Manual Therapy (Part 1/3): What we are -NOT- doing

Have you had your back cracked by a Chiro, PT, or DO? Had a massage? Undergone acupuncture? These interventions are wildly popular and it makes sense – the interventions are satisfying for both the practitioner and patient. The practitioner can utilize a cool, fancy treatment and the client or patient theoretically walks out feeling better. This is a win-win, right?

It depends…

On the theoretical framework underlying their application. These interventions have traditionally been applied with a goal of correcting some micro tissue or joint level dysfunction. The dysfunction is often seen as the source of the patient’s problem (often pain — which we know isn’t accurate  *see here*.) Spinal manipulation was applied to re-position “out of place” or “subluxed” vertebra. Massage to break up fascial adhesions or muscle trigger points. Acupuncture (and it’s variants) have a variety of proposed mechanisms from releasing trigger points to altering energy flow. Are you a practitioner practicing and establishing treatment plans guided by this kind of framework? Are you a patient paying a professional to have these perceived dysfunctions, like an “out of place” vertebra, fixed? If so… it’s time to re-assess

The traditional view of manual therapy is outdated

At the heart of these explanatory models is the idea that practitioners can use their hands to alter the tissue or joint interface. As a layman observing spinal manipulation (back cracking) it may make sense. However, this idea doesn’t hold up. Chaudhry in 2008 examined the force required to deform fascia (essentially change connective tissue – think similar to ligaments) and found it requires 9075 newtons of force to deform the fascia lata by… just 1%.¹  Unless we’re talking about the big green guy running around with the Avengers, no practitioner can generate that amount of force. So, we as practitioners cannot produce true, mechanical and physical change to the tissue. However, even if we throw that article out and say we can the traditional view would still be outdated because…

We can’t specifically isolate force to spinal segments or micro regions

These explanatory models also rely on the idea that practitioners can apply force and generate motion in a very specific, targeted way. It makes sense — we would have to be able to do so if we are going to isolate and move a specific “out of place” vertebra back into alignment or “release” a specific spot of muscle or fascial restriction. But guess what? We as practitioners are not that specific. Kulig in 2004 found force applied to any lumbar vertebra resulted in motion at all vertebra in the lumbar spine.² Similarly, Lee in 2005 found the same pattern in the cervical spine.³

But that’s mobilizations! The surrounding segments aren’t locked out like with manipulations!

I can see this argument — manipulative techniques were designed to be more specific. But… our specificity with manipulations is also lacking. Cavitations (the ‘pop”) are not isolated to either the specific vertebra or even the side being targeted.^4,5 Ross in 2004 examined cavitation locations with thoracic and lumbar manipulations and found more than half of the cavitations did not occur at the target segment.⁴ This means practitioners were less than 50% accurate— the average error was more than 1 vertebra away in the lumbar spine (not so hot considering there are only 5 lumbar vertebra total.)⁴ Dunning in 2013 examined cavitation location in the cervical spine and found similar trends.⁵ Dunning found cavitations occurred on the opposite side just as often as they did on the side being targeted and most frequently happened on both sides. So, even those techniques intended to be specific don’t appear to be.

But maybe the practitioners in the studies just aren’t as good as you, right?

Maybe you are a manual therapy or manipulative god and have perfected your technique to a degree nobody else has – I can’t say that isn’t the case. However, even if we assume that we can generate sufficient force to make plastic changes -and- direct that force in a specific manner we still run into problems because…

We can’t reliably identify where we are anatomically

Before we can say we are directing force in a specific manner we need to be able to identify the vertebra or area of interest. However, we can’t even do that! Quite a few studies, including systematic reviews, are published examining the inter-rater reliability of landmark palpation like the vertebra or PSIS.^6,7,8 Studies have also been published examining trigger point identification.^9,10 Inter-rater reliability essentially looks at how much consistency or agreement there is between two or more practitioners. In general, the inter-rater reliability for landmark identification is horrendous! This means practitioners cannot consistently identify and agree where a certain vertebra or landmark is located on a person. For some numbers — from a brief skim spinal palpation appears to have a Cohens of ~0.02-0.40 meaning essentially only 2-40% of landmark identification agreement can be explained by more then random chance. If practitioners cannot consistently identify where a specific vertebra or trigger point is then we cannot say we are moving that vertebra into alignment and cannot say we are inserting a needle into or releasing a trigger point. However, even if we could…

