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Diagnosis and Palpation in Manual Tx

 
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Diagnosis and Palpation in Manual Tx - February 15, 2005 10:08:00 AM   
JLS_PT_OCS

 

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Hello everyone...

This thread is intended to discuss the various systems of manual therapy we all practice, what kind of diagnosis or palpation is used, the role of palpation in making clinical decisions, etc.

Not for the faint of heart, we also will be discussing pertinent research related to the reliability and EBM issues of these techniques.

Please share your thoughts...

-Jason.

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com
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Re: Diagnosis and Palpation in Manual Tx - February 15, 2005 10:31:00 AM   
JLS_PT_OCS

 

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The topic of using a specific diagnostic approach of palpation to localize a specific motion problem came up in another thread.
Whether it is an Osteopathic Model, or McKenzie, or any one of several other biomechanical models used to diagnose a movement problem.

I have found nothing in my personal experience or the available literature that makes me think the Osteopathic method of diagnosis / treatment is of great use. Both speaking for myself and experienced PTs, FAAOMPTs, and some DOs and DCs I have met...I have found joint-specific, position-specific treatments (example, correcting FRS R at L4) to be utterly useless. My practice is dominated by more general techniques of mob, manip, MET, and others not aimed at a specific level or supposed dysfunction.

But I was taught the Osteopathic approach in school. I have since abandonded it.

I find this sort of palapatory model a useful paradigm or place to start if general manual therapy techniques do not bring relief. But as a rule, I do not currently even begin to palpate deeply for supposed motion restrictions unless a general technique (usually the Chicago type maneuver of Flynn et al's recent work) fails to help.

I certainly use the treatment techniques I was taught, and they are from the Osteopathic model. My quarrel with it is that it does not address other factors such as neuromuscular control and it claims a level of diagnostic specificity that is clearly unwarranted given our current state of knowledge about same.

What do others think?

Would be especially interested in the methods our Chiropractic colleagues use for diagnosis, if they are comfortable sharing.

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Diagnosis and Palpation in Manual Tx - February 15, 2005 2:28:00 PM   
dosrinc

 

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Jason, nice topic
I find the Grimsby Pyramid model of tissue specific evaluation to be extremely helpful in deciding what tissues to focus my initial treatment techniques toward. It serves to help sort through, organize and correlate the many different pieces of data that are collected on the initial visit both subjective and objective. The Pyramid also serves to stimulate critical thinking and is a great tool to use when discussing a case with colleauges or students. Don't know how it would stand up to intertester reliability ect. but I do know that research on this is currently being conducted.

Rick

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Re: Diagnosis and Palpation in Manual Tx - February 15, 2005 11:38:00 PM   
Alex Brenner PT MPT OCS

 

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Jason,
It is pretty peculiar how similar our beliefs are. I echo everything you state above. I am also a recovering osteopath :)

I think this type of approach (osteopathic or palpation) leads one to believe that the SI joint is a big culprit in lower back pain and I used to kind of believe this too. As my experience has grown I feel the SI joint is much, much less a "player" in low back pain.

In the recent past I exchanged peer review with another therapist notes and was surprised that he would diagnose about 9 out of 10 of his backs as SI joint dysfunction. I just don't buy it.

_____________________________

Alex Brenner, PT, MPT, OCS

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 12:28:00 AM   
Diane

 

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I agree that palpation, motion or otherwise, of anything bony or jointy, is likely an exercise in futility and bound to be misleading. Better I think (after a few decades of trying) to observe movement patterns and draw conclusions from that.

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 7:38:00 AM   
Shill

 

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jason et all,
I couldnt agree more that too much weight is placed on palpation findings, especially for asymmetry "issues". If anyone gets a chance to get back into the gross anatomy lab, now that you know what you are doing in PT land, take a gander at just how different the bony landmarks look (and feel for that matter) from right to left. Asymmetry to palpation is the norm, not the exception. We are not the perfectly symmetrical beings that nice pictures portray, nor do things look as perfect as they appear on computer generated gross anatomy programs. You need to see the real deal to appreciate this.

Palpation is useful for identifying pulses, tissue temperature, abnormal soft tissue masses, and likely a number of other things that I dont have time to recall at the moment, but basing my treatment approach on this alone, does not mesh with my need for being comfortable with my working PT diagnosis.

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Steve Hill PT

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 8:05:00 AM   
Jon Newman

 

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Hi Jason,

Nice topic. I agree with all here. Unfortunately I live in "symmetry world" and find it difficult to talk to anyone about treatment, hence my time spent here.

