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Robert Cooperstein, MA, DC
Motion Palpators, Please Lighten Up
J Amer Chiropr Assoc 2013 July-August;50(4):24-27
|Abstract: Dr. Cooperstein takes on the challenge of static vs. dynamic listings.|
Chiropractic technique hangs by a thread. After some 118 years of this, we have not convincingly demonstrated that the information provided by our examination methods has much to do with the outcome of care. I am not referring to serious cases with clear findings, like orthopedic tests suggesting herniated disc, but rather the other 95 percent or more of patients who come in with fairly straightforward musculoskeletal pain complaints. We do what we can to diagnose (we used to say “analyze”) these patients, which amounts to coming up with listings.
To put it simply, listings are indications for care. Whatever the historical derivation of the term “listing,” which seems to suggest a leaning or misaligned spine, we now ascribe several characteristics to the term. There are dynamic listings, having to do with impaired joint motions; static listings, which involve bones that have lost normal juxtaposition; and most recently provocation listings,1 which in essence are evoked responses to “challenges” that we put into the neuromusculoskeletal system. As examples of the latter, we observe if relative leg length appears to change when the head is turned, or if presenting lumbar pain at L5 is made worse or better with pressure on the left transverse process of L4.
Most listing systems have not worked out very well for chiropractors nor for those in the other manual therapy professions. Static listings tend to lack validity, in the sense that there is poor correspondence between radiographic subluxations and patient complaints. Patients with radiographic lesions do not tend to have corresponding pain, and patients with pain do not tend to have corresponding radiographic lesions. There is little evidence that patient improvement has much to do with radiographic improvement. Dynamic listings have fared no better. They tend to lack reliability. There are dozens of studies, many done rather well, showing little interexaminer agreement above chance levels.2 I point this out despite having published two studies wherein cervical and thoracic motion palpation were found to be reliable under some fairly delimited circumstances.4,5 As for provocation listings,3 which more or less mark a return to classical orthopedics, the jury is still out on how clinically valuable they will be. Personally, I am encouraged, and have myself published a little on provocative blocking,6-8 which was inspired by work done by McKenzie researchers on the degree to which defined vectors mattered in the exercises they prescribe.8
And so we have a standoff here: invalid static findings vs. unreliable dynamic findings. There are no winners in this situation, except perhaps those who consider us anti-scientific cultists. As a technique instructor, I take a class through a certain dilemma once every three months as a training exercise in critical thinking. I demonstrate for them surrogate muscle testing,9 which has been used in situations where the patient cannot be directly muscle tested by an examiner. For example, a 2-year-old child, who doesn’t understand the concept of resisting during a muscle strength test, is tested by having a parent touch her spine while the examiner muscle tests the parent. This test was apparently developed by Applied Kinesiology doctors. Upon seeing surrogate muscle testing, most of the students at first laugh, but then their amusement turns to chagrin as they express their dismay than no one in the chiropractic profession seems prepared to just put a stop to it.
Then I show them classic motion palpation—seated palpation for rotation of T4 on T5 to the right, for example. When I ask them how that looks, compared with surrogate palpation, they think the right answer is “Whew, that looks very good.” Yes, they are reassured that good motion palpation has vanquished bad surrogate muscle testing. But then I pull a reverse double whammy question out of my hat: “Why do you prefer an examination procedure that would require a small forklift to carry its negative studies from one room to another to an alternative examination procedure that has not yet been tested, at least to my knowledge?” Trust me, you can hear a pin drop when I raise that question.
But then I ride in like the Lone Ranger and solve the problem. We reject unstudied surrogate muscle testing because it looks very, very bad. And we accept (or at least suspend disbelief concerning) motion palpation because it looks very, very good. In fact, it is reasonable to be charitable to procedures that just make sense, lack of rigorous evidence notwithstanding. We call that “construct validity” and it is well-respected. If we did not allow for that sort of thinking, a big chunk of chiropractic and medical procedures would be eliminated overnight with nothing to replace them, leaving big voids in our clinical armamentarium. As an example, what would happen were we to demand high-quality evidence to support thoracic spinal manipulation? You already know. We would have to put on our business cards and office signage the following proviso: “Practice limited to cervical and lumbar spine treatment.” If we want to take the position that thoracic spine care is as evidence-based as well-researched cervical or lumbar spine care, it is only because it is reasonable to believe, since the thoracic spine closely resembles these other spinal regions, that clinical trials that have been conducted for them may be safely extrapolated to the thoracic spine.
