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Author Response
On “Ilial anterior rotation hypermobility…” Vaughn HT, et al. Phys Ther. 2008;12:1578–1590.
Evidence Please
Are We Missing the Evidence-Based Point?
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H Todd Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, Carbondale, IL
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tvaughn{at}siu.edu H Todd Vaughn
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I would like to thank Poulter,1 Cibulka,2 and Hesch3 for their responses to the
case report titled “Ilial Anterior Rotation Hypermobility in a Female Collegiate
Tennis Player.”4 I appreciate their professional input regarding the case
report and admire their commitment to holding the physical therapy profession
accountable for fostering evidence-based practice. Several criticisms were made;
some I feel are justifiable, whereas others warrant a response. I will address
each of the responders separately.
Poulter states, “The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm. This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, TENS, ice, ultrasound, massage and taping.” A treatment-based classification system identifies a heterogenous group of patients and places them into subgroups based on the examination data. The classification of the patient in each subgroup guides the treatment plan.5 The assumption of this type of classification system is that all patients will fall into a particular subgroup. Each patient is unique and may have multiple impairments that require a multi-treatment approach. Based on examination data, my patient would need to be classified in both the mobilization and immobilization treatment subgroups, as proposed by Fritz and George.5 Currently, there is only a treatment-based classification system for classifying patients with acute low back pain to treatment subgroups.5 I propose that a treatment-based classification system be developed for patients with sacroiliac joint dysfunction (SIJD). I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.6 I certainly could have classified my patient as having general low back pain and ignored the patient’s mechanism of injury and the impairments identified in the examination. This approach was used by the athletic trainer for 2 weeks after the patient’s first onset of pain. The athletic trainer had the patient continue this active treatment paradigm until she no longer could play tennis, walk with a normal gait pattern, and sit with normal posture. Poulter suggests that a body chart and valid outcome measures should have been utilized in the case report. I agree that a body chart would have increased clarity of the location of the patient’s pain. The patient reported right low back pain as a general descriptor; her pain was palpated inferior to the posterior-superior iliac spine (long dorsal sacroiliac ligament). I also agree that the Oswestry Disability Index7 could have been used with this patient. However, it was apparent, based on the patient’s goals, that returning to competitive tennis was the true measure of attaining her functional outcome. Poulter asked, “Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode?” Based on the history, examination, and mechanism of injury, I believed the patient developed right ilial anterior rotation hypermobility secondary to excessive stress to her long dorsal sacroiliac ligament (LDL). The LDL restrains anterior ilial rotation and was susceptible to sprain secondary to performing repetitive 2-hand backhands. The literature suggests that ligaments can regain 50% of their normal tensile strength by 6 months after injury, 80% after 1 year, and 100% after 1 to 3 years.8-10 The subsequent treatment program was designed to stress the LDL gradually over time, being careful not to exceed its tensile strength during the remodeling phase. The sacroiliac belt and taping technique were necessary at 6 months during tennis play secondary to the high pelvic rotational forces and the LDL only having approximately 50% of its tensile strength. The patient was reexamined 1 year later and was found to have no impairments or functional limitations. We hypothesized at 1 year that the ligament had regained its tensile strength and, therefore, the sacroiliac belt and taping technique no longer were necessary for tennis. I do not understand the basis for Poulter’s comment suggesting that I contributed to the patient’s 6-month chronic episode. Furthermore, I believe that I was able to offer the patient a solution to her complex problem. Cibulka states, “How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity?” I recognize the deficiency of valid tests associated with the sacroiliac region, specifically, those tests related to SIJD, where pain patterns are related to extra-articular structures. With the lack of a treatment-based classification system and valid tests, accurate diagnosis and subsequent treatment of SIJD should be based on a combination of historic clues, palpatory findings, segmental and regional motion testing, overall functional biomechanical examination, and appropriate diagnostic testing.9 I apologize to Cibulka for not citing his article titled “Unilateral Hip Rotation Range of Motion Asymmetry in Patients With Sacroiliac Joint Regional Pain”11 in my literature review. Its omission