Wait…PT’s perform manipulations?!

Wait…PT’s perform manipulations?!

 

“Without the ability to match patients to specific interventions, clinicians are left without evidence or guidance for their decision-making”

 

This couldn’t be truer. If we believe that all patients with back pain are the same, then we will give all patients the same treatment. If not all patients respond to the same treatment, then we can say that not all back pain is the same. We have to be able to classify which patients are most likely to respond to a specific treatment; otherwise we are just throwing spaghetti at a wall and hoping that some sticks. When a patient walks into the clinic, I am forming hypotheses as soon as I see the patient get out of the chair in the waiting room. By watching a patient move from the chair to walking and from walking to sitting, we can start to assess pain response (facial expressions) and movement quality (upright versus bent forward or sideways in addition to stride length of the legs and how much rotation is happening with arm swing). We can also have a short chat with the patient to determine how the patient describes their symptoms. Some patients are okay with waiting until we get to the private area before telling their story and others just want to start unloading their story before I have pen to paper to write things down. These are all of the actions that I take into consideration before we even get to the room to assess the patient.

 

“Identifying methods for classifying patients with LBP has been identified as an important research priority”

 

Why do most things matter…MONEY! We as a country lose almost $100 billion per year on back pain. This is a lot of money. If we were to put in a dollar every second to pay for this, it would take 31 years to equal $1 billion! As you can see, LBP is an ailment that we have to figure out in order to keep healthcare solvent.

 

“The purpose of this study was to develop a clinical prediction rule for identifying patients with LBP likely to respond favorably to a specific manipulation technique.”

 

This is a derivation study, the first step of trying to come up with a clinical prediction rule. One must understand CPR’s prior to reading and implementing the research. Here is a quick link that has to do with the types of CPR (clinical prediction rules). Also, there is much controversy surrounding CPR’s from people such as Dr. Chad Cook, who I highly respect. I don’t know if I would go as far as he does in saying that Clinical Prediction Rules are dead, but they do have to be read thoroughly and criticized. They also have to be validated and placed into an environment in which they can be utilized in order to have an environmental impact. This has been done with diagnostic CPR’s such as the ankle or knee rules.

 

Me personally, I don’t believe that we should give up on a quest to determine which intervention works best for a specific set of the population. We can provide value to our customers by providing the best evidence based treatments that we have available. To kill off a method of prescribing treatment limits a therapist’s ability to confidently provide treatment.

“…patients with LBP at two outpatient facilities: Brooke Army Medical Center and Wilford Hall Air Force Medical Center…between the ages of 18 and 60 years…baseline Oswestry disability score had to be at least 30%”

 

This study is highly specific to a military crowd, with an average age of younger than 40. Now if this is not the patient that is being treated in my clinic, it is difficult for me to make the correlation from one population to another. The only thing that we can say for certain about the results of this study is that is pertains to the population that was involved in the study. The baseline Oswestry disability score (for more on the Oswestry see this link.

 

“After the manipulation, the therapist noted whether a cavitation was heard or felt by the therapist or patient.”

 

The cavitation is the audible pop that people think of when getting a fast manipulation. This is similar to popping your knuckles. This pop is not needed for a manipulation to occur, as the movement and speed instead of by the noise that occurs define the manipulation.

 

“A maximum of two attempts per side was permitted.”

 

This doesn’t make sense to me to perform multiple manipulations directed at the same region. The authors noted that if no cavitation was produced that another manipulation would be performed up to four maximum manipulations. We just covered that an audible pop is not needed, so I am unsure why two were allowed for the patient. Let’s just assume that a patient gets better from the manipulation, was it one manipulation or two manipulations that improved the patient? Is it possible that a patient could get better with one, but then get worse with the second…even though a cavitation is heard? There are too many variables that start to play into this study.   This is the landmark study for giving the prediction recommendations for spinal manipulation in PT. Which brings us to the next point.

 

“Two additional treatment components were included: 1) instruction in a supine pelvic tilt range of motion exercise…and 2)instruction to maintain usual activity level within the limits of pain.”
Now we have 3 possible variables introduced into this science experiment. Any scientist would look at this and say that there are too many independent variables, which can affect the outcome. The first is obviously the manipulation. The second is the pelvic tilt. The third is time.

 

“The mean OSW (Oswestry Disability Index) score at baseline was 42.4+/-11.7, and at study conclusion was 25.1 +/- 13.9.”

 

This means that the scores initially ranged from 31-53 and the final scores ranged from 11-39. A change of 10 can be considered significant, so there was a significant change overall for the better.

 

“Thirty-two patients (45%) were classified as treatment successes, and 39 (55%) were nonsuccesses”

 

A majority of patients didn’t respond to the intervention(s), but it was close to a coin flip. This indicates that if we manipulated everyone that came through the door, we would have a success (about 50% improvement in ability) in about half of the patients. This isn’t a bad ratio if it is only done in one visit.

