It's hard to give up old tricks

Some will never give up on the elusive search for the cause of the patient's low back pain. I have no inherent problem with gaining a better understanding of spine pathoanatomy to the extent that it might actually influence what I do with the patient. However, other than ruling out serious complications, the 'so what' factor rears it's head time and time again in reviews of special tests purported to differentiate SIJ- vs. disc- vs. facet-mediated pain. Perhaps spinal stenosis is the one exception, but even then, a focused clinical exam and a framework of treatment that matches treatment to sub-groups based on symptom response wins hands down any day....and actually does make a difference in outcome.

John

Comments

[Jason Silvernail]

Great study, John - thanks for posting this, and your comments are right on target as usual.

I wonder if this will change the claims of the CEU factories out there who claim to be train people to make these very specific diagnoses. I found those sorts of claims in more than a few places, including such perennial favorites as NAIOMT and IAOM-US.
Navigating the CEU and even residency landscape can be very difficult with so many outmoded concepts still being taught as truth.

It seems to me that the primary focus of the exam, after determining we are looking at a neuromusculoskeletal problem, is to determine whether the origin of the pain is primarily mechanical or chemical.

I heard a friend once say "Constantly considering countless causes confounds every clinician." This study puts some numbers on that, after all.

[Carina Lowry]

I realize that this post may cause endless debate about technique and several will repeat the mantra "the technique doesn't matter..."

BUT before you slap your forehead consider this argument. Why does a particular technique make it into the literature? Was it based upon guru-ism? Is it based upon the techniques we have learned from giants...Maitland, Kaltenborn, McKenzie, the Cleveland crunch, the SIJ slam, etc? Is it the most comfortable technique chosen by the therapist or for the particular patient's body type?

Or is it based upon this nebulous concept we all know about but can't seem to describe called feeling the joint, ie palpation, ie endfeel, ie SKILL. This I realize has countlessly been shown to be unreliable yet we ALL use it here. I even wager that we use this before we manipulate--the final minor adjustments as Tim so aptly describes it.

I am sure we've all had the patient that just didn't respond to the first technique out of the bag and then when we pulled the second technique out it worked even though we were supposedly moving in opposing direction with the technique. All in all each technique should have some rationale behind it as to why we think it will work. I think we are doing a great disservice by discounting the basis of examination whatever school of thought it is.

I'd like to know if you don't use any basis for selecting a technique how do you decide which one to use? If you use the literature then that brings the argument full circle as to how the researcher chose that specific technique--crystal ball or otherwise.

Carina

[Jason Silvernail]

Hi Carina.
If I am working with a patient with LBP who meets the criteria for manipulation, I always start with the procedure that was studied. If that fails to bring relief or improvement, my next go-to is the sidelying lumbar manipulation (osteopathic "opening" or chiropractic "diversified").

Of course this is simply trial and error, and there's no reason to think that some facet of my examination lead me to use technique "B" versus technique "C". In this case when "A" failed, of course. I have had a few people who met the criteria for manipulation but didn't do well with or couldn't tolerate the positioning for the supine SIJ "chicago thrust" from the study. Anecdotally, they seem to do well with a sidelying opening technique subsequently. But perhaps if I was using a "closing" technique right afterward, then I'd say that was the helpful one.

The evidence shows manipulation to be a very nonspecific treatment. While I do think that skill enters into it, I don't think it's as big a factor as many would like to think. Especially those who spent a lot of $$ to learn specific exam techniques and/or a million different ways to manipulate for a million different presentations.

I don't think I need a crystal ball at all - I'm willing to bet that if the sidelying manipulation technique had been done in the CPR studies then we would have seen similar results. Certainly all evidence points in that direction.

There's more than way to manipulate a spine - and at this point, they seem all roughly equivalent, and the choice seems to be one of patient and operator comfort, and NOT desired mechanical force transmission or target joint.

