Trial of a Test - Low Back Pain

[neuromuscular]

I would like as many as are interested to give feedback on a test that I have ben using for 15 years.

It suggests a condition that has been overlooked.

I have looked in numerous research areas and text books, but I cannot find any thing similar

The test is:

Landmark the ASIS to ASIS. Have the patient do hip abduction directly lateral in the coronal plane from closed at 15 cm or 6 inch increments to the abilty of the patient to perform. Note results.


Landmark the PSIS to PSIS and have the patient perform hip abduction as above. note results.

Landmark the ASIS to PSIS first on the right and then on the left as you have the patient do hip abduction as above.

I have found the following statistics:

No back pain:

No deviation inferior or superior to any great extent

Low back pain:

Only 10% have bilaterally equal pelvic angles that increase either to the posterior or anterior rotation.

The balance had differing pelvic angles. (90%)

Of this group:
60% right ant, left pos
20% right ant left neutral
20% right ant while left lesser angle ant.

See what you get for results.

Best regards.

Neuromuscular

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[linbin]

hi
i feel the deviations can be quite normal .there are various structures which contribute to such deviations and detecting may be a bit time consuming .i doubt whether it is of any use

[neuromuscular]

hi
i feel the deviations can be quite normal .there are various structures which contribute to such deviations and detecting may be a bit time consuming .i doubt whether it is of any use

Try the test with hip abduction. the results are obvious. The information is the most objective.

The facts will speak for themselves.

Pelvic angles deviate little in those with no back pain.

Pelvic angles deviate greatly in those with back pain.

Your scepticism is similar to Andry Vleeming,whom I have spoken to, but who is pursuing the problematic SI joint. I feel the joint has little to do with it.

How many joints of the body are supposed as stuck as often as the SI joint? That should be a twig to our thinking that maybe something else is the problem.

Try the test and note your findings.

Best regards,

Neuromuscular.

[Canuck Physio]

Will give it a go shortly

[neuromuscular]

Will give it a go shortly

Great. I am sure of the test as it has been in use for 15 years and with over 1,000 patients The success rate of the therapy is quick and better than i have seen with any other hip assessment.

My best to you,

Neuromuscualr
From western Canuck land, Canada

[jesspt]

I've seen you propose this test numerous places on this site. Do you have any research regarding this test?

[neuromuscular]

I've seen you propose this test numerous places on this site. Do you have any research regarding this test?

Sorry that I did not get back to you before this as I had an emergrncy appendectomy.

The test is being taken on by the OGI.

I know that many will find the thought of doing a test on the pelvic angles as unusual However, I was after the most objective nformation on the patient. I have found that muscle testing, no matter how thoroughly done or if a machine is used, is not as objective as I would like to see.


I have found that this test is accurate. however, getting to know how to read the test results and apply it in clinic will be the task for most who are new to this idea or test.

The important factor is to stresas the pelvis in an accurate, repeatable way that can be linked to the patients pain and problem.

When the OGI is done with the test results, the research paper will be generated.
I can say that the initial testing by the OGI is positive and that the test and therapy are holding up against other forms of testing and treatment.

I do see that this test will increase success rates for low back pain and hip pain.

Try the test and see what your results are in your patient load. I found it very accurate and showed how the patient responded to the specific stress generated by the hip abduction.

As for corroberating evidence, I have talked with Andry Vleeming, Ola Grimsby and others. There does not seem to be any research in this direction as most have not considered pelvic angles of significance. This may be because most have done the assessment at anatomical neutral footstance without hip abduction like Wendy Jardin of the Dalhousie University in Halifax, N.S., Canada.

Hope that this is helpful. I would be glad to give you any other information that you would wish.

My best to you,

Neuromuscular ED

[neuromuscular]

hi
i feel the deviations can be quite normal .there are various structures which contribute to such deviations and detecting may be a bit time consuming .i doubt whether it is of any use

Dear Linbin:

Many at first feel as you do. However, that is because research and papers are almost nonexistant on this subject as the researchers for the OGI are finding out. Their research is finding that the pelvic angle differences make a huge difference to their assessment and subsequent therapy.

