The title of this blog was inspired by a slide I found on Twitter, by Dr. Chad Cook PT (@chadcookpt) during his lecture at the 2017 New Zealand Manipulative Physiotherapists Association Conference. Dr. Cook’s slide offered five points on manual therapy; this blog will focus on the fourth point.
- Manual therapy is a better choice for pain modulation than the alternatives
- Manual therapy is an intervention that is part of a changing flow of care
- We still do not know how to identify responders; this hasn’t helped
- Maybe we aren’t measuring things the right way
- Let’s stop trying to elevate manual therapy beyond what it is; It’s a pain modulating intervention
I really appreciated these five points. They were a breath of fresh air in the current PT landscape where a seemingly growing number of therapists boldly and confidently bash manual therapy and look down on its clinical usefulness. There is no shortage of anti-manual therapy opinions and at times I wonder why. Is it the sometimes dogmatic ways that some manual therapy is taught? Is it the certain guru mentality “I can fix it every time” brand of manual therapy? Is it the lack of consistent evidence for an individual intervention? Is it because of a lack of consensus established for how manual therapy works? Are the effects too short term? Does it arise from inconsistently identifying responders or subgroups for a particular method of manual therapy? Have there been too many clinical failures that have soured an openness to its potential? Is it too expensive to pursue certifications and training when the evidence is not solid? I don’t know.
Occasionally, I question if I have missed something, as I continue to use manual therapy day-in and day-out. Though these pauses only clarify my favorable opinion of manual therapy. Personal experiences with manual therapy, pain neuroscience education, and a biopsychosocial approach have made me an optimist. This optimism has led to a belief that anything is possible and all available options, including manual therapy, should be considered when treating patients in pain. This belief has shifted my thinking in many ways, and one specific way is how the end results of manual therapy are measured.
Every patient presents with unique beliefs, genetics, culture, knowledge, cognitions, environments and past experiences. These different variables create complexity and make it challenging to understand how, and if, they are contributing to a lived pain experience. One example of how individuals differ during a pain experience was studied in the 2013 European Journal of Pain study by Hodges et al. This study examined how experimentally-induced acute noxious stimulus affects trunk muscle recruitment and movement patterns. (HERE) EMG recordings were taken of anterior and posterior trunk muscles while healthy individuals flexed and extended with and without experimentally induced pain. Results showed that acute back pain leads to increased spinal stability (protection) in all participants, though the pattern of muscle activity was not stereotypical and involved individual-specific responses to pain.
In other words, all participants showed enhanced spinal protective strategies in the presence of pain, but no two participants protected the same. Let this sink in….all had the same noxious input, but all protected differently. Movement changes when pain is present and the individual nature of pain as a protective response is powerful.
Intrinsic differences and personal characteristics of each patient demand an openness to all possibilities during a pain experience.
Pain is a protector, and produces protective responses (HERE). Is it a far stretch to say that if all protect differently in a pain experience, then all may un-protect differently? From a purely clinical view point this is where manual therapy may have its most powerful ability to be measured; safe hands-on encouragement of a human body’s system to “protect less”.
To measure something, it first has to be defined. The term manual therapy can mean many things to different people. The term manual therapy by itself is not very specific. My current definition for manual therapy has been influenced by many. It says, “manual therapy is the skillful art of applying graded, safe, and progressive external pressures to shift protective responses, while engaging the patient’s mind during application, within a patient-centered encounter under the pain science umbrella”. In protection terms when a manual therapy technique is not effective in the clinic it is not viewed as failure, but instead says it has no “un-protective” value for this particular patient. Manual therapy was considered, without anchoring or bias, and treatment continues in other ways. When manual therapy does work, there is less worry about how it worked, other than it shifted a person’s individual protective strategy back to a state of less protection. The context of manual therapy here is always viewed and presented as introductory companion to longer-term solutions like building self-efficacy through pain neuroscience education, exercise, and conditioning with progressive loads.
Manual therapy grounded and measured in outdated biomechanical models has not performed well. Several studies show short-term results at best (HERE). We know there are amazing neurophysiological effects of manual therapy and there are great models that have been examined (HERE). Though we continue to see even the most recent studies show contradictory findings: (HERE) vs. (HERE).
How can we measure manual therapy beyond the way it is currently being measured and will it even matter? Can measuring manual therapy in terms of protection help? While I am not a researcher, a recent paper by Rodger Kerry discusses how shaping future research could be considered (HERE). The ideas presented in this paper seem to fit well when asking if PT research is being measure effectively.
We can all do better with our explanations and expectations of manual therapy by considering Dr. Cook’s introductory points. Each one of us should develop a modern model for applying manual therapy that is research-informed, but open to possibilities provided by the individual-specific protective response of body systems (HERE).
At the end of the day, we should not ignore nor neglect our manual therapy skills. We have been hands on since the beginning of our profession! Sensory drives neuroplastic and neurophysicological changes, and manual therapy is full of sensory input. Closing our minds to the possibilities that manual therapy may shift protective responses is absurd. Leaving manual therapy out of the equation leaves too much on the table and welcomes missed opportunities to help patients. As researchers continue to measure the responses of manual therapy differently I hope all PT’s come to the conclusion that manual therapy is not bad, but a vital and valuable part of our profession.
What are your thoughts?