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Foot mobilisation and manipulation any evidence ?

Discussion in 'General Issues and Discussion Forum' started by Simon Spooner, Feb 14, 2011.

Tags:
  1. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Ok, so here again we have some more of the inductive reasoning/ empirical evidence supporting your deductive reasoning, Ted. Mike kindly posted the abstract:
    Proteoglycan alterations following immobilization and remobilization in the articular cartilage of young canine knee (stifle) joint.
    Säämänen AM, Tammi M, Jurvelin J, Kiviranta I, Helminen HJ.

    Department of Anatomy, University of Kuopio, Finland.
    Abstract
    The distribution of proteoglycans (PGs) at 11 sites on the knee (stifle joint) cartilage of young female beagle dogs was studied following cast immobilization for 11 weeks in 90 degrees flexion and after a subsequent remobilization for 15 weeks. Immobilization induced a reduction in PG uronic acid at all sites (mean of -38%), but the greatest depletion (-64%) occurred at the anterior and posterior extremes of the femoral condyles, i.e., at locations where the immobilized cartilage lost contact to the opposing cartilage. Following remobilization, the content of uronic acid remained lower than in the age-matched controls (-18% on average), particularly at the minimum contact sites most affected by immobilization (-33%). The chondroitin-6-sulfate to chondroitin-4-sulfate ratio was reduced by immobilization in most locations (average of -14%) and returned to control values after remobilization. There was no consistent change in the percentage of aggregating PGs observed in Sephacryl S-1000 gel filtration after immobilization or remobilization. However, following remobilization, the aggregating PGs showed an enhanced proportion of the slower mobility band in agarose gel electrophoresis, indicative of a larger monomer size. In the contralateral, load-bearing knee joint, both the uronic acid content and PG monomer type distribution were identical to those observed in the experimental joint, suggesting that the state reached after the remobilization period was due to factor(s) influencing both sides. The results suggest that contact forces between articulating surfaces are required to maintain normal PG content and that the control mechanism works locally at each cartilage site. Restriction of joint mobility and loading in young animals is concluded to cause persistent changes in cartilage matrix. Furthermore, the use of the contralateral joint as the sole control in this kind of studies, although experimentally convenient, seems not to be appropriate.

    So, what they did was to take some young dogs and stick their legs in a plaster cast for 15 weeks and then took the casts off. Did the researchers perform soft tissue mobilisations on the dogs knees? Or by remobilisation do they mean that the dogs joints were allowed to move? Either way the remobilisation didn't appear to undo the changes induced by immobilisation and reduced weight-bearing since the researchers concluded that: "restriction of joint mobility and loading in young animals is concluded to cause persistent changes in cartilage matrix."

    And from this you are deducing that if you take a patient who is not a young dog, has not been immobilised in a plaster cast for 15 weeks and perform mobilisation techniques on them it will reverse joint degeneration. Is it just me?
     
  2. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Or using the definitional retreat fallacy as it's known in reasoning.
     
  3. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Or bull****ting as it's commonly known in these parts. By coincidence I just received another lot of tripe in the spam folder from our good friend Rhubarb who now warns an unsuspecting public not to be misled by devious marketing campaigns. Why do I get a sense of deja vu when reading this thread?

    http://curingchronicpain.com/?p=1060
     
  4. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Now, I'm no expert on radiographic analysis, but if we had someone stand in relaxed stance, x-rayed their foot and then had them stand in a more pronated position and x-rayed the foot again, would we see an apparent reduction in the joint space at the medial edge of the talonavicular joint when the foot is more pronated? Does this mean they have degenerative changes, or just that the joint is in a different position? I'll see if I can find the radiographs we took for the STJ locator study tomorrow since during that study we took films of the same feet in relaxed calcaneal stance, max pronated and max supinated positions immediately after one another...

    Edit: found the disc with them on and as I thought, "degeneration" at the medial edge of talonavicular joint can be made to magically disappear simply by having the person stand in a different position when taking the x-ray (see doc attached). Born skeptical, me.
     

    Attached Files:

  5. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Lets take another look at the abstract to the article which Ted used as empirical evidence for his deductions regarding FMT:

    Proteoglycan alterations following immobilization and remobilization in the articular cartilage of young canine knee (stifle) joint.
    Säämänen AM, Tammi M, Jurvelin J, Kiviranta I, Helminen HJ.

