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You Manipulators!

 
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You Manipulators! - June 30, 2010 2:53:16 PM   
greghouse

 

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How often do you guys use manipulations? Which ones do you like/most effective?
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RE: You Manipulators! - June 30, 2010 5:53:14 PM   
ginger

 

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very rarely , usually only if I'm begged. It fails as a means to the end I seek, which is ,to solve the problem and be redundant.

(in reply to greghouse)
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RE: You Manipulators! - July 1, 2010 12:29:06 AM   
Geert Jeuring

 

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Hello Greghouse, I use them on a daily Basis, except for Manipulations of the upper cervical spine. I´m very conscious of the dangers there and don´t have a lot of use for them.
I use the simple Manipulations for the thoracic spine the most, because, in my opinion, they improve biomechanics in the lumbal and cervical spine. I consider a Manipulation positive, if it improves ROM.
Over the years I´ve gained on technique (as most will have) so that I can reduce thrustspeed and power. Very often the positioning of the patient with a little overpressure is sufficient.

Geert

(in reply to ginger)
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RE: You Manipulators! - July 1, 2010 11:38:29 AM   
Golden_ace63

 

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We have the clinical predictive rules built into our eval forms, so we can identify those who might benefit from manipulation. There is literature to support the effectiveness of manipulation on the appropriate population.

CPR for General Lumbosacral Manipulation: (Rule considered positive if 4/5 are present)
- NO symptoms distal to the knee
- Symptoms < 16 days
- At least one hip IR > 35 degrees
- At least 1 segment hypomobile with PA testing
- FABQ work subscale < 19

CPR for thoracic thrust manipulation: (4/6 = 96% success rate, 3/6 = 86% success rate, 2/6 = 71% success rate)
- No symptoms distal to shoulder
- Symptoms < 30 days
- Decreased upper thoracic kyphosis
- Looking up does NOT aggravate symtpoms
- Cervical extension < 30 degrees
- FABQ < 12

I use the thoracic thrust manipulation (or at least mobs) on almost every neck patient I see with excellent results.

Literature has shown that cervical mobs are just as effective as manipulation, with less risk so I mobilize but never manipulate.

(in reply to greghouse)
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RE: You Manipulators! - July 1, 2010 2:53:23 PM   
greghouse

 

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Golden Ace, is it(thoracic manipulation) the one where you have the pt. interlock their fingers behind the neck or one in prone?

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RE: You Manipulators! - July 1, 2010 11:15:43 PM   
Golden_ace63

 

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I like to use both the prone mobs/manipulation as well as the supine manipulation with arms of the patient folded across the chest and the hand/knuckle of the manipulator at the desired segment and using your weight to apply the manipulating force. 

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RE: You Manipulators! - July 3, 2010 7:08:21 AM   
JSPT

 

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Slightly off-topic:

Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.

I'll perform a grade 5 HVLA mobilization of the thoracic and lumbar spines on rare occasions, less than once every few months, but I will never HVLA the cervical spine.

I have no idea why you would perform a manipulation of the neck when muscle energy and stretching can accomplish the exact same thing, without the risks of manipulation. 

Agree with Golden's CPR criteria.

(in reply to Golden_ace63)
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RE: You Manipulators! - July 5, 2010 10:08:56 AM   
Elegantly_Wasted

 

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Golden Ace,

The Tsp manip for the Csp CPR has not been validated. And Josh mentioned at Manipalooza a month ago that they have run a validation study with the finding that the CPR was not supported. His suggestion was to continue maniping the Tsp because the effect size is so large.

(in reply to JSPT)
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RE: You Manipulators! - July 5, 2010 2:02:09 PM   
bonez

 

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quote:

ORIGINAL: Elegantly_Wasted

Golden Ace,

The Tsp manip for the Csp CPR has not been validated. And Josh mentioned at Manipalooza a month ago that they have run a validation study with the finding that the CPR was not supported. His suggestion was to continue maniping the Tsp because the effect size is so large.


Forget me from barging in here but as the member of the crucified on this board, if the CPR is not found to be valid why do we keep doing what we are doing. My understanding is that you are trying to support care with evidence. If we can throw out this finding cause "it works" then there can't be any stones cast at others that don't follow what the evidence says.

(in reply to Elegantly_Wasted)
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RE: You Manipulators! - July 5, 2010 2:53:23 PM   
TexasOrtho


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Agree wholeheartedly with bonez. CPRs have a long way to go before adopting them as part of routine clinical practice. Compelling start in terms of literature, but they haven't closed the deal through validation.

Crucified?

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to bonez)
Post #: 10
RE: You Manipulators! - July 5, 2010 4:52:11 PM   
Geert Jeuring

 

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From: Mhnesee, Germany
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quote:

The Tsp manip for the Csp CPR has not been validated

As I´m not originally a native speaker and specially not used to the specific abbreviations in englisch speaking countries I would appreciate the full terms, so I can participate fully in the conversation.

