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Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant
Manual Therapy 17 (2012) e11–e12
Contents lists available at SciVerse ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Letter to the Editor
Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant
We thank Adhia and colleagues for their contribution regarding Sacro-Iliac joint (SIJ) motion (Adhia et al., 2012). They conclude, “The results support clinical and research utility of this technique for non-invasive kinematic evaluation of SIJ motion.Further research. is warranted.” In our opinion, their findings are not relevant to manual therapy practice, and we don’t see the need for further clinical research using this method. SIJ related pain classically has been “diagnosed” clinically via palpation-based tests of relative movement and asymmetry (Huijbregts, 2008; Arab et al., 2009; Adhia et al., 2012). SIJ motion is very small, highly variable, and difficult to measure and variation in anatomy exists between and within individuals (Harrison et al., 1997; Cohen, 2005; Huijbregts, 2008; Goode et al., 2008). From an anatomical and biomechanical plausibility perspective, measuring and connecting this small and highly variable motion to any diagnostic process may be futile. Common clinical tests of position/movement of the SIJ are unreliable within and between examiners (Goode et al., 2008; Laslett, 2008). Investigations that exhibit reliability have wide confidence intervals (Robinson et al., 2007; Arab et al., 2009). Symptom provocation testing appears superior, and is the criteria used in a consensus guideline (Szadek et al., 2009). After investigating the reliability of provocation tests (Laslett and Williams, 1994), Laslett et al. went on to perform a double injection study (Laslett et al., 2003) for diagnosis of SIJ related pain. A composite of tests for spinal motion and symptom provocation was found superior when compared to this “gold standard” for SIJ related pain (Laslett et al., 2003, 2005; Laslett, 2008). Even this process is not fully conclusive (Szadek et al., 2009). Regarding clinical utility, in a developed (Flynn et al., 2002) and validated (Childs et al., 2004) clinical prediction rule for an “SIJ region” thrust manipulation, no palpation-based testing of the SIJ was included in the rule. Palpation and movement based tests of the SIJ region have been studied and have failed to demonstrate usefulness in helping clinicians diagnose or treat SIJ related pain. Palpatory examination has a valid role in manual therapy, but this is related to symptom provocation, mechanical testing (Laslett, 2008), and an impairmentbased clinical reasoning approach (Whitman et al., 2006). This is quite different from the positional and movement symmetry diagnostic process in Adhia et al. The paper may perpetuate an overly biomechanical focus in the assessment, treatment, and understanding of pain. A strict
DOI of original article: 10.1016/j.math.2011.09.005. 1356-689X/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2012.02.017
biomechanical model of pain and manual therapy has little support in the current literature investigating mechanisms and predictors of success (Bialosky et al., 2009). Given our understanding of the multifactorial neurophysiology of the pain experience (Melzack, 2001; Bialosky et al., 2009; Moseley, 2012), 3D modeling of small, variable joint motions has no meaningful clinical utility and we don’t advocate its use regardless of the precision of biomechanical measurements. This research is not flawed or poorly executed and it may be relevant for biomechanical studies. However, the results are not clinically applicable considering the current weight of evidence which calls into question the reliability, validity, and relevance of palpatory SIJ diagnosis. We are confused as to how we as clinicians could utilize the author’s technique in clinical practice, and why, given the current state of the literature, the authors propose we should. Conflict of interest The authors of this letter have no financial interest to disclose. The views expressed are those of the authors alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
References Adhia DB, Bussey MD, Mani R, Jayakaran P, Aldabe D, Milosavljevic S. Inter-tester reliability of non-invasive technique for measurement of innomiate motion. Man Ther 2012;17:71–6. Arab HM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. Inter- and intraexaminer reliability of single and composites of selected motion palpation and pain provocation tests for the sacroiliac joint. Man Ther 2009;14(2):213–21. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther 2009;14(5):531–8. Childs JD, Fritz JM, Flyn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141(12): 920–8. Cohen SP. Sacroilliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005;101(5):1440–53. Flynn T, Fritz J, Witman J, Wainner R, Magel J, Rendeiro D, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27(24):2835–43. Goode A, Hegedus E, Sizer P, Brismee J, Linberg A, Cook C. Three-dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. J Man Manip Ther 2008;16:25–38. Harrison DE, Harrison DD, Troyanovich SJ. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J Manipulative Physiol Ther 1997; 20:607–17.
