Shane L. Koppenhave
Manual Therapy
Received 13 November 2013; received in revised form 27 May 2014; accepted 3 June 2014. published online 24 June 2014.
Corrected Proof
Abstract
Assessment of spinal stiffness is widely used by manual therapy practitioners as a part of clinical diagnosis and treatment selection. Although studies have commonly found poor reliability of such procedures, conflicting evidence suggests that assessment of spinal stiffness may help predict response to specific treatments. The current study evaluated the criterion validity of manual assessments of spinal stiffness by comparing them to indentation measurements in patients with low back pain (LBP). As part of a standard examination, an experienced clinician assessed passive accessory spinal stiffness of the L3 vertebrae using posterior to anterior (PA) force on the spinous process of L3 in 50 subjects (54% female, mean (SD) age = 33.0 (12.8) years, BMI = 27.0 (6.0) kg/m2) with LBP. A criterion measure of spinal stiffness was performed using mechanized indentation by a blinded second examiner. Results indicated that manual assessments were uncorrelated to criterion measures of stiffness (spearman rho = 0.06, p = 0.67). Similarly, sensitivity and specificity estimates of judgments of hypomobility were low (0.20–0.45) and likelihood ratios were generally not statistically significant. Sensitivity and specificity of judgments of hypermobility were not calculated due to limited prevalence. Additional analysis found that BMI explained 32% of the variance in the criterion measure of stiffness, yet failed to improve the relationship between assessments. Additional studies should investigate whether manual assessment of stiffness relates to other clinical and biomechanical constructs, such as symptom reproduction, angular rotation, quality of motion, or end feel.
FaceBook Discussion
Stephen PerleChiropractic Research Alliance
Jul 1 ·
Redirecting
View previous comments…
i have also done this with patients….I go through and do my analysis on existing patient and come up with how I think they are progressing….
Stephen and Greg, I thought for a minute that your families may have been vacationing together until I read you are in different towns.
Last one for now…I found that you don’t ask “how are you doing today” because they often will respond differently then if you ask “how have you been doing since I last saw you”. (Today may be a crappy day but the week prior was awesome). Point is, clinical assessment is very tricky which is why we look at controlled research which attempts to account for some of these variables. Is it sterile, yes, but that is one of its advantages and one of its disadvantages.
“Michael so you use an unreliable procedure to correct a pathology which a lot of evidence says is not the mechanism behind manipulation and you say this all seems reasonable.”So let’s inform all DC’s that Dr Stephen Perle, with certainty, declares that motion palpation assessments for articular fixations are unreliable so we should all stop doing them, and evidence shows that patients’ pain does not improve because of manipulation, so we may as well stop doing them too.Stephen what procedure do you use? You haven’t answered yet, except to name things that don’t have validity, such as articular fixation assessment, and it sounds like manipulation as well, so I presume you don’t do either of those – is that right?
So how do you assess your patients? What treatments do you provide? What are you providing treatment for?
The image is from Haavik Mar 2014. If we now know that spinal joint position errors (JPE or “subluxations”)
Excerpt of the abstract: “eye movements…hol
the eyes…the chiropractic window to the spine
Michael you are a master at illogical leaps. Saying that we have poor evidence that A particular assessment is valid or that our theory about why an intervention is effective doesn’t mean that there aren’t other assessments that have better evidence or that a treatment whose mechanism is as yet unexplained isn’t effective.We do not have to know anything about why SMT is effective in order to use it. I think only our profession’a poor self esteem leads us to pontificate on what SMT does. Patients don’t care. They just want to know if you think it will help. A few want greater depth and those one can point to current literature and note it is a area of active research. Keep in mind that aspirin was clinically effective from the time of its syntheses at Bayer in 1897 without Vane’s 1971 discovery of COX inhibition.So why would you think I don’t use manipulation? Where did I ever say that?
I use on patients and teach manipulation both spine and extremities, different soft tissue and rehab procedures including but not limited to MDT ((McKenzie) and neurodynamics (Butler). Basically conservative mgt of MSK conditions. I just don’t tell people theory as if it is fact.
IF this is a research group then we need to be a tad less rigid in our thinking and live with the equivocal nature of our understanding. Learn to accommodate our lack of knowledge while striving to fill those gaps. As Karal Lewit, MD once wrote, “we work at the acceptable level of uncertainty.” And C.O. Watkins, D.C. Warned us years ago, “Resolve to be bold in what we hypothesize but cautious and humble in what we claim.’
