This past week we had a patient come to our clinic with low back pain. He had previously been to another healthcare professional who notified him that he had 13 subluxations and recommend a specific course of treatment. I have attached the summary provided to the patient. You will see that each specific level of a subluxation is identified on the spine and to the right is the recommended course of treatment. Yes, if you add these up the total number of suggested visits is 84! I have also attached an article titled “Subluxation: dogma or science”. The authors suggest that reorienting the profession to a credible science will bring a brighter future to the profession and patients.

I agree with the authors’ conclusion and believe that the authors’ statements apply to any of the healthcare professions. As we seek professional autonomy the need to continue to base our decision making and treatment selection on credible science will continue to be a priority in PT. Previously John and I have had the discussion regarding the credibility of identifying a sacral torsion. Does the patient have a left on left or a left on right? What is the science behind this? Can we reliably detect these? My guess is no but that is based strictly on personal experience rather than evidence. What if we think the patient has a left on left and we treat it as a right on right? Is it possible we will achieve the same clinical outcomes?

I am interested to hear the thoughts of others..

Josh

Download Chiro_eval_2006.pdf

Download Subluxation_dogma_BMS_2005.pdf

Comments

[Jeff Hebert, DC]

Josh,

There is no way to defend this type of practice. Obviously the motivations of those who practice "subluxation" correction are not in the patient's best interest. Something tells me that if you contacted this chiropractor, he or she would have never heard of Dr.'s Fritz, Childs, Delitto, et al. Furthermore the concept of a clinical prediction rule would be absolutely foreign.

As a chiropractor, I shudder to think that individuals such as this represent my profession to many.

PS- I picked up your textbook several weeks ago and have found it to be an excellent resource- thank you.

Jeff

[Ben Hando]

Josh, I think you're questions get to the heart of the matter with regard to the problems with positional diagnoses.

This is a subject that continues to fascinate me. As a new grad, I drove myself to the brink of insanity trying to detect sacral torsions, and subluxations (a result of my PT programs emphasis). It was a huge relief when I finally let go of that system of eval.

The thing that I never understand is that the current osteopathic model of evaluation (ERS, FRS, sacral torsions, etc...) as far as I can tell at least partially, came out of Fryette's work- hence Fryette's laws.

Fryette's original paper was published in 1918. Since then, much more sophisticated biomechanical studies have been conducted, (panjabi, and others I can't remember now). These studies haven't corroborated Fryette's laws, but have rather shown a huge amount of variability with spinal mechanics even within 1 individual. So the notion that even if we could detect this motion through our fingers (highly unlikely)--that we're somehow detecting abnormal positioning or mechanics seems downright silly to me.

I realize that there's all sorts of other reasons to abandon this form of evaluation. And the work of Riddle and many of the EIM crew has revealed the problems with many spinal positional dx tests rather convincingly, (i.e. abysmal reliability, validity, etc...). I would think just spending 5 min. leafing through the SI section of your book would raise doubts in even the most ardent believers of positional dx eval.

But still, every time I go to a course where we spend the first two days relearning Fryette's laws and practicing these mental gymnastics of Left on right and ERS, FRS, etc... I always feel there's a huge elephant in the room, and the elephant is an amalgam of Fryette, 1918, and all the other biomechanical studies that have refuted his work. It always perplexes me. I'm getting perplexed now just thinking about it. I'm perpetually perplexed.

Sorry for the long comment. I hope some of our experts and history buffs chime in on this one.--Great post.

Ben

[Bill Egan]

Josh,

It would be easy to do some finger pointing at another profession here, but as you mentioned there are some problems existing within all professions. I seen patients who been to PT elsewhere who have had there hip "put back in", their disc bulge "reduced", or their fascia "released." There are many models and stories out there that try to provide a rational for the selection of treatmens and explain its subsequent effects. Following the evidence, when available, should substantially reduce the amount of this dogma. The efforts of clinical researchers like yourself are gradually introducing more science into the profession.

As far as sacral torsions are concerned, I think the two manipulation CPR studies blew these theories out of the water. The technique utilized was originally designed to "correct" either an anterior inominate or a so-called bacward sacral torsion. The results of palpatory tests designed to detect these lesions failed to fall out as predictors of success with the technique.

Bill

[Josh]

Jeff,

Thanks for your comments. We have some of the same problems in our profession so you are not alone. For example, a few months ago I was sent a patient who had received 57 treatments from a physical therapist for cervicogenic headaches. All the patient had received was craniosacral therapy (no manual therapy directed at the cervical spine or DNF strengthening- despite the evidence telling us to do so). During my examination of the patient I asked him what his last therapist said regarding the reason he was not getting better. The patient replied that the therapist was telling him “his sutures weren’t staying in place”. I nearly fell off my stool on that one.

Josh

[David Penn]

LOL- I hate when those damn sutures slip out.. That was a good one Josh. I am dumbfounded.DP

[Jason Silvernail]

Well, of course I have a lot to say about the manual palpatory diagnostic model that continues to be taught and practiced in the PT world.

I find it difficult to believe that our schools and outside organizations who "certify" therapists in manual treatment still parrot this absolute garbage. How much more evidence do we need to conclude that the manual palpatory diagnostic system is almost completely worthless?

