Functional examination techniques

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Physio’s and the love for palpation ? Do we really feel what we think we feel ?

Indeed, physio’s all over the world are trained in “feeling”, we are palpation specialists and are able to feel the slightest hyper- or hypomobility in a number of joints in the extremities and specifically in the spine. Palpation is often the major part of a clinical examination process. On top of that our diagnosis merely depends on those palpation findings. Is this a reliable way to examine a patient suffering from a soft tissue lesion ? I strongly believe the diagnostic value of palpation is quite overrated.

A few examples perhaps ?

We use graded mobilization techniques on segmental levels in the spine and make a distinction between grade I-IV mobilizations etc.
Do we really mobilize the segment targeted ? Perhaps not… ?

(McGregor et al. (2001), Can interventional MRI provide an insight into the mechanics of a postero-anterior mobilization ? Clinical biomechanics 16:926-929 : “The scans demonstrated clear deformation of the overlying soft tissues and some angulation of the spine as a whole, but minimal, if any, intervetebral movement”)

Many love to mobilize the sacro-iliac joints. May I refer to the total irrelevance of sacro-iliac mobility tests :

(“…Van der Wurff et al. (2000) and other authors (Vincent-Smith and Gibbons, 1999 ; Robinson et al. 2007 ; Rajendran and Gallagher 2010) have found that , when performed in an isolated manner, almost all mobility tests of the SI-joint do not present satisfactory results in terms of reliability and validity to justify their clinical application…” ;
Van der Wurff et al., “clinical tests of the sacroiliac joint : a systematic methodological review, part 2, validity”, Manual Therapy 2000, 5(2), 89-96 ; Laslett M. et al., “Diagnosis of sacroiliac joint pain : validity of individual provocation tests and composites of tests”, Manual Therapy 10 (2005) 207-218)

Unfortunately the same applies for so-called lumbar segmental instability tests, which seem to be popular nowadays ( Alqarni et al. “Clinical tests to diagnose lumbar segmental instability : a systematic review”. JOSPT, vol 41, nr 3, p130-140, march 2011 : “However, to date, none of these clinical features have been validated as accurate diagnostic signs of structural LSI” ).

Manual testing of “instability” in the ankle joint, as the result of an inversion trauma, also seems to have very limited value (Wiklin E. et al. :”Manual testing for ankle instability”, Manual Therapy 17, nr6, december 2012, 593-596 “Inter-rater reliability was poor for manual tests of ankle stability”) .

So, what is the moral of the story ? A hughe number of tests frequently used in general manual therapy seem to lack validity, so, why are they still taught and performed ?
Isn’t it time to incorporate new objective knowledge and to re-think certain procedures within general manual therapy ? Based on actual science more and more information is available that illustrates the irrelevance of a number of test procedures.

Indeed, we physio’s, we claim to feel a lot of things we simply can’t feel, so, perhaps now is the time for less “artificial hypercomplication”, less “wishfull thinking” and more objectivity.

The good news is, that incorporating those actual insights and neglecting irrelevant procedures, makes the diagnostic procedures more clear, easy and relevant.

I wish you a lot of fun and professionalism in your further orthopaedic discovery.

 

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