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Sorry Stanley…Not Quite Sure that Manual Therapy Specificity Matters

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

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20 replies »

  1. This is the comment I made when I first read this transcript last year:

    When critically analyzing Dr. Paris’s lecture in light of the current research investigating manual therapy mechanisms and predictors of response to manual therapy in addition to recent pain neuroscience and the psychology of the pain experience, I can not help but be perplexed. I find HIS view of manipulation specifically, and manual therapy generally to be out of step with the current research as well as limiting and short sighted. As much as I respected and value his prestige and past contributions to the field of PT, I think his perspective and thought processes in this lecture are way off base. When taken into account with his obvious bias given his CE and university empire ($$$), much of his comments cary little weight IMO, and even smaller literature support.

  2. Joe, I think what you saw here was Stan’s last bit of defense. If he’d been speaking to a group as unsophisticated as we found in the last century no one would have said a thing in opposition. His presence simply doesn’t carry the weight it once did.

    I would know.

  3. Wel thought out and written response to Dr. Paris’ paper. Sadly, the evidence regarding non specificity of manual therapy and lack of reliability of a palpatory based clinical decision making model is over a decade old now. When will main stream physio transition to an approach that is more in line with the evidence?

  4. Just because there are a studies indicating that the “lumbo-sacral general” manipulation is effective, does not mean that it is always more effective. My thought is that since there are 5 lumbar vertebrae and 12 thoracic you can get “lucky” in the lumbar spine. We also should try to be gentle and specific in the cervical spine, given the records of other professions.
    Lastly, since we do not have a reliable and valid means to measure PA stiffness, maybe we should be doing RCT’s to see what methods work better. I also agree that from a pain perspective the research has not yet started to be understood clinically.

  5. Steve says:
    “My thought is that since there are 5 lumbar vertebrae and 12 thoracic you can get “lucky” in the lumbar spine.”
    Where’s the evidence that specific techniques are more effective in the thoracic spine?

    “…since we do not have a reliable and valid means to measure PA stiffness, maybe we should be doing RCT’s to see what methods work better.”
    This sounds tautalogical. If segmental mobility measures are unreliable, then that casts doubt on their validity. If these tests lack validity, then that casts additional doubt on the notion of applying specific mobilization/manipulation techniques to begin with. How many studies do we devote precious research dollars to in an effort to find this “holy grail” dysfunctional spinal segment? Why is that in health care, unlike every other industry, there’s an attitude that resources are unlimited?

    “I also agree that from a pain perspective the research has not yet started to be understood clinically.”
    There’s lots of stuff we DO know about persistent pain and how to apply this knowledge clinically. The problem is that we’re not teaching it to our students nor are we applying it in the clinic. We seem to prefer the path of empericism- if it works and we can charge for it, then just keep doing it.

    • You make some great points, Joe. Point #4 is (I think) alluding to a study that found that over 75% of healthcare professionals practice mainly what they learned in school regardless of graduation date. In order for continuing education to have any lasting impact, most people need multiple review sessions and the opportunity to work under a similarly trained mentor. Alas I cannot find the reference right now, but I’ll post the link ASAP. But this is not the structure of “typical” continuing education courses. As you mentioned in the last lines, it is hard to let go of old ideas and the primacy effect is at work: what is learned first is learned best.

      I think people offering the “typical” course might proclaim this as misleading so as not to lose prospective students.

      John, I think you’re absolutely right that our research resources should be carefully allocated. And many students are not being taught recent evidence on pain neurophysiology because of our strong biases toward tradition. But I have to argue with your line of reasoning regarding the reliability and validity of joint mobility measurement. Validity and reliability are completely independent. The notion that joints can be hyper- or hypomobile is completely valid. Our ability to measure it might be valid in that we are applying a test that could conceivably work. The reliability of my assessments agreeing with each other versus someone else’s assessment would not confirm or deny the validity necessarily (even if we had a more objective measure than the 0-6 number judgements that I learned in school – a 3 is by no means half as mobile as a 6). Just because we can identify the intended target doesn’t mean we can hit the bullseye with any accuracy. But until we develop an objective, interval measurement scale for joint mobility most of our studies on joint mobilization or manipulation will be completely worthless and segmental specificity will not matter. Perhaps the KT-1000 arthrometer would work with some modifications.

