Good stuff from the APTA on manipulation

This is a quick-hitter post I thought some of you out there might find interesting. I recently had a pleasant but slightly contentious discussion with a local chiropractor that wandered off into the topic of manipulation and scope of practice.

"I find it curious that PTs are so eager to criticize chiropractic, yet are equally eager to manipulate."

- Dr. Unnamed Chiropractor, DC

First of all, let me please go ahead and thank God for the ability to guide my emotional and physical restraint. Were I a younger man this is something that would have put me over the edge. Fortunately I was able to sit on my hands and restrain my tongue long enough to calmly discuss the issue with him. My talking points included:

• The physiology of manipulation (i.e. its role as a self-perpetuating "adjustment"versus a means to normalize function).
• The messages of self-restoration in physical therapy compared to chiropractic (I know - this is the supposed mantra of the chiropractic profession. I guess you only need a lifetime of adjustment before realizing this self-correction...)
• Unsubstantiated claims regarding risk of a manipulation performed by a physical therapist

The conversation was brief, but I felt amazingly well prepared. Best of all...I carried it off with a sense of satisfaction that I did the right thing for our profession in sending a message to the chiro that we are well trained to perform thrust-mobilization (manipulation) and have a better model of care to support its use.

Right on the heels of this conversation, I received an email from the APTA which I strongly suggest you review if you are close to this situation. The email was from our Advocacy section and outlines some great presentations and handouts regarding PTs and manipulation. I'm a vocal critic of my organization on some issues, but man they do some great things with our dues. It is a tough check to write each year, but I feel more strongly it is the right thing to do everytime I get one of these emails. This will be a great resource for us for some time to come.

P.S.

Thank you all for the great responses to my first podcast! They were greatly appreciated. Stay tuned and I've got some really good topics on the way. Also, I may be updating the format of my blog to be more user friendly and offer easier access to archived posts and my podcasts. Hang in there and we'll continue to grow!

Stiff posterior capsule? Maybe not...

It is common practice for physical therapists to include an assessment of the posterior glenohumeral joint capsule in patients with shoulder pain. The rationale is that a tight posterior capsule may exert a "Diablo" effect on the proximal humerus and reducing the subacromial space. This is further substantiated by the obeservaton that GIRD (Glenohumeral Internal Rotation Deficit) often seen in throwing athletes is due to limitations of the posterior capsule. These two clinical observations form the rationale for stretching and mobilizing the posterior joint capsule.

However, there is recent evidence that questions whether the posterior capsule is truly responsible for the limitations in internal rotation commonly seen in our patients. A case report by Poser and Casonato in the Journal of Manual Therapy examined a 42 y/o male with a 12 week history of shoulder pain. This patient was the "classic" impingement case. No cervical pathology was identified and there was no evidence of capsular involvement. The primary findings were positive Hawkins and Yocum's testing along with painful resisted abduction.

Internal rotation was measured using electrogoniometry at 90 degrees of abduction. Additionally, a dynamometer was used to measure abduction force. The patient's pain levels were recorded during the pre-treatment testing. The treatment consisted only of soft tissue massage to the infraspinatus (7 minutes) and teres minor (3 minutes). The patient was positioned in a manner as to avoid any tension placed on the posterior capsule. No other treatments including or activity modifications were given.

After three treatment sessions, internal rotation improved from 68 degrees to 88 degrees and all impingement signs were nearly abolished. The authors concluded that reductions in internal rotation often seen with impingement syndrome may not be attributable to posterior capsular tightness. An alternative theory may be that shoulder pain induces a dysfunction of the posterior glenohumeral muscle musculature.

I must admit am a "mobilizer of the posterior capsule". However after reading this case report and using a bit of reasoning, I realize there may be a better explanation for loss of internal rotation we see in our patients. Although this is but one case report, it certainly made me realize I can never get too comfortable with a particular approach or conclusion. I'm not entirely ready to let go of the possibility that the posterior capsule plays a role in shoulder impingement. However, I imagine with further anatomical and histological of this area will confirm my suspicions that there are other mechanisms at play.

A POSER, O CASONATO (2008). Posterior glenohumeral stiffness: Capsular or muscular problem? A case report Manual Therapy, 13 (2), 165-170 DOI: 10.1016/j.math.2007.07.002

Manual Physical Therapy: We Speak Gibberish

Tim Flynn and John Childs have done it again...I wish they'd stop making so much sense. It will likely lend more credibility to our profession than we deserve at times. In the latest JOSPT editorial (March 2008) the gang outline our serious language problem in orthopedic physical therapy. They even offer some salient solutions to remedy the problem.

• Develop a common language we can agree upon
• Teach students manual skills versus indoctrinating them into a specific schools of thought
• Publish a framework of common treatment techniques using a common language independent of political bias
• Develop a glossary of technique descriptions for the Manipulation Education Manual
• Develop a dialogue with members of the international community regarding this common language

In my first few years as a therapist, I abandoned many manual techniques because of the aforementioned political bias and risk of associating with the faith healers of the manual world. Authors who advocate a more science-based approach to our patients continue to give me hope that our profession may be ready for the responsibility of autonomy we demand. If we are able to work toward the ideals that Flynn and colleagues put out there, we'll be adhering to the rigors of science rather than the trappings of politics.

Flynn, T.W., Childs, J.D., Bell, S., Magel, J.S., Rowe, R.H., Plock, H. (2008). Manual Physical Therapy: We Speak Gibberish. Journal of Orthopedic and Sports Physical Therapy, 38(3), 97-98.