Manipulation

[DPT ATC]

I have a question for students in PT programs. Are your programs teaching you spinal manipulation techniques? There is so much evidence for its effectiveness, but I am frustrated that my school is choosing not to teach us the techniques. What are other schools doing?

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[_FNG_]

We are being taught spinal manipulations with the exception of cervical manips because of the risks involved. Peripheral joint manipulations are here and there but not the focus of our interventions.

One of my professors said that Tim Flynn (big publisher), while talking at CSM, put up the CAPTE (PT education credential people) number and told any students in the place to call that number and report their school if they aren't being taught manips.

I'd also be pissed about the lack of education, I was mad even with the lack of cervical manips (VBI tests being asymptomatic)

edit: this is a little off-topic but I've heard many schools still teach some "fringe" techniques such as craniosacral, Barnes myofascial release, PRRT, etc. I really think APTA/CAPTE needs to start buckling down on what services can be delivered under the guise of physical therapy. If people want to do that stuff, fine whatever, just don't call it PT. The profession, imo, needs to start self-regulating a little harder.

 

[lee9786]

We are being taught spinal manipulations with the exception of cervical manips because of the risks involved. Peripheral joint manipulations are here and there but not the focus of our interventions.

One of my professors said that Tim Flynn (big publisher), while talking at CSM, put up the CAPTE (PT education credintial people) number and told any students in the place to call that number and report their school if they aren't being taught manips.

I'd also be pissed about the lack of education, I was mad even with the lack of cervical manips (VBI tests being asymptomatic)

edit: this is a little off-topic but I've heard many schools still teach some "fringe" techniques such as craniosacral, Barnes myofascial release, PRRT, etc. I really think APTA/CAPTE needs to start buckling down on what services can be delivered under the guise of physical therapy. If people want to do that stuff, fine whatever, just don't call it PT. The profession, imo, needs to start self-regulating a little harder.

I agree. Regulation establishes credibility. There should be more consistency among what programs are teaching for the DPT programs. Pretty much the whole idea behind the DPT is to establish credibility. You'd think the people that decided to put this in place would have a pretty good plan. It doesn't seem this is the case.

 

[MinnDasota]

Interesting. Hopefully you guys will learn mobs during clinicals at least. It is an important part of the curriculum and should be taught so it's unfortunate that you haven't been taught. We were taught mainly Maitland grade 1-5 joint mobs and Mulligan Mobilization with Movement (MWMs) for everything from the cervical spine to the SI joint. Also learned a lot of muscle energy techniques but that's not really mobs.

In Connecticut, as a PT, we can't do grade 5 mobs unless you have done a certain amount of manual therapy hours in practice. On the other hand, I think we can in NY.

 

[Elbrus]

I second what FNG has posted, and I too have heard Dr. Flynn make an open invitation to contact him on this issue.
Both thrust and non-thrust manipulation are CAPTE requirements, and any school not including it within their curriculum is out of compliance.

Here is a link to an article published by Ken Olson, PT, DHSc, who is a past president of AAOPT discussing the existance of this requirement. Other references can be found, but this was one located with a quick search.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2565083

I wouldn't hesitate contacting Dr. Flynn, or the AAOMPT office to remedy this situation. Loosing accreditation over this issue wouldn't be a good thing.

Best wishes. -Elbrus

 

[jesspt]

DPT ATC -
Your school should be teaching you manipulation. But, if they don't, post-graduate education for manipulation is becoming a bigger thing now, and isn't a bad way to get an introduction to that specific intervention.

FNG -

I'd also be pissed about the lack of education, I was mad even with the lack of cervical manips (VBI tests being asymptomatic)

How sensitive and specific is that test for vertebral artery insufficiency? Should a negative VBI test be our only criterion for avoiding a thrust manipulation?

 

[jesse14]

DPT ATC -
Your school should be teaching you manipulation. But, if they don't, post-graduate education for manipulation is becoming a bigger thing now, and isn't a bad way to get an introduction to that specific intervention.

FNG -


How sensitive and specific is that test for vertebral artery insufficiency? Should a negative VBI test be our only criterion for avoiding a thrust manipulation?

