As I’m working on presentation to 3rd year students in a few weeks on manipulation, I am always floored to see this picture for lumbopelvic manipulation as the cornerstone of decision making for clinicians to implement a procedure of manipulation for low back pain. This is the essential treatment, based on clinical prediction rule from Flynn 2002, for individuals who will respond favorably.

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Now I know regional manipulation may not always be necessary (see recent study here in Phys Ther 2013 by de Oliveira RF), but does this really is good picture of the definition of manipulation, which is according to the Guide to PT;

skilled, passive movement of joints and soft tissue, etc.

This doesn’t look very skilled to me.

Nothing against the study or the authors, as this research study is a milestone in our profession, as well as overall treatment of LBP.  Many other studies have been proposed based on this research but as the foundation for manipulation? What do you think?

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4 comments

  1. I would argue that the APTA’s definition of spinal manipulation needs to change rather then the picture. As we know the term spinal manipulation has been defined by a wide variety of individuals including Cyriax, Paris, Webster, and Maitland. Since July of 2000, the APTA along with Dr. Paris currently agree that mobilization and manipulation are synonymous. Prior to this time the Guide to PT separated the definitions as I believe they should still be. 1999 Guide definition of manipulation…a skilled passive hand movement that usually is performed with a small amplitude at a high velocity. Mobilization…a skilled passive hand movement that can be performed with variable amplitudes at variable speeds. manipulation is one type of mobilization. Manual therapy techniques: a broad group of skilled hand movements, including but not limited to mobilization and manipulation. So why did the definition change to the broader one in 2000? Stanley Paris once wrote…”mobilization has been the more common term in the US due to PT’s wishing to avoid the word manipulation which has to some an implied association with chiropractic. While that might have been true it is no longer the case”. I believe it still is the case! So based on the CURRENT APTA definition for manipulation/mobilization the picture is probably not the best but we should look back at the history of this term and think about the implications of this definition for the future.

    1. Hey John, thanks for your response!
      There is definitely a history behind SMT, even in our short profession’s career. It is a difficult concept to “define”, and to piggy back on your comment, there is an immense amount of definitions out there, including Guide to PT, AAOMPT, APTA. Evans in 2004 has a good article on this.

      I did not know the Guide has changed its definition over the years, good to know. I do too still believe the definition has economic implications and we are still battling this intervention. In the state of NC, you cannot perform SMT without first getting approval by referring MD; however, dry needling is acceptable and full direct access. Financial motive here?

      We just need to use manipulation and not hide behind other terms.

      Hv

  2. Harrison,

    Since this research was published, this technique has drawn the ire of many a manual therapist being labeled as ‘nonspecific’, ‘un-skilled’, or even ‘un-safe.’ However, it has been used in several RCT’s and shown to be effective as part of a multi-modal treatment package for some patients with LBP. It also appears in several of the classic manual therapy texts such as Stoddard, Greenman, and Hartman. Dr. Richard Erhard, a founding member of the AAOMPT, popularized this technique amongst physical therapists and conducted some of the earliest research using it.

    I agree that it may appear less skilled then say a sidelying rotational lumbar thrust. In my experience it also seems easier to learn and master in the beginning for students and novice manual therapists. But perhaps the true skill comes in the decision making leading up to whether to use manipulation (or not), the assessment/reassessment process, and what additional interventions to include as part of the treatment package. Probably most important are the communication skills of the therapist to be able to establish a rapport with the patient, use non-threatening language to encourage active recovery, and create a ‘therapeutic alliance.’ What do you think?

    Bill

    1. Hey Bill,
      Excellent points! Your comment about the communication between the patient/therapist and the alliance is what can’t be taught. It comes with experience and makes a good therapist. You can be a “master manipulator”, or a “master therapist”; I would take the latter all day long. This is, as you say, the clinical decision that leads to the best outcomes.

      The late Dr. Peter Huigbrets said once in an article,

      “If you have enough bananas, you can train a monkey how to manipulate.
      But even all the bananas in the world will not help you teach the monkey when to manipulate…”

      This is what I teach to my students and seems to be your practice pattern too. This is what really leads to outcomes.

      I will say too that this is much less skilled, at least in my opinion, than rotational thrust / million dollar roll. It just seems as I could teach this technique to the father / wife, etc. for HEP! I will say I get better results with the rotational manip than the “Chicago” technique…just my personal opinion.

      Hv

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