Please do not too readily dismiss this idea. I feel that when the OGI has finishes the study and the paper is produced that the initial reaction will be like yours. However, as the test becomes more "mainline" that many will wonder how they did without it.

My suggestion is that you try it. You will have some problems integrating it at first. However, its value will be shown in short order.

Pelvic angles in the population with no back pain are near to the horizonatal plane. Those with low back to extremity pain deviate greatly.

Best regards,

Neuromuscular.

[jerryhesch]

Evaluating lateral mobility of the hip, pelvis and lower spine seems to be a relevant thing. If the pelvic girdle cannot move in one direction, it will move in another. Long ago i noted a subtle form of lack of lateral pelvic mobility which I named a pelvic side glide dysfunction. It can be observed in stance and gait at times, but many times it is too subtle and yet is very apparent when client is supine and passive force is applied to the lateral pelvic to induce left to right side glide andcomparing to the opposite direction. One first takes up the slack and then induces an additional impulse. Gentle passive stretching for 5 minutes is usually sufficient, done in sidelying over a few pillows. I suspect that what you describe may be a lack of available side glide mobility which then induces the lumbo-pelvic-hip region to take an alternate route. I agree thatassymmetry of pelvic landmarks does NOT mean the the ilium has rotated on the sacrum or the reverse of that. A person with fused SI joints can still move in that manner, the pelvis moving on both femoral heads. Our profession is very young and yes we have some research and yes we need so much more. I encourage your efforts and look forward to hearing more. who is OIG?
SincerelyJerry hesch, MHS, PT www.heschseminars.com
Home

[neuromuscular]

Evaluating lateral mobility of the hip, pelvis and lower spine seems to be a relevant thing. If the pelvic girdle cannot move in one direction, it will move in another. Long ago i noted a subtle form of lack of lateral pelvic mobility which I named a pelvic side glide dysfunction. It can be observed in stance and gait at times, but many times it is too subtle and yet is very apparent when client is supine and passive force is applied to the lateral pelvic to induce left to right side glide andcomparing to the opposite direction. One first takes up the slack and then induces an additional impulse. Gentle passive stretching for 5 minutes is usually sufficient, done in sidelying over a few pillows. I suspect that what you describe may be a lack of available side glide mobility which then induces the lumbo-pelvic-hip region to take an alternate route. I agree thatassymmetry of pelvic landmarks does NOT mean the the ilium has rotated on the sacrum or the reverse of that. A person with fused SI joints can still move in that manner, the pelvis moving on both femoral heads. Our profession is very young and yes we have some research and yes we need so much more. I encourage your efforts and look forward to hearing more. who is OIG?
SincerelyJerry hesch, MHS, PT www.heschseminars.com
Home

Dear Jerry Hesch:

OGI is the Ola Grimsby Institute.

Ola Grimsby and the MTIPT have shown great interest in this research.

I do not concentrate on the SIJ as much as on the distortion to the innominate bones as the hip abduction progresses. Many have a tough time conceptualizing this as it is not as most experts put forth because of the manipulative approach early on in the history of therapy dominates thinking. The early theories still dominate research from Europe such as that of Andry Vleeming, which has in turn affected the work or should I say dominated the work of DIane Lee. In North America, the idea of SIJ dysfunction, regardless if the early influence was osteopathic or chiropractic theories, still dominate thinking.

I use the postural assessment with hip abduction because it gives the most objective information on the patients condition. There are two type of tests involved. The hands on landmark test as described with the ASIS to ASIS, PSIS to PSIS, and ASIS to PSIS (R&L) with the hip abduction. The second test is to see how the overall body movement occurs when the person is stressed by the hip abduction. In this one, the practitioer stands about 10 feet to 12 feet away and watches from each side in turn as the patient does hip abduction. In most of the patients, the torso flexes, the buttocks move posterior and the knees flex. The variations show how the patient is affected. Other overall distortions are noted that differ from this basic one.

