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Why the Result is Most Important

9/9/2014

17 Comments

 
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Recently, The Manual Therapist wrote a blog post about what is most important when treating a patient: the what, the why, and the how. To relate it more directly, what you have refers to specific diagnoses. Why you have it refers to the theory of why the pathology occurred, i.e. movement impairment syndromes. The how refers to how we actually treat and assess. Much of medicine and physical therapy is often stuck in the "what" phase. We tend to assign diagnoses to tissue pathology and often look to treat what we believe is the source of the pain, not the original cause. Many physical therapists are moving towards the "why" mindset where we look at a more complete chain of the body to determine why our patients are in pain. This typically leads to a more well-rounded treatment approach. The "how" comes back to what we are actually doing and how we are treating our patients. I recommend reading the original post by Dr. E to get further clarification.

This post comes with good timing in the wake of Tiger Woods' "sacrum" comments. In case you missed it, Tiger Woods recently played in a golf tournament and had to withdraw, because he claimed his "sacrum went out." As a result, there was a backlash from much of the young PT community claiming how it was a horrible diagnosis, Woods' physical therapist had poor communication skills, etc. The discussion lead to many physical therapists and physical therapy students ranting about how the research for SIJ Dysfunction as a diagnosis is poorly supported based on higher level evidence (which is correct) and some even saying how the SIJ doesn't move at all. Based on these comments, it would appear many do not assess or treat the Sacroiliac Joint. While I may agree that we shouldn't worry about actual tissue diagnoses, I get frustrated by people's reluctance regarding any potential SIJ treatment given my personal clinical success. In the residency at Scottsdale Healthcare, we were taught various assessment and treatment techniques for the SIJ, but the distraction manipulation could be used as a "shotgun" approach and treat typically any form of SIJ dysfunction. In my limited experience, in the patients I feel would benefit from the manipulation, they tend to be 100% within just a few visits. Now a manipulation by itself is never the answer alone, but it can be an extremely useful tool. We need to build on preventing future recurrences of pain and teach our patients to maintain improvement independently. Some patient's arrive at clinic in excruciating pain and are nearly pain-free after manual treatment. A manipulation and mobilization are not the only potential treatment for what some would diagnose "SIJ Dysfunction." Repeated motions towards the directional preference may be appropriate as well. Basically, many of treatment techniques like these have theories to support them, but the evidence is not always as established. That doesn't mean successful treatment techniques should be discounted.

I again recognize our limited ability (and importance) of truly diagnosing what we think we see with the SIJ, but I must continue to stress the impact of when we assess, treat, and reassess. This is the importance of the how I discussed at the beginning. If the patient feels better immediately after a treatment technique, something I did had the desired effect! We currently are unable to be certain in knowing the exact mechanism our techniques have, but we should not ignore positive results. I have written extensively in the past about the problems with the studies regarding manual therapy, especially the SIJ, but that is not important in the end. What is important is that we find effective ways in getting our patients better as soon as possible. If that means doing a manipulation or mobilization where we think we are targeting the SIJ, then so be it. Do not let the limitations in higher level research prevent you from providing your patients with the most effective care.

-Chris

17 Comments
JeromeFrenchPT
9/9/2014 12:34:33 am

Hi Chris,
Did you read this great post from Peter O'Sullivan about Tiger's low back pain?
http://blogs.bmj.com/bjsm/2014/08/22/common-misconceptions-about-back-pain-in-sport-tiger-woods-case-brings-5-fundamental-questions-into-sharp-focus/

Reply
Tim Stevenson
9/9/2014 07:03:27 am

Chris,

Great post! I whole heartedly agree with your comments. I think this all boils down to PERSPECTIVE. I also still perform techniques directed at the SIJ and have favorable outcomes in doing so. Reading your post made me start to think though. I aiming treatment at the SIJ how sure are we that we are affecting the SIJ and that that is what is giving us the positive outcomes. In other words, could an SIJ distraction manipulation actually just be a high intensity afferent neural stimulation to the high density of neural structures found in the posterior pelvis region and not really be affecting the SI joint mobility/position at all?...