Sacral torsions, ERS, FRS, etc, etc...why don't we just say "subluxation" and get it over with?
Every single PT student I've had in the last few years comes to me indoctrinated in this crap, and without exception they are immensely relieved when they are told I don't care about it. They claim they never could feel what they were "supposed" to feel in the labs. Can imagine how the poor chiro students must feel?

I am heartened by research of late that has found utility in more global measures of stiffness in the spine without resorting to positional or motion palpation.
I do think there is a role for some degree of manual diagnosis.

Sorry for the rant, but this is an elephant we have got to start addressing, starting with our education programs!
Are PT faculty who teach manipulative therapy curriculums listening to this evidence?
J

[Ole]

Hmm, without the motion palpation. How do you all decide where to manipulate? And what are those more global measures and stiffness Jason? And again how do you decide where to manipulate with that information.

Not big on motion palpation myself. Just curious what y'all are doing.

[Matt Stehr]

Research tells us that we cannot reliably palpate dysfunctions at the SIJ. I have yet to come across any study that shows that intertester or intratester reliability is acceptable for any palpation tests. As a matter of fact, research does show that translatory motions at the SI are 2 mm or less and rotary motions are less than 2 degrees. I can't palpate that.
I think back to when I first graduated and the PTA I worked with picked up an SI problem on every LBP patient after I had evaluated them and found none. I thought I was just incompetent, but apparently no one else can reliably pick them up either.
My anatomy prof coined a term that I think applies here- "hallucipation"- the combination of hallucinating and palpation. Perhaps Jason Silvernail remembers that term as well...

[Jason Silvernail]

Ole-
Look here: http://www.rehabedge.com/ubb/ultimatebb.php?/ubb/get_topic/f/3/t/000045.html

This is the whole point. Trying to find a "place" to work on is the conceptual problem. There is no place with a problem. The treatment doesn't do what we've been told it does. ie, it doesn't force Facet A to move on Facet B in pattern C.

Matt-
I remember it well. Funny, he was encouraging us away from the palpatory diagnostic model 8 years ago when I was there.
J

[Jeff Hebert, DC]

Hi Jason,

I hope all is well with you. While the interrater reliability of motion palpation certainly has been brought into question, it appears that the "stiffness" assessment that you refer to has shown to be reliable (Fritz, et al).

I do wonder how far this concept can be taken. In other words, if P to A stiffness is reliable and detecting an ERS is not, at what point in between is the cut-off? Can stiffness be selectively reliably determined in rotation or lateral bending?

While I think you consistently make valid points regarding motion palpation, IMHO, I think it may have value which has yet to be determined.

Jeff

[Jon Newman]

Jeff,

If I detect stiffness, what does that tell me? Reliablity is certainly important enough but only in the context that it actually tells us something. Do you suppose the stiffness is a defense or a defect?

[Ben Hando]

Guys-just a point of clarification. The Fritz et al. study you're referring to actually found PA assessment to NOT be reliable. Interestingly, it did prove to be valid and clinically useful. I would refer you to the article itself for a good explanation of how a test can demo' low reliability, but still have acceptable validity. They do a better job explaining this than I ever could. Rob Wainner also had an 'op-ed' in JOSPT that discussed this.

PA assessment can be useful for predicting who will respond to manip, or conversely who will respond to a stab program (Hicks et al.-05). So, Jon, the finding of stiffness or no stiffness IS telling you to do something, very specific in fact!

Both of these articles can be found in this blog's archives. October I think...

Ben

[Jon Newman]

Help me out Ben. What specifically is it telling me? One does not need to have stiffness on a PA test to benefit from manipulation.

Does anyone have any idea of what the incidence of PA stiffness is in an asymptomatic population?

[Jeff Hebert, DC]

Ben,
I greatly appreciate you pointing that out. It appears that I need to review the study.

Thanks,

Jeff

[Ole]

Thanks for that link Jason. And to all others for the comments. It is good to know that I am not alone in this. I always had issues with PAs and especially SIJ movement. I also practice in a more general way regarding mobs/manips. Maybe it was just lazyness on my part - but something didn't feel right to me either. I kinda felt I didn't always need all of the information I was getting (or thinking I was getting).

I mostly use Active Release Techniques during which I do get a lot of information which helps me determine where to manip etc.

Very interesting discussion!

[Dan Pinto]

Can we get past the naming ERS, FRS, etc - can we talk about treatment? EBP is about getting away from the how does it work and asking "does it work?" Should we care that MET was based on Fryette's law? Jull et al published a study in which she and her fellow researchers used manual therapy (inlcluding MET) in the cervical spine in an effort to treat patients who suffered headaches. Now we have evidence that manual therapy is useful in decreasing cervicogenic and migraine headaches. The naming allows a construct, perhaps we could use facet closing/ opening or we could say this isn't moving so I'm going to move it with the help of a muscle contraction. Whatever you want to say, there is some preliminary research out there showing that the use of MET has some benefit in the cervical spine patient. I think there is also a study showing benefit in the lumbar spine. I will get references but for now I'ld like to say, let's not throw the baby out with the bath water as we pursue EBP. We should study how we treat and see if it works.

[livaCauff]

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I wish you health!

[orem chiropractor]

I really appreciate you.You have a good insight about your topic.Thanks for sharing.