Here in Ontario we have a very brief overview on manips...at least at my school. We have had a guest lecturer come in to teach us a few L and T spine manips. That's about it. We to learn Maitland and Kaltenborn mobs and a bit of MWM stuff. I plan on taking post grad ortho clourses and eventually becoming an FCAMT (Fellow of the Canadian Academy of Manipulative Therapists). It is a long and challenging goal, but one I highly want to do!

 

[Cyres]

DPT ATC -
How sensitive and specific is that test for vertebral artery insufficiency? Should a negative VBI test be our only criterion for avoiding a thrust manipulation?

I've read one paper where they calculated the sensitivity of the typical supine/extension/rotation VBI test to be low, around 0-10%, but with a strong specificity around 95%. The n was small, however, making validity an issue.

From what I understand the VBI test is/has falling out of vogue. It does not serve as an accurate screening test and appears to place more strain on the arteries than the manipulation. (Verdict is out on whether or not it places patients at risk for an event.)

Jefferson's fx, alar ligament and transverse ligament tests make it into my pre-manual therapy screen. Likewise if they have any hx of carotid/VA arteriosclerosis or other structural pathology. ORIFs and hypermobility are avoided segmentally.

 

[_FNG_]

From what I understand the VBI test is/has falling out of vogue. It does not serve as an accurate screening test and appears to place more strain on the arteries than the manipulation.
Jefferson's fx, alar ligament and transverse ligament tests make it into my pre-manual therapy screen. Likewise if they have any hx of carotid/VA arteriosclerosis or other structural pathology. ORIFs and hypermobility are avoided segmentally.

JessPt, you're right the accuracy of these tests are sketchy at best but they're just something that our class has been taught to do everytime. What Cyres wrote is a more complete screening process that would likely be more accurate (except I don't know what Jefferson's fx *google here i come*).

 

[usaDPT]

If you want manipulation skills, you need to look into the University of St. Augustine. (whether you're applying to PT school or con ed) I'm about to graduate in August and will only need 6 months of clinical experience in order to return and take my MTC. I don't know of any other schools that provide as much training in manipulation, especially spinal.

There is some research out there that suggests non-thrust cervical manipulation is just as effective as thrust maninipulation. However, there are circumstances where it may be necessary. (i.e. facet capsular entrapment)

 

[divinePT]

I will be graduating from Shenandoah University in VA. We have learned and practiced many spinal Gr V manipulations including cervical. The idea that there are risks should not deter PT's from performing manipulations. And as far as only using the VBI test to determine appropriateness is way off. Hopefully all of you advocates of manipulation have learned the CPR clinical prediction rule which have been validated over and over again. Hypomobility of at least one segment, IR of less that 60 in one hip, FABQ score less than 19, acute less than 16 days, no radiating sx below knee or elbow. 5/5 results in 90 +LR whereas 4/5 results in 80 +LR.
As far as not manipulating cervical spine I have found in clinicals it is hard to find practicing PTs that perform Gr V at all much less in the c spine. The reason for this is simply they didn't have that in their programs when they were in school. That is where we come in as students to perform inservices and educate them that in reality the risks of harmful effects following Gr V manipulation are 100 times less than that of NSAIDs causing such issues as GI bleeds and ulcers.
We were told in class that only 18% of practicing PTs perform Gr V manips. That's sad. Its our job to change that when appropriate.

 

[jesspt]

One of the reasons that you don't find many therapists performing grade V manipulations in the cervical spine is that there is yet to be any conclusive evidence that shows their superiority to mobilization in the cervical spine. Why assume the added risk? Also, many PTs have not been trained in manipulation, as has been stated above. Even now, many PT programs choose to only instruct their students in lumbar and thoracic maniupulaition and only teach them cervical mobilization.

