Trial of a Test - Low Back Pain

[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