I urge all to try the test. However, many have trouble thinking outside of the box and this makes using the test difficult for individuals who cannot visualize or conceptualize. I have found this in many of the leaders in the profession from Holland to America and to Australia.

The test is anatomcally and physiologically sound.. The main test or trial of the test is in Lincoln, Nebraska, USA. The research paper will be published in approximately six months or less.

I have found that the torsion or shear pressure on the joint is not from internal, but external factors. This runs counter to much of the research which test the joint. Presently, the feedback forms on the in clinic results have given us a well over 90% success rate at reducing the pain by 90% and the measured ROM tests indicate dramatic increases in ROM. Patient treatment cycles are reduced to 3 to 6 treatments for the majority and patient refferals are up.

The limitations of this theory are that the neuromuscular system of control must be in tact to treat the patient. Things like CP have not been treated and the probable out come would not be great. The other limiting factor is the ergonomics of the patient at work. Certain professions require some follow up. The worst are flooring installers and long haul drivers. It has been amazing that some who used a cane to come in, forgot the cane when leaving.

I hope that this give you more insight into the test and theory.


Best regards,

Neuromuscular.
B

[neuromuscular]

To All:

The apprehension to this test is normal. However, I urge all to try the test with hip abduction.

Then make your own decision and not that based on past theories.


Best regards,
Neuromuscular.

D

[neuromuscular]

An update:

In doing the paper search for the new research abstract no reference was ever found to the type of test indicated in this post.

Even in contact to experts in Europe and USA, none knew of a test using hip abduction.

The research abstract is slated for year end.

Just a heads up to those who will try the test.

Best regards,

Neuromuscular.

[neuromuscular]

To All:

The presentation in Seattle, Washington, USA was a success and numberus physiotherapists who have Masters and Docturates attended.

The overall reaction was very positive.

Many will incorporate the pelvic assessment with hip ABD in their routines.

Hope that those who have read this thread will try it also

For those who wish a transcript of the presentation, please place your request on this thread.

Best regards,

Neuromuscular.

[neuromuscular]

To All:

I have put out this test as I find most references are concerned with SIJ and not innominate bone position in low back pain. This test shows how bone transition occurs as hip ABD progresses. It shows how muscular imbalance affects the bone position.

Try it. See what information it gives you on your patient/client and give me feedback.

Thanks

Neuromuscular

[alophysio]

Hi all,

For a critque on the test neuromuscular proposes, here is our "conversation" over the last year and a bit...please be sure to read from the start otherwise the end will be out of context!!

http://www.physiobob.com/forum/ortho...-si-joint.html (New research: No such thing as "stuck" SI joint)

Try the test and see.

I personally had no change in my practice from the test. When i find an overactive Adductor muscle, i treat it.

I use a systematic and wholistic approach to assessment and diagnosis, not just one test or model...

Anyway, try neuromuscular's test and see what happens

[neuromuscular]

Dear Alophysio:

Thank you for your reply.

I know that you still advocat the SIJ testing.

I cannot understand why, as you have agreed a number of times that the SIJ is not the problem in the majority.

The innominate bone position test or APAS test is not concerned with the supposed SIJ dysfunction that the SIJ testing is preoccupped with.

Why do a test that provides no useful in formation other than that the failure of the Gillett test indicates "fixation" or "a stuck" SIJ or the load transfer test indicates a failed load transfer? How does this contribute to the overall assessment of the patient????????

The innominate bone position test gives an orderly flow of information which builds on the previous. Accuracy in the fewest steps is the goal of every practitioner regardless of discipline.

The SIJ is a bit of frivolity in this vein of thought. It adds nothing as to what is the cause - structure or function: joint or muscular. The practitioner must do other tests to determine which is the problem. The innominate bone position test or APAS test, does give useful information right from the start of the assessment cycle. The other tests build on it. However, I have tried to do therapy on the basis of the outcome of the APAS test alone and it can be a stand alone test, if one wanted it to be. The SIJ tests cannot do that!

Best regards,

Neuromuscular

[alophysio]

Dear Neuromuscular

Who said anything of doing an SIJ test?

