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who's going to do the manipulation?
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who's going to do the manipulation? - October 2, 2006 5:05:00 PM
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rwillcott
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I just wanted to share my experiences with using the CPR for lumbar manipulation. I find this technique works wonders for those who have at least 4/5 of the cpr's.
What I've been noticing is the reaction of patients when I explain to them that they would benefit from a manipulation. It's quite amusing at times. It's given me an understanding of patients perceptions and also misconceptions about what we do as PT's.
I had a patient today that met 4/5 of the cpr's. I then proceeded to explain to him that he would benefit from having a manipulation of his back. His response to me was "Who's going to do that? Are you going to send me somewhere?" And to his amazement I informed him that I would be performing the manipulation! He agreed and he left pain free and quite pleased.
I guess this is probably an example of the amazing marketing Chiro's have done over the years. Many patients don't think of PT's when it comes to manipulation.
I wonder what we could do as a profession to improve upon this? Has anyone else experienced anything similar?
Rob
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Re: who's going to do the manipulation? - October 2, 2006 5:11:00 PM
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cascopoint
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I think it will help as our profession begins to increase instruction within the academic institutions. I have had the same reactions not only from patients but from co-workers as well who are still intimidated by manipulation even though you are more likely to die exercising on a treadmill than suffer a cauda equina injury during a lumbar manipulation.
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Re: who's going to do the manipulation? - October 2, 2006 5:30:00 PM
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Jon Newman
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My answer is, minimally, "Anyone who thinks they must".
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Re: who's going to do the manipulation? - October 2, 2006 9:22:00 PM
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nari
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My answer is: "Anyone who thinks there is no alternative".
Nari
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Re: who's going to do the manipulation? - October 3, 2006 1:50:00 AM
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SJBird55
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Rob, I do well with using the clinical prediction rules. Patients that have fit the criteria have always been open to my attempt at manipulation. I always have to joke and tell the patients that, "Yeah, I know. I'm not a chiropractor. Heck, I don't even know how a chiropractor manipulates. I know a few techniques though." LOL Actually, the patients tend to respond quite positively. Hobbling in to walking out and back to life.
Jon and Nari, your responses have me pause to wonder if you do know the value of literature... good literature... even if it flies in the face against your beliefs. Are we only supposed to use literature that suits our beliefs? Only use literature that substantiates our beliefs?
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Re: who's going to do the manipulation? - October 3, 2006 2:23:00 AM
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Jon Newman
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Yes SJ I'm an idiot when it comes to knowing what good literature is. I need a cultural authority like yourself to spell it out for me. Actually, since I know it all, any literature I read that contradicts my "beliefs" should be burned so that others don't get confused and be led astray.
Give me a break. Are you suggesting there is no alternative to manipulation? That it is literally impossible to have good results without it? I can tell you this, if my patient with those characteristics isn't progressing, I wouldn't hesitate to use it. I haven't yet. Perhaps, in time, I will need to. I will feel I must.
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: who's going to do the manipulation? - October 3, 2006 2:31:00 AM
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nari
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Actually, SJ, I do know the value of good literature that is supported by research, though I am not sure what you include in your definition of 'literature'.
Use of the word 'belief' works both ways - if one believes that a couple of RCTs dictates how we have to work and we do not question this, despite the fact the results may not be synonymous across the research world - then where are we?
Nari
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Re: who's going to do the manipulation? - October 3, 2006 3:51:00 AM
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rwillcott
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This was not an attempt to start an argument over the use of manipulation. It's hard to argue the recent rct's that support the cpr's for a sub-group of LBP patients. I repeat, sub-group of LBP patients. In no way am I suggesting that manipulation is the be all end all. In fact, far from it. However, it works wonders for those who meet at least 4/5 cpr's.
In fact, I belieeve there's been a follow-up to the Childs et al study that shows that in a 1 year follow-up, those who met the cpr's and were manipulated were 8 times less likely to develop back pain. Hard to argue with!
I was just sharing my experiences with the use of manipulation and the cpr. Let's not let this get out of control and turn into a useless argument over who's right or wrong.
Rob
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Re: who's going to do the manipulation? - October 3, 2006 4:00:00 AM
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Shill
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Jon and Nari,
With all due respect, can you think of another technique for ACUTE LBP that is (not opinion, but backed with research) better, in terms of immediate outcome?
You know that this is the current best evidence, for ACUTE LBP, fitting the CPR. (Except perhaps waiting two weeks, then if that doesnt work, waiting 4 more weeks, but that is beside the point, when the ACUTE pain can be relieved or reduced nearly immediately).
