Over a year ago, Dr. Stanley Paris gave a controversial speech regarding the past and future of manual and manipulative therapy at the American Academy of Orthopedic Manipulative Physical Therapist conference. A paper, which evolved from his speech,can be read in its entirety here and addresses his concern that much of the current research on Manual and Manipulative Therapy is largely on non-specific regional techniques and their effects rather than focusing on pathoanatomical or mechanical considerations. To him, this is concerning.
Now don’t get me wrong, Dr. Paris has done a considerable amount of work to encourage and promote the practice of manual therapy in Physical Therapy practice. For this we are indebted. But concepts and theoretical constructs evolve with time and research. In this post, I want to make the argument that while Manual Therapy is very, very, very important, the specificity likely does not matter. I am going to make this argument by addressing some of the “concepts” and “concerns” which were proposed by Dr. Paris.
Concept 1: “Manipulation is for stiff joint, stabilization is for unstable joints and education is for all.”
Dr. Paris makes the claim, “I consider the spinal facet joint to be the principle source of spinal pain followed by myofascial and sacroiliac dysfunctions with the clinical disc the result of the preceding dysfunctions. Thus it could be said that the clinical disc is the denial or failure of precise manipulative therapy and management.”
This first concept demonstrates a commonly held belief that manipulation has a direct biomechanical effect in assisting a joint in movement (research has demonstrated that manual therapists accept the face validity of manual physical assessment of segmental motion to a great extent, with few questioning or voicing skepticism.1) Fritz et al. performed a study on the assessment of “stiffness” following manipulation and did find evidence to support that the effects of lumbar spinal manipulation are multifactorial and there appears to be a reduction in “stiffness”.2 Another article, which examined the “stiffness” of the thoracic spine following spinal manipulation, found no significant change.3 This concept has been a widely held “truth” but the current evidence is inconclusive.
The supporting claim further demonstrates a void of the modern understanding of pain. There is no such thing as “Spinal Pain”. Pain is Pain. We may suspect that a spinal facet joint could be providing an input to the body-self neuromatrix, but how can we ignore all of the levels of tissue which we “push” when attempting to assess a spinal facet joint? Should we be ignoring the potential effects on the skin? Or the innervated superficial or deep muscles? Or fascia? How can we simply blame the joint? I believe this is faulty logic which we must move past…
In addition, I thought that the work by Laslett4 dispelled the myths of our ability to detect and classify sacroiliac joint dysfunctions? And the systematic review by Lucas et al. addressed the lack of reliability of myofascial trigger point detection. What else do we need to do to move forward?
Concept 2: “Effects of Manipulation: Psychological, Mechanical, Neurophysiological and Biomechanical”.
I don’t have much arguement with Paris here. He addresses placebo, expectations, etc. BUT when discussing the neurophysiological effects, he places a large emphasis on the Gate Control Theory vs. the Neuromatrix. This may be leading to the faulty logic in concept 1. His understanding of pain appears to be “bottom-up” vs. “top-down”. The folks over at Body in Mind have supplied us with an over-whelming amount of literature to support the latter.
Concept 3: “Evidence Based Practice vs. Evidence Informed Practice”.
Paris is a fan of “informed” practice because “there is simply not enough solid evidence of a reliable nature on which to “base” practice today”. He discusses the “three legged stool” put forward by Sacket which states that Evidence Based Practice is a combination of Clinician Expertise, Patients Culture (what they accept works best) and Literature.
Despite his argument, there is a growing amount of reliable literature to utilize in our evidence based practice of manual therapy for the treatment of back pain. Since Paris’s speech, Cook et al have published several articles which have assessed the effects of mobilization and manipulation in individuals with mechanical low back pain. The articles maintained external validity while taking into account patient expectations and clinician bias, and found a few important things. For example, A manual assessment, and a positive response from it, can be a prognostic indicator for a positive outcome (reduced pain and disability). In other words, there is a significant association of a positive within- and between session changes (pain and disability) in predicting a positive outcome from manual therapy.5 Another study from this group further supported these findings and found that mobilization and spinal manipulation were equally effective in the treatment of mechanical low back pain.6
Concern 1: “Evidence in Motion“.