Can you see in my immediate post above where i have mentioned they should do that instead?

I have simply proposed that people try YOUR test and see. How is that wrong?

I have simply stated that when i find an overactive muscle, i treat it - how is that wrong?

I have simply stated that your APAS test has not made a difference in my clinic - how is that wrong?

I have simply stated that i use a different, more holistic method of assessment and treatment - how is that wrong?

And then AGAIN i ask them to try your test and see for themselves...

... So why is it that you are attacking me???

To quote yourself - "The lady doth protest too much, methinks." (Hamlet Act 3, scene 2)

But to simply answer your questions...

1. SIJ problems exist - the joint itself is not the problem in the majority - by that i mean articular dysfunctions (form closure).

2. It is good that the APAS test is not preoccupied with the supposed SIJ dysfunction - it is good because

a. it therefore cannot make statements about SIJ dysfunction - by your very own admission you have now stated that it doesn't concern itself with SIJ dysfunction...

...so how can you state the the SIJ moves or doesn't move by this test?

You have defeated your own argument by your own statement!

b. The APAS test cannot define what dysfunction is occurring in any case - it simply *might* tell you that a dysfunction is occurring

3. Read Hungerford's papers again - it is not about a fixation or not neuromuscular - it is about whether failed load transfer occurs or not!

4. Innominate bone use as markers suffer the same reliability issues as the Stork test so if you want to use a static test for a dynamic human being, then be my guest

5. YOUR APAS TEST suffers from logical issues, anatomy issues and commnon sense issues. The bottom line is that it will never pass research testing simply because your assumption that all problems are muscular or held there by muscles is simply naive and incorrect.

6. My version of the Stork/Gillet test tells me about foot/ankle, knee, hip, SIJ, L/S, T/S and even C/S dysfunction - can yours do that? If we are going to play the game "who has the bigger one" then you will lose because

a. your test is limited. My test isn't as limited as yours
b. your test does not have any research to prove it works. Mine does.
c. Your test is limited to the coronal plane - Mine can work in the coronal, saggital and transverse planes.

Lastly - my test is not an SIJ test!!!

[neuromuscular]

Dear Alophysio:

I am chosing not to reply to you any more, because you have shown an antagonistic candor from the start that I have tolerated.

You have used inuendos and intimidation from your first time with comments like "hidden agendas" etc.

You have only breifly considered what I have to say. Consider the comment on the driver position may influeence test results: You reply that the pedals are on the same side for left and right side driver position. That is just one ergonomic factor. Others are:
1. Which way does a driver in each area do a shoulder check: The same way or opposites?
2. Which arm is used to shift gears, tune the audio and adjust the climate controls? The same or diferent?
3 Which does the driver use as the pivot leg?
4. Which arm does the driver use to hold the wheel as he shifts gears or changes other controls?
5: Which way does the driver's body gravitate to - to the inside or to the door?
There are others.
These are details that you chose to ignore. Have you done this with the test and other items???? Ple3ase don't ignore what you wish to and highlight that which you want. I am sure that your students do not appreciate this either.

You do not give what I say more than a cursory attention and then dismiss it. You claim that I do "cherry picking" when I show flaws in present theory, but you quote without noting the flaws. Further, you attack concieved errors in logic for other theory, but ignore errors in the model you propose. Be honest and upfront!!!!!

If you cannot impress with secular authority, you appeal to God by Biblical passages. I am tired of your candor. I get very bored again by such tactics of supposedly "Christian" makings. God does not bless or make your secular matters.

Get over it.

I am not willing to converse with this type of attitude.

Goodbye
Neuromuscular.

[physiobob]

Dear neuromuscular & alophysio

Firstly happy new year to you both. Secondly, thanks for your continuing contributions to the forum as I am many others enjoy a heated debate. And your's is one of the best.

But I think generally you guys are getting a little personal, perhaps through frustration as you both believe strongly in the views you are suggesting.