This column was written to replace a misalignment-oriented column I had submitted for this issue because a reviewer had objected to my lack of evidence to support the practice of detecting and manipulating for BOOP: Bones-Out-of-Place. I get it. The evidence is weak, as I have described. I have had this happen before. Although I don’t know the views of this particular reviewer, a litany of others have advocated for an alternative procedure, motion palpation, which has been more heavily studied, and irrefutably found to be usually unreliable. They get peeved simply on seeing the word subluxation in an article, or even for suggesting radiography can detect subluxations (i.e., little misalignments).
Unlike surrogate muscle testing, static palpation for misalignment and adjustments that follow from that at least make sense, as much sense as motion palpation. From that point of view, it would be illogical to reject the one and at least tolerate the other. As for categorically rejecting BOOP thinking, it might be best to consider this paradox: “It seems a contradiction that abnormal posture is not predictive of pain, yet improvement of even normal posture is followed by significant relief of pain.”10 I think poor old Kuhn would turn over in his grave if he could see how overeager some chiropractors are for a paradigm change11 that replaces static with dynamic analysis. He would ask, “Where’s the new theory that permits predictions different from those derived from its predecessor?” He would not accept motion palpation as the answer.
Beginning around 1980, chiropractic has in fact been experiencing a paradigm change, with increasing momentum for dynamic analysis and correspondingly decreasing enthusiasm for static analysis. Call it BOOP-think. I have been asking students for the last 10 years to rate their support for either “crooked bone” or “sticky-joint” models of chiropractic care on a 5-point scale, where 3 would mean that the student thought these models of equal utility (not that they had no idea what to think). Having done this some 40 times, I can now state unequivocally, at least for my college on the left coast, that the evidence is in: these 4th-quarter students’ opinions form a bell curve distinctly skewed toward the motion palpation side of the spectrum. I would say they have plateaued at this time at around 4 in that direction. Yes, they think the sticky-joint model makes more sense. I make no effort to budge them from that place since I lack evidence that either model is more clinically useful than the other. However, each quarter I am already licking my chops in anticipation of having these same 4th-quarter students in my 8th-quarter lab one year later. That’s when I will show them what I have been calling “monorail” palpation, a procedure I believe is rather efficient at finding lumbar and thoracic subluxation. I have had a research proposal to investigate this approved by the institutional IRB but have not had a chance to conduct the study yet. (At the PCC Homecoming event this year, a speaker described the “finger gliding straight edge” palpation practiced by early Palmer chiropractors, which may amount to the same or a similar procedure.)
The advocacy groups for dynamic analysis, at least in my opinion, seem irrationally confident in their approach relative to what we have learned in studies, whereas the less vocal advocates of static analysis seem battle worn when it comes to defending the original chiropractic precept of D.D. Palmer that says bones can misalign and that can lead to adverse health consequences. I don’t think we can reach some sort of “grand bargain” (a phrase we hear in the news a lot these days, having to do with favoring either higher taxes or less spending to balance the federal budget) by stipulating that the vaunted “vertebral subluxation complex” includes both misalignment and fixation/restriction (the latter two terms are not synonymous, but I can’t get into that here). It has been a truly surprising discovery for me that sticky joints and crooked bones don’t need to coincide at the same spinal level, even if manual therapists think they should. I have procedures to detect either misalignment or fixation. I simply treat what I find. I think the subluxation complex model has led more to wishful thinking than any breakthroughs in understanding anything about spine problems. If you demand that the spinal site of care you have decided on needs to exhibit a set of hyphenated pathologies - kinesiopathology, myopathology, histopathology, etc.), you will of course deceive yourself into thinking they are present. Human minds are funny that way, with an infinite capacity for self-deception and an unslakable thirst for self-fulfilling prophecies.
