Physical Therapists Are Learning HVLA Thrust Manipulation By Warren Hammer, MS, DC, DABCO
Soon, physical therapists (PTs) will all graduate as doctors of physical therapy (DPTs). The American Physical Therapy Association's vision stance is:
"By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy, recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, function, and health."
The PT profession should be commended for continually seeking to improve itself.
When this subject is brought up, I often hear that many PTs don't necessarily desire to practice on their own and many don't want diagnostic responsibility; but that doesn't necessarily mean the majority of PTs will feel this way in the future, especially when you read the APTA vision statement.
When chiropractors are asked about PTs learning to use "chiropractic" manipulation, many say that they (the PT) will never be as competent as a DC.
It appears to me that chiropractors, who at this stage are the ultimate spinal and joint manipulators and are achieving the maximum results that can be obtained by manipulation, should wake up about their future regarding their status in the world of neuromusculoskeletal disease (NMSD).
First of all, our profession should be at the forefront of research on manipulation, which we are not.
Second, we should realize that manipulation is not the end-all regarding the treatment of NMSD.
Third, we must pay attention to literature, which states, for example, that manipulation plus soft-tissue evaluation and treatment is more beneficial than manipulation alone. And fourth, we must pressure our colleges to include more subjects in their curriculum that deal with soft-tissue subjects and the more dynamic, biomechanical-type evaluations of human movement.
What initiated my thoughts on this subject was a research report that recently appeared in the Journal of Orthopedic & Sports Physical Therapy. The randomized study involved the treatment of 107 patients with neck pain between the superior nuchal line and first thoracic spinous process, regardless of duration. Fifty-six patients received both cervical and thoracic high-velocity, low-amplitude (HVLA) thrust manipulation specifically to C1-C2 and T1-T2 spinal segments; and 51 patients received a non-thrust mobilization to the same region.
For the HVLA group, if no popping or cracking were heard, the HVLA thrust was repeated. For the non-thrust mobilization group, Maitland5 grade IV PA mobilizations to both the cervical and thoracic areas were performed for 30 seconds each. The key finding of this study is that HVLA treatment resulted in greater improvement in disability, pain, atlantoaxial ROM and motor performance of the deep cervical flexor muscles at a 48-hour follow-up versus non-thrust mobilization. What is also informative is that the HVLA treatment of cervical pain benefited from HVLA treatment of the adjoining thoracic spine.
Unfortunately, this study did not evaluate long-term effects, but at least it is another study that substantiates the value of HVLA manipulation.
The battle for our future, of course, involves much more than proving that our "adjustments" work for neck or lumbar pain.
It is necessary to incorporate every type of manual treatment that proves its worth in our armamentarium.
Chiropractic has been around for about 122 years. We still have problems, as we will probably always have, but time is catching up with us.
Creating a bright future for our profession requires some instant thinking out of the box.
Re: Physical Therapist's may/will Take Over « Reply #1 on Mar 31, 2012, 2:59pm »
Chiropractic is geared to a wellness model effectively stating that by the reduction of dysfunction, wellness is better attained. Yes there is overlap in which PTs and DCs do, but the PTs are not chiropractors direct competition.
I foresee this only benefiting the chiropractic profession by demanding a progression towards a more defined scope and more privileges.
Physical Therapy in itself has many issues, and who knows what burden these changes may have on them. Do their unethical practices go up, malpractice. ect. surely there are many pros and cons.
Re: Physical Therapist's may/will Take Over « Reply #2 on Mar 31, 2012, 8:38pm »
"Chiropractic is geared to a wellness model effectively stating that by the reduction of dysfunction, wellness is better attained."
A major problem with this is that the statutes that govern scope of practice in most states do not support the expansive diagnosis and treatments that are a part of the "wellness model." DCs often want to self-define their scopes as anything that does not include surgery or pills, but most state laws do not support that approach. DPTs are just one more factor limiting the future of chiropractic.
"The real problem (isn't chiropractic but rather) society's tolerance of disproven theory, unsubstantiated claims and unethical professions." -A. Botnick DC.
