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Thurst Manipulation of the Cervical Spine: To Do or Not to Do

There has been some recent email traffic amongst a close group of colleagues on this article recently published in JOSPT. You can read the study for yourself, but the gist is that the combination of upper cervical and upper thoracic high velocity thrust manipulation was more effective in the short term (48 hours) than nonthrust mobilization in patients with mechanical neck pain. The question centers around whether and/or how to incorporate this evidence into practice. Rather than offering a summary of the comments, I thought it would be helpful to simply paste the comments verbatim and then open it up for a conversation on the blog. I did do some editorial clean up of syntax, grammar, etc. I left names off because I didn’t get permission to include their comments. However, these are each thought leaders in their own right who generally don’t mind expressing themselves so I am taking a risk that they won’t mind. I did remove comments that could be linked back to a specific individual. Other than these exceptions, the comments are verbatim.

Comment 1
This is an area that I have struggled with for years. Currently I do not teach upper cervical manipulation to the entry level students. I have taught upper cervical manip to entry level students in the past, but I don't think they can control their hands enough to do it safely. Now one could argue that the manip James Dunning used in this study might be safer than some of the other upper cervical manips that involve rotation (ala Gibbons and Tehan), but I still don't think entry level students can learn this properly in the time we have to teach it. I do teach middle and lower cervical manipulations and they do ok with it. I do not think upper cervical spine manipulation is an entry level skill, and, one could argue, that cervical manipulation in general should not be taught until there is more evidence. I do use upper cervical manipulation a lot in my patient care and find it extremely useful, but I treat a young, healthy population (college students) and do a lot of screening.

Comment 2
I don't have much to add except that it would be interesting to see what the longer term outcome looked like. I am curious why they didn't report at least a discharge time frame outcome like 4-6 weeks. Obviously even longer term would be better. Presuming there are no differences at 4-6 weeks, I am not sure the outcome is worth even a small risk (real or perceived), especially if some of the patients were acute, the stage in which a stroke might naturally occur regardless of a manipulative intervention.

Comment 3
I don’t have a lot more to say but agree that the students don’t have enough feel or clinical knowledge to perform upper cervical manips. I certainly don’t teach it to them. They can do very well using MET and Mobs. Actually, even though the study in question uses cervical manips, there are others out that say mobs and manips are of similar benefit in the cervical spine. So, again the discussion of risk benefit is appropriate. I won’t shy away from having the students read the article, but I don’t think that is what I would want to project. A healthy discussion following is a good idea.

Comment 4
Agree with the only clarification being that upper cervical manip is a motor skill that can be learned by entry-level students if there were enough time and there was a definitive benefit that justified the resources for packing it in and teaching it. Given the current structure there isn't. That having been said, it very well may be that this is something Interns can learn after they have been in the clinic for a while, performance has been assessed, and the CI can give adequate time to teaching this to Interns who would have developed more skilled hands. I think we just need to be consistent in our philosophy about teaching manipulation. It isn't about 1st professional or "experienced" (there are a lot of those I wouldn't teach either). It’s about time, resources, and priorities based on evidence (harm/benefit).

Comment 5
Framing this is important.

1. I do not specifically teach thrust manipulation of the upper cervical spine to entry level nor do I advocate it for post professional at least without a serious dose of respect to this area.

2. As evidence emerges, this may change. So, it is in within the scope of practice of entry level PT as are PNF techniques. However, a student may or may not learn all the PNF or manipulative skills. So we need to be very clear that it is within the scope but caution is warranted.

3. I treat an older population and am less nervous about them in terms of a VBI stroke (carotid different picture). I actually am much more cautious in our student labs because that group is at higher risk for a VBI stroke than my crusty old folks. Now I am more aware of BP, HR, overall stroke risk, etc in my older adults but much more concerned about treating younger adults, particularly “loose neck” females.

Hopefully this is enough to get a decent conversation going on the blog regarding whether you agree or disagree. Before commenting, do try and review at lease the abstract of the study as it will likely help inform your thoughts and comments. Hope everyone has a great weekend!