Alophysio is perhaps on the hard line or peer reviewed trials and evidence based stuff. Neuromuscular is perhaps on that side where people are trying to come up with something practical that others can later investigate to their satisfaction.

I would not want any comments that "get personal" to interfere with your great contributions.

For what it is worth I think it is great that someone is clinically trying to develop our assessment. As a pure maths and physics student prior to physio I am also very, very critical on the collection of data, the operationalisation of the initial questions asked as to what that data was collected and importantly the subsequent conclusions or statements that are made about the results. I do take alophysio's comments on that and think this is worth stating.

For what it is worth this topic refers to a "Stuck SIJ". This is where I believe most people researching this topic miss the point. You cannot look for mobility in something that is stuck. You cannot show it in realtime MRI etc. The point is that it move from a position at time A and through some force moved to a position B. Clinically we cannot see the move from A to B as they are at B when they come t visit us.

Perhaps a 3D scan such as PET or SPEC scan when the patient is asymptomatic (perhaps a position A) with some type of rotational marker system and later a follow-up comparison3D scan when they are symptomatic (perhaps a position B) might lend itself to assisting us whether or not to acknowledge that a shift is the SIJ is possible and then whether that might lead to pain. So far I have not seen evidence of this but it seems pretty logical to me.

Clinically though it doesn't really matter what us going on as long as there is an assessment technique that leads to a treatment technique/process, that leads to a reduction in symptoms. For the later is what we are after as clinicians.

We do not like to remove any commentary from this forum suffice to say that I am happy to remove any personal things that may have been said in frustration. SO please let me know via a direct message if there are things you'd like removed.

Try to keep things on track, perhaps (as I have seen from email correspondence) you two should be working on the same development as coming up with something together after all this debate would be a benefit to us all and a great forum on which to facilitate that for the wider community.

Big smile to all.

[alophysio]

Hi,

I apologise for my comments.

Please don't take it personally Neuromuscular. I am genuinely concerned with your health.

Cheers

[neuromuscular]

Dear Physiobob:

Thank you for your input.

I will not keep in touch with this forum.
It is not because of you or the forum.

I have had to ask several times for people, who gave very negative, if not insulting remarks, to just try the test. There appears to be little room for true research. Today research is how many prominent individual you can quote..

That is not my idea of research. That is the idea behind getting others to praise you, because you praise them. That is peer pressure and not peer review.

My idea of reseasrch is to take what you use now and pit it against some other process that would prove or disprove it. Then note the outcomes of each.

Right now the form closure/force closure/neuroplogicqal/emotional model is the "flavour of the month" if not the past decade or so.

Will it stand the test of time? Only time will show that.

We had the idea from Ptolemy that the earth was flat. It was agreed on and quoted extensively although other less known theories and ideas were put forth. Later, Capernicus and even later Glilleo put forth a different model that others - authorities of the time - strongly objected to. Time proved which was closer to the correct idea. Time proves or disproves all things.

I have had extremely unprofessional remarks from three different people in Australia - one of whom praised their method, but put down fellow therapists in England. That is not professionalism to me!

It is one thing to disagree on ideals and theories. It is quite another to put others down.

I have been stated to have a "hidden agenda". I do not have any desire ot sell or make money off of this idea. I just want others to be open to a new idea that many of those who we view as authorities agree has not been tried.

However, I do feel that others have revealed their hidden agendas in that their method is thebest dang whiz bang super duper all inclusive all-in-one version of the load transfer SIJ test which can assess from the tip of the patients toes to the back. I do not claim a panacea, just a new approach and theory.

I have used Andry Vleemings Book entitled Movement, Stability and Low Back Pain for the simple reason that it shows the preoccupation with the SIJ and SIJ testing by ALL disciplines as this was a complilation of some of the most eminent people of our time period. It shows a preoccupation with SIJ and related tests by its three and a half pages of references to the SIJ but no reference what so ever to the adductors. That to me shows where present "wisdom" is headed. Diane Lee and others have stated that the present theory has flaws if not gapping holes which require more research. I do not think that we should lightly brush these aside.

