Assess Movement, But Don't Bother Palpating For It!

Passive Intervertebral Movement or PIVM is still taught at entry-level, post-graduate, and also many fellowship and residency programs. Why?

Ok, I know why, for the same reason that special tests like Gilet's are still instructed, along with short wave diathermy. So I will not get into that too much.

As movement professionals, we should be assessing just that, movement at it's most simple and functional, the easiest and most reliable way we can. Most studies showed that PIVM had poor inter-rater reliability and fair to good intra-rater reliability. For my OMPT Fellowship, I learned PIVM in sitting, standing, sidelying, and prone. I learned springing, palpation for gapping, rule of the lower finger, rule of 3's, sacral torsions, feeling for a spinous process moving toward my finger, and feeling for it going away. Gives me the chills just thinking about it.

After 2-3 years of doing this repeatedly (11 years ago), I convinced myself that I actually felt something. However, the more I got into soft tissue work, repeated motions, and assessing functional movements, the less I did any of these motion palpation tests (or any special tests for that matter).

My recent blog about teaching spinal manipulation was a big change, the first class where I instructed PIVM for the cervical spine; only to direct treatment and to be correlated to AROM and repeated motions. I quickly demonstrated thoracic springing, and did not teach lumbar PIVM at all.

Currently, my focus is assessing movement, however it is streamlined from several different sources. I check repeated motions via MDT for Sx alleviation (not provocation, which anyone who is listening actively to the history should know). That is a huge shortcut, if most derangements are posterior, and they tell you flexion, sitting, bending, and valsalva peripheralize and make their symptoms worse, do you really have them flex in standing and sitting just to see if they were right about themselves? For most, my experience tells me you do not, just get right to the alleviation directional preference movements!

Now, thanks to the SFMA (and still only by the text), I have been checking related regions for interdependence and grading them as functional normal, functional painful, dysfunctional normal, and dysfunctional painful. It is quite an easy, but systematic way for assessing motion, very similar in it's execution to a repeated motion exam.

These systems lead me to treatment, and seem much more reliable (MDT is proven reliable for assessment), not sure about the SFMA - will ask soon at my upcoming course). Despite PIVM also previously leading me to treatment, I often came to the same conclusion and using the same treatments without testing PIVM each time by only assessing gross osteokinematic motion or functional movements. Of course, each treatment is also a test, so I still do some PIVM to see if a mob or manip is painful or has less motion than "segments" above and below, but only so I do not manipulate the cervical or thoracic spine just anywhere without abandon.

I am sure if research duplicated thoracic and cervical specificity versus non specificity, the results would be the same as they were for the lumbar spine -as in no difference for outcomes, both being similarly positive with the right populations. It is just the cervical spine is most likely not as safe, nor comfortable to manipulate with zero specificity and the thoracic spine has too many segments not to at least choose a motion segment and start from there.

Wow, I envisioned this as a much shorter post. What's the moral of this story? Slowly regress from doing PIVM regularly. Grade movements simply, full or limited, painful or not painful is a great start. Then check and re-check function or those movements after your chosen treatments and correct exercises. It enables within visit outcomes without all the hassle of grade 2 1st rib inferior glide, grade 2 T3-5 rotation left, grade 3 T6-7, grade 2 T7-8 - don't forget the rules of 3's nonsense we all learned. Perhaps for next April 1st, I will post a Case of the Week on Sacral Torsions, is it IS or SI?