[insert image of CEU certification factory instructors nervously shuffling papers]

[Steve Jorgensen]

Carina,
I tend to agree with Jason, in that patient and clinician comfort with a particular technique is a big factor in my choice of technique. Actually, because I learned a sidelying lumbar manipulation first, that is the one to which I will generally default, although I have more recently been trying the version used in the L-spine CPR study (I presume that is the one to which Jason alludes when he uses the term "Chicago thrust"). It would seem that manipulation works via a neuromodulation effect, and I look at this question as one of how most comfortably to neuromodulate a given patient. A thought I have on the skill aspect is that with practice and experience, one might better/more quickly be able to pick up on some of the cues that indicate that technique A will work beter than technique B for this or that patient (although asking the patient how he/she feels in the pre-manip. position and observing facial expressions for clues should not be sneezed at!). I do also believe that there are skill aspects involved in the motor control aspect of performing a manip., and possibly in making the patient as comfortable as possible in the required position. Probably, people differ in the speed with which they learn these skills (my own observation suggests that this is so) but I think that the evidence suggests that these skills are generally teachable.

Steve.

[Carina Lowry]

Steve and Jason,

I would have to say that in general, I agree with your comments. I also use both techniques interchangably with good results if they are going to work fairly fast within 1-2 treatments. I find the chicago thrust/SIJ slam a little more conducive to the wiry body types because it's quite difficult to get an apple shaped body into that position and sometimes difficult with pears as well if the patient is quite endowed at the hips.

However I have to bring up these points:

For the manipulation rule, absolutely I use it. However, I think we should talk about prevalence of who actually fits the rule in a normal civilian population since both studies were conducted in a direct access military setting for the majority of their patients. In the original Flynn study, 32 of 71 patients (43.6%) were categorized as successful with Oswestry decrease >50%. In the subsequent Childs follow up study, out of 543 patients, 157 met the study criteria, with randomization, manipulation group had 23 of 70 positive on the rule but 31 of 70 were considered a success. So that's 23 of 543 patients (4.2%)of the general population with low back pain who walk through the doors who would meet the rule and have a successful outcome. I don't know about you all, but I use manipulation more than 4.2% of the time....and I definitely mobilize more than that. I pull out those dusty old palpation skills that are so unreliable and even use a muscle energy technique or two. I just think that by only using the CPR's, we lose some of the other valuable tools and techniques out there. The CPR's are great in their own right, don't get me wrong. I just think by avoiding all mechanical assessment skills, we are being short sided as a profession.

Carina

[Jason Silvernail]

Hi Carina.
I don't think it's "short sighted" at all to summarily reject supposed mechanical assessment tools that have pretty poor reliability and even more questionable construct validity.

What is the prevalence of these supposed joint restrictions revealed by the mechanical assessment process? I don't believe that has ever been studied. I wonder what the results would be? Given the established poor reliability and questionable (at best) construct validity, is there any reason to think that these findings would be any LESS prevalent than herniated discs, facet arthropathy, or degenerative disk disease revealed via MRI?

I don't limit manipulation to only those who meet 5/5 on the rule. Even for those who only met 1/5, the possibility of getting a huge ODI reduction is close to 50% (in the 40s if I remember correctly).

While I'm glad you're not strictly sticking to the rule, I don't see any actual evidence that these detailed mechanical assessments you mention are useful. How is listening to the evidence short-sighted?
I thought that's what "Evidence in Motion" is all about...

[Carina Lowry]

Oh Jason. You make me laugh. I don't propose assessments that take hours. Are you kidding? I don't have that much patience...but I don't think that we should completely toss some of these motion and pain provocation tests either. Although they wouldn't be my first choice out of the box, I imagine they would be useful in some cases.

I would think that you would not be able to see joint restrictions on MRI since this is a static test and not a motion test...but regardless I doubt if you'd really be able to see anything on it and it would be a poor gold standard at best. Just like you can always see all those subluxations on plain films. ;-)

This is likely what makes all these palpation tests so un-valid and unreliable since there is no gold standard to compare them to. I don't propose that we'll ever really have one either.

But let's get back to the studies at hand. In the Fritz post-hoc study of the same patients in the direct access military setting the lumbar manip rule was developed on, 6 factors were found to be predictive of a non-successful outcome in 20 of the 71 patients (28%): duration of symptoms >16 days, presence of leg and back pain, no hypomobility noted in the lumbar spine, having less hip internal rotation, and a negative Gaenslen's sign interestingly enough. Actually 2 SIJ tests were noted in the study: asymmetry of the pubic tubercles and the positive Gaenslen's sign. These factors were noted in those who failed to improve with manip.

