Model Issues

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This post is going to be on the longer side. The aim is to take a look at some available research to highlight the issues with most manual therapeutic models and suggest that we may want to make some professional Gestalt shifts (aka changes in perspective based on the same information).

To begin, if we take a look at some available research regarding visceral and cranial osteopathy we see that the current state of research presents both a high likelihood of bias as well as no significant signs of diagnostic reliability or efficacy (8, 9, 14). Before moving beyond this I want to state clearly that the essential question asked in this current research was “does it do what it says it does?” and the answer is a clear NO. Does this automatically mean that NOTHING is happening? Again, the answer is a tenuous no. Something is happening but it is not what is claimed by either the cranial or visceral models. We essentially see NOTHING happening to the cranium or the viscera with the applications of these approaches. Anecdotally, we likely see something happening to the patient. What does this disconnect suggest? It suggests that the model creates an effect but is completely erroneous on the mechanism and location of the effect. In video form I have generally communicated that what will often happen is that a phenomenon will be identified by someone, they will figure out a way to consistently interact with that phenomenon, then they will figure out a story to communicate so that others may repeatedly interface with that phenomenon. The issue is that the story is often incorrect even though it allows other people to perform the work. Recently I saw a link to a paper that described this phenomenon in a more succinct manner. The paper makes the distinction between a treatment model and a conceptual model. A treatment model:

  1. Provides a theoretical explanation of palpatory findings
  2. Prescribes treatment
  3. Gives predictable results

A conceptual model:

“A conceptual model must provide the most accurate description and understanding possible; it must closely represent reality, (although a model may idealize away extraneous facts for simplification). As scientific advances increase our knowledge and newer better understanding becomes available, our conceptual models must change to stay current.”

Based on available evidence it would seem that MOST models in manual therapy (osteopathy or otherwise) would be, based on the above description, best termed treatment models. There is some research that would generally suggest most of the models in osteopathy do not operate on their believed mechanisms (7). In relation to the challenges with the conceptual models many manual practitioners utilize it would be worth considering that they not be utilized for communication purposes due to their inaccurate nature.

Another issue with manual therapy is palpatory accuracy. One research paper that was testing the palpatory accuracy for landmarks in the lumbo-pelvic region identified a range of 22%-86% accuracy for identification of soft tissues and 26%-69% accuracy for identification of bony landmarks (6). The variation in accuracy was highly related to BMI. From this single paper we get an initial impression that the HIGHEST reported accuracy level was 86% for soft tissues and 69% for bony landmarks. This is just one study…well, if we look around we generally find the same phenomenon (2, 3, 11, 12, 13, 15, 16, 17, 18, 19, 20). Broadly stated, the papers linked to based on the reference numbers suggest that palpation is not particularly accurate. It is difficult to speak of being accurate to a specific structure with palpation when a large amount of research suggests otherwise. There is evidence suggesting palpation in conjunction with ultrasound increases accuracy of identification of lumbar vertebrae (1, 13). Utilizing ultrasound for accurate identification of lumbar vertebrae is more useful based on time and resources for surgical procedures then in a manual therapeutic clinical setting however it does suggest that for the sake of ACCURACY it provides a possible tool. There is evidence to suggest that, with consensus training, inter-observer reliability may improve with respect to palpation (4, 5). Before moving on, consensus training would best be described as training that allows for the same task to be undertaken consistently by different people in this context. Improving inter-observer reliability is not necessarily the same as improving palpatory accuracy, however it does show that there is some signal suggesting that if multiple people are trained in a clear and consistent fashion they are more likely to find the same things. The two papers being referred to (4, 5) do not have large sample sizes so the ability to see them as indicative of what would happen in a large group is low although they do provide evidence for a good starting point.