Re: Physical Therapist's may/will Take Over « Reply #4 on Mar 31, 2012, 10:51pm »
Also looks like PTs are looking into using activators or as they call it PIM (physiotherapy instrument mobilisation) http://physiotherapyinstrumentmobilisati.....html......http://physiotherapyinstrumentmobilisation.blogspot.com/p/pim-technique-photoblog.html
Joined: Mar 2004 Gender: Male Posts: 8,549 Location: USA
Re: Physical Therapist's may/will Take Over « Reply #5 on Apr 1, 2012, 6:36am »
Notice there is no research cited. PTs using Activator instruments, I think I want to wretch. Plus using spring powered mechanical instruments is about 10 years out of date.
It will be interesting to see if Chris Colloca DC approaches their group and forms a crossover between the DCs and the Australian PTs to increase his ImpulseIQ mechanical adjusting instrument sales. You heard it here first.
"The real problem (isn't chiropractic but rather) society's tolerance of disproven theory, unsubstantiated claims and unethical professions." -A. Botnick DC.
"Chiropractic is geared to a wellness model effectively stating that by the reduction of dysfunction, wellness is better attained."
A major problem with this is that the statutes that govern scope of practice in most states do not support the expansive diagnosis and treatments that are a part of the "wellness model." DCs often want to self-define their scopes as anything that does not include surgery or pills, but most state laws do not support that approach. DPTs are just one more factor limiting the future of chiropractic.
Chiropractic needs to come to terms with the fact that it has nothing to offer in the area of "Wellness". Seriously. Name the condition and what the chiropractor has to offer can easily be just googled- resulting in responses by reputable sources that don't believe in spinal fairies. Besides, why go to a DC for advice when RDs, PTs, Exercise Physiologists, etc. are available?
Chiropractic needs to come to terms with the fact that it has nothing to offer in the area of "Wellness". Seriously. Name the condition and what the chiropractor has to offer can easily be just googled- resulting in responses by reputable sources that don't believe in spinal fairies. Besides, why go to a DC for advice when RDs, PTs, Exercise Physiologists, etc. are available?
The model of chiropractic is in which a happy healthy functioning body is able to maintain balance and oppose types of stressors.
There are so many models that describe what chiropractors do. i.e. that a mechanical musculoskeletal condition may increase input ANS etc... However the common denominator is reducing a sort of dysfunction(subluxation). The diversity of chiropractic includes many ways in which they can practice.
The internet is riddled with false misleading information. In fact the consumer is more likely to misuse information when they obtain it. Next problem is that there is no history being taking and the issue is not being monitored. In fact the simple act of going to walmart to buy a knee brace is "self-medicating" and can pose issues.
The consumer is also not going to search drive look and attend varying professionals to improve their wellness. Get an RD, get a personal trainer, see their GP, then go to a specialist, run here... there... etc When someone has a problem they most often seek their GP. The GP most often will provide a solution to pretty much any complaint one has and often a medication to subside the symptoms.
People love chiropractic because it is diverse and they can choose a practitioner which their practice coincides with ones belief. From evidence based to more philosophically oriented.
Re: Physical Therapist's may/will Take Over « Reply #8 on Apr 2, 2012, 6:48am »
If a patient goes home from their GP without a medication or something they question if they were treated.
Begs the question how important is it to be compassionate, have dignity, understanding, creativity belief i.e. the art.
@Allen, the evidence is not fully defined. The complexity of the human body in general poses many ends left untied. The forefront skepticism should be with consumer protection, not a vindictive attack at something that addresses an issue from another angle that poses less risks and utilization of natural noninvasive methods.
Integrative care is the future, a collaboration of all healthcare professionals.
Integrative care is the future, a collaboration of all healthcare professionals.
On this I would agree.
But I do not think the chiropractors I'm aware of would agree with you. They do not refer out anything. They believe they can heal all. (particularly the guy who likes to mentally communicate with the ailing body part) So the question I have is how do you get them to refer out what they cannot help with? How do you get these same individuals to wrap thier heads around the idea that they are not specialists in everything when they believe they are?
People love chiropractic because it is diverse and they can choose a practitioner which their practice coincides with ones belief. From evidence based to more philosophically oriented.
This statement is a generalization and I can not agree with it. I think you might have stated it better to say those who have chosen chiropractic and stayed with it like it because..etc/
Chiropractic needs to come to terms with the fact that it has nothing to offer in the area of "Wellness". Seriously. Name the condition and what the chiropractor has to offer can easily be just googled- resulting in responses by reputable sources that don't believe in spinal fairies. Besides, why go to a DC for advice when RDs, PTs, Exercise Physiologists, etc. are available?
