Jargon and Manual Therapy

The OU Course featuring Peter Gibbons and Phil Tehan mentioned in my previous post was an outstanding success on many fronts, one of those being the presentation by Bill Kinsinger, MD and the being the thought provoking dialogue that was generated. As is the usual case with manual therapy courses, we discussed what was thought to be occurring in-vivo biomechanically, what was known to be occurring biomechanically, and the impact of how we document what was done. We had the privilege of having an anatomist, Carl DeRosa, PT, PhD in the class to help guide the discussion. As you might imagine, there was plenty of gracious opinion, acknowledgement of a lack of data, and that mostly what we had to guide decision making were merely models. 

However, the reality of documenting what we do remains and that reality is troubling when you think about it. From an internal perspective, the jargon we use can impede inter-therapist communication who follow different models. For example, one therapist documents they corrected an ERS right lesion while another documents that they performed an opening procedure to improve left flexion and sidebending yet another states that they “gapped” the joint. The external perspective is even more concerning. What are referring physicians to think when they read the PTs note that they or “gapped” a spinal joint or worse yet, corrected an “upslip”?

I am not necessarily pointing fingers here but rather asking the question. Should we pursue a way to get rid of the jargon and standardized our documentation of the manual procedures we use? 

As usual, comments and debate are welcome. 

 

Rob

Comments

[Britt Smith]

Rob,
Your commentary on jargon is so very relevant to our practice. We are full of jargon from various camps of physical therapy, osteopathy, chiropractic as well as body workers/physiologist (e.g. Ida Rolf). Carl DeRosa, one of the most insightful & perceptive persons I have every had the pleasure to know, has continue to pose the question: What is the universallanguage of manual therapy (specifically manipulation)? We need this dialogue to further improve our thought processes and communication of our practice. Thanks for posting this discussion.
Britt

[Jason Silvernail]

Rob-

Great post.

However, I do not believe we will ever change the language of manipulative therapy until we change the way in which it is taught and presented - not only in schools, but by outside groups who offer manual therapy education.

There is no point in trying to standardize the concept of (for example) an opening/ gapping/ ERS correction manipulation if we do not acknowledge that the very concept of a diagnosable biomechanical problem has been thoroughly refuted!

When will our schools and programs move away from the mechanistic biomechanical model of manual therapy and on to one that incorporates the neurobiological knowledge we now have? When will we focus on what seems the most plausible mechanistic explanation of manipulative efficacy- neural effects?

As long as we train students and pracititioners to see the body through biomechanical goggles, any attempt to standardize these terms is useless.

The strict biomechanical approach ignores much of what we know about pain and recovery from injury - to include cognitive-behavioral and psychosocial aspects - and replaces it with the concept that if we just move the joint to correct a movement problem (that we so confidently diagnosed - it's of course an ERS left at L4/5!), the patient will be fine!
This approach has not made sense for a long time, if indeed it ever did.

And yet, concepts that have been proven untrue or to be generalizations only such as Fryette's laws and the "rule of threes" still are taught as gospel truth by PT programs and by manual therapy training and certification organizations. Many of these excessively biomechanical principles are required as "ground work" for most manual therapy organizations, and indeed their tests for certification involve the mastery of this "knowledge". You can tell I won't be signing up for one of these programs anytime soon.

I think the work that many of the EIM staff is outstanding in leaching the mysticism and difficulty out of manipulative therapy. But we still have a long way to go before we are teaching the use of manipulative care in a way consistent with the established science. I have said before and I repeat today, if our use of manual therapy centers around biomechanical illusions and FRS/ERSs, how are we then different from the chiropractors? Whether it's an ERS dysfunction or a subluxation, they are equally useless in the pursuit of responsible and evidence-based application of manipulation therapy.

Discussions like this are a start, but we need the leaders in the field to take a position on this issue, especially in the context of our legislative battles that center around this issue.

J

[Britt]

Jason,
I agree, it makes more sense (and is more accurate to the body of evidence for treatment effects) to talk about manipulation as a 'facilitation' or 'inhibition' technique(s) than all the mechanical descriptives. However, we could argue that descriptives of the techniques, themselves (e.g. rotation, sidebending,) are more useful for application vs. descriptives of intention or mechanism-of-action.
Just some thoughts.
Britt

[Jason Silvernail]

Britt-
I agree that most people who have thought in depth about manipulation see that the jargon reflects the techniques used and not necessarily the problem to be addressed. However, it has been my experience that the vast majority of students and practitioners see the jargon as an actual description of a biomechanical construct that they are trying to change with their treatment.