You can argue that you dont agree, but tossing in opinion statements about the intellect of those who follow the best practice evidence simply opens the door for people to question why you might say these things. Statements such as these seem to have a tone of a superiority complex, which bothers me, due to the fact that at the moment, there is nothing that seems to be shown to be superior to manipulation for ACUTE LBP fitting the CPR....like it or not.
Respectfully,
Steve
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Steve Hill PT
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Re: who's going to do the manipulation? - October 3, 2006 4:06:00 AM
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SJBird55
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So, Nari and Jon, for a subgroup of patients that meet the clinical prediction rule for manipulation, what is the alternative that you use that I could read about that is just as specific with the intervention to employ, the description of the patients in which your alternative method is used, and the prognostic results that should occur? Rob, I'm not really headed into a right or wrong discussion, but I need some assistance in understanding the views of others. As Rob mentions above, I don't manipulate every patient, but if they do meet the criteria, I do.
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Re: who's going to do the manipulation? - October 3, 2006 4:23:00 AM
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Jon Newman
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Steve,
How you thought I was being superior or insulting someone's intelligence is beyond me nor have I suggested anyplace that manipulation should not be used. In fact, I even stated that I wouldn't hesitate to use it if my patients were not improving.
The literature is supposed to guide practice and I use it exactly that way although I do use more than one piece to do it. I try active/educational approaches first and have had good success with that, enough that I have not yet had to employ the passive technique of manipulation. I'm sorry, I guess.
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Re: who's going to do the manipulation? - October 3, 2006 5:10:00 AM
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proud
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Yes rwillcott, pretty hard to deny the results using the CPR. Let's hope our universities remove the "technical gurus" from teaching positions and start teaching simple research based information.
To answer your question, if the ortho div had it their way...you would not have manipulated that patient...you have not developed your skills "little grasshopper".
I say teach it in the schools, apply it safely and in appropriate clinical presentations, and public perception will change. It starts in the universities.
Ask yourself this; out of the graduates in your class, how many would manipulate? And who is to blame for that low number? You guessed it, the ortho division courses and the "gurus" plunked into teaching positions. That is not appropriate as it creates a conflict of interest...don't you think?
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Re: who's going to do the manipulation? - October 3, 2006 5:28:00 AM
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Sebastian Asselbergs
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Take a look at this: are we going to apply this to our practice as rigorously?
Group instruction (cheaper)
Alston SD, O'Sullivan TJ.
Back Care Programme, Dept of Orthopaedic Surgery, Waterford Regional Hospital. suzannealston@comcast.net
BACKGROUND: Adults with recalcitrant mechanical low back pain of more than six weeks duration can encounter unacceptable waiting periods for specialised care. AIM: To evaluate the effectiveness of rapid treatment by means of group sessions. METHODS: We instituted a rapidly accessed patient education programme in physiotherapy for low back pain. Pain and disability were assessed before and after the programme. The programme included four sessions of group instruction for self-actuated physiotherapy There were six to 10 patients per group. RESULTS: In eight months, 160 patients were admitted to the programme. The average waiting time was 16 business days for the first appointment. Seventy-three per cent of the patients who attended some portion of the programme completed all sessions. At least 30% of the incompletions were ascribable to rapid improvement. Of patients completing the programme, 80% reported significant resolution of the pain and improvement in function.Twenty per cent reported no significant response, but no patients worsened during participation. Of the 20% with no subjective improvement, 50% were pursuing medico-legal claims. In comparison, 9% of those reporting a successful response were pursuing litigation. CONCLUSIONS: Group instruction in physiotherapy for low back pain is safe, generally successful, and highly acceptable to patients.
PMID: 16285342 [PubMed - indexed for MEDLINE]
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Re: who's going to do the manipulation? - October 3, 2006 5:30:00 AM
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Sebastian Asselbergs
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..seems to fit my style of practice - very little "treatment" on the boby with acute low back pain - much education. Done. Cheaply.
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Re: who's going to do the manipulation? - October 3, 2006 6:08:00 AM
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PHSPT
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“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).
I felt a need to remind ourselves as to what it means to practice Evidence Based Medicine. A RCT ranks extremely high on the current level of evidence. "It just doesnt get any better than this" hence the validation of the Child et al CPR.