John

We Can Do Better than a ‘Hope and Prayer’ Strategy for Clinical Education in Physical Therapist Academic Programs

Below is the text from a talk I recently gave via Skype at the PPS Graham Session this weekend in Charleston, SC. I unfortunately was unable to attend due to a last minute military deployment. Many thanks to Steve Anderson and the Graham meeting participants (and as I understand it, was record attendance and a terrific meeting) for allowing me to be there virtually via Skype to deliver my talk. As always, it's a genuine privilege to be in the same room (whether face-to-face or virtually) with friends and colleagues who are members of the greatest profession on Earth.

John

Delivered via Skype on Saturday, Jan 14 at the recent PPS Graham Session in Charleston, SC
Despite positive reforms in physical therapy education in recent years including the transition to a doctoral level education, clinical education has lagged. Physical therapy clinical education remains a highly fragmented and ill equipped system, marked by an inefficient 1:1 student to instructor format consisting of several short duration clinical affiliations, which leads to disjointed, highly variable, and non-collaborative learning. If we are going to be a meaningful contributor to health care reform and more importantly, play a prominent role in the reform process, we must hurriedly wake up from our delusions of grandeur, embrace the fact that we have a deep chasm in clinical education that must be closed, and wholeheartedly distance ourselves from the status quo.

The current physical therapy clinical education system leans heavily on a ‘barter arrangement’ completely dependent on the altruism of clinical practices at the sheer mercy of the academic program. For example, the short duration of the average clinical affiliation combined with the Interns’ limited skill set mitigates their potential to become a productive, value added member of the staff. Clinical resources are inefficiently expended to help the Interns learn the various systems, documentation standards, billing procedures, etc., only to have the student move on to their next clinical affiliation immediately after their useful assimilation into the practice. In short, the indirect costs for clinical practices to provide clinical education under the current model are steep and bothersome. Other than altruism, it is curious how academic programs have been successful in affiliating with clinical practices at all. Yet, in our typical peace gene like fashion, we oblige the “predatory” behaviors of academic programs who have duped us into believing that it is our professional duty to provide free clinical education for students while the academic program rakes in substantial tuition dollars during clinical affiliation semesters for which the academic program provides virtually no services!

Before I offend those of you in the audience who are on faculty in an academic program (ok, I probably already have!:)), think about this with me for a moment in practical terms. As educators in entry-level academic programs, we sit in many a faculty meeting debating the pedagogical pros and cons of adding “ABC” content, taking away “DEF” content, dedicating more time to topic “X”, less time to topic “Y”, etc. In fact, many of our curricular “experts” even get passionately defensive when making such arguments. You should see some of the heated debates that ensue when it comes to determining what content should be included in the didactic phase of physical therapy education! As a result, our students tend to progress through a highly organized and systematic curricula during this phase, evidence by a detailed schedule and syllabus. Nothing is left to chance. For example, it’s no mystery to the student as to what books they need to buy, what time they need to be where for what class, and what content to review prior to each class. We diligently measure student performance through countless rigorous written and practical exams. What strikes me as most odd then is why we don’t appear to be bothered by the lack of a clinical education curriculum that you can "touch and feel". For example, can a single DCE in the country tell me what content their students are learning on week 4 of their clinical education experience? How about week 18? What about week 23? Unfortunately, the default strategy for clinical education hinges on a “hope and prayer” strategy in which we send our students out into widely disparate learning experiences with little to no connectivity between clinical sites or even to the academic program. We then sit back and “hope and pray” that our students have a good experience. Think about the lunacy of our current 1:1 model with me for just a moment. Even the most highly capable clinical faculty do not have the depth and breadth of knowledge and experience necessary for a comprehensive clinical education experience. By the way, if we are to achieve meaningful reform in clinical education, clinical faculty must have the same faculty status and privileges of full time core faculty, if not higher!