  6. Personally I do use manipulation as part of treatment. But when we were at training college, we used to quote Maslow who said, “I suppose if the only tool you have is a hammer, it’s tempting to treat everything like a nail.”

  7. Great to bring this to attention Joe! I had read is piece by Dr. Stanley awhile back so thanks for bringing it back up. I have not, nor plan to take any of St. Augustine’s courses as I feel it is money driven but I will say Dr. Stanley was a pioneer in our field and will not be treating the way we do now without his insight. Just like all great thinkers, philosophies can be wrong. We have since moved on with new evidence arising (at least some of us). This has been the case thru history. I would imagine it being difficult to change your teachings after all these years, so no surprise he is defended his approach. You are doing a great job, as well as all other forward thinkers in PT in current time, to challenge these notions and make our profession push on.

    Harrison
    @intouchpt

  8. Joe,
    Great post! I couldn’t agree more in terms of specificity and manual/manipulative therapy… There have been a few high quality studies looking into the our ability target a specific segment. Lets just say we’re not as good as Mr. Paris believes. the effects of manual therapy are multifactorial, as you stated, and to infer that the effects are primarily biomechanical in nature and that the therapist can impose targeted, specific changes seems a little absurd. There’s no questioning the benefit of manual therapy techniques, but the mechanism continues to be poorly understood.

    Lee et al, 2004 (http://www.clinbiomech.com/article/S0268-0033(04)00235-9/abstract)
    Kulig et al, 2004 (http://www.ncbi.nlm.nih.gov/pubmed/15029938)
    Kulig et al, 2005 (http://www.ncbi.nlm.nih.gov/pubmed/15901121)

  9. I would like to suggest our reason for treating a segmental dysfunction (specific) versus general is based on examination procedures. The debate to me is between my perception of treating a functional loss of mobility versus the patients report of their pain. If Paris treats functional loss of joint mobility and not pain, then there is no attempt to modulate, desensitize, reinhibit or “sculpt” the protected movement pattern. So in essence, treating what appears to be merely joint signs and not reproducing or addressing the painful guarded or compensated movement would be non-specific to the patient but specific to the examiner. That’s your intra. If you reproduce the patients painful movement pattern and provide a graded exposure approach or modulate, that then becomes valid and specific to the patient, who cares about the therapist? The problem is between examination procedure and the critical reasoning… Critical reasoning should not be solely based on a RCT nor on expert opinion… The truth is as elusive as the Tao… If spoken, you have no idea. The patient needs to tell you what the problem is and you need to get them better. If 80% of medicine is an art… What’s that make PT? take a hint from history… The evidence I use today will be dated in 5 years and I will jump onto the newest evidence until that ultimately becomes dated. Now let me practice for 50 years and i wonder what would come out of my mouth?

  10. Dear Dr Stanley Paris,
    back pain in the USA is a great problem.

    I suggest we should make mutual business in the USA. Or you might be famous as a sponsor of a new effective method for back pain treatment. If not interested, you may forward this message to any US entrepreneur, like Mark Cuban.

    I am an old Russian retired medical doctor, not even good at computer. It is absolutely not possible for me to go through any grant application procedure and I am not in the USA. I only hope to find a person, or a company, in the USA, interested to become my reliable partner- investor or investigator in mutual business.