What do others feel about palpating for painful spots (sans acute trauma). How does that lend to our diagnosis? I don't think there is one right answer, just curious as it pertains to people's experience.

I'll give two examples. I find that most people are tender when you poke them in the area of the piriformis. They tend to be extra tender there when they are in pain in general or if they appear apprehensive about an exam in general.

I find poking about the shoulder almost futile as it seems shoulder pain does not seem to localize well for the most part.

jon

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 9:08:00 AM   
Diane

 

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Jon, you asked for how people "feel" about "feeling" as in palpating.. nice. Are you doing an informal poll? Anyway, palpating for soft tissue 'feel'(as opposed to bone and all the ways it can confuse one), different types of tenderness with different grades of expected discomfort, palpating "layers" and texture, and mobility and slide, all these kinethetic 'qualia'... all these considerations contribute to an internalized, procedural, idiosyncratic, not-very-translatable vocabulary that grows by doing. In the process of getting 'good' at this sort of layered palpation, (i.e.: not being obsessed with diving immediately all the way down to the bone) one can start to feel the nervous system responding to exploratory touch such that by the time you get to the "bone".. things are better, pain is often better, movement is usually freed, and there's usually no need to do any more. Simple. The palpatory assessment/exploration overlaps with treatment.

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 9:43:00 AM   
JLS_PT_OCS

 

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I agree with others, especially Diane (somebody call Ripley! :) ) about how I spend less time pushing on people on the table and more time watching the way that they move and how that affects their symptoms.

Things like hip/lumbopelvic and scapulothoracic rhythmn, squatting or bending, etc.

I also agree again with Diane (twice in one day!) that when started gently, palpation and tissue exam overlaps with treatment.

For example, I find this true for people with thoracic area pain and movement restrictions, which may or may not be present with associated myofascial or trigger point type symptoms.

I have found a gentle PA exploration with hands in manipulation type postion does very well to relax the tissue, and often get cavitation and some relief of symptoms in neck or Tspine without a thrust.

Army - I agree, it is scary. Or maybe expected. One of our famous former Army PTs, with an MS in biomechanics and a PhD in Kinesiology, echoed Steve's thoughts and stated once "I am a recovering biomechanist." I thought that was well put.

I would also agree with Jon about painful spots or trigger points-- push hard enough, or on a patient in pain and/or afraid of what you're about to do to them, and just about anything will hurt. I rarely direct my treatment at painful spots/trigger points.

I thought John Duffy had an interesting point about this when he said the presence of trigger point type things was a signal to him that something was not right, and used their presence or absence to gauge recovery or treatment effectiveness. I thought that was pretty cool and a great idea.

Any chiros about to give their two cents?
Dr. Priest, wherefore art thou?
Would love to get your input, sir...

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 1:45:00 PM   
steve

 

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Jason and all,

Great topic. Jon, I live in a similar world as you where all the therapists look for symmetry and segmental restrictions throughout the spine and find solace in listening to the opinions expressed on this board. There was a great research article in the Journal of Manual and Manipulative Therapy as a summary of research done on palpatory findings by a fellow named Peter Hujberts a couple of years ago. Kappa values for the lumbar spine were .4 for mobility and .6 for provocation (Off the top of my head), certainly not high enough to base all of our clinical decision making on. Even if these assessments were absolutely perfect, there is evidence that specific mobilizations/manips are not so specific and there is no evidence that specific techniques are superior to general. Why the powers that be persist on training individuals with an overly compex, biomechanically and segmental system and we (Therapists in general) continue to buy it is beyond me.

I think there is an inherint danger in giving these biomechanical diagnosis to patients as oppossed to clearing a patient for serious pathology, stating that with 85% of low back pain we cant identify a specific structure at fault and then providing lots of reassurance, education on the importance of maintaining activity as tolerated and teaching them in the clinic that its OK to move, be it through manual techniques and/or exercise. We've all had a patient come in and say "My L4-5 is stuck".

Having said all of the above, I use a biomechanical assessment of the cervical spine based on the research by Jull that found 19/20 therapists were able to locate a segment that was also found to be responsible for pain via nerve block. In the SI joint I use the 4/5 provocation tests (FABers, thigh thrust, sacral shear, distraction and compression). In the lumbar spine, make sure nothing nasty or neurological is going on, identify any potential yellow flags - Psychosocial issues as per the Dutch physiotherapy guidelines on the treatment of low back pain. The manual treatments that I choose to use are generally non specific and complement the active based component of my treatment rather than the focus of treatment and this becomes progressively the case the more chronic or psychosocially a patients case may be.