    Department of Anatomy, University of Kuopio, Finland.
    Abstract
    The distribution of proteoglycans (PGs) at 11 sites on the knee (stifle joint) cartilage of young female beagle dogs was studied following cast immobilization for 11 weeks in 90 degrees flexion and after a subsequent remobilization for 15 weeks. Immobilization induced a reduction in PG uronic acid at all sites (mean of -38%), but the greatest depletion (-64%) occurred at the anterior and posterior extremes of the femoral condyles, i.e., at locations where the immobilized cartilage lost contact to the opposing cartilage. Following remobilization, the content of uronic acid remained lower than in the age-matched controls (-18% on average), particularly at the minimum contact sites most affected by immobilization (-33%). The chondroitin-6-sulfate to chondroitin-4-sulfate ratio was reduced by immobilization in most locations (average of -14%) and returned to control values after remobilization. There was no consistent change in the percentage of aggregating PGs observed in Sephacryl S-1000 gel filtration after immobilization or remobilization. However, following remobilization, the aggregating PGs showed an enhanced proportion of the slower mobility band in agarose gel electrophoresis, indicative of a larger monomer size. In the contralateral, load-bearing knee joint, both the uronic acid content and PG monomer type distribution were identical to those observed in the experimental joint, suggesting that the state reached after the remobilization period was due to factor(s) influencing both sides. The results suggest that contact forces between articulating surfaces are required to maintain normal PG content and that the control mechanism works locally at each cartilage site. Restriction of joint mobility and loading in young animals is concluded to cause persistent changes in cartilage matrix. Furthermore, the use of the contralateral joint as the sole control in this kind of studies, although experimentally convenient, seems not to be appropriate.

    Yet Ted quoted the article as stating:
    "We conclude that articular cartilage, showing signs of atrophy after long-term immobilization, was capable of restoring its biomechanical properties during remobilization."

    I haven't read the full article, but those two conclusions seem rather different to me. And from the abstract alone, the research does not appear to have even attempted to assess the biomechanical properties of articular cartilage....
     
  6. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon, please accept my humble apologies. My attempt at humour has gone down like a lead balloon. Always difficult in such an impersonal medium.

    I would like to sincerely thank you Simon, for participating in this thread. I appreciate that you have been willing to take time out of your busy schedule to contribute to this discussion.

    Yes Simon, I wrote:
    and

    and

    to clarify that deduction is dependent on inductive/empirical evidence. You seem to be suggesting that I'm ignoring this fact.

    This thread has been an excellent example of how we all look for evidence to support our own position. Mark has done this by invalidating my thesis that Phase 1 joint degeneration cannot be reversed by ignoring the distinction I made of the 3 phases of DJD and stating that Phase 2+ degeneration cannot be reversed.

    The interaction between Simon & David could, no doubt, continue on for a few more pages as more evidence was listed to support individual positions.

    This thread demonstrates how valid points that support FMT have been ignored. Whether we like it or not, when things 'stick in the craw' as Simon has put it, we all lose our ability to be impartial. I am no exception.

    I have been completely transparent about the lack of inductive research in relation to foot mobilisation and common foot biomechanical disorders. But even if there was a lot of research in this field, I wonder if we'd still be picking and choosing evidence to support our own biases. As Simon has pointed out, even when the research is done, the quality is questioned:
    I know that FMT needs evidence based research, but then we have the La Trobe University stating:
    www.latrobe.edu.au/podiatry/mobilmanip/maniphxtheory.html

    I'm of the opinion that FMT needs the minds of people like Simon to research the field.

    Simon, your Podiatry Pages listing states:
    Your services offered include:
    What evidence base do you use to support the efficacy of your physical therapies?
    Can you please list your references.

    Ted.
     
  7. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    What sticks in the craw is the misuse of language used to promote your courses. Forget the distinction you made between the different phases of degenerative joint disease, if Joe Public reads your course advertisment, what do you think they would make of the statement
    Granted it's not as outlandish as "My technique cures arthritis" but that's exactly what it infers and in that respect it's up there with "orthotics cure infertility" ad infinitum. I understand the desire to have a unique selling point, but you undermine the whole case for FMT when you peddle statements like the one above, or cite references such as the one Simon illustrates - and which you have still not addressed.
     
  8. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    I don't have time for this today as I'm travelling and will be away for the weekend.