I think the problem with a biomechanical descriptor is that it tends to foster the strict biomechanical point of view and prevents our students and novice pracititioners from moving beyond that paradigm.

To say nothing of changing the behavior of the more experienced PTs, many of whom make good money teaching, testing, and handing out certification letters for the demonstration of knowledge of the biomechanical paradigm.

It may, for the purposes of communication, be better to just list the type of technique (amount of force/Mobilization grade) and the patient position (sidelying, prone, sitting, etc) to achieve the result we are looking for, as far as clarifying jargon goes.

Thanks for your thoughts, as always...

J

[Mary Wooten]

To all:

Along the lines Jason mentioned, clearly communicating what we do to other PTs and providers, may be able to be accomplished in the here and now (while the debates and issues mentioned above play out in years to come) by simply documenting the general/generic version of the manual intervention followed by the specific maneuvers - possibly in parenthesis. At least most people – esp the non-PT folks - reading the documentation would have a vague idea of what we did instead of no clue at all. So, "have at it" with all the jargon you want, but including the broader description as well may be very useful for clarification purposes.

Respectfully,
Mary
(First time - a bit "shy" about posting. . .)

[Tim Flynn, PT, PhD]

I could not agree more with the call for standardized language to describe what we do. This I believe will happen sooner rather than later. Lets add to Jason and Mary's call for what is needed.
Patient Position:
General Vertebral Level:
Direction of Movement:
Grade:

Now many times the language is really a short hand to the therapist. For instance, I am a recovering biomechanist... but I still think in terms of direction of movement when it comes to treatment. So if you say FRS I can visualize a 3D motion to treat. However, this does not mean anything more than a perception of motion. My opinion is that the jargon often comes about as a way to decrease the volume of words to describe a movement. The problem is when the jargon is not consistent and takes the place of reality.
Tim

[Rob Wainner]

All,

Great comments. Do I sense some support for proposing a documentation format for manual therapy iterventions? As Jason mentioned, while our evidence base in this area has progressed how we communicate with our own and other medical colleagues remains a mess.

I disagree that we can't come up with some sort of standardized format..the one Tim proposed would be a great start (Tim, is this going to be an agenda item for a to-be-named AAOMPT committe? Hmmm).

I also agree that while the models we use don't facilitate how we communicate and document, they are excellent for teaching techniques and motor skills for the application of manipulation techniques. I am not a baseball player, but I bet when teaching someone to throw a curve ball biomechanical language isn't the primary means of communication. Same thing applies here.

I think addressing this issue would be a very helpful step in advancing the practice of manual therapy in general, and manipulation specifically. As was addressed in John's post regarding the Scientific Ownership of Manipulation, we should lead the way in this area and using credible communication will do a world of good for those within and especially for those outside our profession.

Rob

[Bob Wiederien]

I agree. It is hard to standardize documentation just within one clinic between one therapist to another.
Having it standardized, or even partially standardized would be great!

I pretty much already use what was already suggested plus a couple more components:

Patient Position and
"Name for Technique" (I personally use terms such as "Million $ Roll" in sidelying, "Corkscrew technique in prone", " supine thoracic extension with 'Texas Twist'", etc.

General Vertebral Level (because we can't really tell it is exactly at only one level that gets moved):

Direction of Movement:

Grade (with or without High Velocity Thrust (HVT):

AND!!! Patient Response to treatment (improved ROM at limited segments, decreased pain to 1/10, etc).

So, a basic template would look like this:

Patient Position:
Technique or Provider position:
General Vertebral Level:
Direction of Movement:
Grade (I - V), (with or without HVT):
Patient Response (ROM,Pain,etc):

Great Discussion!

Bob

[Julie Whitman]

Bob,

I agree with 99% of your post, especially the comments about reporting the patient's response to treatment.

The one area where I don't agree with you is on use of technique descriptors. I believe we should get rid of the "technique" jargon ("corkscrew", "million dollar roll", etc).

You could easily say something like "Sidelying left rotation / distraction Gr V technique. Immediate response: Lumbar flexion improved to 120 degrees with 2/10 pain to post thigh..." or "Rearfoot distraction, Gr V. Immediate response: Improved to 10 deg DF & able to squat without pain".

Perhaps if you wanted additional "descriptors" as your own memory aid, you could add that information in parentheses after providing the other information?

