Symmetry: Good or bad objective measure?

[fozzy40]

Hello all,

I had a conversation with one of the PTs I refer to regarding a patient I sent to their clinic the other day. Long story, kind of a difficult patient but the discussion came down to symmetry. Jess PT posted a great article by Lederman [“The Fall of the Postural-structural-biomechanical Model in Manual and Physical Therapies: Exemplified by Lower Back Pain.” Journal of Bodywork and Movement Therapies (2011)] which approaches this topic a couple of months back.

So the question is how important is symmetry to you?

Thanks for your thoughts!

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[Fiveoboy11]

Hello all,

I had a conversation with one of the PTs I refer to regarding a patient I sent to their clinic the other day. Long story, kind of a difficult patient but the discussion came down to symmetry. Jess PT posted a great article by Lederman [“The Fall of the Postural-structural-biomechanical Model in Manual and Physical Therapies: Exemplified by Lower Back Pain.” Journal of Bodywork and Movement Therapies (2011)] which approaches this topic a couple of months back.

So the question is how important is symmetry to you?

Thanks for your thoughts!

I've been to quite a few clinics where there have been PT's who are strong believers in alignment as it pertains to low back pain. I personally do not think it holds water as it is doubtful anyone is symmetrical. How can it be measured to begin with gross and innacurate/unreliable palpation testing. How can someone even get a good viewpoint of alignment, even if it did relate to low back pain, if the patient is in a supine position when they are checking it from one side of the table? People are meant to be assymetrical, i.e. the brain, organs, extremity dominance, face.... The spine or extremities are no different.

I have seen cases where patient's feel they're immediately better after being "aligned" or getting put back "in" by other PT's I've worked with but I think of it this way: If someone went to the ER for say a kidney stone and was given a strong opiod, that would alleviate the pain, but it's not a solution. Perhaps it was the mobilization that alleviated some of the pain, or a strong placebo. Quick fixes, especially for chronic low back pain do not exist.

I look forward to what everyone else thinks too.

 

[fozzy40]

Thanks for your thoughts Fiveoboy!

I think symmetry is important to an extent. However, symmetry to me is a small dot of the big picture. I still believe that correcting the underlying cause is the most effective way to treat things long term. However, correcting biomechanical adaptations takes months, days, years...who knows?!? Plus, in the end, being more symmetric never means the symptoms aren't going to return or that you are less likely to be injured.

 

[jesspt]

Fozzy- You can probably guess this, but it means nothing to me. Not. A.Thing.

 

[jesspt]

Thanks for your thoughts Fiveoboy!

I think symmetry is important to an extent. However, symmetry to me is a small dot of the big picture. I still believe that correcting the underlying cause is the most effective way to treat things long term. However, correcting biomechanical adaptations takes months, days, years...who knows?!? Plus, in the end, being more symmetric never means the symptoms aren't going to return or that you are less likely to be injured.

Symmetry as an objective measurement is only important, as Five alludes, if we can accurately measure it, and if the absence of it (or presence of assymetry) is supported by a sound scientific theory as a contrubtor to musculoskeletal pain. Taken further, if symmetry meets these two criteria (which I don't think it does), it is only improtant to look for it if we can modify asymetry in a meaningful way, which I don't think we can. Here's a link to an article from Physical Therapy which lends support to my position:

http://www.physicaltherapyjournal.com/content/72/12/893.full.pdf

 

[fozzy40]

Argh...I hate symmetry! I have a patient on month #6 working on getting symmetric. Argh...okay I'm done

 

[jesspt]

Argh...I hate symmetry! I have a patient on month #6 working on getting symmetric. Argh...okay I'm done

Ha ha! I feel your pain. I just started treating a patient who has had 5 months of LBP that her health care provider told her is due to a "torsion that just won't stay corrected, probably because one of my legs is a quarter inch longer than the other." Good luck deconstructing that meme.

 

[truthseeker]

I think the term symmetry is overblown. I do look for "moderation" i.e. I like it (and usually our brains like it) when we live and move primarily in and through the mid range of our available motion.

I think Asymmetry implies that we are living or moving at or near the end range. No one is really symmetrical and so setting it as a goal is quixotic.

 

[fozzy40]

Fortunately for me, I'm not writing the script for PT so there's less pressure for me to deconstruct that mess. Unfortunately for the patient, it's her time and money.

 

[GTT4DPT]

Symmetry as an objective measurement is only important, as Five alludes, if we can accurately measure it, and if the absence of it (or presence of assymetry) is supported by a sound scientific theory as a contrubtor to musculoskeletal pain. Taken further, if symmetry meets these two criteria (which I don't think it does), it is only improtant to look for it if we can modify asymetry in a meaningful way, which I don't think we can. Here's a link to an article from Physical Therapy which lends support to my position:

http://www.physicaltherapyjournal.com/content/72/12/893.full.pdf

Jesspt,

Thanks for the link. The title of the article is "The Effects of Manual Therapy On Connective Tissue".

Is your point that the mechanical forces produced during manual therapy are likely insufficient to create changes in existing structural asymetries? If that's the case, do you have any thoughts on neuro-muscular re-ed to address functional asymetries?

 

[jesspt]

Jesspt,

Thanks for the link. The title of the article is "The Effects of Manual Therapy On Connective Tissue".

Is your point that the mechanical forces produced during manual therapy are likely insufficient to create changes in existing structural asymetries? If that's the case, do you have any thoughts on neuro-muscular re-ed to address functional asymetries?

Yes, one of my points is that we can't produce enough force to permanently deform connective tissue, meaning that most of the changes we see in ROM after manual therapy probably are due to a neurophysiological mechanism, not a bio mechanical one.

Additionally, I think "functional asymmetries" as you call them are often a "defense" and not a "defect" so if we reduce the patient's pain, the asymmetry resolves, but not for the reason many of our peers seem to think.