Complicating matters, there are only 3 prerequisites for qualifying as a clinical instructor in our current model. First, you must have a PT license. Second, you must have a heart rate and pulse. Third and final, you must not be in a coma. If you meet these 3 criteria, you will be inundated with requests from DCEs around the country to affiliate with their program. Lest you doubt me, just ask any DCE how many contracts he or she attempts to manage under the current system. Most will answer somewhere between 250-500 contracts, yet the program is only able to assign 1 or 2 students each year per location in most cases. Therefore, the DCE inefficiently spends countless hours managing affiliation agreements with practices that take very few students in aggregate over time. As a result, the clinical education sites are rarely connected to each other in an organized way and frequently even remain at an arm's length from the academic program, tethered only by the clinical affiliation agreement. You don’t have to be an ISO 5000 certified quality engineer to understand that quality assurance across this many educational experiences is impossible.

Fundamentally, the potential transformation of physical therapy clinical education is dependent upon the ability of academic institutions and clinical practices to align themselves in a symbiotic relationship that delivers mutual benefit and value for all stakeholders. The medical model of clinical education has long proven useful in the training of residency-trained physicians. Interns would train collaboratively in group settings rather than a far more narrow learning experience that occurs when you only have 1 clinical faculty member. We should foster the development and evaluation of a standardized internship curriculum that leverages online learning management systems and team-based learning to deliver a consistent learning experience regardless of location. In other words, we need to “crowd source” clinical education so that the full “universe” of knowledge is available to them, not an isolated slice. One could even envision a matching process whereby students are competitively matched to specific residency programs…the right student to the right clinical education experience at the right time, the results of which would further incentivize quality and standardization and create a win/win/win proposition for students, educational programs, clinical practices, and most importantly, the patients to whom we provide care.

Finally, it’s an outrage that our graduates currently have debt that is completely out of proportion with their ability to recoup their investment. As it currently stands, there is no compelling economic argument to pursue a career as a physical therapist because of the inability to achieve a return on investment that justifies the necessary debt burden of the average student. Unfortunately, academic programs are in a negative incentive situation when it comes to such reform because students currently pay tuition to their academic institution while completing their clinical rotations, creating a veritable cash cow for the academic program, yet the academic program provides few services during this period. In fact, I routinely advise students that when their DCE calls them during their clinical affiliation to check in on how things are going, they should make the DCE stay on the phone for at least 100 hours to even begin recouping the value of the investment of tuition dollars the students have poured into the program.

We must disruptively innovate within clinical education to attract the best applicants into our profession, many of whom currently pursue careers in medicine instead. Similar to the medical model, students should attend physical therapy academic programs for didactic learning experiences, graduate once that component is finished, sit for licensure, and immediately begin a formal internship/residency lasting a minimum of 1 year. Interns would receive a modest stipend in exchange for receiving a high quality standardized training program delivered under the auspices of a credentialed graduate medical education system that adheres to rigorous accreditation and quality standards. Migrating the preponderance of clinical education to the post professional, post licensure setting would shorten the typical academic program by 1/3 (2 years rather than 3), trimming tuition accordingly.

In summary, we can no longer justify clinical education being relegated to 2nd class citizen status, and surely such a low view is inadequate for the contemporary Vision 2020 physical therapist. We are starting to see some innovative internship models emerging, such as those at the University of Pittsburgh, MGH Institute of Health Professions, the US Army-Baylor Doctoral Program in Physical Therapy, and Rocky Mountain University, among others. However, the rate at which the transformation is happening is far too slow. Fundamental reform of clinical education is critical for guiding the future of physical therapist education, and the immediate possibilities for such reform are real and tangible. In doing so, clinical education can be transformed into a collaborative and highly effective experience that will serve to elevate the role of the physical therapist in our health care system. Disruptive innovation is needed…and needed fast!

This patient really does exist. He’s a rancher down here in South Texas. 5am he’s already out digging fence posts, pulling wire, pitching hay, or rebuilding cattle guards…and he stays at it until dusk, occasionally stopping for a glass of ice tea or a taco.