was not intentional, and the article should have been included. I also agree that the terms used to describe the sacroiliac joint need to be operationally defined. There is too much “jargon” that leads to confusion when discussing the sacroiliac joint. Hesch discussed several interesting points in his response. I agree that the corrective exercise for the right ilial anterior rotation hypermobility could have been enhanced by adding abduction and lateral (external) rotation of the hip. The “upslip” of the innominate should have been examined with passive mobility testing in the prone position, as Hesch suggested. Hesch also brings up an interesting point that the Ostgaard test theoretically could induce anterior rotation of the ilium. Extensive research is needed to validate tests related to the diagnosis of SIJD. H Todd Vaughn HT Vaughn, PT, DPT, OCS, MTC, is Senior Lecturer, Physical Therapist Assistant Program, Southern Illinois University at Carbondale, 374 E Grand Ave, Mail Code 6740, Carbondale, IL 62901 (USA), and Senior Physical Therapist, Select Medical Corporation, NovaCare Rehabilitation, Benton, Illinois. References 1 Poulter DC. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx. 2 Cibulka M. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx. 3 Hesch J. On “Ilial anterior rotation hypermobility in a female collegiate tennis player.” Phys Ther. 2009;89:xxx–xxx. 4 Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590. 5 Fritz JM, George S. The use of a classification approach to identify subgroups of patients with acute low back pain: interrater reliability and short-term treatment outcomes. Spine. 2000:25;106–114. 6 Brolinson PG, Kozar AJ, Cibor G. Sacroiliac dysfunction in athletes. Curr Sports Med Rep. 2003;2:47–56. 7 Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940–2952. 8 Vailas AC, Tipton CM, Mathes RD, et al. Physical activity and its influence on the repair process of medial collateral ligaments. Connect Tissue Res. 1981;9:25–31. 9 Tipton CM, Matthes RD, Maynard JA, et al. The influence of physical activity on ligaments and tendons. Med Sci Sports Exerc. 1975;7:165–175. 10 Tipton CM, James SL, Mergner W, et al. Influence of exercise in strength of medial collateral knee ligaments of dogs. Am J Physiol. 1970;218:894–902. 11 Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009–1015. |
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Jerry Hesch, PT, MHS, is Manager, Hesch Seminars and Physical Therapy, LLC, 1609 Silver Slipper Ave, Henderson, NV 89002-9334
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jerryhesch{at}cox.net Jerry Hesch
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This case report on right anterior ilial rotation hypermobility (RAIRH) presented a successful outcome with a comprehensive approach in 33 visits.1 It was particularly inspiring to read of the use of film, which clearly identified a problem with the patient’s tennis stroke. After resolving RAIRH, the client’s tennis stroke was retrained to address prevention of recurrence. The authors were thorough in their literature review, revealing some research that could discourage evaluation and treatment of RAIRH, while providing a good rationale for including treatment of RAIRH as part of a comprehensive approach. There were many insightful statements within the article, and my copy is well highlighted. I would like to share some general thoughts and observations I have made regarding the topic.
In the case report,1 the term “altered function of the pelvis” was part of the definition of sacroiliac joint dysfunction (SIJD). This is very appropriate, as research and opinion have been presented indicating that asymmetrical pelvic position and movement, and its testing and treatment, do not necessarily imply actual position and movement dysfunction (PMD) intrinsic to the sacroiliac joint (SIJ).2-4 However, it seems reasonable that extrinsic restrictions, such as pelvic asymmetry, could change the direction of forces going to and through the SIJ and even reduce SIJ mobility and shock attenuation, as the authors stated, referencing Nyberg.5 Also relevant is a study showing that SIJ manipulation does not alter the joint itself.4 The authors1 clearly stated that other extra-articular proximal tissues often become symptomatic and dysfunctional, which does not always imply intra-articular PMD or pain. For the remainder of this letter, any empirical reference I make regarding intrinsic SIJD (ie, ilium moving on sacrum) also implies the alternate possibility of PMD of the pelvis (entire pelvis moves as a unit). The clinical reality perhaps is that at times these may be mutually exclusive entities and at other times they may be a combination of both. The authors1 utilized hip flexion (in the sagittal plane) as a corrective exercise for RAIRH. As RAIRH is a triplane phenomenon, I believe that this could be enhanced by adding abduction and lateral (external) rotation of the hip, as described by DonTigny.6 The direction of force would essentially be parallel to the SIJ and might encourage anterior gapping. The corrective force would occur primarily in the sagittal plane, less so in the frontal plane, and only slightly in the transverse plane. In the “Discussion” section, the authors1 mentioned the possibility of the innominate slipping vertically on the sacrum, which