Author: Eric Robertson

John Childs:  Pathoanatomy is only relevant for guiding treatment decisions in roughly 10-15% of cases of LBP. Even in these cases, the pathoanatomy may be serious (ie, cancer, fracture, etc) so the percentage of cases in which pathoanatomy is relevant for guiding physical therapy treatment decision-making is even less. This is the reason why concepts of “treatment-based classification” and “subgrouping” patients with LBP  based on clinical examination findings have become such an important research priority over the last 10 years. The elusive search for the pathoanatomic diagnosis and “magic bullet” treatment lies at the root cause for the disaster of LBP management in the U.S. and a re-focus around identifying pathoanatomy would be a big step backward rather than forward. 

Childs:  The manipulation CPR as developed by Flynn and validated by Childs can only be generalized to similar patients that were included in these 2 initial studies and only using similar treatments. In both the Flynn and Childs studies, the SMT intervention was standardized and limited to a single high velocity thrust technique. Childs et al also included a comprehensive exercise strengthening program to the intervention. In contrast, Hancock et al allowed therapists wide latitude in which manual therapy techniques to use. The large majority of therapists (97%) elected to use lower velocity mobilization techniques and the 4-week intervention did not include an active exercise component (strengthening or otherwise), thus it’s difficult to compare the 2 studies. It is not surprising at all that Hancock did not find any differences in outcome based on whether patients fit the manipulation prediction rule because they tested an altogether different treatment approach. Their study does provide strong evidence that lower velocity mobilization procedures, in the absence of an active exercise component, is likely ineffective for patients with LBP.

 

 

Childs:  There is no evidence to suggest that SMT directed to a specific segment can be done in a reliable and valid way. Even presuming it could be done, there is no data to suggest that a “specific” approach is more clinically effective than a general approach. Many studies have demonstrated that the effects of SMT are likely occurring above and below the targeted segments. Much research is now being directed at understanding the mechanism through which SMT acts to improve pain and function. It seems that selection of the right patient is a more important priority than which technique is used. There is data now in the lumbar spine to suggest that SMT incorporating high velocity thrust manipulation is more effective than mobilization in the subgroup of patients who fit the manipulation rule.

 

Childs:  Pick the right patient and use SMT frequently in conjunction with an active exercise strengthening program. Don’t lose sleep if the models of “diagnosing” presumed biomechanical dysfunctions confuse you or don’t make sense. In all likelihood, they are mostly invalid and not useful for decision-making anyways. The key is being able to match patients to the right treatment based on key clinical examination variables associated with a successful outcome from a particular standardized treatment approach.

At some point, technology will touch upon everything, and I wonder if these auxiliary legs might be the wave of the future for assistive devices. Instead of a clumsy rolling walker, one might simply strap on these robo-legs and go.  Could I be instructing how to strap on and use robo-legs in a couple of years?  

ERIC