Are muscle energy technique assessments and techniques helpful in the treatment of acute low back pain, or does the assessment, diagnosis and terminology used with MET create long term fear avoidance and psychological treatment dependance? Is there language we can use when we treat the sacroiliac joint (SIJ) or pelvis to dethreaten your patient's pain, get them active again and assist their long term recovery?
MET is widely performed by manual therapists, including Physiotherapists, and involves assessment of the SIJ using tests such as Gillet's or Stork, identifying the position or "positional faults" of the ilium relative to the sacrum, such as upslips, downslips, anterior or posterior rotated ilia, alongside sacral torsions. Clinical careers, including my own, go through multiple iterations and continue to evolve. Throughout my clinical career I have completed MET courses, developed an understanding of MET, and used this treatment approach fairly extensively in the past. With this in mind, how does MET for the pelvis stack up, is it useful, and what problems does it create?
In my younger days I have manipulated quite a number of patient's to "correct an upslip", a "downslip" or some sort of torsion, and regularly helped improve patients pain. This was likely due to neurophysiological effects, descending pain inhibition from higher centres and potentially stimulation of the peri-aqueductal gray. One of the main issues I encountered early on was that on the patients return, whether they had improved or not, their upslip had returned 90% of the time, unless I could convince myself that I had "fixed it" by standing on the other side of the bed, and assessing how level the pelvis was with my left eye instead of my right. If you have been manipulating patient's upslips, have you noticed the unfortunate return of the upslip or anterior rotation? This led me to question whether my manipulation was actually doing what I thought (and told my patients) it was. I also started to question the effect of my assessment, language and description of findings to patients, and whether I was really helping them long term.
In my opinion, there are a number of issues with MET, including the reliability of tests (Wurff et al., 2000) along with the construct validity and anatomical evidence that would highlight the improbability of positional faults. All of that may be important or not, however at the end of the treatment day, what is important is the patient. One of the major side effects of being "diagnosed" with a twisted, malaligned or slipped pelvis or ribs, is the potential negative effects on the patient's psyche. Patients in my clinical practice often quote therapists "diagnoses" from previous episodes of back pain, feeling like they have an incurable disease that occasionally needs a shot of manipulation to get them through their malalignment. Undoubtedly this also has to do with the education and discussion they have with the therapist, or how they interpret the explanation, but having an "unstable pelvis" may create fear avoidance behaviours, and does not tend to do a lot for dethreatening back pain or assisting their return to high levels of activity, to say the least.
Despite the reasonably common short term improvements in symptoms following MET treatment, after a while (some would say a fair while... maybe I'm a bit of a slow learner) I stopped treating in this way. Following this, one patient in particular stands out that presented with low back and pelvis pain. She asked for manipulation of her SIJ, with a simple pull on her leg, because her "pelvis had gone out again". She reported that she had pressed the brake pedal on the car too hard, which had caused another "upslip", and she needed to be manipulated back into place. Upon further questioning, this happened regularly to her, and she had to be really careful with pressing the brake pedals on her car, stepping off gutters, any fast movements and had a huge amount of fear-avoidance because of her beliefs about her "pelvic instability". Beliefs such as this are easy to instill in patients with the use of language and physical assessment, followed by improvement in symptoms when the pelvis is manipulated "back into place", can have long-term devastating psychological effects and fear avoidance behaviours. Similar to all beliefs, plantar warts and unwanted bodily hair, they can also be extremely difficult (if not darn near impossible - as with this patient) to remove.
As therapists, we are all trying our best to have excellent short and long term improvements on our patient's pain, and help them return to a healthy and happy life. The next time you are thinking of assessing for and diagnosing a malaligned pelvis, or manipulating the SIJ, stop and think about the long term effects of this on your patient, choose your language and terms in a way that will help to dethreaten your patient's pain, and help them return to an active life without fear of their pelvis "going out" again. Rather than describing your treatment in terms of manipulating joints into place, or twisted and slipped sacroiliac joints, you can describe their pain using language like "irritated" tissues, and explain how you want to help strengthen the muscles around their low back and pelvis to cope with daily life and return to any and all activities.
References
Van der Wurff, P., Hagmeijer, R. H., & Meyne, W. (2000). Clinical tests of the sacroiliac joint: a systematic methodological review. Part 1: reliability. Manual therapy, 5(1), 30-36
Van der Wurff, P., Meyne, W., & Hagmeijer, R. H. M. (2000). Clinical tests of the sacroiliac joint: a systematic methodological review. Part 2: validity. Manual therapy, 5(2), 89-96.