Reply
Chris
9/9/2014 08:32:57 am

Thanks for that link Jerome. Yes I read that piece awhile ago and really appreciate the review of some recent literature and multi - modal approaches. My fear with that type of dialogue however is that useful techniques such as manual therapy are being discouraged when they can help a patient lower year pain threshold and become more active for other parts of therapy.

Tim thanks for your comments. I completely agree. There is no way currently of knowing exactly what our manipulations may do. But the fact that they can work for the appropriate patient is extremely useful when combined with other treatments!

Reply
Steve
9/9/2014 09:24:11 pm

Lets be careful here. Will we accept any technique that appears to work? Is there not some level of evidence, research, and construct validity that must inform practice? Would you perform MFR, and Craniosacral techniques? Therapeutic touch?
RCT's that compare techniques using valid and reliable outcomes may be needed to get us to a place where we can say what "works" better.

Reply
Chris link
9/11/2014 02:17:08 pm

Thanks for your comments Steve. To answer your questions:

-Will I accept any technique that appears to work? Absolutely. My end goal is getting the patient better. That is it.

Is there not some level of evidence research and construct validity that must inform practice? Of course I will use EBP to guide my decision making, but I won't limit it to what a few higher level studies show or don't show. I am the first person to put down modalities, but if a patient tells me they get better with a specific one, you better believe I will use it initially (and educate the patient on the benefits of other treatment techniques and lack of support for something else). Let's discuss what many SIJ studies claim first: we cannot feel movement in the SIJ as clinicians reliably. The ability to palpate segmental mobility as a new grad versus a FAAOMPT is significantly different. What types of clinicians did the SIJ studies have performing the examinations? I'm not saying I fully believe we can quantify SIJ or segmental mobility testing, but it is something to consider when looking at a study.

-Would you perform MFR, Therapeutic Touch and Craniosacral techniques? If I were trained in them and knew appropriate patients for which the techniques would be successful, I would absolutely perform them. I am not trained in them, so I cannot tell much to the clinical effectiveness. Let me say it again, my goal is getting my patients better, and if I were to encounter a patient that thought something like Craniosacral therapy was what would get them better, I would incorporate it into my care.

I love the push for better EBP, but so much of it is behind actual clinical application consistently. If I have been performing IASTM on patients successfully improving their muscle function, pain and ROM, but there are no studies that show we can do it, should I just throw the technique out of the way?

Reply
Brian
9/9/2014 10:28:09 pm

Great post. Of all the manual techniques I use, mobilizations/manipulations to the SI jt produce the most significant rapid changes in pain. I like to test/retest supine to long sit and almost always see a dysfunctional position move to functional which almost always correlates with a moderate to large reduction in pain.

Reply
Steve
9/10/2014 02:11:04 am

There is absolutely no evidence for, or reports of validity and / or reliability whether inter or intra tester with the long sit test. It even suffers from a basic lack of content validity!
It is (IMO) outdated, subjective, and we as PT's should not be using it. I would be interested to know why people use it, if anyone does?

Reply
Chris link
9/11/2014 02:21:41 pm

If you are going to look at the research, there are actually several test clusters that utilize the Supine to Longsit Test, along with other movement based tests. They all tend to lack the reliability and validity that you suggest. The only study that has been promoted as valid showed a cluster of SIJ pain provocation tests, which has many faults IMO. There is a push for a combination of movement-based and pain provocation tests for a cluster, but it has not been met yet. I actually rarely incorporate these tests into my care. I base my examinations off the SFMA and repeated motions. I occasionally use a few SIJ tests to confirm suspicion as a cluster, but that's it.

JeromeFrenchPT
9/11/2014 05:35:25 pm

Steve don't forget that the placebo effect is a powerfool tool. Even if our goal is the EBP we sometimes have to play with the placebo effect. And i think placebo effect is EBP...because it works. It's all about how we explain things to patients and incorporate some placebo techniques which the patient (and the clinician) believe in and some more evidence techniques.
ps: It si hard for me to explain all my thoughts in english. So, I hope my post is understandable!

