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Re: Diagnosis and Palpation in Manual Tx

 
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Re: Diagnosis and Palpation in Manual Tx - March 1, 2005 7:14:00 AM   
Jon Newman

 

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Hi all,

I'd like to take a moment to reiterate Jason's thread starting question here:

"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."

I see palpation being used for clinical decision making frequently. To detect asymmetry or mobility of a joint and then coming up with a plan to do something about it. But I think Jason's question also encompasses the following question.

What does joint mobility and asymmetry tell us about why someone is in pain?

jon

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Re: Diagnosis and Palpation in Manual Tx - March 1, 2005 4:14:00 PM   
Yogi

 

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Jon, just to show I've been paying attention, it shows us a possible reason for mechanical deformation or chemical irritation (or both) [they may be inseparable on the micro level].

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Re: Diagnosis and Palpation in Manual Tx - March 1, 2005 5:29:00 PM   
Barrett

 

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Yogi,

If what you've said is some sort of answer to Jon's question, I really don't get it.

Are you saying that the palpable asymmetry accounts for the complaint?

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Post #: 63
Re: Diagnosis and Palpation in Manual Tx - March 1, 2005 7:14:00 PM   
Synergy

 

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Roger,

Why do you not palpate/examine landmarks in sitting, standing, walking (functional positions)? Also, why do you not perform mobility testing?

Barrett,

Why wouldn't palpable asymmetry be a source of pain and a potential patient complaint?

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Post #: 64
Re: Diagnosis and Palpation in Manual Tx - March 1, 2005 7:45:00 PM   
Barrett

 

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Chris,

Because palpable asymmetry is common among those without pain, to say nothing of the fact that symmetry is commonly present among those with pain.

I think we need to consider other factors as well as tissues we cannot actually palpate.

Pain of mechanical origin is the result of the relationship between the individual patient's mechanical deformation and tolerance. These can vary with remarkable speed, and neither is easily palpated.

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Post #: 65
Re: Diagnosis and Palpation in Manual Tx - March 1, 2005 10:14:00 PM   
Synergy

 

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Thanks for the reply Barrett! Your first comment of asymmetry/symmetry versus no pain/pain may very well be the case for some individuals. However, from what I have seen (I am still wet behind the ears mind you), asymmetries have usually led me closer to a diagnosis if not the reason for the patients pain complaints.

In treating these 'asymmetries', why does a majority of my patient population feel better and move better?

Again, this may not be the case for many patients, asymmetries being synonymous with pain/pathology.

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Chris Adams, PT, MPT

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Post #: 66
Re: Diagnosis and Palpation in Manual Tx - March 2, 2005 5:58:00 AM   
Barrett

 

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Chris,

What's the difference between a diagnosis and a reason for pain?

What factors in the patient lead toward a painful asymmetry as opposed to a painless one?

After a few days of relief is the asymmetry still gone?

Which tissues do you think you are affecting with your care, and would an asymmetry have any correlation to them?

I assume your patients feel better because your care has reduced a relevant mechanical deformation and/or enhanced their tolerance for the mechanical deformation they still possess; this is rarely a mystery. However, is your patient now capable of maintaining and reproducing this?

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Post #: 67
Re: Diagnosis and Palpation in Manual Tx - March 2, 2005 7:06:00 AM   
Pelfixer1

 

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Dear Chris:
I only palpate the asis's and medial malleoli to assess the alignment of the pelvic joints and this is best done in the supine (anatomical) position.
Thanks for your question.

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Post #: 68
Re: Diagnosis and Palpation in Manual Tx - March 2, 2005 10:01:00 AM   
Shill

 

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Roger,
What are your thoughts about studies such as this,

Spine: June 15, 1999 24(12) p 1234
The Association Between Static Pelvic Asymmetry and Low Back Pain
[Exercise Physiology and Physical Examination]
Levangie, Pamela K. DSc, PT

Where conclusions are drawn as follows:

Results. Pelvic asymmetry was not positively associated with low back pain in any way that seemed clinically meaningful. Asymmetry of posterior superior iliac spine landmarks showed some evidence of a weak positive association with low back pain.

Conclusions. In the absence of meaningful positive association between pelvic asymmetry and low back pain, evaluation and treatment strategies based on this premise should be questioned.

Just curious,
Steve PT

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Steve Hill PT

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Post #: 69
Re: Diagnosis and Palpation in Manual Tx - March 2, 2005 11:00:00 AM   
Pelfixer1

 

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Dear Steve:
I have not read the article/reviewed the study, but as soon as I have I will give you my opinion.

Thanks!