 

We’ve all seen this type of referral at one point or another. The question is how to handle it when it comes. Do we take responsibility for this patient’s outcome and simply ignore the referral requests? Do we follow the requests and then blame the shoddy outcomes on the referring provider? Or maybe we allow that gnawing feeling in our viscera loose to argue the valor of current EBP or just the sheer stupidity of the logic in “no active exercise” to the referring provider.

How do you coach your residents or fellows to handle these?

I think that a good approach with this type of encounter is to be very direct. Pick up the phone or get over there and visit the doc.

Seek to understand first.

  Why is he so specific in his requests? You'd like to understand... He may have had a bad experience with a PT or he may be looking simply for pain relief and not wanting to "stimulate" the irritated nerve region too much... etc. Get his perspective (don't start off trying to change it), and then gently and humbly answer his concerns and offer why the EBP approach can perhaps better reach his aim/intent which is hopefully yours as well.

 

Bottom line: Look to build a relationship and collaborate with this referring provider vs. compete for "best knowledge" on managing these patients. His student loans are larger than yours. His perspective is that he's got the edge on "best knowledge".

ab

@bennettab

andrew@texpts.com

#Physicaltherapy Students at Bradley Getting it Right-Golden Goniometer Award Wnners

Got to hand it to these students. In light of the recent hoopla about the problems with treating chronic pain, it is re-assuring that our next generation of PT's will get it right by applying evidence.  Enjoy!

Golden Goniometer Award Winner from larry benz on Vimeo.

 

EIM'S Manual Therapy Certification Track - What Is It and Why You Should Care

What Is It?  EIM’s Manual Physical Therapy Certification Program provides post-professional training for physical therapists and is designed to create PTs who are experts in manual therapy.  This certification program consists of 6 graduate level courses (19 credit hours).  The courses include:

• Evidence-based Physical Therapy Practice
• Manual Therapy History & Professional Growth
• Management of CervicoThroacic Disorders
• Management of Lumbopelvic Disorders
• Management of Lower Extremity Disorders
• Management of Upper Extremity Disorders

90% of the Manual Physical Therapy Certification Program happens wherever you happen to be. It consists of an intensive combination of didactic, collaborative and laboratory experiences using a blend of distance learning, self-paced modules, and weekend intensive on-site courses.  And the best thing about it, you will be learning from world-class faculty and clinical researchers that come from a variety of the best academic programs and clinical practices in the country.  The goal of the program is to create highly skilled, evidence-based practitioners who are proficient in spinal and extremity manipulation and other manual therapy procedures integrated within an evidence based practice framework

Why Should You Care?  This Manual Physical Therapy Certification can be a stepping stone to board certification in Orthopaedic or Sports Physical Therapy and advanced clinical practice providing  an attractive option to PTs who prefer to  by-pass the  heavy monitoring and rigid structure of Residency Programs.  Should you change your mind and decide to complete a Residency program down the road, the Manual Physical Therapy Certification Program allows you to apply already earned credit hours towards an EIM Residency Program or to the EIM Orthopaedic Manual Physical Therapy Fellowship.

What Initials Will I Earn?   The EIM programs are committed to providing an excellent education in a number of defined areas. We encourage PTs that have completed our certifications to state exactly what they are certified in and not to use “initials” behind their name.  The average patient/client in our country does not have any idea what a physical therapist does, nor are they aware of the large volume of evidence that now supports physical therapy interventions for a wide range of musculoskeletal disorders. We are largely responsible for this identity crisis.  Thus we strongly urge all of graduates of EIM certifications programs to spell out what their certification is and not to use initials.

For example:

John Q. Smith, PT, DPT

Manual Therapy Certification – EIM Institute for Health Professions

 

What is the Difference between Certification and Fellowship in Manual Therapy?  In the U.S. fellowship programs in manual therapy are credentialed jointly by the APTA and AAOMPT.  Graduates of approved fellowships such as the EIM Orthopaedic Manual Physical Therapy Fellowship can then apply for Fellowship in the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT).  The EIM Fellowship program is designed to create leaders in the manual therapy community. The expectations of Fellowship require an additional level of rigor and demonstrated excellence outside the clinical practice of manual therapy in the areas of teaching and research as well as extensive clinical mentorship hours.  However, should you choose to pursue a manual therapy fellowship in the future, course work from the Certification track can be applied towards your EIM Fellowship. 