Reply
Steve
9/14/2014 12:46:06 pm

I very much appreciate the posts which followed mine. I agree research and EBP are behind what experienced clinicians do on a daily basis. BUT, we need to separate what works and what is equal to doing a random manual treatment.
The literature on SIJ mobility shows that experienced clinicians are worse when comparing intratester reliability. So experience actually makes one worse.
And I would NOT perform CS therapy of MFR on a patient and if I did I would have an ethical issue billing them. They do not work. They have been shown not to work. If the patient THINKS they work, then there is some FABQ issues and they will likely THINK other things work as well.
BTW--in what cluster is the long sit test included? That is a motion test, not a pain provocation test...

Reply
Chris link
9/15/2014 02:37:12 pm

There is a difference between experienced and highly trained, but I would love to read the studies that you are referring to. I know a lot of bad clinicians that have been practicing for 30+ years.

The cluster I was referring to only included pain provocation tests: compression, distraction, POSH, sacral thrust test (Gaenslen was thrown out as it was found it did not contribute at all the diagnostic accuracy). What I was referring to with the supine to longsit test, was that there are other clusters with poor diagnostic accuracy that include it, but there are proposals for a combination of movement-based tests with pain provocation. This has not actually been developed yet however.

Reply
JeromeFrenchPT
9/17/2014 12:08:58 am

In the Canadian Academy of Manipulative Physiotherapy fellowship courses i learned the use of four provocation test, distraction, compression, sacral thrust and P4 test. If, at least, two tests are positive maybe the SIJ is a part of the problem and need more assessment.
Also i found this in Manual Therapy
H.S. Robinson, J.I. Brox, R. Robinson, E. Bjelland, S. Solem, T. Telje

The reliability of selected motion and pain provocation tests for the sacroiliac joint

Man Ther, 12 (1) (2007), pp. 72–79
If you don't have access, i can mail it to you.

Steve
9/17/2014 04:44:28 am

Here are SOME:
Goode, et al JMMT 16,1, 2008, 25-38-------“Motion of the SIJ is limited to minute amounts of rotation and of translation suggesting that clinical methods utilizing palpation for diagnosing SIJ pathology may have limited clinical utility.”

Tullberg. Spine. Vol 23, #10, 1998

Paydar D. Thiel H. Gemmel H. Intra- and Interexaminer reliability of certain pelvic palpatory procedures and the sitting flexion test for sacroiliac joint mobility and dysfunction. Journal of the Neuromuscular System. 1994. Vol 2, No 2.

Herzog W. Read L. Conway P. Shaw L. McEwen M. Reliability of motion palpation procedures to detect sacroiliac joint fixations. Journal of Manipulative and Physiological Therapeutics. 1989. April. Vol12, No 2------“High expertise was associated with lower intraexaminer agreement scores than lower expertise.”

Reply
Chris link
9/17/2014 03:03:59 pm

-The movement in the SIJ is small yes, but insignificant? No.

-That systematic review's inclusion and exclusion criteria were basically non-existant. What that means is there could be a whole lot of poor studies in there.

-The study where "high expertise was associated with lower intra-examiner agreement scores than lower exertise"....the "experts" were just chiropractors (who says they are experts? it could be a new grad chiro!). And that whopping sample size of 11 clinicians with 10 patients was not very impressive either. If it were any smaller, it might have to be a case series haha I think I recall from stats classes that a sample size had to have at the very least have a population of 30 in order for it to have a chance to translate to the general population.

These are just a few grievances with these studies and why we must be so hesitant with what a study claims to report.

Reply
Steve
9/20/2014 08:43:08 am

Yes, I see your point. BUT, are there any studies, other than the general lumbosacral manip technique that show the effectiveness of SIJ assessment procedures?
Even if the validity and reliability are suspect, can you find anything that says that treating the SIJ specifically decreases pain and improves function...

Chris
9/21/2014 11:49:36 am

Yes, my clinical experience. As my post discussed, the evidence is limited. Just because there isn't a study that shows a technique or assessment method to support it, doesn't mean it should be thrown out the door. Test, treat, and retest. The outcome is most important. As evidence catches up to actual clinical practice, we can incorporate the findings more judiciously.

JeromeFrenchPT
10/7/2014 06:46:35 pm

Great post from Dr E about Non-specific Effects.
http://www.themanualtherapist.com/2014/10/thursday-thoughts-non-specific-effects.html

Reply



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