That is where we come in as students to perform inservices and educate them that in reality the risks of harmful effects following Gr V manipulation are 100 times less than that of NSAIDs causing such issues as GI bleeds and ulcers

I hear this statistic used all of the time when therapists are addressing the issue of risk of manipulation. But, you're not really comparing apples to apples here. One of the well documented risks of cervical manipulation (particularly upper cervical, rotational thrust manipulation) is stroke. Comparing a stroke to an ulcer is sort of like comparing an amputation to a paper cut. Sure, the incidence of stroke following manipulation is incredibly low, but it does exist. And, with very poor clinical screening tools to determine (prior to treatment) who is likely to be vulnerable to a vertebral artery injury with manipulation, I think therapists who choose not to perform cervical manipulation can make a strong argument for their case.

Having said that, Lumbar, and thoracic manipulation are very safe, and have a growing pool of data which highlight their effectiveness. I use both daily.

 

[facetguy]

I hear this statistic used all of the time when therapists are addressing the issue of risk of manipulation. But, you're not really comparing apples to apples here. One of the well documented risks of cervical manipulation (particularly upper cervical, rotational thrust manipulation) is stroke. Comparing a stroke to an ulcer is sort of like comparing an amputation to a paper cut. Sure, the incidence of stroke following manipulation is incredibly low, but it does exist. And, with very poor clinical screening tools to determine (prior to treatment) who is likely to be vulnerable to a vertebral artery injury with manipulation, I think therapists who choose not to perform cervical manipulation can make a strong argument for their case.

Having said that, Lumbar, and thoracic manipulation are very safe, and have a growing pool of data which highlight their effectiveness. I use both daily.

Conservative estimates are that 8000 people die each year from NSAID complications, most of them bleeding ulcers, and another 100,000 are hospitalized. Tack on the cardiovascular complications from COX-2s and we are no longer talking about abstract risks. Sure, stroke is a devastating adverse outcome but is also extremely rare.

 

[jesse14]

Conservative estimates are that 8000 people die each year from NSAID complications, most of them bleeding ulcers, and another 100,000 are hospitalized. Tack on the cardiovascular complications from COX-2s and we are no longer talking about abstract risks. Sure, stroke is a devastating adverse outcome but is also extremely rare.

Sounds like a chiropracor debating this issue lol I think the issue also has to do with risk vs benifit. Are the PROVEN benifits worth the potential risks for C-spine manips? As a PT, I will learn them and use them sparingly. I follow the CPR's and know that an upper T-spine manip can help neck pain just as good (or better) than a C-spine manip. With that said, i used to get bad tension headaches any have had my upper C-spine maniped with good results. Please, don't take my anecdote as a reason to manip eveyone who has tension headaches lol. Just be careful who you use it with (detailed history etc) and you should be fine. My motto with manips is: IF IN DOUBT, DON'T DO IT!!

 

[usaDPT]

I'm only aware of 1 CPR that has actually been validated and it only applies to the lumbar spine. I don't know of any for cervical or thoracic that have been validated. If there is some research out there, please direct me to it. :thumb:

Childs JD, Fritz JM, Flynn TW et. al. A Clinical Prediction Rule to Identify Patients With Low Back Pain Most likely to benefit from Spinal Manipulation: A Validation Study. Annals of Internal Medicine. 2004; 141 (12): 920-928.

And even if a patient presents with 5/5, manipulation shouldn't be set in stone. Clinical judgement should still be used. What if there is a nearby instability or minor disc involvement?

Also, check out this study...

DiFabio R. Manipulation of the Cervical Spine: Risks and Benefits, Physical Therapy. 1999; 79(1): 50-65.

'There is no compelling evidence that thrust manipulation has any better outcomes than nonthrust. Since arterial and brainstem damage and death has been reported with thrust manipulation and since screening tools have not been found to be sensitive or specific for identifying those at risk for injury, nonthrust manipulation is recommended in the cervical spine.'

Enough facts, now for my opinion: I come from a heavily based manual school and firmly believe in manipulation (Grades I-V). But, techniques should be chosen very wisely. Remember to use the least force necessary at all times. Sometimes, grade V's are necessary. Sometimes III's and IV's will do just fine, so why risk it? As long as we're using our clinical judgement and have our patients' best interest in mind, we'll be ok.