is named “upslip.”7,8 I suggest that in the prone position, the client could be screened for upslip PMD. A superior spring to the ischial tuberosity and an inferior spring to the posterior iliac shelf would both be blocked with upslip. I define the posterior iliac shelf as the flat portion that is in the midline, at the top of the posterior portion of the ilium. As upslip is a nonphysiological motion dysfunction, both spring tests would reveal blocked mobility, as the ilium is stuck at end range. In contradistinction, a physiological motion dysfunction, such as RAIRH, can go further in the direction of dysfunction and is blocked moving out of dysfunction, as the authors noted with passive testing. Much of the literature addresses passive motion as a pain provocation test. I encounter more clients with nonsymptomatic SIJ/pelvic PMD than I do clients with symptomatic SIJ/pelvic dysfunction.9,10 In my opinion, treating clients who have asymptomatic SIJ/pelvic dysfunction seems appropriate from the perspective of prevention and reducing the suboptimal biomechanical influence on proximal and distal structures. The Ostgaard test is a special test (provocative), which was described in the article.1 The test is performed with the client positioned supine. The therapist stabilizes the sacrum and imparts a posterior glide to the pelvis through the flexed hip (90º), which is reported by Ostgaard11 and the authors1 to induce a posterior glide of the ilium. I agree that the force induced with this test is a posterior glide. However, the mid portion of the hip joint is at least 7.5 cm below the transverse axis of the SIJ (S2). Therefore, I believe that it would primarily induce anterior rotation of the ilium, rather than pure posterior glide. I again congratulate the authors on a very thorough and successful case study. Thank you for the opportunity to share some general thoughts, opinions, and empiricism on the subject. References 1. Vaughn HT, Nitsch W. Ilial anterior rotation hypermobility in a female collegiate tennis player. Phys Ther. 2008;88:1578–1590. 2. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25:364–368. 3. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: a roentgen stereophotogrammetric analysis. Spine. 1989;14:162–165. 4. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint: a roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128; discussion 1129. 5. Nyberg R. S4 Course Notes: Functional Analysis and Management of the Lumbopelvic Hip Complex. St Augustine, FL: Institute Press; 1997. 6. DonTigny R. Function and pathomechanics of the sacroiliac joint. Phys Ther. 1985;65:35–44. 7. Nyberg R. Pelvic girdle. In: Payton O, Di Fabio RP, Paris SV, et al. Manual of Physical Therapy. New York, NY: Churchill Livingstone Inc; 1989:378–380. 8. Greenman P. Principles of diagnosis and treatment of pelvic girdle dysfunction. In: Greenman P. Principles of Manual Medicine. Baltimore, MD: Williams & Wilkins; 1989:257. 9. Hesch J, Aisenbrey J, Guarino J. The pitfalls associated with traditional evaluation of sacroiliac dysfunction and their proposed solution. Presented at the Annual Conference of the American Physical Therapy Association; June 25, 1990; Anaheim, California. 10. Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4–7. 11. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19:894–900. |
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Michael Cibulka, PT Maryville University
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mcibulka{at}maryville.edu Michael Cibulka
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I was pleased to find the article about sacroiliac joint dysfunction by Vaughn and Nitsch in the December 2008 issue of PTJ. Reading the paper gave me some thoughts on how evidence is being interpreted and used in the clinic. Current evidence suggests that the diagnosis of sacroiliac joint syndrome is difficult because of the paucity of tests with good measurement properties. Thus, I agree with Vaughn and Nitsch's statement that “there is a lack of sensitive and specific tests to diagnose SIJ [sacroiliac joint] pain, which is commonly referred to as 'sacroiliac joint syndrome' (SIJS).” However, a few paragraphs later the authors state, “Accurate diagnosis of the type of SIJD is essential in determining the appropriate therapeutic intervention.” How do we interpret the apparent contradiction between not having the evidence and yet needing this evidence to make an accurate diagnosis? How do you make an accurate diagnosis with tests that lack sensitivity or specificity? The apparent contradiction in the introduction surely does not lend itself to trusting the diagnosis. I believe there is more evidence about the sacroiliac joint that often is overlooked by clinicians. How do we make sure that published evidence is being used in the clinic? After reading the description of this patient who was missing significant right hip medial (internal) rotation, I could not help wonder why the authors did not include previously published evidence? Prior research has shown that patients with limited hip medial rotation are related to patients who have a unilateral posterior tilt of their innominate.