I have had personal things misrepresented by others These may be the viewpoint of that individual, but they do not represent the whole of the situation. That, I find very unprofessional.


I will not engage in discussion with such types of communication.

I ask all to try the two tests the Gillett or standing SIJ test with hip flexion and/or torso flexion ( load transfer swing phase if you like that designation better) and compare the same landmarks with the standing SIJ with hip ABD. What results does the practitioner see????? That is all. I do not want to lecture or sell a book or services. This was done free of charge and will continue to be so. I ask that they do this without prejudice and free of past ideals. Then, have each decide for themselves.

Since this posting on this thread, I have had interest from a Canadian university to do a trial or test of the idea on a small scale. I do not wish to continue to be hauled onto the carpet again and again as has been the experience in this forum.

I have said that I do not consider it professional to use certain ideals on a secular site and I still feel that way.

Using the power of authority is never beneficial.

My best to you and I hope that the forum will show more openness in the future.

I do not wish to continue, so if you wish to remove my threads that is acceptable to me. I do not want to be part of a character bashing.

Best regards,

Neuromuscular.

[alophysio]

Dear neuromuscular,

Sorry you feel this way.

I have had extremely unprofessional remarks from three different people in Australia - one of whom praised their method, but put down fellow therapists in England. That is not professionalism to me!

Please do not take the moral high road here. You have insulted and put down the research of many people including Andry Vleeming and Diane Lee.

I do not want to be part of a character bashing.

Please be fair. Part of the reason i respond is because there is no one to defend these people whom you attack.

You quote Andry Vleeming book which is from 1997 (which means the material in it is likely to be at least a year old) - he has a later books - have you read that one?

As for my test, i do not propose a super duper test, merely that when applied correctly, it can give you more information that your APAS test.

I do not claim a panacea

...but i believe you do...

As for your "agenda"...here is what i believe your agenda is - from http://www.physiobob.com/forum/ortho...i-joint-2.html

1. Put forward an idea without background
2. Put forward an idea and hope people give you the background (which i have done a lot of)
3. Don't care about the past or what is out there and push on ahead with your ideas...

It is my hope that you are open enough to accept any critique of your ideas.

Before i conclude, i believe that it has been shown that i have defeated all your arguments with logic, scientific reasoning and simple common sense and knowledge. I do not need to appeal to God for help because your arguments was very weak. I merely quoted scripture because that is where the quote was from...so if you choose to be ignorant about how to reference something, by all means...but you seem a bit touchy on the ol' religion/secular thing...

Anyway, I will leave you with this parting thought...

If insanity is to do the same thing over and over and expect different results (source uncertain - ?Franklin, ? Einstein, ?others), then perhaps...

1. You are correct and all the questions which i have asked (and not had answered) will be answered easily

2. Or perhaps my arguments are valid and you will hear them again and again until your ideas change.

3. There is always room for another option because i do not know everything!

The thought is this...if you come across more people who employ the same arguments and critique your test the same way and come to the same conclusions, then PERHAPS they may have a point and not just be slaves to authority. If you knew me, you would understand that i do not bow down to authority but i do respect other people's work...

Good luck...

[gcoe]

It looks as if these particular threads on Neuromuscular’s test and subsequent management are coming to an end. However I think we should consider what happened, how people responded and where it lead us.

Experimenting on Patients without Conducting Bona Fide Research.

If this topic was about a rare condition where there is little evidence for tests or interventions then we are in a situation where we have little to fall back on. With an absence of evidence then we apply the best assessment and management strategies, based on clinical reasoning - both hypothetico-deductive reasoning and pattern recognition. At times we may fall try novel assessments and management strategies simply because doing something may be better that doing nothing. Here a site like physiobase.com is a great place to share ideas and find out what other people have tried.

However this is not the case here. Low back pain and pelvic pain are the most researched area of physiotherapy to date. In this area there are tests and treatments with adequate evidence. There is way more to learn but the research is at a maturing level of development. So when a colleague comes along and repeatedly invites an audience of physios to try out a novel test and treatment approach that has no evidence to date and where the proposal is extraordinary; who deliberately tries to get as many people involved in the testing as possible, I don’t think this is ethical. Groups of patients are being experimented upon, mostly unknowingly.