Speaking of illogical leaps, you said: “Michael so you use an unreliable procedure [palpating for articular fixation] to correct a pathology which a lot of evidence says is not the mechanism behind manipulation and you say this all seems reasonable.”Did I miss understand what you are saying, because it sounds like you said that articular fixation palpation is unreliable, and providing manipulation is not the mechanism that corrects the articular fixation and consequent nerve irritation?I appreciate you stating that you do provide manipulation, but I’m curious what reliable procedure you use to assess the need to provide it if, and how you believe the manipulation that you provide is affecting the patient’s pathology?
ps we can discuss without the ad hominem attacks – telling me “you are a master at illogical leaps”
Here’s another thing I don’t understand and maybe you can clarify it.I like what you said: “IF this is a research group then we need to be a tad less rigid in our thinking and live with the equivocal nature of our understanding. Learn to accommodate our lack of knowledge while striving to fill those gaps. As Karal Lewit, MD once wrote, “we work at the acceptable level of uncertainty.””But the headline of your post says, “I think that this is another of the nails in the coffin of saying that we are feeling for joint mobility.”
That statement implies that the case is closed (or coffin) and nailed tight – yet you also say that we need to be less rigid in our thinking and live with the equivocal (ambiguous) nature of our understanding. These statements seem completely contradictory to one another.
I think what this thread has demonstrated quite nicely is that eventhough research is essential it too has its limitations. Evidence Based chiropractors seem to hold the ‘moral high ground’ often looking down on other chiropractors who also include other aspects of the chiropractic story as part of their motivation to be a chiropractor. So it seems this superior attitude might not be based on the rock hard foundations that they liked to believe…..in other words they may be as ‘off course’ as the chiropractors they like to ridicule.
Eugen Roth, I would argue that a true evidence based chiro would take into account the “other aspects of the chiropractic story”. Dale mentioned earlier evidence based vs research based…two very different ideas.I don’t think anyone here is arguing a “research based” approach. We’ve all agreed on two separate threads that practitioner experience is incorporated into the 3 pillars of EBM…this 3rd ‘do over’ hasn’t seemed to make a big difference however.
Actually, nobody in the Chiro profession is “looking down” on anyone when it comes to research. In fact, the collective “we” is/are trying to “pull us all up”, and the profession as well, via high quality research.
That is the overarching goal of this group here on Facebook!
When a profession was/is built upon experimenting on patients as they walk through the clinic doors one can expect some resistance to more formal research especially when it doesn’t confer with perceived clinical outcomes. Many chiros attribute much to the subluxation and built a whole profession on its nastiness and the glories of its correction. Some is valid, some is not…research helps us find the dividing line. Cognitive dissonance occurs when a doc finds himself on what is perceived as the wrong side of the line. We need to be flexible and open minded, not only as clinicians but also as researchers, melding the findings from both on the search for truth.
The trouble is that most of us (no doubt myself included) look for evidence to support our beliefs. Sometimes if there is compelling evidence we might change our position……b
I look for evidence to challenge my beliefs, because, darn it, I may just be wrong
Maybe we look for evidence to confirm our beliefs subconsciously.
The criterion measure itself seems suspect. It would be possible to do flouroscopic measures of intersegmental motion while the indenter ramped up force, so a measure would then be of compliance as motion divided by applied force. As it is, the large contribution of adiposity to indenter measurements makes the readings quite remote from the quantity allegedly being measured.
Michael A Koplen, you never did answer my question regarding the % of the “failed everywhere else” cases did NOT get the results they were looking for in your office?
It’s part of our nature to look for evidence for confirmation of our beliefs. I try to combat that by looking for truth regardless where it leads. If truth leads me out of chiropractic then sobeit.
Most health care disciplines are not burdened with the issue of their practitioners wanting or needing to be proven right.
Michael A Koplen I saw were you stated that 95% of your patients have already been to the MD, PT and have failed to resolve their problems. They come to you and you are very successful in treating them. I believe you. Also some of the highest evidence that we have for SMT therapy is for the treatment of chronic neck and back pain. I believe that the research validates your treatments to your patients. I also believe that with a high level of confidence we can tell our patients with chronic neck and back pain yes we can help you. Now how it works I am really not sure, or why it works, but again I know that I can help patients with those conditions.
Craig Benton…….just playing devil’s advocate here……the likes of Prof Ernst and other sceptics claim there is not a shred of evidence that chiropractic is effective for treating anything. He claims the only ‘results’ that chiropractic care gets is as a result of placebo. He claims it is all woo-woo, make believe, psuedo-science and a con. He and his side kick, Blue Wode, site plenty of research to substantiate their claims that not only is chiropractic totally useless but extremely dangerous causing the vertebral artery to disintegrate and causes strokes. So Prof Ernst & co has plenty of evidence to support their postion. So now who does the public believe? Which research do they believe?
