As you know, I mostly write about "technique," with an emphasis on low-force methods and soft tissue; but today, let's detour into philosophy, with comments on art and science. I aspire to a best-practices approach, finding the underlying problems and pain generators, and using a combination of self care, low-force manipulation and soft-tissue treatment to solve the problem quickly.
Today's article is inspired by a letter to the editor from Dr. James Lehman titled, "Manual Medicine Not Required."2 One of Dr. Lehman's main points is that motion palpation is not reliable. I'll explain why I still use motion palpation.
He also states, "Through the use of physical examination, the chiropractic physician must reproduce the patient's pain with any combination of procedures that compress, contract, or stretch the pain-generating tissues."
The provocation model is something I completely agree with. I appreciate Triano, et al., for their article reviewing this concept.3
The Value of Palpation
It is quite easy to criticize the use of motion palpation for assessing joint dysfunction, as it is not a "reliable" tool according to the research. I know the same could be said for palpation of tight and tender places in muscles in fascia.
Some of our critics would say that these manual tools are not useful or reliable. I would say, I am a chiropractor. The origin of "chiro" is the Greek word kheir – "hand." To become skilled in the use of your hands is a key part of becoming a quality chiropractor. Chiropractors have both training and extensive experience in palpation of joints and muscles. The expertise of the seasoned chiropractor may be hard to measure, but has enormous value.
I will not stop using my hands to evaluate, even if this tool is not perfectly reproducible. History and physical exam are useful tools, which our medical colleagues seem to use less and less. I fear manual practitioners will become "dumbed down" by the current emphasis in the schools and the research, both in the physical therapy and the chiropractic profession.
My opinion: Palpation plus provocation plus treatment, followed by in-session re-evaluation, makes for a powerful set of tools for evaluating and relieving pain. I prefer the term evidence informed, as I think it better describes what a "best practices" chiropractor should aspire to. I suspect the best chiropractor is one who is comfortable in the gray zones; the areas that do not have a definite yes or no.
Would We Be as Effective?
Would we be as effective without the subjective art of palpation? I know I would not be. Do I recognize the inherent lack of perfect accuracy in this approach? Absolutely. Diagnosis is a challenging art, especially in the musculoskeletal arena. If chiropractors and PTs are taught our hands are not useful diagnostic tools, I suspect these skills will erode in the professions. I appreciate the evidence-based approach, but I recognize it has limitations in its application to the complexity of approaching the individual patient.
I quote Dr. Stuart McGill, who makes this point more elegantly than I could. (I encourage you to read his entire commentary.4)
"Musculoskeletal (MSK) disorders are different: their symptoms are highly variable in terms of pain, there is often more than one source of pain, the dosage of intervention is critical (as too much exacerbates and too little has no effect), and the outcomes are highly variable in terms of duration and effectiveness. Why should 2 clinicians obtain the same impression when examining a biological system that is continually in a state of flux? If their skills were equal and the patient remained static, then reliability may be possible and even justifiable. But this is not the case with most MSK disorders. Thus, the typical "rules for reliability" associated with evidence-based medicine need a liberal amount of reflection for logical application in MSK situations. Machines can be extremely reliable, but no diagnostic machine (however reliable) has ever lived up to hyperbole or obtained a better outcome for MSK disorders than a highly skilled clinician. The best pattern recognition system, data integrator, decision processor, and manual applicator of corrective cues remains the skilled clinician."
I attempt to treat each patient as an individual, and find what is profound and significant in their pattern. What can we, the patient and I, change? All of my teachers have emphasized this concept.
I suspect that if the insurance companies and panels had their way, the highest ratings for quality would go to the doctor who checked the most boxes on their electronic health records. Is this the way we want to go? I don't. (I could say more about how EHR has perverted health care, but that is not the topic of the day.)
A Key Part of the Clinical Picture
I want to pay attention in the moment, using my critical observation skills, my ears, eyes, and with my hands, and get to the root of the problem as quickly as possible. I always want the patient to walk out with tools that include a better understanding of what I think is wrong, and what they can do to help themselves.
I appreciate the biopsychosocial component of every patient who walks through my door. I appreciate that every word I say to my patient has weight; and that I can influence the patient toward healing or toward continued illness with my communication. I appreciate that centralization of pain is a critical component of chronic pain and is not easy to reverse.
There are parts of the "pain science" approach I find useful, and parts I strongly object to. One important strategy for chronic pain is to show the patient a motion or exercise they can succeed at; ideally one that immediately changes their pain. This is a powerful motivation tool and one simple way to start to change centralized pain.
I am not a scientist. I am a clinician who tries to learn from the scientific literature. I acknowledge that assessing joint motion, used on its own as the singular basis of manipulation, is not adequate. Manual medicine research is very hard to make practical. The whole is far more than the parts. The subtleties of addressing a difficult and chronic patient presentation requires integration of multiple components. The good clinician's brain and hands are great pattern recognition tools if we use them well.
References
- Heller M. “How to Become a Wizard in a World Run by Muggles.” Dynamic Chiropractic, Oct. 15, 2015.
- Lehman J. "Manual Medicine Not Required." (Letter to the editor based on "Are PTs and DOs Lousy at Spinal Manipulation?"). Dynamic Chiropractic, October 2020.
- Triano J, et al. Review of methods used by chiropractors to determine the site for applying manipulation. Chiro & Man Ther, 2013;21:36.
- McGill S. Invited commentary on intrarater and interrater reliability of select clinical tests in patients referred for diagnostic facet joint blocks in the cervical spine. Arch Phys Med Rehabil, 2013;94:1635-7.
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