With kind regards,

Geert Jeuring

(in reply to bonez)
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RE: You Manipulators! - July 5, 2010 8:18:07 PM   
james079

 

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Geert, du bist nicht allein !
Jim McGregor

(in reply to Geert Jeuring)
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RE: You Manipulators! - July 5, 2010 10:50:28 PM   
fubve

 

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Hello Greghouse,
After I got my certification in Spinal Manipulative Therapy (Cert.SMT), I kind'a say I use it pretty often. I used it in conjunction with theraEx.
I say, I do lumbar and TL junction 50%, SI 20%, CT junction and thoracic 20%, Cervical (including OA and AA) 10%.
I have pretty good response to right population. Differential diagnosis, screening including imaging and right population makes success of treatment.

UL

< Message edited by fubve -- July 5, 2010 10:51:52 PM >


_____________________________

Ulysses Juntilla, DPT, Cert.SMT
Certified Spinal Manipulative Therapist, American Academy of Manipulative Therapy
Member, American Academy of Orthopedic Manual Physical Therapists (AAOMPT)

(in reply to greghouse)
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RE: You Manipulators! - July 6, 2010 1:38:42 AM   
Elegantly_Wasted

 

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quote:

ORIGINAL: bonez

quote:

ORIGINAL: Elegantly_Wasted

Golden Ace,

The Tsp manip for the Csp CPR has not been validated. And Josh mentioned at Manipalooza a month ago that they have run a validation study with the finding that the CPR was not supported. His suggestion was to continue maniping the Tsp because the effect size is so large.


Forget me from barging in here but as the member of the crucified on this board, if the CPR is not found to be valid why do we keep doing what we are doing. My understanding is that you are trying to support care with evidence. If we can throw out this finding cause "it works" then there can't be any stones cast at others that don't follow what the evidence says.


Considering this is my second post on Rehab Edge and I have been "lurking" for 6 years I don't know that I can be lumped in as one who has "crucified" anyone.

With that said, I agree that the trend towards adopting CPRs has been in many cases inappropriately swift. With the dearth of supportive literature for a lot of our manual techniques I can understand why it happens however. We are begging for scientific support for what we do and, perhaps, prematurely latch on.

When the results of the validation study are published I think it will serve as a reminder for clinicians that reading evidence does not make you an evidence informed clinician - critical evaluation of the literature is even more paramount lest we head down the road of woo with firmly entrenched beliefs and practice patterns based on poor studies in small numbers.

(in reply to bonez)
Post #: 14
RE: You Manipulators! - July 6, 2010 3:44:49 AM   
ginger

 

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Elegant , Bonez is a chiropractor, I"m thinking the reference to crucifixion may be a sense that his group are routinely offered as the slow learners within the manual therapy fraternity, although once you get to know Bonez, I believe you will quickly accept that his credentials in no way mark him as either slow or worthy of the cross. He's too late for easter anyhow.

(in reply to Elegantly_Wasted)
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RE: You Manipulators! - July 6, 2010 2:16:17 PM   
bonez

 

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Thanks Ginger, I expected that proud would have been on me before you got in. The prozac must be working!

(in reply to ginger)
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RE: You Manipulators! - July 6, 2010 9:47:19 PM   
rwillcott

 

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If I remember correctly there have been other studies supporting thoracic manipulations for cervical pain. 

(in reply to bonez)
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RE: You Manipulators! - July 6, 2010 9:57:15 PM   
TexasOrtho


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A recent one (from Cleland I believe) supported the use of T-spine manip for cervical pain. Still processing alot of the data on manipulation. I think the number needed to treat for thoracic manips was around 6, but I'll review those numbers. My experiences with thoracic manipulation have been pretty positive for cervical pain. I'll be honest however that my numbers needed to treat are indeed around 3-5; meaning one patient benefits for every three to five manips I perform.

This is probably heavily influenced by my peri-manipulative priming of the patient (which sucks quite frankly because it usually ends up being very manipu-neutral). My NNT is also influenced by the fact I don't perform them routinely enough to be as competent as someone like bonez, who I imagine performs them much more routinely.

Plus I have to admit my own bias toward allowing the patient to move themselves out of a painful situation through self-guided movement and progressive exercise.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to rwillcott)
Post #: 18
RE: You Manipulators! - July 11, 2010 8:22:42 PM   
Andrew M. Ball PT PhD

 

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Hello ya'll. Been a while since I've served as a RehabEdge moderator, or have posted for that matter, but there are some points that need to be clarified here, so I thought I'd step in:

SOME of the CPR's have been validated, the major issue with Flynn's CPR is the way that some novice clinicians over generalize it's application beyond the group upon which it was developed (e.g. PPPP, spondy, nerve root pain, etc.). Also, please be aware that there is a CPR (not as far along in the validation process as Cleland's CPR), for using Cx manipulation for Cx pain . . . not to mention all the DC's, DO's, and DPT/Cert. SMT's that use cervical manipulation for cervical pain. I've attached reference info for a few CPR's that ya'll may or may not be aware at the end of this post.