In the original Flynn CPR study, 25 of 27 subjects in the nonsuccess group had two or fewer variables. This did not change the probability of success. But in the Childs follow up validation study, fewer than 3 variables had a - LR of .10 which really drops the probability of success to less than 10% if you use a pre-test probability of 45% and use the nomogram. So does this mean that we should never manipulate those with 2 or fewer factors? Not likely since the two major factors of only low back pain and pain less than 16 days are the most predictive variables with a large +LR also that was reported in another recent Fritz study...

But you didn't answer my question about the prevalence in a civilian setting. Do you think that we would see the same results in your average outpatient clinic?

Just wondering.

Carina

[Jason Silvernail]

Hi Carina.

I don't think I addressed the length of time these assessments would take - I'm more concerned about their construct validity than anything else.

On the MRI findings - I don't think we can reliably feel these supposed restrictions, and I *know* we can't see them on imaging tests. My point about the MRI was to ask whether we had any reason to believe that we wouldn't find all sorts of motion restrictions and impairments in an asymptomatic population, just like we find degenerative changes in an asymptomatic population.

For if we could demonstrate that things like the dreaded pelvic asymmetry, leg length differences, rotated ilia, hypomobile facet joints, etc, etc existed commonly in the asymptomatic, then we would have even less reason to pursue these examinations than we do now. No doubt that some measures with poor reliability and construct validity (eg general lumbar PA mobility) turn out to be useful in making treatment decisions, but the evidence demonstrates that the vast majority of these tests simply aren't useful at all.

On the numbers from the validation and CPR studies- I'm not where you're going with those. I thought I made clear above that even those with less than 3 factors might be good candidates for manipulation. For people who can tolerate the procedure, I often will try it with 2 or fewer factors present because it sometimes yields dramatic results.

On generalizability - a wide range of age groups were examined in the study, not just active duty military members, so I'm not sure why the results *wouldn't* be easily generalizable to other populations.

But regardless of whether it would or wouldn't, what does that say about the state of evidence for mechanical and motion testing for joint restrictions?

At the end of the day, we're left with unreliable assessments with very questionable construct validity, that aren't necessary to deliver effectively any of the basic interventions in the classification model (including manipulation).

So, why continue using them and why continue teaching them to our students? And why do we continue telling our patients that they hurt because of one or more of these findings?

What do you think?

[Vince]

As an individual who has his fair share of spine issues and as a clinician, I think there is a role for at the very least to make the attempt at trying to be as specific as possible. From my personal experience as a patient, I have had both specific and general techniques performed to my pelvis, thoracic, and cervical spine. From my personal experience, it is usually the specific technique that tends to help (ie pain, improved AROM) From the clinician standpoint, I use both general and specific techniques in my practice. I also see alot of patients who have gotten plenty of general manipulation techniques via their chiropractor and failed thier care. Many of these clients respond well to specific manipulation where general manipulation failed.

Although I agree with you that I'm probably not that "specific" with PIVM testing or specific techniques, but i find that they can be useful and i tend to have good outcomes using them.

As a patient, I have felt the differnce between a general technique and a specific techniqe and I'd rather have the specific technique.

What I have struggled with from a professional standpoint is that I'm not argueing the research the research you discuss is invalid. (although I may disagree with some of you regarding some of your comments). But if the technique doesn't matter, I don't see any problem with "specific" techniqes. If that makes me less of an evidence based practioner, so be it.

Maybe one you PTs who are much smarter than me can answer this question? If the technique doesnt matter and if general manipulations are the ONLY manipulation to help with LBP, why shouldn't I teach my client to self manipulate thier neck and lumbar spine and discharge them?

Thank you for the oppotunity to comment, although I'm have this feeling that I going to stir up a hornets nest

[Jason Silvernail]

Hi Vince.
Thanks for your comments. No hornets here.