Looking at the preceding paragraph we gain two general concepts:

  1. Palpation is NOT a good way to ACCURATELY locate SPECIFIC structures
  2. There is evidence to suggest that consensus training improves inter-observer reliability (aka people are MORE likely to find the SAME stuff)

What do we make of this? I don’t know what you make of it however I see a signal suggesting that palpation for ACCURACY is not what I should be striving for. There are differences in anatomy between one side of a patient and the other, there are common anatomical abnormalities (supernumerary ribs, 4 or 6 lumbar vertebrae, etc…) which will affect accuracy. Research suggests a relationship between body composition (BMI) and palpatory accuracy. Essentially, there are NORMAL phenomena that impede palpatory accuracy. Knowing that there are NORMAL phenomena that impede palpatory accuracy suggests that it is not accuracy of specific structures we should be striving for. In this light, I put forth that we should be looking at the thing that does not move in a given region. It is worth consideration that the improvement in inter-observer reliability with consensus training suggests that if we utilize the same examination methods we will likely find similar things. Keep in mind that I have said we LIKELY find similar things and we won’t know if we DO find similar things unless we test that.

So, we don’t have good evidence to support the current claims of mechanistic action within osteopathy (or other manual therapies) and we don’t have information to support accurate palpation of specific structures. What do we have? We have qualitative anecdotes about therapeutic benefit from osteopathic manual therapy. We have fairly consistent and repeatable results on the level of the individual clinician. We don’t have strong support for osteopathic manual therapy with respect to consistent efficacy for pain reduction (at least not that I have encountered…I am quite confident that there will be some who read this and believe they can consistently deal with pain to which I will say prove it on a large scale please). The fairly consistent and reliable results on the level of the individual clinician would, anecdotally at least, seem to be in the form of improved motion of a given region. Prior to moving on, I want to clarify that, when I say motion, I mean motion of both joints and tissues. By motion of tissues I am primarily referring to soft tissue pliability or tissue yield under a short lever approach (aka generally a hand pushing in to a soft tissue). Whether the motion is of joints (which means soft tissues as well) or the pliability/yield of a soft tissue under short lever pressure, the consistent feature of osteopathic manual therapy seems to be MOTION on a gross (large/visible) scale. Regardless of mechanisms of action, the consistent feature of all treatment and conceptual models seems to be MOTION. I have put forth thoughts on this in video form when looking at palpation and assessment.

The aim of this post is to suggest, on a small level, that the research focus of osteopathic manual therapy SEEMS to have been pointed in the direction of attempting to prove that the things we THINK we are doing are correct…and the consistent answers we have found through research is that we are not doing what we THINK we are doing. We are not always touching the bone we say we are touching (accept for obvious ones such as the humerus or femur). We are not changing the things we say we are changing. There seems to be a cultural desire within osteopathy to reject the research and say that the methods are flawed with the undertone that this flaw is because it is not proving what we WANT it to prove. I would suggest that, instead of TRYING TO PROVE THAT WE ARE ALREADY CORRECT, we should shift focus to try to figure out WHAT IS ACTUALLY HAPPENING. When we begin to approach a greater understanding of what is actually happening we will be able to more usefully communicate it so that others may repeat it…we will have improved treatment and conceptual models. In the act of trying to prove what we THINK is happening we consistently look foolish because we are consistently off base and refuse to let go of those explanations. We may be better suited to create a research program that identifies what is happening and begin adjusting our models from there…

 

References:

  1. Baka N., Leenstra S., Walsum T. (2017). Ultrasound Aided Vertebral Level Localization for Lumbar Surgery. IEEE Transactions on Medical Imaging. PP. 1-1. 10.1109/TMI.2017.2738612.
  2. Cooperstein R., Haneline M., Young M. (2015). The location of the inferior angle of the scapula in relation to the spine in the upright position: A systematic review of the literature and meta-analysis. Chiropractic and Manual Therapies. 23 (7).
  3. Cooperstein R., Truong F. (2017). Systematic review and meta-analyses of the difference between the spinal level of the palpated and imaged iliac crests. Journal of the Canadian Chiropractic Association. 61(2), pp. 106-120.
  4. Degenhardt B., Johnson J., Snider K., Snider, E. (2010). Maintenance and improvement of interobserver reliability of osteopathic palpatory tests over a 4-month period. The Journal of the American Osteopathic Association. 110. 579-86.
  5. Degenhardt B., Snider K., Snider E., Johnson J. (2005). Interobserver reliability of osteopathic palpatory diagnostic tests of the lumbar spine: Improvements from consensus training. The Journal of the American Osteopathic Association. 105. 465-73.
  6. Ferreira A., Póvoa L., Zanier J., Machado D.M., Ferreira A. (2017). Sensitivity for palpating lumbopelvic soft- tissues and bony landmarks and its associated factors: A single-blinded diagnostic accuracy study. Journal of Back and Musculoskeletal Rehabilitation. 30. 1-10. 10.3233/BMR-150356.
  7. Fryer G. (2017) Integrating osteopathic approaches based on biopsychosocial therapeutic mechanisms. Part 1: The mechanisms International Journal of Osteopathic Medicine, Volume 25, 30 – 41. DOI: 10.1016/j.ijosm.2017.05.002
  8. Guillaud A, Darbois N, Monvoisin R, Pinsault N. Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review. BMC Complementary and Alternative Medicine (2018) 18:65 DOI 10.1186/s12906-018-2098-8
  9. Guillaud A, Darbois N, Monvoisin R, Pinsault N. Reliability of diagnosis and clinical efficacy of cranial osteopathy: a systematic review. PLoS One. 2016 Dec 9;11(12):e0167823. https://doi.org/10.1371/journal.pone.0167823.
  10. Jordan, T.R. (2006) Conceptual and treatment models in osteopathy II: Sacroiliac mechanics revisited. AAO Journal. 16 (2), pp. 11-17.
  11. Kilby J., Heneghan L.R., Maybury M. (2011) Manual palpation of lumbo-pelvic landmarks: A validity study. Manual therapy 17(3):259-62. DOI: 1016/j.math.2011.08.008
  12. Merz OWU, Robert M, Gesing V, Rominger M. Validity of palpation techniques for the identification of the spinous process L5. Manual Therapy. 2013;18(4):333–8. DOI: 10.1016/j.math.2012.12.003
  13. Mieritz RM., Kawchuk GN. (2016). The Accuracy of Locating Lumbar Vertebrae When Using Palpation Versus Ultrasonography. Journal of Manipulative and Physiologic Therapeutics. 39 (6) pp. 387-392. DOI: https://doi.org/10.1016/j.jmpt.2016.05.001
  14. Pellet M., Chenel A., Behr M., Thollon L. (2018). Is digital image correlation able to detect any mechanical effect of cranial osteopathic manipulation? – A preliminary study. International Journal of Osteopathic Medicine. V. 29, pp. 10 – 14. DOI: https://doi.org/10.1016/j.ijosm.2018.07.004
  15. Póvoa L., Ferreira A., Zanier J., Silva J. (2018). Accuracy of Motion Palpation Flexion-Extension Test in Identifying the Seventh Cervical Spinal Process. Journal of Chiropractic Medicine. 17. 22-29. 10.1016/j.jcm.2017.11.005.
  16. Robinson R, Robinson HS, Bjorke G and Kvaleet A. (2009) Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5. Man Ther 14: 409‑414
  17. Snider, Karen & W Kribs, James & Snider, Eric & F Degenhardt, Brian & Bukowski, Allison & Johnson, Jane. (2008). Reliability of Tuffier’s line as an anatomic landmark. Spine. 33. E161-5. 10.1097/BRS.0b013e318166f58c.
  18. Snider, Karen & Snider, Eric & F Degenhardt, Brian & Johnson, Jane & W Kribs, James. (2011). Palpatory Accuracy of Lumbar Spinous Processes Using Multiple Bony Landmarks. Journal of manipulative and physiological therapeutics. 34. 306-13. 10.1016/j.jmpt.2011.04.006.
  19. Stovall B., Kumar S. (2010). Anatomical Landmark Asymmetry Assessment in the Lumbar Spine and Pelvis: A Review of Reliability. PM & R: the journal of injury, function, and rehabilitation. 2. 48-56. 10.1016/j.pmrj.2009.11.001.
  20. Tanaka K., Irikoma S., Kokubo S. Identification of the Lumbar Interspinous Spaces by Palpation and Verified by X-rays. (2013) Brazilian Journal of Anesthesiology Volume 63, Issue 3, pp 245-248. https://doi.org/10.1016/S0034-7094(13)70224-1

2 thoughts on “Model Issues

  1. Pingback: Articles Of The Week October 21, 2018 « The Massage Therapist Development Centre

  2. Pingback: Cognitive Biases: I am not the First to Notice… | Classical Osteopathy in Ontario

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