There are so many models that describe what chiropractors do. i.e. that a mechanical musculoskeletal condition may increase input ANS etc... However the common denominator is reducing a sort of dysfunction(subluxation). The diversity of chiropractic includes many ways in which they can practice.
The internet is riddled with false misleading information. In fact the consumer is more likely to misuse information when they obtain it. Next problem is that there is no history being taking and the issue is not being monitored. In fact the simple act of going to walmart to buy a knee brace is "self-medicating" and can pose issues.
People love chiropractic because it is diverse and they can choose a practitioner which their practice coincides with ones belief. From evidence based to more philosophically oriented.
Quote snipped....
Diversity? HeHe! Yes, you're right about that, but it's because the profession lacks standards.
Let me ask you this: Do you think spinal manipulation is a reasonable treatment of, say, diabetes?
Well, your Board Examiners do which is just plain stupid. The patient would be better off getting advice on Diabetes from WebMD than going to a chiropractic board examiner.
Nonetheless, our focus in the earlier post was actually "Wellness". I would never suggest a patient self-diagnose over the internet.
Also, chiroreform, the chiropractic efect on the ANS is clinically negligible. I twon't fix anything.
Are you speaking of manipulations in general, or the idea of utilizing all natural modalities to reduce chronic stressors(Exercise, Diet, Lifestyle, etc.)
The fact of the matter is there are even many psycogenic causes on inflicting the ANS system as well. Depression has effects on health, pain has impacts.)
Given there is poor evidence to directly correlate a specific manipulation to its effects, the mechanism of pathology is globally poorly defined in general or from what we understand. Yes we know interactions and processes we know a lot, but we don''t know a whole lot as well.
As I said health is a combination of Art, Philosophy, and Science. None alone can explain everything. And what needs to be addressed is consumer protection. Chiropractic education greatly improved and no they are not on par with MDs but could a DC treat diabetes? Yes there are mechanical symptoms that can be addressed which may or may improve the natural opposition to stress the body has.
"The real problem (isn't chiropractic but rather) society's tolerance of disproven theory, unsubstantiated claims and unethical professions." -A. Botnick DC.
could a DC treat diabetes? Yes there are mechanical symptoms that can be addressed which may or may improve the natural opposition to stress the body has.
I would like you to explain what these (mechanical symptoms) are that since you seem to be familiar with them. As I am on a diabetes team and take this very seriously we (the team) would be interested to know.
I would like you to explain what these (mechanical symptoms) are that since you seem to be familiar with them. As I am on a diabetes team and take this very seriously we (the team) would be interested to know.
Neuropathic joints, most commonly seen in the foot and ankle cause serious biomechanical alterations. It is important to monitor proper joint mobility and relieve stressed soft tissues. I am sure you are well aware how important it may be to brace regions of instability and hyper-mobility to prevent further damage.
Limited joint mobility in the foot owing to increased foot pressure and foot ulceration. Mobilization may retard decrease or increase ROMs.
Ossification of the posterior longitudinal ligament in the cervical spine hindering full range of motion in the cervical region/thoracic region.
Stiff hands, adhesive capsulitis of the shoulder. Noteworthy that loss of motion in the shoulder requires additional compensation of the spine.
Tunnel syndrome is a common diabetic sequela and is often managed successfully with conservative measures splinting and soft tissue work.
Additional monitoring and co-managing to reduce musculoskeletal symptoms and improve patient satisfaction and out look.
Joined: Apr 2010 Gender: Male Posts: 960 Location: The Great White North
Re: Physical Therapist's may/will Take Over « Reply #17 on Apr 4, 2012, 9:10pm »
Those are good examples chiroreform. And what you have described here is that there is something a chiropractor can do that aids in the secondary complications of the disease process. Not the disease itself. I think that you have made a very significant distinction here. And I'm glad. I have seen the writing of some chiropractors describe treatment that aids in reversal of the disease itself.. through simple adjustments and the healing powers of same. You have not done that.
Having 100 different techniques with conflicting and incorrect biomechanical assessments is an embarrassment not something to be boastful about.
Nemo, chiroreform doesn't consider what others think, his statements are all unsupported opinion and industry propaganda.