 

“…duration of symptoms < 16 days, at least one hip with >35 degrees of internal rotation, hypomobility with lumbar spring testing, FABQ work subscale score <19, and no symptoms distal to the knee…were used to form the clinical prediction rule.”

 

Here it is! All students are expected to memorize this by the time that they graduate from PT school. All PT’s (at least those that work on backs) are expected to know these criteria for manipulation. There are of course some that will state that CPR’s aren’t very effective in practice, but this rule seems to have stood the test of time over many studies.

 

“…a subject with four or more variables present at baseline increases his or her probability of success with manipulation from 45% to 95%. If the criteria were changed to three of more variables present, the probability of success was only increased to 68%”

 

WHAAAT!? If someone has 4 of the 5 guidelines from above, the success was 95%! This is yuge. I’ll take those odds of success to the tables any day of the week. Now with this said, I have manipulated very few patients. Those that I have manipulated had immediate positive results and the pain was abolished…didn’t return upon follow-up over the course of 2 weeks. I may not be manipulating as many patients as I could, but I also give the patient the opportunity to independently manage and abolish before attempting to perform a manipulation. It’s a theory from another spine management system.

 

“In the present study, only one manipulation technique was used, and it is unknown whether other techniques would provide similar results.”

 

This is also very important to state. There was little research regarding manipulations in the physical therapy research. It must be said that not all manipulations are created equal and that performing a different technique may not have the same result. It may be better or worse. We can only extrapolate this study’s results to those that would match the type of patient treated in this study and the manipulation performed in this study.

 

 

 

 

EXCERPT FROM:

Flynn T, Fritz J, Whitman J et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain Who Demonstrate Short-Term Improvement With Spinal Manipulation. Spine. 2002;27(24):2835-2843.

Author: Dr. Vince Gutierrez, PT, cert. MDT

After having dedicated 8 years to growing my knowledge regarding the profession of physical therapy, it seems only fitting that I join the social media world in order to spread a little of the knowledge that I have gained over the years. This by no means is meant to act in place of a one-one medical consultation, but only to supplement your baseline knowledge in which to choose a practitioner for your problem. Having completed a Master of Physical Therapy degree, the MDT (Mechanical Diagnosis and Therapy) certification and currently finishing a post-graduate doctorate degree, I have spent the previous 12 years in some sort of post-baccalalaureate study. Hopefully the reader finds the information insightful and uses the information in order to make more informed healthcare decisions. MISSION STATEMENT: My personal mission statement is as follows: As a professional, I will provide a thorough assessment of your clinical presentation and symptoms in order to determine both the provocative and relieving positions and movements. The assessment process and ensuing treatment will be based on current and relevant evidence. Furthermore, I will educate the patients regarding their symptoms and their likelihood of improving with either skilled therapy, an independent exercise program, spontaneous recovery or if the patient should be referred to a separate specialist to possibly provide a more rapid resolution of symptoms. Respecting the patient’s limited resources is important and I will provide an accurate overview of the prognosis within 7 visits, again based on current research. My goal is to empower the patient in order to take charge of both the symptomatic resolution and return to full function with as little dependence on the therapist as possible. Personally, I strive to be an example for family and friends. My goal is to demonstrate that success is not a byproduct of situations, but a series of choices and actions. I will mentor those, in any way possible, that are having difficulty with the choices and actions for success. I will continue to honor my family’s “blue-collar” roots by working to excel at my chosen career and life situations. I choose to be a leader of example, and not words, all the while reducing negativity in my life. I began working towards the professional aspect of the mission statement while still in physical therapy school. By choosing an internship that emphasized patient care and empowering the patient, instead of the internship that was either closest to home or where I knew that I would have the easiest road to graduation, I took the first step towards learning how to utilize the evidence to teach patients how to reduce their symptoms. I continued this process by completing Mechanical Diagnosis and Therapy courses A-D and passing the credentialing exam. I will continue to pursue my clinical education through CEU’s on MDT and my goal is to obtain the status of Diplomat of MDT. Returning back to school for the t-DPT was a major decision for me, as resources (i.e. time and money) are limited. My choice was between saving money for the Dip MDT course (about 15,000 dollars) and continuing on with the Fellowship of American Academy of Orthopedic Manual Physical Therapists (FAAOMPT) (about 5,000 dollars), as these courses are paired through the MDT curriculum or returning to school to work towards a Doctorate of Physical Therapy degree. I initially planned on saving for the Dip MDT and FAAOMPT, but life changes forced me to re-evaluate my situation. The decision then changed to return for the tDPT, as my employer paid for a portion of the DPT program. My goal for applying to and finishing the Dip MDT and FAAOMPT is 10 years. This is how long I anticipate that it will take to finish paying student loans and save for both programs, based on the current rate of payment. I don’t know if I will ever accomplish what I set forth in the mission statement, but I do know that it will be a forever struggle to maintain this standard that I set for myself.

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