    Here's just a few examples of the kind of evidence I use to support my physical therapy interventions with patients:

    Heat and cold
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004522/frame.html
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD002826/frame.html

    Ultrasound
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001275/frame.html
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003132/frame.html
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001250/frame.html
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003375/frame.html

    Frictions
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003528/frame.html

    Stretching
    http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD004575/frame.html

    etc etc etc

    As you can see, the Cochrane library provides an excellent source for best evidence.
     
  9. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Mark, which course advertisement did you get that quote from?

    Ted.
     
  10. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon,

    Thanks for that. But I randomly picked the reference for Frictions and I see the abstract states:
    Ted.
     
  11. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Post 12 Page 1 of this thread.
     
  12. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    That's exactly what I tell the patients. What i try to avoid is making claims which cannot be substantiated by the evidence base. For example, I wouldn't tell a patient that by mobilising a joint it will reverse degenerative changes.
     
  13. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Oh, I see, so it wasn't from any of my advertising used to promote my courses as you claimed:

     
  14. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Well done, that's a very professional attitude.
     
  15. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Anyway enough of shifting the burden of proof fallacies, ted. Let's go back to those poor dogs who had their legs put into plaster casts....
     
  16. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    What's the point? Burden of proof is key to what we accept as true and you're calling it a fallacy. We'll have to agree to disagree.
     
  17. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Forgive me, but isn't the title of this thread Foot Mobilisation Technique (FMT) Courses - UK 2011? What is your initial post other than an advertisment of this course?????
     
  18. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    No ted, shifting the burden of proof is a fallacy used in debate to deflect attention away from the moot point. This is what you did when you went to the website and asked me to provide evidence for my practice. You committed the fallacy of shifting the burden of proof. There was also a tu quoque in there. Anyway about those puppies and plaster casted legs...?
     
  19. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Well gosh. Hasn't this thread turned exciting since I last read it.

    I hardly like to stick my hand in the blender but I feel I must clarify a point on page 1.

    I think AK testing is a load of whahooey (although I'm open to being shown otherwise).

    I put FMT techniques on a somewhat different point on my skepticism scale. I think there might just be some useful clinical possibilities there. I've seen no evidence, but then I do lots of stuff with no evidence. Some of it makes sense to me, which is enough to make me interested, if not convinced.

    I agree that this thread is Shameless promotion for Teds course. But I believe that is what the conference bit of the forum is for. I've put courses up here. Others have also. Its not the same as some gatecrashing unconnected threads to promote your product / method as so many people do. So I think shameless is right. As in, no shame should be ascribed. There is a course on a relevant subject, which we are being made aware of. Maybe I am missing the point but I can't see anything wrong with that!

    We might well have an EBM scrap about FMT. When I know a bit more about FMT I might even weigh in on one side or other. But should that not be on a thread called "FMT, is it a load of old cobblers"?
     
  20. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Agreed, and when Craig finds the time I should be more than happy to have this thread split off from about post 4 and given the title of foot mobilisation/ manipulation any evidence?.
     
  21. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Not a Craig but a Mike.

    There you go all required posts moved I hope.
     
  22. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon, reflecting on what's happened in this thread and given the points you've raised, I believe that a constructive way forward is to continue this discussion face-to-face.

    I would like to invite you to participate in my FMT Course in London in April as my guest, at my expense. In the course we discuss the evidence base for mobilisation techniques and enquiring, sceptical minds like yours always contribute to a robust, interactive discussion among all the participants. We've barely scratched the surface in this thread, compared to what's covered in the course, in order to use foot mobilisation in practice.

    I hope you can accept this invitation and we can meet.

    Ted.
     
  23. Dananberg

    Dananberg Active Member

    Having practiced foot manipulation for many years and seen the effects in a broad range of subjects including those with degenerative joint changes, I have developed my own perspective.

    It is important not to confuse the relief of symptoms of DJD with the actual improvement in the cartilage status in joints. First, nociceptors (pain sensing nerves) are NOT present in joint cartilage. So, the pain of DJD must be periarticular vs. interarticular (it’s got to be were the pain sensors are located). Joint capsules, subcondral bone, and fascia are as much (if not more) related to the sensation of pain as the actual joint surface, as this is where the pain sensing nerves are located. Therefore, changing the cartilage status is not a requirement to reduce or remove symptoms. Mobilization and manipulation work on pain sensing far more than they do on reestablishing cartilage (if at all). For those who practice manual medicine on the lower extremity, it is easy to assume that the improvements patients report are related to the changes in joint surfaces. This does NOT appear to be the case as the data from the studies presented on this tread clearly show limited to no actual joint changes. However, joint mobes/manips have been practiced in humans long predating Hippocrates. When treatments methods last for thousands of years….this, in and of itself, amounts to an interesting body of evidence as to effectiveness. That said, the why is of real importance. The ability of nociceptors to modulate the threshold at which they signal pain seems to be at the heart of manual care of apparent interarticular joint pain.