Julie

[John Ware, PT, MS, FAAOMPT]

Rob,
I believe the Standards Committee has already taken up the issue of manual therapy jargon. I think Catherine Patla is the current chair. The issue came up at the '04 AAOMPT conference, and, of course, was tabled. Are you out there Catherine?
John

[Rob Wainner]

OK, for some reason I knew this discussion couldn't be original and had to have occurred prior to this.

Is there any room on the table now? It is time.

Rob

[Dan Pinto]

I believe there are multiple reasons why we should simplify our language not the least of which is the general perception that we (as a profession) have the authority to apply a name change - in effect we are "owners" of the techniques. This can be seen as a documentation practice guideline. Much like a clinical practice guideline we can use the latest literature to justify our position. It allows those in the profession to set the agenda vs. the agenda being set by third party payers or others outside of our profession. I think it is long over due.

[Tim Mondale]

I recently read a paper that described the the difference between thrust (which they called manipulation), and non-thrust (which they called mobilization)as a thrust being a force applied to the joint that moves it beyond the passive range of motion. They defined mobilization as a non-thrust type of manipulation that is applied within the passive range of motion. It made me think of some of the arbitrary and innacurate ways we try to define terms like these in manual therapy.

First of all in this case if we are really exceeding someones passive range of motion limits I think there may be some injury implications there. As we know the majority of thrust techniques are thrusting a barrier in a segment that we have created by combining levers, and are nowhere near any end of range. In any case I think we can go just as far (in range , out of range) with a non-thrust as with a thrust. The other one that I've heard as a difference is a patients ability to stop a non-thrust versus a thrust. This doesn't make much sense to me; a patient can guard and stop anything they want.

For my money there is no difference between the two terms mobilization and manipulation. They both represent skilled passive movement applied; in this case to the joint and associated structures. There are grades and the the last grade is a thrust somewhere near an end of range that the practitioner has established. Everything else is non-thrust.

Tim

[John Ware]

Tim
Your statement that we "know" we are thrusting at a barrier attained through combined levers is based on an unproven, and untested premise, i.e. that combined levers can be used to attain a "barrier" at a spinal segment. This is biomechanistic wishful thinking. Furthermore, the use of combined levers to attain a "barrier" doesn't jive with the recent acute LBP CPR, where a "regional" lumbar/SI technique is used with proven efficacy (or effectiveness?, somebody help me) for pts that meet the rule. I think biomechanistic rationale for manual interventions is appropriate at least from the standpoint of pt safety. But, there just isn't the evidence to draw any conclusions that motion "barriers" are being attained with multiple levers- just a lot of biological plausibility and, on the more cynical side, a lot of guruism and continuing ed. dollars.
John

[Paul Mintken]

Great discussion, and long overdue! Just wanted to respond to Jason’s comments regarding how we teach manual and manipulative therapy. We have retooled our curriculum over the last 2 years by moving away from the osteopathic model to the Tim Flynn “Move it and move on” model. Finding a textbook that does not fill the students’ heads with useless terminology is challenging. We have tried to come up with a comprehensive yet manageable required reading list (thanks much to Tim Flynn). We have included the CPR’s and integrated the Treatment Based Classification. We have limited the “jargon” to opening versus closing restrictions and direct versus indirect techniques. Tony DeLitto stated at CSM recently that he does not believe that the pelvic signs (for SI dysfunction) are valid and reliable, but he still teaches them because they will see their CI’s using them, and there would be an uproar from the clinical community if we stopped teaching them. Deciding what to teach and what not to teach is very challenging. Respecting where we have been but embracing where we are going is a daily struggle. We give them an introduction to the “cosmos” of manual therapy they will be exposed to upon graduation, but state that the science is lacking for most of it. Carl DeRosa comes to speak to our DPT students every year on “The Doctoring Profession”, and he relates a story about learning how to “diagnose” sacral torsions, being confused (a world renowned anatomist should be able to feel these things, right?), and thinking that he was the only one that was not getting it. I was trained in an osteopathic model, and have been “liberated” by EBM. I never could remember how to treat a right on left sacral torsion. I will leave you with a final question: What should we be teaching our students?

[Jason Silvernail]

Excellent post, Paul, and thanks for getting to the heart of what, in my opinion, the jargon argument is really about.
The bottom line, is of course, Paul's question - What should we be teaching our students?