    My device to treat low back pain (LBP) is patented in the UK. Method is pending in the USA. It is an auto-traction method that I, a medical doctor, developed for myself. It works in upright vertical position, has only one contra-indication, is cost-effective (as all other treatments are abandoned) and may help keep LBP patients capable to work. I am now assessing interest in this device (method) and would like to know whether you would be interested to take this project forward into medical practice.
    As a medical doctor using this method to treat my low back pain I can claim that:
    1. This method kept me, a young LBP patient, capable to work.
    2. It was cost-effective as all the other treatments were abandoned.
    3. It keeps me, now an old LBP patient, from becoming a back cripple (unfortunately, there is no absolute cure for herniated disc LBP).

    There are some other advantages of this method that require further investigation:
    1. Using this method by patients with simple backache might prevent subsequent disc injury that is highly possible in this group.
    2. This method may be a helpful and cost-effective treatment for patients with neck pain.
    3. This method may be a helpful and cost-effective treatment for patients with ankylosing spondylitis.
    4. It may be reasonable to use this method for preventative measures by people in groups of risk: sedentary mode of life, drivers, porters, weight-lifters, oarsmen and some other sportsmen or parachute jumpers.
    5. This method can be used for spine curvature correction.
    6. Regular use of this method might prevent development of osteoporosis in the bones of spine, upper limbs and shoulder girdle (it is a positive side effect).
    7. This method might prevent periodontal disorders providing the gums’ massage (it is another positive side effect of this method).

    On the figure attached: 1 – frame, 2 – head back pillow (chin support is not visible on this figure), 3 –over-door chin-up bar (available in a sports shop). All details if you are interested and, if not interested, please forward this message to an appropriate person or company.
    My email address: ifedyaev@yahoo.co.uk
    PS: This is absolutely new and effective method – it will reduce the number of hospital admissions, it will create jobs in the USA, it will increase export, it will be famous all over the world.
    Kind regards
    Ivan

  11. Great post Joe, I really enjoyed it and look forward to learning more when I begin fellowship soon, I decided to go the Timko tract vs. St Augustine tract; for some of the exact reasons you’ve mentioned above. Some of what you mentioned above makes me think of a recent article I read (I’m looking for the exact reference and when I find it I’ll include it below) where Dunning attempted to record the amount of cavitations noted with cervical manipulation. I believe what he found is that there were 3.7 cavitations, indicating that multiple levels were being targeted vs. specific segments.

    What I get confused about is if the patient is improving and we are able to get them better via mobilizations or manipulation, does it really matter if we are targeting specific joints or not. I also think he’s definitely missing the “top to bottom” effect of pain, and that pain is pain. I don’t think you can ignore the impact mobilizations have on the skin, muscle, fascia before even getting to the joint. I think it’s important to focus during the examination, find the direction of pain, implement manual therapy, reassess and then go from there.

    Dr. Paris is a brilliant man and no one can ignore what he has contributed to the field of physical therapy, but I think it’s hard to ignore some of the underlying factors for him going after EIM ($$$).

    Thanks for the insight Joe!

    Mark

  12. Now don’t get me wrong……..you’ve been a PT for 3 years and you feel it necessary to create this much of a blog on this topic?? I agree there is much room to investigate on PIVM and the specificity of mobilization especially concerning the spine. I say dig in about 10 more years of clinical experience and then go on to attempt making a case. 3 years does not an expert make.

  13. Hi Jim,
    Thanks for the comment. I do have more than 3 years of experience (not sure where you have derived this number) and am also manually trained with both a COMT and FAAOMPT. The argument over years of experience actually leads to a genetic fallacy, in and of itself.

    Now that stated, which concepts above do you disagree with and why?

    • Sounds like a comment derived from anger and passion. Interesting to hear his comment. Please forward

      Francois A. Prizinski, DPT, OCS, COMT, FAAOMPT Sports Medicine of Atlanta Manual Therapy Fellowship & NxtGen Orthopaedic Residency, Administrator/Curriculum Coordinator

      Physical Therapy at The Orthopedic Group 1145 Bower Hill Road, Suite 305 Pittsburgh, PA 15243 412-276-2040 412-276-2458 fax

      >

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