivness isn't the same as evidence of reasonableness, and if the origin of the patient's pain is mechanical deformation it stands to reason that movement of some sort, manipulative or not, stands a chance of helping. Big deal.
I'm far more concerned with the underlying theory and the biologic plausibility of the proposed method of correction. Manipulative technique, or any method that proposes to alter the targeted connective tissue in the desired direction for that matter, has massive problems from this perspective. I did it for years, I taught it with many of the top people in that discipline and I have abandoned it entirely. My patients told me to do something else and the literature supporting my current method is far more compelling, in my opinion.
Check out the new video on my site for an idea about active movement for pain relief you might not have previously considered.
Joined: August 25, 2000
Hello, If one reads the November 2004 issue of JOSPT, there are some nice articles on manual physical therapy.
What to believe? It depends on the situation. Just like the Hooked on Evidence articles in the PT Journal, one may look at the evidence at hand and make a clinical decision to apply that research to a clinical question.
I don't often have time to reply but this was an interesting thread. I work in an outpatient clinic and I use some mobilizations in my practice and they can be an effective tool. I do not use manipulation because I do not have the patients in my caseload that would receive the most benefit from it, so I can't comment on it.
Jon, you asked,"Why is stretching a joint capsule a good thing? I thought that may hurt based on my interpretation of some of the research I've read."
Are you sure that is what you are doing with a mobilzation? Why do grade 1 and 2 mobs work because you are not influencing the joint capsule at that intensity? I am not sure what they are teaching now in the universities but 23 years ago I was taught that you were stretching the joint capsule. But then I was also taught back then that doing a PA over the paravertebral muscle was doing a rotational mob to a lumbar vertebra. It was suppose to be somehow influencing the transverse process. Ya right, through 2 inches of muscle!
With spinal mobs it is my impression that you are stimulating the type A afferents in the muscle spindles to get a reflex relaxation of the muscles. I primarily use rotation mobs on the spinous process quite often combined with abit of ultrasound and my patients are more compliant about the exercises I give them which is ultimately what I think makes them better. If it is placebo, at least it gets them moving.
Peripheral mobs are a whole different ballgame I think. Why does someone with an acute frozen shoulder with restricted passive movement suddenly have greater movement after a procaine injection or with acupuncture? Neither influence the joint capsule. I used to do the usual glides to a knee after an ACL repair but since I started using Mulligan techniques 10 years ago, my ACL patients started getting full ROM in about 1/2 the time it took before with less work from me and less discomfort to the patient. Mulligan techniques don't stretch the joint capsule. So I don't know quite what is going on. I only know what gives me results.
Basically there is still a whole lot that needs to be researched in physiotherapy. There are therapists calling many treatments placebo because there is not a good study out there that validates it's effectiveness. I feel one has to rely on their own experience as to whether it is effective for them and continue taking courses and asking questions. There are many techniques that I was taught over my 22 years of practise that I do not use anymore but I still use ultrasound, mobilzations and yes, even TENS because if any of these techniques work to get a patient to move then it is therefore an effective treatment for me.
You also have to remember that what works for one therapist may not work for another. I have no confidence in manipulation because the chiros in my town tend to only manipulate (no exercises) and I have had many patients come in after a year of weekly treatments from the chiro and have the problem resolved in as little as 6 weeks after an active exercise program. Yet manipulation works for ArmyPT who is seeing alot of acute injuries so it is a good treatment technique for him. Remember, most of these studies say that such and such a treatment approach was not effective in this study; it does not say it is absolutely, definitely not effective. Find out for yourself.
Joined: April 25, 2004
From: Amherst, WI
I appreciate you addressing the joint capsule question.
As far as placebo goes: It would be hard to argue that there is anything intrinsically wrong with placebo as more and more evidence suggests that a true physiologic effect is rendered with placebo. The placebo issue that I struggle with is how the placebo is delivered. That is, does the person have to pay for it? Also, does the person leave believing something in them is disordered in such a way that can only be remedied with the use of the placebo a seller offers. The answer to the previous question is often yes, because that is how placebos work. And of course they work best when the seller believes in them also. This is serendipitous because the seller is then on solid ground (of sorts) because he/she is doing what they truly believe is right beside the fact that his/her successes are greater for their belief. These are tough issues without easy answers.
Joined: November 15, 2003
A thought here, which may or may not help to clarify. Placebo effects are not fraudulent, they directly involve areas such as the anterior cingulate, and therefore can be just as effective as an 'analgesic' or stimulus-altering massage or glide or mobilisation. Anything which alters the brain's interpretation of afferent stimuli and thus alters function for the better, is useful. We should make the most of placebo, even if we do not cinsciously employ its effects.
It never ceases to amaze how we as a profession (PT) resist joint manipulation(of all grades including 5 thrust) when there is more evidence to support it's effectiveness in use for both acute and chronic low back and neck pain than for most any other intervention. You can fall on either side of the debate, but to deny that it may be one of the most effective skills we have to offer is to deny what has been fairly well substantiated. We must stop dismissing the possible beneffits because of our fear, or our longstanding desire to disparage anything thought of as chiropractic, or osteopathic. If ultrasound or E-stim had the support in the literature that manipulation does we would all be doing a lot more of it. I would ask those of you advocating other forms of approaches to think about the evidence to support it. Not many PT's that I'm aware of treat with just joint manipulation, but when we include exercise and education in the appropropiate amounts you're probably doing as good a job as you can.