Reader Question: Unspecified LBP | Modern Manual Therapy Blog

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.


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.


  1. I think it corresponds well with my line of thinking. If we are to look at just the low back/pelvis in isolation (which I don't, but will use it here as an example), I'm usually more focused on AROM of the spine and associated concordant pain, and attempting to utilize PIVM or PA testing for segmental mobility (IE if someone has pain with forward bending, I'm curious about forward bending PIVM mobility - despite poor reliability). While I'm doing this I also tend to focus in on the tender segments, if available. I'll still look at the pelvis for asymmetries, but now my thinking is that these are often secondary to being in pain (not always), or they may guide me to identify muscular / soft tissue restrictions or involuntary guarding patterns. Lately I haven't been performing ilium or sacrum mobilizations even if I think something is off (again with lower back pain, I will look more closely if SI test clusters are positive), and seem to be getting similar results.

    What I don't do that my co-workers do is attempt to identify and correct rotations in the spine, for example my co-worker yesterday told me she corrected a L3/L4 and L2/L3 right rotation, which she then had to re-correct once the patient went from standing to prone lying again. While I will see these positional faults in the thoracic spine, I haven't read any research to support reliably identifying them, and if they are valid to the patient complaint. I may just not be skilled enough to identify them in the lumbar or cervical spine, but I think what's important as you mentioned earlier is getting something moving. I also don't tell my patients they are out of alignment, or that they have a rotation in their spine which I have just corrected, which my co-workers do, I try to keep things simple and state that there are structures that just aren't moving well.

    I appreciate the response, and I'm curious if you have opinions or suggestions on my thought process, as it is always changing.

  2. Looks like you're on the right track in combining cluster tests that have been proven reliable and valid with less reliable tests like PIVM. In our fellowship program, we teach that taken out of context, tests like PIVM may have less reliability than the whole of the exam, which is often not studied.

    I have abandoned early in my career looking for positional faults in the lumbar spine. As recent research shows, manipulating lumbar stiffness regardless of the segment or side 1-2 times works well enough for resolution of complaints and return to function. Trying to palpate 1-2 degrees of motion in gapping and approximation can be a frustrating experience! You can have similar results by treating the concordant sign rather than palpation for position. Keep up the good work!