He presents this group (Evidence in Motion; EIM) as one of two historical manual therapy groups (along with Cyriax) who disregard precision in manual therapy interventions. He considers this group to “focus on pain relief” as compared to his focus being on “normalizing arthrokinematics”. He further believes the techniques used by this group do not meet the current definition of manipulation: “A skilled passive movement to a joint and related tissues etc.“.
I am not quite sure how Paris could discuss the effects of manipulation being multi-factorial and then blast the EIM group for being too non-specific? Didn’t he state that effects of the techniques influence much more than just the joint? But then states his focus is on the joint?
EIM isn’t the only group producing literature supporting the non-specific effects of manipulation. As shown above, Cook et al. demonstrated that mobilization was just as effective as manipulation in the treatment of mechanical LBP. I argue that this group was targeted because they 1. are highly influential to many PTs 2. invalidate some of his thoughts and teachings 3. are one of the biggest threats to his residency and fellowship programs.
Concern 2: “Concerns over Image”.
He states that he is “hugely embarrased to see this picture (below) representing spinal manipulation published in a medical journal”. His arguement is that this does not appear “skilled”. He follows with the thought that the CPR paper, in which this was published, was a low level of research and that at an Oxford Debate, sponsored by the APTA, demonstrated that the number of those against the CPR’s beat those who were in support.
The article in which this image appeared was published in a high-impact journal (Annals of Internal Medicine). I can assure you that the peer-reviewed process was likely quite intensive. This image depicts the intervention as used by researchers involved with this study. I am not quite sure what he wants here. The intervention used was non-specific. That is what was depicted. I know he is not a fan of EIM’s face appearing alongside the term “manipulative therapy” , but this argument is a bit childish.
Concern 3: “Some published research is too basic.”
In this portion of the paper, he discusses a RCT which assessed the effects of manipulation for the thoracic spine, which has caused him “great concern and anxiety.”
While I agree that “quality” literature must be produced, this attack appears to only focus on the EIM group (he really does have some beef with you guys) and not on manual research as a whole. It appears to be driven on his disagreement about the specificity of manipulation. A systematic review published in BMC Medicine in 2010 examined if targeting manual therapy interventions improved outcomes in patients with non-specific low back pain. The authors concluded that the results of the studies included were too patchy, inconsistent and of too low power.7 So despite his disagreement, his view of specificity is not supported either. And in this case, we must revert to Occam’s Razor.
Concern 4: A paper published in Physical Therapy which concludes that “typical continuing education courses do not improve the overall outcomes for patients treated by therapists attending the course”.
Paris suspects this quote, which was included in the abstract, is misleading. You can go ahead and read his arguement on page 27. I do not know enough about this subject to comment but if the readers of this blog have an opinion or are familiar with research on this subject, please share.
Overall, Paris’s speech represents the current debate and evolution taking place in the field of manual therapy. It is difficult to let go of concepts and ideas that we identify ourselves with, but we must learn to move on.
What are your thoughts???
1. Abbott JH, Flynn TW, et al. Manual physical assessment of spinal segmental motion: intent and validity. Manual Therapy 2009; 14: 34-44.
2. Fritz JM, Koppenhaver SL, et al. Preliminary investigation of the mechanisms underlying the effects of manipulation: exploration of a multivariate model including spinal stiffness, multifidus recruitment, and clinical findings. Spine 2011; 36: 1772-1781.
3. Campbell BD, Snodgrass SJ. The effects of thoracic manipulation on posteroanterior spinal stiffness. JOSPT 2010; 40: 685-693.
4. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual tests and composites of tests. Manual Therapy. 2005: 10; 207-18.
5. Cook CE, Showalter C, et al. Can a within/between-session change in pain during reassessment predict outcome using a manual therapy intervention in patients with mechanical low back pain?Manual Therapy (2012), doi:10.1016/j.math.2012.02.020
6. Cook CE, Learman K, et al. Early use of thrust manipulation versus non-thrust manipulation: A randomized clinical trial. Manual Therapy (2012), doi: 10.1016/j.math.2012.08.005
7. Kent P, Mjosund HL, et al. Does targeting manual therap and/or exercise improve patient outcomes in nonspecific low back pain? A Systematic review. BMC Med (2010), doi:10.1186/1741-7015-8-22