Time to Let Motion Palpation Die?

Unreliable, invalid, and creating a sense of fragility in patients. Does motion palpation deserve a place in clinical practice?

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Having recently graduated from physical therapy school I can say that motion palpation is still being taught, but in a fettered or restrained manner consistent with the known unreliability of these methods.  It was approached as if we had to learn it because we would experience it in the real world from other clinicians, which we most certainly do, and as such we must understand the rationalization of their methods.  But somewhere along our clinical career paths many lose the skeptical mindset cautioning us of the unreliable, invalid premise of motion palpation and instead use the dated rationale unscrupulously ignoring that the practice of evidence based practice would preclude motion palpation.

I admit my bias against motion palpation originated immediately upon its presentation of physical therapy school with the known validity and reliability issues.  I recognize evidence based practice is not only comprised of scientific literature, but also clinical experience, and patient values.  I would argue, however, that each of these tenets of evidence based practice are compromised in this area.  Motion palpation is not just unwarranted because it is based on unvalidated concepts and unreliable techniques, but because it is inherently not in our patients’ best interest.  This comes not solely from the act of motion palpation itself or subsequent treatment, but in our attempt to explain why we are palpating and what we are correcting.

To explain this, I will use the common motion palpation surrounding the sacroiliac joint, an area of minuscule movement which clinicians have been attempting to feel for altered position and dysfunction for decades.  Let’s say a patient comes in complaining of pain around the sacroiliac joint.  A thorough lumbar, pelvic, and hip examination with use of the test item cluster for SI joint pain leaves you confident that the SI joint is the offending location.  At this point many will take to palpating the various landmarks of the sacrum and pelvis in vain attempt to detect any malpositioning of the sacrum or either innominate.  With this, validity has already flown out the door.  Landmarks on the pelvis and sacrum are known to normally vary based on normal morphology (See Study), which is observed both between sides in the same individual and between individuals.  Secondly, we know our hands are not sensitive enough to feel with any reliability the tiny (See Study) amounts of rotation or translation that would occur at the SI joint(See Study)(See Study)(See Study)(See Study)(See Study)(See Study)(See Study)(See Study), especially when we are palpating through the soft tissues around these landmarks.  Radiostereometric radiography with metal ball implantation into the pelvis is the only reliable method of assessing pelvic motion.  So despite the evidence we come to the conclusion that a specific malpositioning exists at the SI joint and a very specific intervention is required.  But this isn’t the truly bad part.  The bad part is that we then TELL the patient, in any number of concerning terms, that they were “out of place”-but not to worry because we can fix them.  So not only have we come to an invalid conclusion, but we use this conclusion to create a sense of fragility and dependency within the patient.  They now know to associate this pain they have with being “misaligned”, “subluxed”, “rotated”, etc. and that this issue can only be addressed with expert hands putting it back into place.  And just like that dependent, fragile patient created.  Does this sound like any model of healthcare you have heard of?  Hmm…

Let me clarify that I am NOT arguing against the notion of sacroiliac dysfunction nor am I arguing that the traditional treatment of SI joint pain do not get clinical results.  There is no doubt that clinicians using the motion palpation method and specific treatments of manipulation/mobilization and muscle energy techniques of SI “correction” can still have good clinical outcomes. In fact, there are some aspects in the methodology that resembles how I still treat some SI joint patients.  But this effectiveness can be explained a large number of ways that are not related to correcting positional faults.  We know manual therapy helps with pain despite highly tenuous biomechanical explanations (more likely neurophysiological in nature.)  We know that the muscle energy techniques are basically just isometrics; isometrics help with pain.  We often combine these strategies with other treatments including exercises (creating mindfulness and self-efficacy) and passive, pain-relieving modalities.  Therapeutic alliance, sense of expectancy, and placebo effects are also gained just by having the patient seen by a clinician who acts with empathy and care towards their concerns.  Not to mention that most musculoskeletal disorders simply get better naturally as a mechanism of regression towards the mean.  So while I still do manual therapy, muscle energy techniques, and other exercises for SI pain; My argument is that we must change what we are telling the patients.  We must stop telling them they are fragile, dependent creatures incapable of resolving pain without being put back into place.  It’s a load of BS and creates an unnecessary psychological burden on our patients and financial burden on the healthcare field.  We must recognize the pareidolia creating biased clinical reasoning and jeopardizing our patient’s physical and psychological well-being; it may be time to move past motion palpation.

Author: Landon Booker, PT, DPT, CSCS

I am a doctor of physical therapy and strength and conditioning specialist practicing in an orthopedic and sports medicine physical therapy clinic in Omaha, Nebraska.

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