Any ethics committee would be horrified to learn that patients were being experimented on this way. If a new blood test with a novel drug treatment was handled in its preliminary stages this way all hell would break loose – and quite rightfully so.

Surely you might say the test is so harmless and relatively quick to do – so it isn’t really putting the patients at any risk. Well it may not be a likely to cause injury but it could delay the implementation of a strategy that is shown to be effective. It will most likely add confusion to the differential diagnosis. And it is costing the patient money (or if it is happening in a publicly funded clinic then it is costing the taxpayer money). And at the end of the day even if this novel approach gets some good results – this is the worst kind of evidence to fall back on – a series of anecdotes. We won’t know if it is due to placebo, the patients being polite or they were going to get better anyway. A real missed opportunity for better developing our knowledge - that was rigorously reviewed and published in the public domain

A better Way Ahead

A better way ahead would have been to have published in a peer reviewed journal a good case study or even a series of cases. Such a study that used a rigorous form of measurement could then stimulate some experimental search in the biomechanics lab. Such a look at this pelvic angle test and the relative activity of the contralateral adductor longus muscle in a group of LBP sufferers and a pain free groups might or might not show promise. One could then look at the measurement properties of the test. Then a phase one trial (small RCT) of the management. Here we are looking at years of research and the need for considerable funding. However such money is available in such an important areas of health with a group of conditions

Extraordinary Claims Need Extraordinary Evidence

Over the many decades in the life of physiotherapy many people have come up with their own tests, management which are at odds with the prevailing view. These approaches spawned BIG NAMES in physiotherapy, books on the techniques, graded continuing education courses all at great cost and time to the practitioner. And at the end of the line are we more knowledgeable? - the proponents always think they are but the evidence as it unfolds is usually less convincing. The rule here is the more extraordinary the claim the better the evidence needs to be. This rule is not about “clinging to orthodoxy” and have a closed mind to another way of looking. It is about taking stock of where the evidence currently lies. And not getting swept away on the latest fad.

As it stands there has been all this debate about this test, patients were tested with unclear results, but are we better informed from it? We await Neuromuscular’s study. Other than that I don’t think this has lead us anywhere constructive.

[neuromuscular]

Dear qcoe:

I will address your concerns, since you are new to the discussion and since you have brought up the matters of ethics.

You mention blood:

Consider what has happened in the area of blood:

In the late 1700s it was considered the ethical proceedure in the medical world to do "blood letting" or massive amount of blood taken out of the patient in a phlebotomy. That changed in 1942 when a Dr. Adams published a paper in favour of transfusing at the level of 10 grams trigger for transfusion. This with the knowledge of blood typing brought in the age of the "magic bullet" of blood transfusion which lasted until the "bad blood" scandal of the 1980s. Then the Sanguis report of Europe (1994) showed the inconsistencies of 43 teaching hospitals. Then the Biomed Report of 1998 showed how a reduction or abstinance from transfusion was recommended.

The ethics of the 1700s changed to the ethics of the 1940s to 1980s which changed again to the newer ethics of today.

Ethics has been described as a flowing river which changes constantly with the terrain. What is ethical today may change to what is not ethical tommorrow.

Physical therapy is not "rocket science" or highly precise internal medicine of surgery. The risks are not that great!

However, would it not be unethical to put forth a proceedure which is considered as ineffective or of questional benefit to the patient and charge for this? WOuld it be "ethical" to proceed with a patient treatment with only part of the available information on the patient? Consider the standing SIJ test with hip flexion or torso flexion. This test is in every text and is used by many professions to asssess for a "stuck" SIJ or "fixation" of the SIJ when in fact it does not show this. In talking with physiotherapists in a one on one or in groups at conferences, the majority agree that this test is very subjective and of little value. Approximately 66% or 2 out of 3 state that the test has very serious questions of reliability. About 90% will acknowledge readily that is has problems. Yet, this test remains in the text books for teaching new therapists. Is that ethical? Further, the test yeilds different results in comparison to the same landmarks with hip ABD. The positive of lack of movement between the sacrum and PSIS becomes the negative in the hip ABD with the PSIS moving superior and lateral to the sacrum. In the normal populace with no back pain, the negative of the "Gillett" test shows no movement of the PSIS to the sacrum with hip ABD.