I would assert that indicates "generic manipulations/adjustments" in general are beneficial. To my knowledge there is no procedural assessment that is foolproof. Rather I would modify the varying techniques to accommodate the specific patient, prone, standing, supine, etc.
Again depending on the state the chiro is practicing in, I would certainly boast that many chiros are taking a complete thorough history, guiding the patient to natural methods of care, refer for any red flags, and collaborating with other professionals.
Yes I do understand that there are wacky techniques and I cannot speak for them, and many I would not even call chiropractic. People have a right to choose what care they get. And the innervation of others should deal with consumer protection. If a person has a strong belief that removal of subluxations through all the philosophical terms is benefiting them... well good for them, belief is a great treatment. Belief, Faith, Yoga etc all have profound impacts of stress. However not only is there a belief but there is a physical adjustment that may have other benefits in itself. I will also add that many who just rack/crack patients either state they are not a substitute for a GP or work in a clinic where they collaborate with other professionals.
This leaves a very low percentage of chiropractors who practice unethically.
[quote author=admin board=outlook thread=5571 post=44213 time=1333462462] Yes I do understand that there are wacky techniques and I cannot speak for them, and many I would not even call chiropractic.
So basically the only things you consider chiropractic are the motion palpation procedures stolen from Dvorak MD in Denmark and widely used by PTs. Everything created by chiropractors and taught in chiropractic institutions isn’t chiropractic. How bizarre.
It will be interesting to see if more experiences change your mindset.
"The real problem (isn't chiropractic but rather) society's tolerance of disproven theory, unsubstantiated claims and unethical professions." -A. Botnick DC.
Re: Physical Therapist's may/will Take Over « Reply #20 on Apr 5, 2012, 10:58am »
What I consider chiropractic is hands on less invasive approach/assessment(adjustments, palpation, mobilization, soft tissue work, listening etc ) and use of natural modalities (exercise, lifestyle, nutrition...) to increase wellness and help resolve MSK conds. Starts off with a examination, diagnosis, and followed by a treatment from least invasive to more invasive. Key point, as most invasive immediate treatments carry more profound effects, however it's more important to address serious issues and pain to prevent prolonging of proper dx/tx plan.
My personal opinion is by better attaining wellness through natural modalities the patient is monitored more closely and the prolonging of taking medications is assessed more often. Ultimately the decreasing amount of medications when possible being adjusted by their GP is a very beneficial thing.
The transition to an active lifestyle and better nutrition clearly is positively demonstrated. I like to assess what chiropractic does to more of functional outcomes, not based on solely pain scales etc. If someone came in w/serious pain wanting to play golf again, well it would be realistic to help them attain that goal again to resume activity though there may be residual pain. Side effects of being able to do something of passion address a psycogenic response and better outlook on health. Health is mind, body, soul; art, philosophy, science; a combination of whatever you please, but its not solely one thing. There is no "best medicine" solely defined by science, far to much unexplainable.
I am close friends with many PTs and yet there is some overlap DC is a whole different profession. Physical therapy would be more adequate for a postop/injury/condition that needs serious rehabilitative attention. Chiropractic could later assess acute compensatory effects from previous MSK injuries via closed kinetic chain, reduce restrictions(adjustments and soft tissue) , develop stretches and exercises to restore a more normal biomechanically favorable movements and address respective regions.
Iv'e seen some bizarre techniques when I shadowed, taking with the patients was a pleasant surprise, and although I have no belief or won't promote them I say to each their own. I seen nothing dangerous as even the patients stated they regularly seek their GPs.
This leaves a very low percentage of chiropractors who practice unethically.
Again, this is a generalization based on presumption. And I cannot agree. I have made mention earlier in this thread about using generalizations and they do not help your arguments. I do appreciate some of the things you are saying.
For instance, the MAJORITY of chiropractors in my area are not evidence based or even reason based. They are outright quacks who convince patients they have problems that they can only get help with through that chiropractor until such time as they ask questions from others and/or see the folly for what it is. There are a couple good ones that truly have helped people but they are the minority. This is a fact.
Please only speak for what you yourself know to be fact. Not what you might presume something to be. It helps with your argument to bring credibility to what you say.
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be at the forefront of research on manipulation, which we are not. 
thinking out of the box.![[image]](http://static.guim.co.uk/sys-images/Guardian/Pix/pictures/2011/12/7/1323281369139/The-cardboard-box-from-wh-007.jpg "[image]")
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