    Howard
     
  24. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Ted, thanks for the offer, but I already have other commitments for the dates of your course. So, if you wish to continue to discuss this constructively with me, we shall need to continue as we have started, here on the Arena. It might be helpful if you could send me full text versions of the Videman and the Säämänen et al. papers, and any of the others that you use within your discussions of the evidence base for mobilisation techniques of the foot.

    skspooner@blueyonder.co.uk

    As far as I can see from the abstract of Säämänen et al. paper the conclusion they draw from their study appears rather different from the conclusion which you quoted for them. It might help if I could see for myself exactly where within their paper they actually said what you quoted them as saying. It might also help me to understand how they actually used mobilisation techniques on the dogs knees after the plaster cast immobilisation of them was removed. Did they use anterior-posterior glides? What were the mobilisations they performed on the beagles knees?

    Is a plaster cast immobilisation of a joint the same anatomically and physiologically as a joint becoming "immobilised " due to some other factor, for example: a hallux rigidus? Viz. is extrapolation of data from studies like that of Säämänen et al. to the mobilisation of a patient presenting with hallux rigidus a valid process?

    Ted, if you could design and carry-out one study regarding the techniques which you promote, what would it be?
     
  25. So, if the pain is due to subchondral bone exposure as seen in O/A, manipulation will not result in change to that pain? We must be careful here of not falling victims of the appeal to tradition fallacy- just because something is old, doesn't make it right. I agree that the why is important; is it down to placebo effect or is it really efficacious in it's own right? How do you perform a placebo mobilisation / manipulation?
     
  26. TedJed

    TedJed Active Member

    This is a good distinction you have made here Howard. Do you think it is possible that improvements in the articular cartilages could lead to improvements in the joint's functional capabilities leading to less stimulation of the peri-articular nociceptors?

    Ted.
     
  27. What improvements in the articular cartilage have been shown to occur, in humans, following manual therapeutic mobilisation of a joint with degenerated cartilage?
     
  28. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    That's a shame Simon. Would you be willing to accept a 'rain check' for when I return in September?

    Ted.
     
  29. Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    I'll see what I'm doing in September, Ted. In the meantime, any chance of answering my questions in the here and now?
    http://www.youtube.com/watch?v=F7jSp2xmmEE
     
  30. TedJed

    TedJed Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    I am not the most qualified person to design such a study (my Grad. Cert. in Research Methodologies is no match for a Ph.D. My wife has a Ph.D. so I know the hard work and effort involved), however I think the criteria that needs to be demonstrated are the results of mobilisation (focus on one condition per study?):
    - on a subjective level (e.g. a measurable pain scale)
    - on an objective level (reliable empirical measure of some sort)
    - a control group
    - a sham/placebo intervention
    - specified/valid intervention(s)

    What other criteria need to be met?
    What would you design to satisfy these, or other, criteria?

    Ted.
     
  31. Ted,

    This is the crux of the argument as far as your claims regarding reversal of DJD is concerned. I have no problem accepting that mobs/manips can improve function and reduce pain. Furthermore I would argue that when used in tandem with other clinical practice - orthoses/hallux wedges/low dye strapping - joint mobilisation can accelerate the intended outcomes (for conditions like FnHL where the articular integrity is uncompromised). May I suggest that you have to be more accurate in what you claim is achievable, unless there is good clinical evidence to suggest otherwise.

    Mark
     
  32. Dananberg

    Dananberg Active Member

    Simon,

    If the subchondral bone is exposed due to erosion, it is certainly more difficult to obtain any type of permanent relief. This is when joint replacement may be advisable. That said, there are times when joint mobes create ROM at sites which are actually stressing other locations. For instance, I am in the process of managing a sad case of a man who worked at a land fill. Cut his leg and didn't use antiseptic, and ended up with a septic ankle and STJ. I saw him 8 months into this ordeal, and finally off antibiotic therapy. STJ was obliterated by the infection, and the ankle marginally so. Ankle and triple arthrodesis was being contemplated. His equinus, however, was causing him to over pronate his mangled STJ, and this produced severe pain. Manipulating his ankle relieved the equinus immediately, and then a heel lift incorporated into a Vasyli-Dananberg device (he had Functional hallux limitus as well) created a rather dramatic effect. Planning on CFO casting in about two months.