In concluding this op-ed piece aimed at getting the motion palpation constituency to lighten up, I would like to recall a passage from a piece I wrote almost two decades ago.12 At that time, I could already sense a burgeoning and irrational intolerance for views outside the motion palpation paradigm. In making the case for technique liberalism, I described what I called the “glass house effect”:
“There is no hard and fast line that separates what is known from what is not known, nor even science from myth. Rather, there is a continuum that defines the fabric of reality, stretching from abject nonsense to proven fact. Where an individual practitioner situates himself on this very elastic fabric is to some degree a question of taste. In a science where so much remains ‘investigational,’ traditionalist chiropractors seek comfort in the science of myth, whereas more contemporary practitioners seem more at home in the myth of science.13 Ideally speaking, the chiropractic profession would weed from its garden those methods that stretch credibility to the point of incredulity, but there is a fundamental problem in doing so: only the thinnest of margins separate officially endorsed "mainstream" chiropractic methods from the others. These latter earn a variety of epithets, anything from "unorthodox" to "experimental" to "quackery," depending on the nay-sayer's degree of charity and sometimes professional rivalry. Admittedly, it may seem odd that Doctor X gets his listings from aura analysis, and adjusts the spine with forces not in excess of 1 ounce, but where is the evidence that Doctor Y, a motion palpator, possesses superior diagnostic acumen or gets better clinical outcomes? To apply an old adage, those who live in glass houses shouldn't throw stones.
1. Cooperstein R. The limits of traditional chiropractic listings and the advent of provocation testing. JACA Online. 2008;45(7):Online access only p 29-31.
2. Haneline M, Cooperstein R, Young M, Birkeland K. An annotated bibliography of spinal motion palpation reliability studies. JCCA J Can Chiropr Assoc. 2009;53(1):40-58.
3. Cooperstein R, Haneline M, Young M. Interexaminer reliability of thoracic motion palpation using confidence ratings and continuous analysis. J Chiropr Med. 2010;9(3):99-106.
4. Cooperstein R. Interexaminer reliability of cervical motion palpation using continuous measures and rater confidence levels. J Can Chiropr Assoc. 2012;in review.
5. Cooperstein R. Padded wedges for lumbopelvic mechanical analysis. J Amer Chiropr Assoc. 2000;37(10):24-6.
6. Cooperstein R, Crum E, Morschhauser E, Lisi A. Sitting PSIS positions and prone blocking preferences: a preliminary report. J Chiropr Educ. 2004;18(1):44-5.
7. Cooperstein R. Sacro-occipital technique use of padded wedges for diagnosis and treatment. In: Chaitow L, editor. Positional Release. 3 ed: Churchill-Livingstone; 2008. p. 179-98.
8. Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine. 2004;29(23):2593-602.
9. Sprieser PT. Further explanation of surrogate testing and therapy localization. Digest of Chiropr Econ. 1987(Jan/Feb):131-32, 5.
10. Irvin RE. Suboptimal posture: the origin of the majority of idiopathic pain of the musculoskeletal system. In: Vleeming A, Mooney V, Dorman T, Sniders C, Stoeckart R, editors. Movement, Stability & Low Back Pain. New York: Churchill Livingstone; 1997. p. 133-55.
11. Kuhn T. The Structure of Scientific Revolutions. 3 ed. Chicago: University of Chicago Press; 1996. 226 p.
12. Cooperstein R. Contemporary approach to understanding chiropractic technique. In: Lawrence D, editor. Advances in Chiropractic Volume 2. 2. Chicago IL: Mosby Year Book, Inc.; 1995. p. 437-59.
13. Quine WVO. Two Dogmas of Empiricism. 2nd. ed. Cambridge, Mass: Harvard University Press; 1964.