In the use of this test, in the chiropractic field, the patient is adjusted or "slam dunked" in the majority on the basis of this test alone. From chiropractic sources, the SIJ adjustment using the "lumbar roll" is used in approximately 60% of the cases based on the standing SIJ test with hip flexion or torso flexion. This can be found in other professions. Medical practitoners will use this test in the hip flexion or torso flexion to assess the SIJ.

If we take the more "in voque" test - the present "flavour of the month" test - of the "load transfer" test, many physiotherapists agree that the test is subjective and inconclusive in their practice. They do not find what they have been conditioned to find. They find it inconclusive. Even the "experts" in this test agree that more testing is needed to verify the results. I agree.

In test after test we find a total disregard for what hip ABD would tell us. Is this because it has not been considered???

I have used the book by ANDry Vleeming entitled MOVEMENT. STABILITY AND LOW BACK PAIN. It has been noted that the publication date is 1997. However, it has been equally ignored that the book has been republished in a second edition. That is like the manual by Tortora and Grabowski which has a copyright date decades old, but has been republished in at least a 10th edition. Or the manual by David Magee in its numberous editions. I use the book edited by A Vleeming et al as it shows the most eminent minds of our era have been focused on SIJ testing to the exclusion of other factors. IS that ethical??? No one is using hip ABD to test the innominate bone position of the patient. Is that ethical? Are we in an era of tunnel vision which excludes certain important information that the practitioner should be aware of???

What is ethical? Is it ethical to use a test with "known" problems on patients without telling them? In your case of blood, today the buzz word is "informed consent". Do you inform your patient that the test you use has limitations?????????????? I do. I tell them that I am going to use a new test that others in physical therapies might not use to assess for innominate bone position. Do you describe what the test will tell your patient about the patient's condition??????? I do. Further, I find that most of the patients I see have had little or no succss with other forms of treatment. They are very happy to find that someone is doing a different form of testing and who informs them of why they will be treated in the protocol which I may use. I tell the patient why I will be doing a proceedure. I tell them that they have the right to decline the treatment. None have so far. All of them appreciate being informed and the option of declining the therapy. Further, they sign a form of consent. Do you have your patient's do this??? I am not afraid of what I will do and hide behind a cloak of secrecy. I believe in patient rights and the informed consent principle. Do you? That is what I consider ethical and proper. Do you?

The physical assessments are not "rocket science" - it maps positions. What can be unethical about knowing more about the condition of the patient??? Do you want to know less??? The present testing is limited and subjective as even the "experts" agree and most physios agree. Should we not be looking for more information of the patient's condition? If we do not, could we not be culpable??? Do you want to be accountable for missing vital information about the patient by not doing a hip ABD test ?????????????????????????????????????????????????? ?????????????????

Neuromuscular

[alophysio]

Dear Neuromuscular,

I will speak for myself if i may...

I don't have a problem with mapping your bone positions and others trying it. It is merely physical assessment after all and i don't think it is dangerous - perhaps at the greater ABD widths and i believe you would provide support or modification if someone was in a dangerous position.

I still maintain that people should try it.

I still maintain that APAS has not changed my assessment or treatment.

I still maintain that my use of the load transfer tests are not subjective if your test is considered objective - they fall in the same realm. Also, studies are being done on load transfer tests, something which has failed to materialise for your APAS testing...here is something i quickly found on google...Motor Control Patterns During an Active Straight Leg Raise i... : Spine

I hope your newly interested people at a CAnadian university do good research for your sake. If you are entirely open about your test, please direct them to this and the other discussions about concerns i have had...or give them my email address.

Cheers