[1] This evidence either was not examined by Vaughn and Nitsch or was not included in their case report because it did not agree with their findings. How do we use evidence that may be contrary to our findings? Do we disregard it, or do we use just the evidence that agrees with our own beliefs? Or how do we ensure that all evidence that is out there is considered? We, as far as I know, do not have a software program that can help us look through all of the related evidence for our papers. This, no doubt, is a daunting task for most. Perhaps one will be developed soon. When is evidence really not evidence? In other words, are the published papers we use to support our important factual points have enough credible evidence? For example, the authors state, “Sacroiliac joint dysfunction manifests as a mobility impairment that is identified based on the type of motion dysfunction (hypomobility or hypermobility) and the direction of the abnormal movement.” This sentence, which clearly sets the tone for the rest of the paper, cites 3 different references supporting their view of sacroiliac joint mobility. The first citation is a review paper, the second citation is course notes, and the third citation is a textbook. The publications cited for support do not include any original research, nor do they contain any substantive or credible research that supports the belief that sacroiliac joint dysfunction manifests itself as a mobility impairment. This lack of evidence lends itself to confusion and surely does not help us in our quest to understand the sacroiliac joint. Throughout the article there are numerous examples of “jargon.” Jargon is best described as using specialized terms that are ambiguous and ill-defined. For example: “Displacement (positional faults) occur when the hypermobile joint overrides the articular prominence.” Jargon usually occurs when we do not have operational definitions that are clearly defined. Lamentably, jargon appears all too common when discussing the sacroiliac joint; in fact, it may be the most-abused joint when it comes to our use of jargon. The terms "upslips," "downslips," "shears," "torsion," "outflares," "inflares," and so on continue to show up in our literature and undoubtedly bewilder any new physical therapist student who is trying to learn how to evaluate and treat this joint. I also believe that our customary and continued use of jargon can hurt our credibility as health care professionals. As we continue on our journey to learn more about the sacroiliac joint, we first must clearly define what we mean before we can move forward. I believe that the sacroiliac joint continues to be a very misunderstood joint and will remain that way unless we provide the evidence that will help us understand it better. Michael T Cibulka, PT, DPT, MHS, OCS References 1. Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998;23:1009-1015. |
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David C Poulter, Physical Therapist
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dcpoult{at}aol.com David C Poulter
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I could hardly believe the content of the article by Vaughn and Nitsch and the inductive and often contradictory logic used throughout the case report. The current evidence-based literature on low back pain is leaning heavily toward a treatment-based classification system, with an active treatment paradigm.[1,2] This article seems to fly in the face of this evidence and proposes a structural-based diagnostic classification based on poor tests and passive treatment, namely bed rest, TENS, ice, ultrasound, massage and taping.[3-7] The active treatment provided to the patient appears to be based on inductive reasoning to address the pseudo-diagnostic category derived at by a series of nonvalid tests, proposed by the authors and flimsily supported by the evidence and anecdotal reference to opinion-based papers. In the introduction, the authors do review the current evidence-based literature and outline that most testing procedures for the SI complex have poor validity, yet proceed to ignore this and use the nonvalid tests to support his pathology-based treatment paradigm. The authors quote Laslett’s research and suggest that the positive likelihood ratio of 3 or more positive SI joint provocative tests is 4.27; however, if they read the article closely they would discover that the positive LHR is 6.97 for 3 positive tests, when patients who centralized during the mechanical evaluation were excluded.[8] It would have been nice to include a body chart for the patient’s original pain pattern because the authors state that the patient has right -sided low back pain. In a study by Young and Laslett[9], they clearly identified that “Sacroiliac joint pain was related to three or more positive pain provocation tests, pain when rising from sitting, unilateral pain and absence of lumbar pain.” This would preclude the patient from having an SI joint problem based on the lumbar spine pain. I am not sure why the authors after quoting Laslett failed to utilize his recommendations and perform a mechanical assessment (McKenzie Method) and provocative testing of the SI joint.