Anectdotal/self-reported (ala Ginger's) evidence is the poorest, therefore should be taken with a grain of salt. My advice for those who are struggling with "If its not broken, why fix it" attitude, to actively engage in journals and see for where our practice is heading as well as the level of available evidence towards a particular tech/approach. It is not about jumping on a bandwagon, but rather about jumping in what works! ask yourself: In terms of levels of evidence, where does my current practice rank?
Evidence levels:
http://www.cebm.net/levels_of_evidence.asp
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Re: who's going to do the manipulation? - October 3, 2006 6:47:00 AM
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srcase
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Just to point out Sebastian, that your cited study was for subacute to chronic LBP (greater than 6 weeks duration), but not acute LBP like the CPR mentioned above.
PHSPT, did you read my long post in the adherent nerve root thread about the drawbacks of using RCT's in PT research? I'm not sure I would state "It doesn't get any better than this", however, taken in view of the whole body of research available, it is an important piece.
I think what some others are arguing is that one study alone shouldn't constitute the only evidence for a particular intervention. AND that definition above isn't the complete definition of EBP....besides individual clinical EXPERTISE, it also includes the patients values and clinical environment....factors which are different amongst those in this discussion for sure.
Lastly, does every treatment you give have a RCT backing it up? (I'm being facetious). Let me again remind you of a previous post quoted from EIM: Herbert's quote "Outcomes of interventions and effects of interventions are very different things". So, I agree with Jon, that research be used as a guide not a mandate, so to speak.
Sarah
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Re: who's going to do the manipulation? - October 3, 2006 7:37:00 AM
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Jon Newman
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If it makes anyone feel any better, I do include the other components in the manipulation arm of the CPR study. That is, ROM and education (and I don't pursue "spinal stabilzation"). The only thing I leave out is the manipulation part. I find it intersting that people attribute the entire reduction in pain and the lasting benefit to the manipulation and yet in the same breath remind people that manipulation is not used in isolation. Perhaps whatever it is I'm substituting for manipulation is having a similar effect as manipulation? I don't know really but unless you feel manipulation's power is in its mechanical effect there is room that there are alternative avenues to produce the same effect.
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Re: who's going to do the manipulation? - October 3, 2006 7:54:00 AM
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proud
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PHSPT,
I really liked your post above. I think you were able to drive the points home better than I have been able. This part:
>>>>ask yourself: In terms of levels of evidence, where does my current practice rank?>>>>
I think if your answer is consistently in the "poorest" level department, you should be thinking long and hard...
.....
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Re: who's going to do the manipulation? - October 3, 2006 8:28:00 AM
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Shill
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Jon,
Here is my perception.
"Anyone who thinks they must.
Anyone who thinks there is no alternative."
These suggest that those who manipulate the acute LBP patient are, perhaps, close minded, with limited decision making skills, as in, "Its all we have, so I must get crackin'". In the aforementioned scenario, from the first post provided by Rob Willcott, there is apparently no need to address alternatives, as this patient falls into the CPR for the modality used, manipulation. Now if said patient noted that there were symptoms beyond the knee, OR, had a grave fear of manipulation due to a prior event with this modality, then bring on the laundry list of alternatives, including the education, waiting and seeing, which results in resolution and improvement for the vast majority of acute LBP.
My mind says that manipulating an acutely painful spine is the last thing I would want to do, and this likely speaks from my own experience of having acute severe LBP, and not wanting anyone to come within a 10 foot radius of my spine during those 3-7 intensely chemically painful days. But the literature says otherwise....I cant understand why it might help, but it apparently does. Who am I to argue with the results? I cant argue with those results, unless I put them to practice to substantiate them. I would also like to see this research repeated by another unrelated group of investigators, but until then, it is seemingly the best practice.
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Steve Hill PT
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Re: who's going to do the manipulation? - October 3, 2006 8:57:00 AM
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jlharris
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Sorry Mr. Newman, I think your shutting your eyes here. When you get that patient that fits 4 or 5 out of the five prediction rules, manipulation absolutely produces dramatic relief of their pain symptoms. And when I say dramatic, I mean from minutes to 24 hours or so.
I find it hard to believe that you get the same results treating the same pt's with "ROM and education". Although, ROM and education is a big part of my clinical practice.
I wonder if you feel that you are being asked to manipulate every acute LBP pt that enters your clinic? That'd be a hard jump to make, and simply isn't the case.
My own personal experience is that the CPR fits about 10% of the LBP pt's I get in the clinic. And the evidence shows that you may be doing them a disservice - in terms of wasted money and delayed outcomes - by ignoring the results of this manipulation CPR.
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Jason L. Harris, PT, DPT
My PT Blog
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