“Michael A Koplen, you never did answer my question regarding the % of the “failed everywhere else” cases did NOT get the results they were looking for in your office?”Simple – most get some relief but of course a certain percentage do not get full relief due to many factors we’re all aware of, such as lack of commitment or $ to continue care, conditions that are so far advanced (DJD) that mild temporary relief is all I can offer them, terrible lifestyle factors (obesity, no exercise), some need extensive exercise and soft tissue manual therapy treatments to support the work I do. Et cetera. The biggest modern challenge are the computer people who commute an hour then sit for 9 – I’m really clear with them that they will get limited results – ten steps forward then 9 backwards from sitting all day. What’s important is being clear with patients about expectations.My turn – my question was never answered. It addresses the hypocrisy going on in this topic. I’ll repeat it:
Stephen said: “Michael so you use an unreliable procedure [palpating for articular fixation] to correct a pathology which a lot of evidence says is not the mechanism behind manipulation and you say this all seems reasonable.”
He’s saying that articular fixation palpation is unreliable, and providing manipulation is not the mechanism that corrects the articular fixation and consequent nerve irritation.
I asked, “I appreciate you stating that you do provide manipulation, but I’m curious what reliable procedure you use to assess the need to provide it if the nail has been shut on the coffin of relying on articular fixation? And how you believe the manipulation that you provide is affecting the patient’s pathology, if it’s not the mechanism that affects the pathology?
You said: “IF this is a research group then we need to be a tad less rigid in our thinking and live with the equivocal nature of our understanding. Learn to accommodate our lack of knowledge while striving to fill those gaps. As Karal Lewit, MD once wrote, “we work at the acceptable level of uncertainty.””
But the headline of your post says, “I think that this is another of the nails in the coffin of saying that we are feeling for joint mobility.”
That statement implies that the case is closed (or coffin) and nailed tight – that palpating for articular fixation is useless – yet you also say that we need to be less rigid in our thinking and live with the equivocal (ambiguous) nature of our understanding. These statements seem completely contradictory to one another.
In summary, put articular fixation and manipulation in the coffin, yet you and the rest of us seem to use it, yet you say it’s unreliable….. what a spin…..
Eugen Roth DC: There’a most always a pattern that when a study or two are being used to create a lie, those forming the lie use extreme, hyperbolic language, superlatives – “not a shred of evidence”; “Put a nail in the coffin of this belief”; “To palpate for ___ is a compete waste of time”; “There is absolutely no indication that supports”I confronted Paul Ingraham on this (medical science writer basically disses chiropractic), and he actually surprised me in saying that the only way to get readers’ attention and get them engaged is to use a shock headline even knowing it’s not totally true, then write a slanted article that generates controversy.I confronted that the research wants to make things out to be right or wrong, when so many variables exist (first two pillars of EBP) that reality is far greater than what the research shows, and outcomes depend on MANY circumstances.
Here’s a brief quote that he said from our dialogue: “I go out of my way to avoid qualifying everything. It’s tedious and unnecessary. Everyone already knows that “it depends,” always. It’s health care!”
Sigh, very simple, if you think a variable, or a combination of, will significantly affect outcomes then provide evidence of such. I know chiros who claim that the adjusting table has to be pointed with the head to the north and we need to walk clockwise around the table otherwise it messes with the patients polarity and that will affect our diagnostics and treatments. So shall we conclude any research that doesn’t include those variables is invalid….of course not, not without valid evidence. So you can say you and your patients are so unique that research can’t capture that uniqueness, then I say…where is your evidence to substantiate that claim?
Eugene Roth I would say that Prof Ernst and others have not read the evidence. Every major medical, not chiropractic, guideline recommends SMT for acute, subacute, and chronic lower back and neck pain. Heck even the surgeons guidelines for surgery for lumbar disc recommend a trial of manipulation is warranted prior to surgery. Also in my looking at the literature the only other treatment that had a higher rate of evidence than SMT for back pain was for a patient to take Tylenol instead of a NSAID if they have stomach problems. As for the issue of cervical SMT and stroke the largest study to date has been the Bone and Joint Decade Task Force which found that there was no increased risk of VBA comparing chiropractic care to primary care. Also I believe that Prof Ernst pays more in car insurance each month than most DCs pay for malpractice because the risk is so low. And lastly to Prof Ernst “you just can’t fix stupid.”
I would be interested In what Ernst thinks of DO and PT doing SMT, is his beef with the procedure or the profession?