We cannot reliably identify joint motion restrictions

These manual techniques were traditionally applied with the goal of correcting a perceived restriction or dysfunction. Even if we -could- identify where we are anatomically -and- isolate force to the target -and- generate enough force to make a tissue change it would all be useless if we can’t identify the thing we are trying to correct in the first place. I bet you know what I’m about to say now — we can’t! The restriction most commonly assessed in my own profession is hypo- vs. hypermobility at a joint or the spine. However, the inter-rater reliability of assessing passive joint motion is, you guessed it, not hot. Practitioners don’t consistently agree on the perceived degree of, or even if a restriction is present.^6,7,11 If we can’t even reliably identify the proposed dysfunctions we certainly can’t treat them.

Quick Recap:

• We can’t produce enough force to make true, physical change to the tissue or joint interface (so we can’t move or release anything)
• We can’t direct and isolate force on the micro level to a specific vertebra (so we can’t specifically move anything)
• We can’t reliably palpate and identify bony structures like vertebra or specific parts of bones (so we can’t identify a specific, micro region to move)
• We can’t reliably palpate and identify the location of trigger points (so we can’t say we are releasing or needling them)
• We can’t reliably identify restrictions in joint motion (so we can’t decide if there is a dysfunction or restriction present)

Putting all of these things together… I contend we need to throw out the traditional, bio-mechanical and micro-focused explanatory model of manual therapy.

 

Are you saying manual therapy is useless and we aren’t doing anything?

Not at all! We just need to re-frame the way we see and utilize these techniques to better align with contemporary knowledge. I’ll be expanding on this in part II and III of this series
(Update: Click *here for part 2 on what we are doing* and *here for part 3 on my perspective on the clinical application of all this*)

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Thanks for reading,

~Adam

 

References:

1. Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, Findley T. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008;108(8):379-90. (https://www.ncbi.nlm.nih.gov/pubmed/18723456)
2. Kulig K, Landel R, Powers CM. Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization. J Orthop Sports Phys Ther. 2004;34(2):57-64. (https://www.ncbi.nlm.nih.gov/pubmed/15029938)
3. Lee RY, Mcgregor AH, Bull AM, Wragg P. Dynamic response of the cervical spine to posteroanterior mobilisation. Clin Biomech (Bristol, Avon). 2005;20(2):228-31. (https://www.ncbi.nlm.nih.gov/pubmed/15621330)
4. Ross JK, Bereznick DE, Mcgill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific?. Spine. 2004;29(13):1452-7. (https://www.ncbi.nlm.nih.gov/pubmed/15223938)
5. Dunning J, Mourad F, Barbero M, Leoni D, Cescon C, Butts R. Bilateral and multiple cavitation sounds during upper cervical thrust manipulation. BMC Musculoskeletal Disorders. 2013;14:24. doi:10.1186/1471-2474-14-24. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565891/)
6. Van trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Inter-examiner reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Man Ther. 2005;10(4):256-69. (https://www.ncbi.nlm.nih.gov/pubmed/15994114)
7. Jill Binkley, Paul W Stratford, Caroline Gill; Interrater Reliability of Lumbar Accessory Motion Mobility Testing, Physical Therapy, Volume 75, Issue 9, 1 September 1995, Pages 786–792,
8. Cooperstein, Robert & Hickey, Michael. (2016). The reliability of palpating the posterior superior iliac spine: A systematic review. The Journal of the Canadian Chiropractic Association. 60. 36-46. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807681/)
9. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil. 2008;89(6):1169-76. (https://www.ncbi.nlm.nih.gov/pubmed/18503816)
10. Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain. 2009;25(1):80-9. (https://www.ncbi.nlm.nih.gov/pubmed/19158550)
11. Brismée JM, Gipson D, Ivie D, et al. Interrater reliability of a passive physiological intervertebral motion test in the mid-thoracic spine. J Manipulative Physiol Ther. 2006;29(5):368-73. (https://www.ncbi.nlm.nih.gov/pubmed/16762664)