Assess Movement, But Don't Bother Palpating For It! | Modern Manual Therapy Blog

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?


  1. HarrisonvaughanptApril 11, 2012 at 9:05 AM

    Exceptional way of wording your thoughts E. it would have taken me twice as long to get out what you stated in short.

    I am surprised they taught you PIVMs in your fellowship training as I thought this was way behind the times. Not calling out your age but I am hoping that isn't taught highly in the training now vs 11 yrs ago! I have heard St. Augustine's program relies heavily on this though... Makes me really think if fellowship training will provide a great deal more as I have fortunately never went this route with PIVMs, etc and glad I didn't waste my time!


  2. There is also research that shows PIVM and PA's to be more effective when they are done in the same way every time. Also, don't forget the flawed methodology of many of these studies. They assume that when PT's say they are assessing L4-5 that they really are on L4-5! Often it appears to be that we have trouble locating a particular motion segment. In my opinion we should continue teaching PIVM and treatment of specific segments and concentrate even more on basic palpation strategies. I do agree that motion and function are important criteria. Read the review by Peter Huijbregts for a starter.

  3. I just completed certification through St. Augustine and was always over whelmed by the amount of PIVM techniques in different positions for the thoracic and lumbar spine. I learned them for certification and have all but abandoned them since.

    What I've found that works best for me, and what has some evidence guiding its use would be cervical lateral glide testing (de las Penas), cervical PA testing (Jull), thoracic spine PA springing (not looking for position faults or rule of lower finger) and central / unilateral lumbar spring testing in conjunction with pain provocation (Cook mentions this as having improved reliability in his book, can't remember the source).

    I don't have a MDT background so I can't comment on that, but having taken the SFMA when a breakout leads to pain, I will treat site with joint / soft tissue manipulation utilizing the above techniques in comparison to their AROM, and then proceed to address the most non-painful dysfunctional pattern. I am still trying to "smooth" out my SFMA breakouts, but I have found that I may have been too busy treating the site vs source of the sx.

  4. When I assess right before treatment, I do very similar, lateral cervical downglide testing, as that is how I perform my manips, thoracic P/A, and lumbar P/A, but unilateral. I would have to be in an old school mood for lumbar though.

  5. You're right Steve, there are studies that show experienced manual therapists not even being able to agree on a level, much less the movement of it. If you find it helps your assessment and directs your treatment, I am sure it is repeatable for you. However, I did not find especially lumbar PIVM helpful (especially the sidelying palpating for gapping and approximation). Plus, in lieu of specificity not being needed for lumbar thrust manipulation for lumbar pain, why test for specific segments?

  6. Do you let repeated motions and active movement testing decide your decision regarding joint manipulative techniques, and/or evidence supporting general vs. specific techniques?

  7. If you see that Isaac who posted above just finished USA certificate in manual therapy, and he too was overwhelmed with the amount of PIVM he was instructed in. I guess it gives you choices if anything. What is your formal manual therapy training?

  8. HarrisonvaughanptApril 11, 2012 at 8:31 PM

    I don't have any great deal of formal training except under Dr. Dunning (I know some may gasp at this from a recent study of possible bias...)

    But otherwise, I have been fortunate enough to have a great mentor, who happens to be the guy who hired me out of school! So I got paid, and learned under the same roof. Not a bad gig :)
    He taught me things he has learned over 10 yrs, explained various courses/approaches that he feels works but most importantly, techniques and approaches that have helped him grow into a successful private practice and a very 'natural' clinician.

    I would like to get more formal training in the future, but honestly don't want to go through a bunch of very specific, non-valid or reliable techniques such as PIVMs. It doesn't help me help the patient anymore in my opinion. This is really what it comes down to.


  9. I let the limitations in motion guide my choice of treatment. If someone for instance has a limited lumbar sidegliding to the right, I check psoas, QL, release them, and retest. If someone has limited cervical SB to R, I release bilateral paraspinals, trap, levator, then go to 1st rib ipsilaterally, and check any remaining joints which may or may not need manipulating then.

  10. A few of my former fellows took Dunning courses and have nothing but great things to say. He obviously is a very skilled manipulator and wants to prove more on cervical thrust as recent studies only want to prove that cervical mobilization is just as effective or even upper thoracic thrust is. Why touch the c-spine at all? Because we can, not all patients respond to criteria set by a study, and some just feel better after manipulation. I know when I have an acutely locked facet, MDT works great, b/c I'm crazy compliant with my HEP, but it hurts like hell until it gets better, which literally takes 100s of reps over the day. One thrust and I get the same effect!

  11. HarrisonvaughanptApril 12, 2012 at 8:08 AM

    Good to hear you say that. I have learned a significant amount under him and actually going through with dry needling under his program as well. He is highly evidenced-based but just like any clinician, does have his bias towards approaches. This is why he is good though. I love that he gets to the point and you don't have to go to a whole week class to learn techniques. I think other courses are too much a money maker.

  12. As a current 3rd year DPT candidate, can I just applaud the level of intentional discussion present on this site? THIS is what causes me to be so enthused about this profession. Keep up the strong work!

  13. Thanks! We are a passionate profession! It's what makes us always near the top of highest job satisfaction rates!