I remember at a course when I heard Tim Flynn tell us that he was a "recovering biomechanist" and that he didn't want to focus on showing us how to diagnose an ERS and an FRS, but rather on acquiring some basic comfort and psychomotor skill. You can't imagine (or perhaps many of you can) the relief I felt. Like many practitioners (I'm sure this goes for the Osteos and Chiros as well)I had long felt that either: 1. everyone was crazy for saying they could feel these things or 2. that I was just incompetent. Note this experience was after I had been practicing about 5 years or so.

Similarly, one of my favorite parts of getting a new PT student is seeing this same look of relief on their face when I tell them I don't believe in biomechanical diagnosis and that we are only going to talk in terms (thanks again Tim) of opening vs closing restrictions generally, for the purpose of technique, not for proposed effect. So now I can give them that same (liberating, as Paul said) experience before they start practicing. So perhaps progress is being made.

I want to say that it's quite remarkable that on a site like this, for the giants of the manual PT world to be discussing this issue of biomechanical diagnosis and what should be taught, we are again demonstrating our scientific ownership of the practice.

For the sake of all PT students now laboring to remember the details of Fryette's laws and holding their arms up as imaginary facets whilst they twist and move and try to imitate an FRS dysfunction, we need to get a grip on this.

At a minimum, at least discarding motion palpation as a diagnostic mechanism, and teaching our students the generalities of spinal mechanics, while using the paradigm Paul mentions (opening vs closing, direct vs indirect), that would be a great start.
J

[Chad M. Thompson]

Rob,

Thanks for the information and update..
I agree and come in to the conversation a little late. Certianly we need standardization to communicate effectivly amongst our own and our physician refferal sources. I find it hard at times to describe more specific techniques. I have taken to genral lumbo pelvic mob or right side lying lateral recumbent. I have certainly found the more verbose I get the harder it is for other to follow what I did.

Chad

[Rob Wainner]

Jason,

I now have to take the other side of the coin.

When we have strong evidence, we follow it. When we don't, the jury is still out and we have to remain open to the possibilities.

With regard to motion palpation, if we had followed the early findings of many who discounted lumbar mobility testing (arguably a motion palpation test) then we would have missed items that are now included as part of the lumbar CPR and instability CPR that were subsequently developed. I would argue that palpation is an extremely important part of manipulative assessment and intervention techniques and always will be; it is integral. It is the value we ascribe to it and relative contribution to various procedures that are the issue.

As an antecdote, both I and Andrew Bennett had patients last week whose clinical presentations strongly suggested manipulation intervention was indicated. However, in both cases standard LP and sidelying rotational manipulation techniques afforded no relief or change in symptoms. Each of us then attempted a technique that stressed a sacral counter-nutation thrust and that affected the major change we were looking for. I chose to do that because the patient felt "stiff" with springing to the sacral apex.

Anyway, my point is that in the pursuit of evidence we can never be content to just fall back on what we know and eschew and berate what we are ignorant of, but must always understand that there is new evidence that has not yet been elucidated. I think the EBP approach is to remain skeptical yet open to exactly what that evidence might be, which includes things that appear to have some value or promise even though they may have a ridiculous story attached. When they have been discounted, then we move on.

Rob

[Britt Smith]

Rob,
Great point. let's not throw babies out with bath water.
With regard to EBP, let me cite a favorite metaphor:

‘The best medical practice is similar to neither baroque nor grunge music; instead it is like good jazz, combining technical mastery with the artistry of focused personal improvisation.
Clinical jazz combines the structure supplied by patient-oriented evidence with physician’s clinical experience to manage situations of uncertainty, instability, uniqueness and conflicting values.’

Shaughnessy & Slawson 1998

If we can structure the language of manual therapy into a clear, concise and universal language, it's like writing musical notation. Jazz is unique and it is American in origin, but loved & performed wonderfully and ubiquitously world-wide.
Britt

[Jason Silvernail]

Agreed, Rob, I understand your point. I'm not as extreme as I come across, just wanting to spark some debate.

If I do come across as extreme in my point of view, perhaps it is only as a counter-weight to the enormous sea of motion palpation diagnosis folks out there who live and die by it and make tons of money teaching it to the exclusion of most everything else. Certainly if everyone took their mechanical diagnosis with a grain of salt (as we all do here) then we wouldn't have much to talk about, would we?

Until that's the case with the majority of PTs and the programs that teach manipulative therapy, we have continued work to do. Much of which, as I'm sure you know, is being done here. :)

Can't wait to see what the Standards Committee from AAOMPT has to say about it.

J

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