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Letter to the Editor / Manual Therapy 17 (2012) e11–e12
Huijbregts PA. Evidence-based diagnosis and treatment of the painful sacroilliac joint. J Man Manip Ther 2008;16(3):153–4. Laslett M, Aprill CN, McDonald B, Young SB. Sacroilliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207–18. Laslett M, Williams M. The reliability of selected pain provocation tests for sacoiliac joint pathology. Spine 1994;19(11):1243–9. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother 2003;49:89–97. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther 2008;16:142–52. Melzack R. Pain and the neuromatrix in the brain. J Dental Educ 2001;65(12): 1378–82. Moseley LG. Teaching people about pain: why do we keep beating around the bush? Future Med Pain Manage 2012;2(1):1–3. Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther 2007;12(1):72–9. Szadek KM, van der Wuff P, van Tulder MW, Zuurmond WW, Perez RSGM. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain 2009;10(4):354–68. Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis. Spine 2006;31(22):2541–9.
Kyle Ridgeway* University of Colorado Hospital, Aurora, CO, USA Panther Physical Therapy, Littleton, CO, USA University of Colorado Anschutz Medical Campus, School of Medicine, Physical Therapy Program, Aurora, CO, USA Jason Silvernail US Army, El Paso TX, USA Adjunct Faculty, Army-Baylor University Doctoral Program in Orthopedic Manual Therapy, San Antonio TX, USA * Corresponding author. 1390 High Street #704, Denver, CO 80218, USA. Tel.: þ1 425 870 3808. E-mail address: [email protected] (K. Ridgeway) 15 February 2012
Contents lists available at SciVerse ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Letter to the Editor
Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant
We thank Adhia and colleagues for their contribution regarding Sacro-Iliac joint (SIJ) motion (Adhia et al., 2012). They conclude, “The results support clinical and research utility of this technique for non-invasive kinematic evaluation of SIJ motion.Further research. is warranted.” In our opinion, their findings are not relevant to manual therapy practice, and we don’t see the need for further clinical research using this method. SIJ related pain classically has been “diagnosed” clinically via palpation-based tests of relative movement and asymmetry (Huijbregts, 2008; Arab et al., 2009; Adhia et al., 2012). SIJ motion is very small, highly variable, and difficult to measure and variation in anatomy exists between and within individuals (Harrison et al., 1997; Cohen, 2005; Huijbregts, 2008; Goode et al., 2008). From an anatomical and biomechanical plausibility perspective, measuring and connecting this small and highly variable motion to any diagnostic process may be futile. Common clinical tests of position/movement of the SIJ are unreliable within and between examiners (Goode et al., 2008; Laslett, 2008). Investigations that exhibit reliability have wide confidence intervals (Robinson et al., 2007; Arab et al., 2009). Symptom provocation testing appears superior, and is the criteria used in a consensus guideline (Szadek et al., 2009). After investigating the reliability of provocation tests (Laslett and Williams, 1994), Laslett et al. went on to perform a double injection study (Laslett et al., 2003) for diagnosis of SIJ related pain. A composite of tests for spinal motion and symptom provocation was found superior when compared to this “gold standard” for SIJ related pain (Laslett et al., 2003, 2005; Laslett, 2008). Even this process is not fully conclusive (Szadek et al., 2009). Regarding clinical utility, in a developed (Flynn et al., 2002) and validated (Childs et al., 2004) clinical prediction rule for an “SIJ region” thrust manipulation, no palpation-based testing of the SIJ was included in the rule. Palpation and movement based tests of the SIJ region have been studied and have failed to demonstrate usefulness in helping clinicians diagnose or treat SIJ related pain. Palpatory examination has a valid role in manual therapy, but this is related to symptom provocation, mechanical testing (Laslett, 2008), and an impairmentbased clinical reasoning approach (Whitman et al., 2006). This is quite different from the positional and movement symmetry diagnostic process in Adhia et al. The paper may perpetuate an overly biomechanical focus in the assessment, treatment, and understanding of pain. A strict