Perhaps a good 12 step program would be in order for all of those of us recovering from biomechanical world. It is interesting to read everyones treatment approach and very informative, hope to hear others.

Steve

PS I'm very surprised that no biomechanically driven therapists have posted on this thread or any others, Diane will attest that virtually every therapist in our part of the world is biomechanically focussed - do they not read forum boards?

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 5:04:00 PM   
nari

 

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When I learnt all the Maitland palpation stuff in the early 1980s I felt pretty useless when lots of physios would excitedly talk about all the bits of anatomy they could identify and palpate;
and I still think they might have been kidding themselves.
It certainly worked, but as we know now, stiffness is not inextricably linked with pain, and is no longer anything we HAVE to do something about.

Steve I like your idea of a 12 step program for ex-biomechanics. When will you publish it???

Soon I hope

Nari

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Re: Diagnosis and Palpation in Manual Tx - February 16, 2005 9:26:00 PM   
FLAOrthoPT

 

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ok, i was on vacation, I am still a biomechanist at heart. I totally buy into the candain osteopathic school, love their courses and find their assessment and treatment to be very effective. I also now love the greg johnson institute of physical art, the older weiselfish-giametteo of the spine, and the imts global cti, lpi type courses. I combine thoses manual skills with a mulligan type philosophy and with a butleresque type peripher myofascial neural glide technique and seem to be doing great with it. I agree about the whole asymmetry part, but I think that gross anatomical palpations can be observed by therapists, and correcting the dysfunction (not just with one mob but with a neuro re-ed component and behavior modification) can almost always elliminate pain. Especially find this true with acute joint pathologies (non whiplash or non high impact) in the c-spine and t-spine. More of the "i slept funny and i cannot turn my head" quick anatomical palpation followed by movement palpation and motion observation with some end range feels, some treatment in the osteopathic realm and viola...so not sure why all the nay say about osteopathic approach, then again i am only about 1 1/2 years into being knee deep in it, before that I was purely a soft tissue man...so maybe this too will pass and I will forget it, but for right now I am loving it, and buying every last second of it. And YES, I too find a LOT of SI pathologies, not 90% but maybe like 40%. But with the osteopathic view I cannot ignore L5 with the SI pathology..ok my chair is uncomfortable..need to go before I get and ERS or something!

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 5:57:00 AM   
Barrett

 

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Steve,

You ask: "Diane will attest that virtually every therapist in our part of the world is biomechanically focussed - do they not read forum boards?"

I had fifty therapists in my class yesterday. Not one was familiar with the board's existance much less read it or contributed.

Bobath didn't palpate, as far as I could tell. She just landed, enhanced another's awareness of their inherent activity and then got out of the way. So do I.

Oliver Sacks says in "The Man Who Mistook His Wife for a Hat" - "Our tests, our evaluations are woefully inadequate-they only show us deficits, not powers." I agree, and I would add that most palpatory exam techniques that do not show us relevant pathology show us irrelevant assymetry and unreliable and misinterpreted motion restrictions.

Other than that they're really useful.

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Barrett L. Dorko P.T.
http://barrettdorko.com

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 6:12:00 AM   
JLS_PT_OCS

 

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Barrett,

I love this statement..."...I would add that most palpatory exam techniques that do not show us relevant pathology show us irrelevant assymetry and unreliable and misinterpreted motion restrictions. Other than that they're really useful."

Can I use that myself? It's great!
And I agree, I just couldn't say it as well...

I would also add that I had no idea this forum existed if I had not been surfing around on the Chirotalk board and found a link...so this is a small community indeed...

J

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Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 7:50:00 AM   
Barrett

 

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Jason,

Go right ahead. In fact, say this to my old friend Stan Paris should you ever meet him. See what happens.

Not only is it a small community it is almost completely mute. What percentage of the 4500 registered members ever post and how many of those use their real names?

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Barrett L. Dorko P.T.
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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 8:21:00 AM   
Diane

 

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Steve,
"I'm very surprised that no biomechanically driven therapists have posted on this thread or any others, Diane will attest that virtually every therapist in our part of the world is biomechanically focussed - do they not read forum boards?"