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Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
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Spring Hill, Fl. 34609

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Post #: 70
Re: Diagnosis and Palpation in Manual Tx - March 2, 2005 11:47:00 PM   
Synergy

 

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Barrett,

I suppose that injury or a life full of 'millions of episodes of microtrauma' (movement impairment syndromes) may lead a patient to painful asymmetries. Shirley Sahrmann comes to my mind when she says "Ideal alignment facilitates optimal movement".

In several cases that I have seen (either my patients or one of my peers'), the asymmetries have resolved and the patients reach that mystical pain-free status. Do I presume this to be true with all of my patients? Certainly not! I would like to think that those who do not respond soon with treatment have more of a motor control issue and this may be true for the groups that respond well (assuming their ability to maintain a correction).

In response to your last question, I would surmise that I'm 'affecting' any tissue in and around the immediate treatment area...not to mention this effect most likely has a central component...well away from the treatment site. I do think the asymmetry has a correlation with these tissues. Theoretically, by reducing or correcting the problem (asymmetry), the tissues around that site play a major role in how this area will adapt to the recent change.

There are so many variables in dealing with asymmetries that it can boggle a mind! How long it has been present may be a good predictor if the correction will remain or if it will return to its 'happy state' (chronicity).

I babbled enough for now! :)

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Chris Adams, PT, MPT

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Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 5:59:00 AM   
Sebastian Asselbergs

 

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Let's not forget that many statements about asymmetries from Sahrman are based on Janda's work - which in turn is based on finding asymmetries and "ober und unterkreuz" syndromes (the origins of "muscle imbalance") in patients with pain complaints or pathologies. A causal relationship has not been established from the usual minor asymmetry leading pathology/pain - yet asymmetry HAS been evident as a result of pathology/pain.
To address asymmetry as a cause of dysfunction or pain is, in my opinion, no more than treating a POTENTIAL symptom. I have seen too many asymmetrical pelvises in my dealings with gymnasts, skaters, wrestlers, dancers etc etc. to be overly concerned with their presence.
I can theorize that asymmetry could possibly develop into some problems - sure - but I think that is far from saying that it is a demonstrable cause (rather than effect) for painful problems.

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Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 6:25:00 AM   
Jon Newman

 

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If you look to athletics for examples where symmetry is emphasized, one ought to expect extremely low levels of pain. I can think of a few off the top of my head:

Bodybuilding

Ballet

Gymnastics

Yoga

I haven't noticed an absence of these types coming to PT for chronic pain problems, and low back pain being common.

I also think of advanced level tennis players who are extremely asymmetric due to their sport and yet don't suffer nearly as much as others in the same sport who have yet to develop these asymmetries.

jon

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Post #: 73
Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 7:19:00 AM   
Barrett

 

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Jon,

Excellent point. We know that bodybuilders struggle to acquire symmetry because it does not naturally occur. Neither do muscles shaped like theirs. Nice to look at, if you're into that sort of thing, but known not to possess the strength or endurance needed for most athletics. The term "girlyman" reaches new hieghts of irony when used by someone who once did this for a living.

Chris,

Sahrmann also says, "...clinical studies have not supported the importance of good postural alignment (read symmetry) to health." (JOSPT August 2002) There's a thread about that article in the Bullypit if you look in the archive about that date.

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Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 10:11:00 AM   
JLS_PT_OCS

 

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Boy, I go away for a week, and look at all this activity1
I have enjoyed reading the posts so far.

Special thanks to Roger for answering questions re: his course. I appreciate his willingness to discuss it with us, and I'm sure many more agree.

Jon,
Thanks for reintroducing the thread, and I definitely question the use of assymetry to determine someone's pain. It may be a factor, but it is it worthwhile to target the assymetry with our treatments?

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Certified Strength and Conditioning Specialist
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jasonsilvernail@gmail.com

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Post #: 75
Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 1:27:00 PM   
JLS_PT_OCS

 

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In this vein, here is an abstract from CSM showing no real change after lumbosacral manipulation. One of the study authors is a coworker, who tells me that assymetry findings seemed to be a mixed bag between those who improved and those who did not.