[6] The Gillet test was used as the main test to determine the positional fault diagnosis. Gillet’s test has a positive LHR of 1.2 for the study by Dreyfuss[10], assuming that the prevalence of SI joint pain is 24% then the posttest odds of having SI joint pain after the Gillet test is only around 29%. Is this enough basis to form a diagnosis and build a 6-month treatment plan around? The authors even state, “Palpation-based methods of the pelvis, when used alone, have demonstrated poor diagnostic value in patients with long- term nonspecific low back pain.” Yet, they proceed to use tests that have been shown to have little, if any, validity to assess, diagnose, and track as outcome measures of improvement and recovery. A recent review on the validity of SI joint tests by Cattley et al[11]stated, “Gillet’s test, FABER, sacral thrust and compression were considered invalid and unreliable.” These findings are not restricted to Cattley’s review; Stuber[12] has recently published a paper on the sensitivity and specificity of SI joint tests, and his conclusion was that “Practitioners may consider using the distraction test, compression test, thigh thrust/posterior shear, sacral thrust, and resisted hip abduction as these were the only tests to have specificity and sensitivity greater than 60% in at least one study.” This is in agreement with Laslett and colleagues' findings.[8] I would suggest that because of the use of inductive logic and nonvalid testing, to reach a diagnostic conclusion, the treatment applied has limited justification or value. This case report also lacks valid outcome measures. It would have been better to use valid outcome tools such as the Oswestry, FABQ, SF-36, or other valid outcome tools outlined in the evidence based literature.[13,14] There seems to be a lack of understanding and screening for red and yellow flags, one of the key elements described in most low back pain guidelines.[15] I would also suggest that the authors seek understanding of the term “regression to the mean,” which may actually account for some of the patient’s outcomes.[16] My question to the authors is: Why did a simple acute low back pain episode under your care become a 6-month chronic recurrent episode? The very nature of the interventions would lead one to illness behaviors and kinesiophobia.[17] I would suggest that the authors need to consider the evidence-based guidelines for low back pain, suggesting advice to patients that includes reassuring the patient of a favorable prognosis, encouraging the patient to stay active, and discouraging bedrest.[15] I would also suggest that this patient would probably fit the clinical prediction rule for the lumbar spine, based on the description of her condition.[18,19] The whole case report was therapist centered, whilst trying to suggest some sort of patient-centered approach. I would propose that the mantra, “offer patients solutions to their current problems, not more problems,” is something the authors should ponder. David C Poulter, PT References: 1. Fritz JM, George S. The Use of a Classification Approach to Identify Subgroups of Patients With Acute Low Back Pain Interrater Reliability and Short-Term Treatment Outcomes. Spine. 2000:25;106- 114. 2. Fritz JM, Cleland J, Brennan GP. Does Adherence to the Guideline Recommendation for Active Treatments Improve the Quality of Care for Patients With Acute Low Back Pain Delivered by Physical Therapist? Medical Care. 2007;45:973-980. 3. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain: bed rest, exercises, or ordinary activity? N Engl J Med. 1995;332:351–355. 4. Hagen KB, Hilde G, Jamtvedt G, et al. Bed rest for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2004;1:CD001254.31. 5. Albright J, Allman R, Bonfiglio RP, et al. Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions for Low Back Pain. Phys Ther. 2001;81:1641-1674. 6. Deyo RA, Walsh NE, Martin DC, et al. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 1990 Jun 7 322 1627-1634. 7. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database of Syst Rev. 2008; Oct 8;(4):CD003008. 8. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89–97. 9. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources of chronic low back pain. Spine J. 2003,3;460–465. 10. Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594–2602. 11. Cattley P, Winyard J, Trevaskis J, Eaton S. Validity and reliability of clinical tests for the sacroiliac joint. A review of the literature. Australas Chiropr Osteopathy. 2002;10(2):73-80. 12. Stuber KJ. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. J Can Chiropr Assoc. 2007;51(1):30-41. 13. Bombardier C. Outcome Assessments in the Evaluation of Treatment of Spinal Disorders: Summary and General Recommendations. Spine. 2000:25;3100–3103. 14. Taylor SJ, Taylor AE, Foy MA, Fogg AJ. Responsiveness of Common Outcome Measures for Patients With Low Back Pain. Spine. 1999:24;1805–1812. 15. Koes BW, van Tulder MW, Ostelo R, et al. Clinical Guidelines for the Management of Low Back Pain in Primary Care: An International Comparison. Spine. 2001:26;2504 -2513. 16. Whitney C, Von Korff M. Regression to the mean in treated versus untreated chronic pain. Pain. 1992;50:281-285. 17. Picavet HS, Vlaeyen JW, Schouten JS. Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain. Am J Epidemiol. 2002;156:1028-1034. 18. Childs JD, Cleland JA. Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther. 2000;86:122–131. 19. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinalmanipulation: a validation study. Ann Intern Med. 2004;141:920–928. |
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