Reader Question: Unspecified LBP

This is a question I received from a reader.

Hi Dr. E,

I'm a PT currently pursuing my MTC through St. Augustine, working with two clinicians who have had their MTC for 10 years. In regards to management of individuals with low back pain (lets say for this discussion non specific mechanical low back pain) our basic premise is identifying asymmetric ilium and sacrum positions and telling the patient "you are out of alignment" as well as identifying specific positional faults throughout the spine (your L3 is rotated right on L4). Prior to attending the MTC coursework I was under the assumption this is what the Paris system is all about, however having attended the majority of the classes I've realized they don;t spend much time on this concept.

My question to you is this, when do you think it is valuable to assess and treat static positional asymmetries in the pelvis? What is your general assessment approach and what do you tell the patient following your evaluation when working with someone with nonspecific lower back pain.(I know that's a vague question) I do not follow in my coworkers footsteps in identifying rotations and pelvic malalignments because I am aware of their poor validity and reliability, and I certainly don't like expressing these concepts to my patients because of the psychological influence they may have on the patient.

Love the blog.

Anon,

There are countless posts and articles about PTs and EBP. Any clinician who keeps up with the research should struggle with this. I try to promote the science of PT as far as it will take me, for manipulation, core strengthening when needed, repeated motion exams for spinal conditions, etc. I also try to promote the art of PT as well. Assessment and techniques that I know will help patients. We do stress in our programs here in Buffalo, NY, all 3 of which have a FAAOMPT teaching in them, that the lack of evidence, does not mean a lack of efficacy.

I still back up my treatments such as TASTM and STM in general with evidence based on why the tissue dysfunction would occur. I base it on anatomy and physics such as stress/strain curves. No 5 grams of pressure for my patients! I stay away from treatments like MFR, cranio, and visceral manipulation that claim to be the panacea of all conditions!

In regard to pelvic assymetries, studies show that iliac crest levels, scapula levels, and leg lengths occur in most asymptomatic individuals. I still look at them on occasion, but not every patient; I tend to place them last on the list, and only if the patient is not responding to my current treatments. It's been a long time since I took MTC courses, going on 12 years, but your colleagues seem to be using the assessments from the S4 pelvic course. The basic tennets of that course is most lumbopelvic hip symptoms come from a lack of movement and positional faults in those areas. I find their palpation based approach easier than the osteopathic approach.

Regardless of your evaluation technique, what ALL treatments have in common whether it's OMPT, McKenzie, or Osteopathic, is that they all get the patient moving again. The research shows that manipulation, mobilization, and repeated end range loading all work for this area, at least for acute non-specific LBP. Since subscribing to the NOI and EIM approach, I do try and stay away from "thought viruses" such as "out of place" but I do tell the patient that one say may be "a bit" rotated and the manual treatment plus exercises given to them should address it as long as they are compliant. I hope this assists your clinical decision making.