For those of you not using cervical or upper cervical manipulation because you feel that there is increased risk, know that your fears are quite likely unfounded:

Cassidy, et al. 2008, Spine 33(45), S176-183 (most current and robust study to date)
No association between HVLAT and VBA stroke in patients older than 45 years. There is an association between PCP visits and VBA stroke in patients older than 45 years. Increased risks of VBA stroke a likely due to patients with HA and neck pain from a VBA dissection that is already in progress and the greater ability of a manipulating practitioner (versus PCP) to recognize VBA stroke in progress. Consider that it might be possible that even simple AROM examination by any practitioner could result in a thromboemoblic event in a patient with a pre-existing VBA (e.g. Challenges notion that non-thrust is safer. In fact, 15 minutes of mobilizing may be more dangerous than a 135 ms thrust).

Sweeny A, Doody C. Manual therapy for the cervical spine and reported adverse effects: A survey of Irish Manipulative Physiotherapists. 15(1). 2010. 32-36.
In a study of Chartered Physiotherapists (CMPT) in Manipulative Therapy Ireland 27% use HVLAT, 9% use HVLAT on upper cervical spine. Of these manual therapists, 26% report adverse event in previous 2 years, 4% of which were after HVLAT . . . and 20% were after non-thrust (including the first and only documented case of a TBI as an adverse event possibly resulting from a PT’s manual therapy).

For those of you who contend that outcomes are equal, or even similar HVLAT versus mobilization, be aware that there is a growing body of literature demonstrating the superiority of HVLAT, particularly with respect to the neurophysiologic effects:

Martinez-Segura, 2006. Pain and AROM after lower Cx HVLAT.
Significant increase in Cx AROM and significant decrease in pain immediately following a single HVLAT (N=34) to either C3/C4 or C4/C5. When subjects received mobilization (n=37) there was NOT significant change in AROM or pain.

Santilli, et al. 2006. HVLAT vs. Mob.
At 6 mo follow-up Local pain (28% pain free HVLAT 6% mob.), Radiating pain (55% HVLAT, 20%mob.), Total days with pain (23.6 days HVLAT, 27.4 days mob.). Study did NOT include CLBP or HNP.

Natalia M. Oliveira-Campelo, et al. The Immediate Effects of Atlanto-occipital Joint Manipulation and Suboccipital Muscle Inhibition Technique on Active Mouth Opening and Pressure Pain Sensitivity Over Latent Myofascial Trigger Points in the Masticatory Muscles. JOSPT. MAY 2010. Volume 40, No. 5.
The application of an atlanto-occipital thrust manipulation or soft tissue technique targeted to the suboccipital muscles led to an immediate increase in pressure pain thresholds over latent TrPs in the masseter and temporalis muscles and an increase in maximum active mouth opening. This is in contrast to suboccipital release MFR technique which produced an increase in pressure pain threshold over laten TrPs in the masseter, but not the temporalis, and furthermore had no effect upon maximum active mouth opening.

Hope that gives ya'll a little food for thought!
Andrew M. Ball, PT, DPT, PhD, MBA

APPENDIX:
Cx HVLAT for Cx pain Tseng, et al. Manual Therapy. 2006
• Initial NDI < 11.5
• “having B mvt. pattern”
• Not performing sedentary work > 5hrs/day
• Feeling worse while extending neck
• Dx of spondylosis without radiculopathy

Tx HVLAT for Cx Pain Cleland, et al. Phys Ther 87(1)9-23. 2007
• Sx < 30 days
• No Sx Distal to Shoulder
• Looking up does not aggravate Sx
• FABQ score < 12
• Decreased upper Tx spine Kyphosis
• Cx extension ROM < 30 degrees

Cx/Tx HVLAT for shoulder pain Mintken, et al. Phys Ther 90(1)26-42. 2010.
• Pain free shoulder flexion < 127 deg.
• Shoulder IR < 53 deg. At 90 deg. AB
• negative Neer Test
• not taking meds for shoulder pain
• Sx 90 days or less

Lx HVLAT for PFPS Iverson, et al. JOSPT 38(6)297-312. 2008.
• > 14 degree difference in hip IR(80%)
• > 16 degree ankle DF with knee flexed
• > 3mm navicular drop
• No stiffness with sitting > 20min
• Squatting most painful activity

< Message edited by Andrew M. Ball PT PhD -- November 6, 2010 5:47:39 PM >

(in reply to TexasOrtho)
Post #: 19
RE: You Manipulators! - July 11, 2010 8:42:38 PM   
bonez

 

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Thanks Andrew

(in reply to Andrew M. Ball PT PhD)
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