Regarding your specific vs general argument - I'm not sure exactly what to say. I have also had the experience that a general technique failed, but a closer examination of where the patients' complaints are and a technique "targeted" to that area did improve them. However, was it the mechanical effect of the manipulation or was it the fact that it was just an additional procedure.
Even if we did conclude that specific techniques are important (and I'm not saying they aren't - I do use them often), that says nothing for the value of the detailed mechanical assessment process.

If the specific results of a mechanical assessment lead you to believe that a particular specific technique would be better, then perhaps we would have something substantive to talk about. But the research is quite definitely on the other side of the debate.

I don't think anyone is saying that general techniques are the "only" ones to use - just that there doesn't appear to be (as) much benefit to them as we previously thought.

Your discharge question is a bit of a straw man, but the goal is of course patient independence and freedom from pain, and manipulation can be part of that.
The weight of evidence suggests currently that general techniques in the absence of a detailed mechanical assessment is all that is required to administer this treatment safely and effectively.
Jason

[Carina Lowry]

Hi Jas,

Sorry I've been out of circulation with moving to Chicago and all. You had asked about why we teach these assessment techniques to our students. Well, I have lots of ideas about it. Maybe teaching our students to assess how the patient moves really isn't such a bad thing. I think we see the preferred patterns of movement, the feedback mechanisms, feedforward mechanisms, and the compensatory strategies with these tests. I think we learn alot from our patients as a clinician just by watching them move. And the best way to do this is through motion testing. It's part of the neurophysiological mechanism of manipulation you keep referring to.

Second, I think that when learning, a student has a better chance of success with standardization rather than just do this technique sometimes and another the other time...Many clinics have standardized exams and have found improved patient outcomes when the exams are standardized. This is not to say that we should pull out Magee and just go through the techniques. We should pick tests that most likely will give us information...ie I wouldn't choose a test for SIJ when the patient subjectively is telling me they have pain to the 1st toe that increases when they sit and decreases with walking and extending backward. So I think the tests should reflect clinical decision making. Now, I'm not arguing for any particular system of assessment at this point. I'm just saying we need a system and that it could give the student a better way to structure the exam and treatment.

These would be the two reasons I could think of to continue teaching these frivolous tests to our students.

The third reason really echos Vince's post. I have been manipulated by some that have been pretty good, some that haven't, and some that are absolute masters. All in all, I try to be as specific as possible. I find I have to use less force and I've also had less force used on me as a patient with a more specific technique. Now, maybe it was just the individual doing the technique trying to add flair, pomp, and circumstance, but it was much more comfortable when it was specific. Do I need eight years of rigorous programme to do this? Not likely, but I have noticed that those with better technique have more years of experience...maybe just lots of practice and better feel through the hands. This may be the other reason to teach our students how to be a little more specific.

I don't know. I think the research will eventually show that technique doesn't matter in the end. It is basically just moving the joint. I will utmost however protect my own hands and body and ensure the patient is comfortable, whatever technique it is.

I was just wondering since you keep mentioning it. How detailed do you think this mechanical assessment is? Isn't that part of clinical decision-making--to narrow down the eval to pertinent tests and then move on to treatment?

Thanks,

Carina

[Vince]

I do find that, in the last year that I have followed posts on this site, there is a general overall negative view on PIVM and specific techniques. This frustrates me because I find specific techniqes and PIVM very useful when I feel I can "feel" movement in certain body types. As far as the research showing these techniqes are unrealible, I don't dispute you. However, I have had incidences where I called over a collegue to confirm or deny my PIVM findings because I wasn't so sure, only to have my collegue completely agree with my findings. This includes the segemental level and direction of hyper/hypomobility.

I don't deny the research, its just that these are my personal observations and experiences. And, I have seen many posts on this site that suggest when should throw out PIVMs all together and that clinicians suggest that it is not important to learn specific techniques. More specifically, why even bother getting a manual certificate because only general techniqes work and your really don't need all of that pesky continuing education.

I come from a music background and technique is huge factor in making a performace mediocere and making a performace great. I can make several anologies about skills that make playing a muscical instrument similiar to performing a specific joint manipulation. So, I find it difficulty to ignore those subtle aspects of palpation and understand there is a possibility those can be developed. But then again, not everyone can play "Eruption" on guitar either. Even professional musicians continue to work on thier skill and try to develop technique! Classic musicians still practice thier scales and study music theory. No one questions this in that industry. But, the way I interprete the "spirit" of these posts is that there is a distinct downplaying of the role of skill. IE: all you really need to know is some general techniques and you'll be just as good as seasoned clinicians. This is different from my experience on what works from day to day in my clinical practice.