Additional Benefits. The Manual Physical Therapy Certification is the most cost and time effective post-professional educational step you can make if your goal is become an evidence-based clinical expert in the area of manual physical therapy.  Successful completion of this program will accelerate your clinical practice in orthopaedic manual physical therapy.  It will also leave the door open to complete  an EIM Orthopaedic or Sports Residency or Fellowship with the credit hours you already have in the bank.

Note: EIM also offers Certification Programs in Upper Quarter Musculoskeletal Disorders, Lower Quarter Musculoskeletal Disorders, Extremity Disorders and Spinal Disorders.   Click here for information on all of the Certification Programs.  

 

EIM is excited to announce a new Executive Program in Private Practice Management with optional tDPT Cohort!

40 students from 20 different states kicked off their program in Louisville, Kentucky this month.  Four of this cohort's students are the second or third in their practice to participate in the Executive Program.  EIM's Executive Program enhances the business intelligence and savvy of owners/managers in private practice with practical applications to provide a competitive advantage in the marketplace.  Click here for program details. 

"In today's ever changing healthcare environment with declining reimbursement we found our practice after 9 years on the edge of disaster. Referrals had declined, we were locked into two low paying contracts and our office morale was at an all time low. Using the tools and techniques learned in the EPPM Executive Program has allowed us to essentially restructure our business; we have eliminated our low paying contracts, our marketing efforts have increased our referrals, our net revenues and profits have increased. We are back to numbers of visits we have not seen for some time. Our staff now takes an active role in providing input and direction of our practice and as active participants morale in the clinic has dramatically changed.  Our business is back on the right track and growing again." - Bob Bacci (EIM Executive Program with optional Transition DPT graduate)

To date, a total of 75 have completed the program and, including the new cohort, 72 are currently enrolled.  Interested in the program too?   Apply today for a head start on clinical courses beginning in July.  Email info@eimpt.com for more information.

Emergency Response Course offered by EIM!

Hello!

EIM’s Emergency Response Course for PTs, taught by me, Teresa Schuemann, starts on February 14, 2011.  This course is a pre-requisite for the EIM Sports PT Residency Program and Emergency Response Course participants will receive a Sports Residency application fee waiver.  However, all therapists are welcome to enroll in the Emergency Response Course. 

This course integrates the objectives set forth by the American Red Cross and the Department of Transportation for Emergency Response and is designed specifically for the physical therapist seeking to provide athletic venue coverage and respond appropriately to acute injury.  The class includes instruction and discussion of assessment, management and prevention of cardio-respiratory emergencies, musculoskeletal injury, environmental injuries and medical emergencies such as shock or diabetic reactions, brain injury and spinal injury.    An intensive laboratory weekend is included on March 26-27, 2011. The Emergency Response Course fulfills the requirements for a physical therapist to be eligible for Sports Physical Therapy Residency Programs and submission of application for the ABPTS- SCS examination.   

Successful completion of both written and practical examinations will be required for this course.  The final practical examination will include successful completion of the following: bleeding control and shock management, trauma victim assessment and management, airway insertion and suction, management of injuries to soft tissue and skeletal structures and management of head, neck and back injuries.  Following successful completion of the course, the participant will be awarded a First Responder Certification (good for 3 years) and a CPR/AED usage for the Professional Rescuer Certification (good for 2 years).

Keep in mind that Sports Section of the APTA members get a $100 discount (make sure to enter discount code “APTA” during checkout to receive this discount.)  And remember, the online portion starts on February 14, 2011 and the on-site portion of the course is on March 26-27, 2011, so register now!