I think they think they are conquering territory and perhaps are above and beyond this form of communication. They think congresses and world class get-togethers and proceedings are the way to go and means to impress. I've never been impressed, really.. the memes failed to take. Brobdinagians come to mind. Hope I spelled that right. I don't fear I will offend anyone by saying that, as their balloon seems way beyond being burstable.

(Jason, "I had no idea this forum existed if I had not been surfing around on the Chirotalk board and found a link" Wow. What a way to find RE.)

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 12:23:00 PM   
chiroortho

 

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[QUOTE]I have found a gentle PA exploration with hands in manipulation type postion does very well to relax the tissue, and often get cavitation and some relief of symptoms in neck or Tspine without a thrust.[/QUOTE] [QUOTE]I thought John Duffy had an interesting point about this when he said the presence of trigger point type things was a signal to him that something was not right, and used their presence or absence to gauge recovery or treatment effectiveness. I thought that was pretty cool and a great idea.[/QUOTE]Jason, I fully appreciate and agree with these two points. And with Mr. Dorko, I find some common ground with the implication that we often feel the need as clinicians to 'address' palpatory abnormalities of irrelevance.

A few thoughts. First, we have to remember to do no harm. Trite, but true. Second, the 'treatment of irrelevancies' may be difficult to ascertain, so if the area of hypomobility is proximate to the area of discomfort, I see no harm in applying a gentle manipulative force. At best, we have fixed it. At worst, we have done no harm. Further, I have avoided comment about the 'Clinical Rule' video offered by my august PT colleagues, but I will admit to one reservation: the therapist seems to be applying a general manipulative thrust to the thoracolumbar area, without any pretense of directing the thrust to the area(s) of dysfunction purported to be present at the time of his clinical examination. The fact that the patients reported lasting symptomatic improvement of 90+% is at the same time puzzling, interesting and provocative for those of us that are of the impression that precision, as far as it is possible, is a virtue.

Thank you for the opportunity to opine. Forgive me in advance if I have offended.

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Greg Priest, DC, DABCO

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 1:29:00 PM   
steve

 

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Greg,

How could anyone that polite offend? With respect to the general manipulation, I would agree that I would have been set aback by the use of such a non specific technique a couple of years back. The more I look at the research and the less I listen to Gurus, the more sense it makes to me. Definately provocation for rethinking the whole specific segmental restriction theory. I believe Childs et. al are presently researching outcomes on general versus specific manipulation - maybe I will have to rethink everything when that comes out.

Steve

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 2:04:00 PM   
Jon Newman

 

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I have not read the following article as I have to submit for it. However, it appears, based on the journal this abstract appears in, that those recovering biomechanists could find something that makes sense to them.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14759756

jon

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Re: Diagnosis and Palpation in Manual Tx - February 17, 2005 2:15:00 PM   
JLS_PT_OCS

 

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Greg, thanks for your input, I value everyone's opinion, and definitely wanted the input of all the manual therapists who read the forum - PTs, DCs, DOs or even LMTs... keep the multidisciplinary love goin' on...
We're all here to learn from each other...

Like you, I frequently manipulate, especially around painful areas. I do not slavishly follow the prediction rule (especially in Tx spine, where no rule exists), and I think your rationale is as good as any.

Even in patients who do not exactly fit the rule 4 or 5/5, manipulation may help, and has at least been found of definite benefit in some cases. More than we can say for many other interventions.
I never palpate for supposed assymetries in Tx spine, but I do use that PA manipulation type position to gauge spinal mobility generally and pain response. But I don't fool myself into thinking that I am correcting an ERS Right of T4 on T5 or something like that. Just generally relieving pain and setting the stage for the exercise intervention, which in my opinion is the most important thing...

Manipulation accuracy/specificity:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15223938

There is a study under review (saw it at CSM last year) of Flynn et al's work on the use of thoracic manipulation to improve cervical range of motion, and no attempt to diagnose a motion restriction was made in Tx spine, to my recollection. But there were statistically significant improvements in neck ROM after the Tx manip, that would be consistent with my clinical experience as well.

It seems most PTs are either taught the Osteopathic model for diagnosis or something very similar.
Any chiros feel comfortable discussing methods of diagnosis or biomechanical theory for manipulation used from their education?

Thanks to everyone for their input on the thread so far...

_____________________________

Jason Silvernail DPT
Board-Certified in Orthopedic Physical Therapy
Certified Strength and Conditioning Specialist
www.silvernailstudios.com
jasonsilvernail@gmail.com

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