My point regarding self manipulation was that if I hear from clinicians that general techniques on the only valid techniques and there is no valid framework for specific techniques, what advantage is there for a PT performing them vs self manipulation? I never found self manipulation to be all that helpful.

Please correct me if I'm wrong on my assumptions regarding the negative view of specific techniques on this site.

I'm enjoying the conversation

[Steve Young]

Great discussion so far...

I think the reason we discuss and critisize using manual assessment is not because we think it shouldnt be part of the manual assessment but rather because its value has been greatly overstated in making clinical decisions. By this I mean that the emphasis was taken away from the history and other clinical tests and put on an assessment tool that gave us far too many red herrings and obscured a patients true clinical picture. The fact that the indicators for patients with dramatic response from manipulation only include one level of hypermobility from a PA and no other manual tests is evidence of this fact. Furthermore, diagnosis of patients based on palpation and monosegmental lesions does carry the possibility of contributing just one more pathological problem for the fear avoidant/ anxious patient to hang their hat on.

With respect to the use of specific technique and the administration of this technique, again it is a problem with the over stating the value of the technique and under appreciating classifying patients to the appropriate intervention. Juniour clinicians become fearful of administering a technique that could clearly benefit their patient based on lack of "Specially trained hands". Paralysis occurs as they try to determine the level and direction of their intervention.

Our time is much better spent learning the diagnostic value of our assessment tools, the evidence surrounding our interventions, identifying the patients who will most likely benefit from these interventions and the ability to identify serious pathology rather than getting hung up on 10 different techniques to manipulate a joint in specific directions. I'm not arguing that the master manipulator has better technique than the novice clinician but I would argue that when we can identify the appropriate patient the outcomes are equal.

"Move it and move on" really says it all.

Steve

[Jason Silvernail]

I find it hard to add anything more of substance to what Steve said.

Carina, Vince -
What Steve Y said.

[Chris Baker,PT, MS,DC,DACBN, MSPT]

You mean to tell me I spent all that time and money on learning these 200 techniques and it doesn't do me any good? http://www.chirobase.org/09Links/chirotech.html

I do think Steve made some great insightful comments. The more accurately we identify the pathology/deficit, the better the probable outcomes. Well said, Steve.

Chris

[Jason Silvernail]

Yes, and identifying the deficit turns out to NOT involve a detailed mechanical joint assessment of the SIJ or Lx facet joints - PIVMs and all...

[more nervous shuffling of papers from CEU factory instructors]

[Carina Lowry]

Steve,

You stated: Furthermore, diagnosis of patients based on palpation and monosegmental lesions does carry the possibility of contributing just one more pathological problem for the fear avoidant/ anxious patient to hang their hat on.

My question to you is why are you manipulating patients with high fear avoidance? Doesn't this just create dependence when it "goes out"? It irritates me to no end to hear a patient say this. I would think we are screening patients for high fear avoidance since this is a part of the manipulation CPR.

I don't usually manipulate those who are high fear avoidance, and if I do, I don't state they have any type of "lesion". I simply explain it to them that the joint is not moving well and needs to move--keep it simple for them. Now, do I have a tendency to use one technique over another based on directional motion testing? Yes, that's where I will start and then if it doesn't work, I'll try 1 or 2 other techniques. I don't think we should manipulate someone repeatedly for 30 minutes. There is another profession for that...

Jason, You don't use PIVM's? Isn't determining hypomobility part of the CPR? Actually Fritz and Whitman found that intrarater assessment of PIVM had good reliability...ie if it feels stiff to you, it is more than likely hypomobile.

If you aren't doing a manual assessment for hypomobility or motion testing, do you even touch the patient during the exam??

I guess I just don't understand what is actually being done during your examination if you aren't assessing for high fear avoidance or assessing for hypomobility to determine to manipulate. After "no pain below the knee", determining hypomobility was the 2nd most predictive factor to determine to manipulate--and the combination of the 2 was 88% specific...