I’ll be at the APTA Combined Sections Meeting and you are invited to an EIM “Meet and Greet” in the Magnolia Room at the Hilton Riverside Hotel in News Orleans on Thursday, February 10, 2011 at 7:30pm.  Make sure to stop by and I can answer any questions you have about the Emergency Response Course or the Sports PT Residency.

Thanks!  Teresa Schuemann

 

Manipalooza 2011 Registration is Now Open!!

Make sure to register ASAP for Manipalooza 2011- spots are limited!  Manipalooza is a 4 day festival of hands on learning in spinal and extremity joint manipulation, mobilization with movement procedures, instrumented and non-instrumented soft tissue techniques & pain management strategies.  This year included updated content, speakers, music, and more!  You will learn the most cutting edge techniques from experts in the PT field.  It will be held at the University of Colorado on May 21-24, 2011.  Click here to view a video with more details about the event and to register.

Everyone who attended last year's Manipalooza had nothing but wonderful things to say:

"I have attended very few continuing education courses that I can say have changed the way I treat...  This course has changed the way I treat!"

“I first want to say what an amazing conference you guys put on.  I have to say in 9 years of being a PT and attending different courses this was the BEST one I have been to.  You guys know how to do it right.  I had so much fun and learned so much this course has and will continue to change how I practice as I continue to do whatever I can to help the people I work with...”

“Thank you to all of the EIM instructors who were so incredibly helpful at Manipalooza-it was worth every minute, I am using the skills I gained with my patients today, on my first day back. Manipalooza changed my life, my practice and ultimately, will improve my patient outcomes. EIM-Thank you, thank you, thank you!!”

"With all the different philosophies and theories behind manipulation (many of which seem to contradict each other), I had found the subject a little overwhelming and confusing.  For this reason, I never felt comfortable or confident enough to use these types of techniques in the clinic for fear that I might do the wrong technique, or do the patient harm.  I came to Manipaloosa hoping that the course would simplify things for me, and separate what the evidence shows, from what is just theory and speculation.  This course far exceeded my expectations!  From the simple, evidence based instruction, to the one on one attention during the labs, I now feel confident in my ability to use the very effective techniques I have learned in this course to better my patient care."

And the 3rd Annual Elevator Pitch Winners are....

   

1st Place: Amy Lee from Physical Therapy Central

 

2nd Place: Jonathan Weber & Denver Lancaster from Regis Univeristy

 

3rd Place: Kristen Martin from Texas State University

We had many great submissions this year and thank every PT and PT student who participated!
Thanks,
Larry

Foundation for Physical Therapy Awards 2010 Florence P. Kendall Doctoral Scholarships

ALEXANDRIA, VA, December 8, 2010 — Four physical therapists were awarded a total of $20,000 as recipients of the Florence P. Kendall Doctoral Scholarships, from the Foundation for Physical Therapy for the 2010-2011 academic year.

The $5,000 Kendall Doctoral Scholarships are awarded annually to outstanding physical therapists as they begin their first year of graduate studies toward a doctorate degree. The scholarships are funded by the Henry O. and Florence P. Kendall Endowment Fund.

Scholarships were awarded to: Ruth Chimenti, DPT, University of Rochester; Dan Cobian, DPT, University of Iowa; Nora Fritz, DPT, The Ohio State University; and Kristan Leech, DPT; Northwestern University.

”We are very proud to support these individuals as they begin their careers in physical therapy research. Their growth and success as researchers will help insure our profession’s future,” said Foundation Board of Trustees Chair William G. Boissonnault, PT, DPT, DHSc, FAPTA, FAAOMPT.

The Foundation for Physical Therapy was established in 1979 as a national, independent nonprofit organization dedicated to improving the quality and delivery of physical therapy care by providing support for scientifically-based and clinically relevant physical therapy research and doctoral scholarships and fellowships.

Contributions to the Foundation for Physical Therapy are tax-deductible and can be made online at www.FoundationforPhysicalTherapy.org or sent to its headquarters in Alexandria, Virginia. The mailing address is 1111 N Fairfax St, Alexandria, VA 22314. For more information, e-mail foundation@apta.org or call 800/875-1378.