    My reference to the longevity of manipulation in human health care was that ineffective methods eventually fall out of favor (leeches, Vioxx), vs. those which work and continue to be effective even with more modern approaches available (colchicine and asprin, for instance). Quite frankly, I am far more likely to prescribe medication which have very long track records rather than those latest and greatest which often show severe adverse effects after enough Rx's are written despite the apparent safety prior studies demonstrated. All of medicine is a balance of risk and reward. With manipulation, there is very little downside, and the upside potential can be life changing.

    My general philosphy on manipulation in clinical practice is that once ROM is re-established and pain level reduced, CFO can be used to keep it from coming back. I do see some patients quarterly, but this is the exception rather than the rule. My experience is that one to two treatments are required. If more....I am missing something.

    Howard
     
  33. Dananberg

    Dananberg Active Member

    Ted,

    I don't think that cartilages changes from manipulation and I am sure I didn't say it did. Changes from mobilizations/manipulations can change stresses on adjacent joints and this would appear to facilitate function. Over time, when used with CFO's, I have seen some rather significant joint changes take place, but this is over years duration and is not a short time visible effect. It is important to say that pain relief can occur rather rapidly, as does functional restoration. Its just not because the joint surface has been repaired, but rather how pain is sensed and modulated.

    Howard
     
  34. Dananberg

    Dananberg Active Member

    Re: Foot Mobilisation Techniques (FMT) Courses - UK 2011

    Simon,

    I was very disappointed to see someone with the quality research background write a paper which so misrepresented the effects of manipulation.

    In this paper, the cited research used subjects without equinus. When there was no change in ROM following ankle manipulation, they concluded that manipulation was ineffective. This is absurd. That's like giving patients Tylenol when they don't have a headache, and assuming that since there is no change in pain status, that the medication has no effect.

    Howard
     
  35. Some more reading ...

    http://www.jmptonline.org/article/S0161-4754(08)00291-1/abstract



    Does distal tibiofibular joint mobilization decrease limitation of ankle dorsiflexion? - abstract

    Full text found here

    The Effect of Talocrural Joint Manipulation on Range of Motion at the Ankle

    Thats all for now some positive some negative which is to be expected. The thing about all studies that look at ROM they kind of miss the boat a little. What the design question should be looking at in my option is not just ROM but dorsiflexion stiffness at the talocural joint.

    ROM may not change but if dorsiflexion stiffness reduces a very positive finding ...
     
  36. Not humans but rabbits: http://www.ncbi.nlm.nih.gov/pubmed/19361369
    Humans: http://www.ncbi.nlm.nih.gov/pubmed/19143242
     
  37. Thanks for these, Simon. I don't have access to the full paper, but have to say I'm not overly enthused with the abstract from the Chinese as they can't even get basic spelling correct, irrespective of the validity or methodology of their research. As stated previously, I'm willing to accept that functional improvement and decreased pain in joints can be achieved with mobs and manips, but remain unconvinced of the claims that osteoarthrosis is reversible with the same procedure.
     
  38. To be fair, it's a paper written in Chinese, the abstract has probably just been put through a babel fish. Even if the authors wrote the abstract in English themselves, their English is still better than my Mandarin.

    The abstract of this and the rabbit study do at least appear to show the influence of manipulation therapy on cartilage. I'm only surprised that Ted didn't mention these studies when asked.
     
  39. Okay, I'm being overly pedantic, but I still remain unconvinced. Working alongside osteopaths and a physio on a daily basis and all of whom undertake joint mobilisation and manipulation - all are extremely sceptical of the claims made regarding reversal of arthritic degeneration and cartilage repair. If there was a even a suggestion otherwise, I can assure you the osteopathic/chiropractic professions would be marketing and promoting the benefits like you wouldn't believe!

    I'm not denying the benefits of this therapy - having had Rx`myself, but, perhaps it's the Rothbart effect insofar as when podiatrists make quite staggering claims - even on wordplay like it would appear Ted has done - then they do themselves and the profession generally no favours whatsoever.
     
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