Hope to learn more about what exactly you two are saying...

Carina

[paul mintken]

A few references from Haxby Abbott. Just because reliability is poor does not mean that there is no validity. Passive intervertebral motion still has clinical utility, and I use it every day. As has been stated before, we never make decisions based on ONE finding. We link the history, patient presentation, physical exam AND research (when possible). We are palpatory beasts, and if you take away my hands, you take away my life. I follow the evidence whenever possible, but I also let my fingers do the walking...

Abbott JH.
Validity of manual examination in assessing patients with neck pain.
Spine J. 2007 May-Jun;7(3):384-5. Epub 2007 Mar 6.

Passive intervertbral motion tests for diagnosis of lumbar instability.
Aust J Physiother. 2007;53(1):66.

Lumbar segmental mobility disorders: comparison of two methods of defining abnormal displacement kinematics in a cohort of patients with non-specific mechanical low back pain.
BMC Musculoskelet Disord. 2006 May 19;7:45.

Lumbar segmental instability: a criterion-related validity study of manual therapy assessment.
BMC Musculoskelet Disord. 2005 Nov 7;6:56.

Paul

[Jason Silvernail]

Carina-

Is this where we are in this discussion, that you feel the need to ask me if I touch my patients?

Anyway- there's more to fear avoidance than the FABQ. Many people with very low FABQ scores still have issues with activity, exercise, and manual handling of their painful area. Regardless of their FABQ score, we need to be very careful of the kinds of memes we are transmitting to our patients, and I think Steve's point is right on on that one.

On PIVMs - I suppose I don't consider the general mobility assessment from the CPR study as a PIVM. Perhaps this is a terminology issue. I think of PIVMs as springing on various facets in order to determine whether I'm looking at Type I or Type II dysfunction, or some other such illusion. I would include sacral springing and palpatory examination of the lumbar and sacral articulations as well under the heading "illusions".

Certainly with the PA mobility assessment, I think the authors did a good job of explaining the paradox of a useful test in the context of relatively low reliability.

You asked what I do in my exam, but it may be more useful in this discussion to know what I DON'T do in the vast majority of my patients: pelvic landmark palpation, sacral base and ilia relative positioning tests, spring testing for lumbar facets ( I do use the PA assessment from the CPR), and various motion palpation tests for the SIJ.
Does that help?

[Jon Newman]

Hi Carina,

"Doesn't this just create dependence when it "goes out"? It irritates me to no end to hear a patient say this."

I don't think this has anything to do with fear avoidance. It seems like a perfectly rational appraisal especially considering the explanation that

"the joint is not moving well and needs to move"

followed by a thrust maneuver.

On my understanding, fear avoidance has much more to do with unhelpful cognitions about the harm certain movments and activities MIGHT produce as well as an understandable unwillingness to experience pain. Thus, people with high fear avoidance are at an increased risk for a poor response to a thrust manuever.

"After "no pain below the knee", determining hypomobility was the 2nd most predictive factor to determine to manipulate"

I thought the most predictive factor was the short duration (<16 days) of symptoms.

Thoughts?

[Steve Young]

Before this discussion gets to polarized, Carina I agree that high fear avoidance patients generally shouldn't be manipulated (Although there are exceptions along with some solid education/reassurance). My point was that when palpatory exams are used as the main guiding source for the application of manual therapy (Ie. the old manual therapy based systems approach and not using the CPR) there is a high likelihood of red herrings and the opportunity for dependence and increased fear/anxiety based on a specific diagnosis for a specific subgroup.

Paul, I'm not suggesting that we give up entirely on a manual examination, just weighting the findings appropriately. It would seem that PA assessment for hypermobility consistantly increases the likelihood (Ie. ratio of 4.0) of excessive translation with imaging but has poor ability to rule out the condition. For stiffness it seems that positive findings have fair, at best, inter rater reliability and if found only marginaly increase likelihood ratios. Of course we should also contemplate if these findings matter - are outcomes improved through this identification? At present it would seem that for the most part they are not and that most of the decision making with respect to the application of manual therapy actually comes from the history and screening examination for more sinister pathology.

Steve