DOI of original article: 10.1016/j.math.2011.09.005. 1356-689X/$ – see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2012.02.017
biomechanical model of pain and manual therapy has little support in the current literature investigating mechanisms and predictors of success (Bialosky et al., 2009). Given our understanding of the multifactorial neurophysiology of the pain experience (Melzack, 2001; Bialosky et al., 2009; Moseley, 2012), 3D modeling of small, variable joint motions has no meaningful clinical utility and we don’t advocate its use regardless of the precision of biomechanical measurements. This research is not flawed or poorly executed and it may be relevant for biomechanical studies. However, the results are not clinically applicable considering the current weight of evidence which calls into question the reliability, validity, and relevance of palpatory SIJ diagnosis. We are confused as to how we as clinicians could utilize the author’s technique in clinical practice, and why, given the current state of the literature, the authors propose we should. Conflict of interest The authors of this letter have no financial interest to disclose. The views expressed are those of the authors alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
References Adhia DB, Bussey MD, Mani R, Jayakaran P, Aldabe D, Milosavljevic S. Inter-tester reliability of non-invasive technique for measurement of innomiate motion. Man Ther 2012;17:71–6. Arab HM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. Inter- and intraexaminer reliability of single and composites of selected motion palpation and pain provocation tests for the sacroiliac joint. Man Ther 2009;14(2):213–21. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther 2009;14(5):531–8. Childs JD, Fritz JM, Flyn TW, Irrgang JJ, Johnson KK, Majkowski GR, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141(12): 920–8. Cohen SP. Sacroilliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005;101(5):1440–53. Flynn T, Fritz J, Witman J, Wainner R, Magel J, Rendeiro D, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27(24):2835–43. Goode A, Hegedus E, Sizer P, Brismee J, Linberg A, Cook C. Three-dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. J Man Manip Ther 2008;16:25–38. Harrison DE, Harrison DD, Troyanovich SJ. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J Manipulative Physiol Ther 1997; 20:607–17.
e12
Letter to the Editor / Manual Therapy 17 (2012) e11–e12
Huijbregts PA. Evidence-based diagnosis and treatment of the painful sacroilliac joint. J Man Manip Ther 2008;16(3):153–4. Laslett M, Aprill CN, McDonald B, Young SB. Sacroilliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207–18. Laslett M, Williams M. The reliability of selected pain provocation tests for sacoiliac joint pathology. Spine 1994;19(11):1243–9. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother 2003;49:89–97. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther 2008;16:142–52. Melzack R. Pain and the neuromatrix in the brain. J Dental Educ 2001;65(12): 1378–82. Moseley LG. Teaching people about pain: why do we keep beating around the bush? Future Med Pain Manage 2012;2(1):1–3. Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther 2007;12(1):72–9. Szadek KM, van der Wuff P, van Tulder MW, Zuurmond WW, Perez RSGM. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain 2009;10(4):354–68. Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis. Spine 2006;31(22):2541–9.
Kyle Ridgeway* University of Colorado Hospital, Aurora, CO, USA Panther Physical Therapy, Littleton, CO, USA University of Colorado Anschutz Medical Campus, School of Medicine, Physical Therapy Program, Aurora, CO, USA Jason Silvernail US Army, El Paso TX, USA Adjunct Faculty, Army-Baylor University Doctoral Program in Orthopedic Manual Therapy, San Antonio TX, USA * Corresponding author. 1390 High Street #704, Denver, CO 80218, USA. Tel.: þ1 425 870 3808. E-mail address: [email protected] (K. Ridgeway) 15 February 2012