In this case, weight bearing assymmetry refers to weight shifting toward one LE over another in standing. It is well-studied in Cibulka's work on assymmetry, and that's why it was used in the study. Frontal plane pelvic assymetry refers to iliac crest height.
Here it is:

Changes in Pelvic Asymmetry, Functional Status, and Pain in Subjects with Low Back Pain More Likely to Respond to Manipulation.
SESSION TYPE: Oral;
SESSION TOPIC: Orthopaedics;
Abstract Details
AUTHORS (ALL): Loomis, Gregory2; Sutlive, Thomas G.1; Weigel, Kara3; Mendoza, Aldo4; Morris, Krystal6; Rendeiro, Daniel5; Wainner, Robert S.1.
INSTITUTIONS (ALL): 1. Physical Therapy, US Army-Baylor University, San Antonio, TX, USA.
2. Physical Therapy, Walter Reed Army Medical Center, Washington DC, DC, USA.
3. Physical Therapy, DeWitt Army Community Hospital, Fort Belvoir, VA, USA.
4. Physical Therapy, Eisenhower Army Medical Center, Fort Gordon, GA, USA.
5. Physical Therapy, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
6. Physical Therapy, Martin Army Community Hospital, Fort Benning, GA, USA.

ABSTRACT BODY:
Purpose/Hypothesis : The purposes of this study were to determine 1) if changes in pelvic crest alignment and side to side weight-bearing differences occur following intervention with spinal manipulation therapy (SMT), and if so, if the changes are associated with a response to intervention; and 2) if pelvic crest alignment and side to side weight-bearing differences prior to manipulation are associated with a successful response to manipulation, both immediately and at 48 hours.

Number of Subjects : 49 volunteers (28 men, 21 women) with acute LBP served as subjects.

Materials/Methods : Pelvic crest alignment and side-to-side weight bearing asymmetry were measured before and after intervention with SMT. Pain and disability self-reports were obtained pre- and post-manipulation, and at 48 hours. Immediate treatment success was defined as a 30% reduction in pain, and success at 48 hours was defined as a 30% reduction in pain or disability, or 3-point improvement on a global rating of change (GRC) questionnaire. Data were analyzed to determine 1) if there was a significant change in alignment/asymmetry measures following SMT, and 2) which variables were associated with success.

Results : Only seated frontal plane pelvic asymmetry (PA) changed significantly after SMT. The following variables were associated with a successful response to manipulation immediately and at 48 hours: PA > 6mm in standing (immediate odds ratio (OR) =11.1, 48-hour OR = 5.2); PA > 6mm in sitting (immediate OR=6.7, 48-hour OR = 2.4); and weight bearing asymmetry (WBA) > 11% (48-hour OR = 3.7).

Conclusions : Frontal plane PA and WBA were associated with a successful response to SMT. Further study of the association between impairments and response to SMT may help elucidate mechanisms underlying therapeutic response to SMT.

Clinical Relevance : The findings of this study may clinicians identify a priori patients who are likely to respond to SMT.

Looking at predictive variables, you had to have a significant pelvic (6mm) or weight bearing assymetry to benefit. Perhaps like a lateral shift?
Anyway, some more evidence that treating the assymetry may not be the way to go...

J

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jasonsilvernail@gmail.com

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Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 5:48:00 PM   
Synergy

 

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Maybe I misled everyone here, perhaps even myself. I don't hold the asymmetry accountable for every patient's complaint of pain. I realize (see one of my earlier posts) that not everyone's asymmetries may be the source of pain and that their potential movement impairment syndromes may actually be their reason for the alleged asymmetries.

All the input/feedback is well appreciated and it really keeps me thinking...keeps the wheel turning so to speak. :)

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Re: Diagnosis and Palpation in Manual Tx - March 3, 2005 8:53:00 PM   
Diane

 

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Chris,
[QUOTE]their potential movement impairment syndromes may actually be their reason for the alleged asymmetries. [/QUOTE]Ditto that, big time.

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Re: Diagnosis and Palpation in Manual Tx - March 4, 2005 12:33:00 AM   
nari

 

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Chris

I ditto that as well, having just read through this thread and noted all the chicken and egg conundrums (or conundra - Latin)..

Asymmetry is not a cause of pain as I see it, it is a visible sign that something else is grumbling away, and that is most likely movement impairment.

jon

Agree. There is probably not one of us who is symmetrical in the ideal sense. In fact, I would say it is the asymmetries all over us which makes for individual dynamic posturing and visual behaviour patterns.
The debate can include the "correct posture" syndrome which is now beginning to disappear quietly, and there is enough data around to show that poor posture is not directly proportional, or even have any association with, pain.

Good posture is what makes the person feel 'OK'and functional - symmetrical or not.


Nari

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Re: Diagnosis and Palpation in Manual Tx - March 4, 2005 9:21:00 AM   
apolipo

 

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I would agree with Chris, Diane, and Nari. I have recently had 2-3 pts. where I could identify asymmetries (bony alignment/muscle length/muscle strength) and even though those asymmetries where corrected, or nearly corrected, their level of pain remained essentially the same. I realize this is anecdotal, but it made me think hard about what I am doing and why. Going to Barrett's course helped as well.

Great thread.

mike t

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