Enough Is Enough - Finding Common Ground In Manual Therapy

            

(Yes I did have one with swearing in it but decided to replace it)

              Anyone who knows me knows that I’m not a big fan of participating in online debates. While they can be useful if performed respectively (for instance one between Alan Aragon and Paul Carter from a few years back) – quite often they tend to turn into heated arguments where both sides have hard headed, dogmatic views and have to be right.

This is no more apparent in rehab than in the controversial, hotly debated topic of manual therapy. Some think that manual therapy is the “end all be all” of orthopedics whereas others claim its useless and creates dependency. Once again these debates have sparked up again and have prompted me to come out of my shell and say “enough is enough.” The purpose of this article is to find some common ground between the two ends of the spectrum.

Side note: as with some of my other articles this is not going to be a lit review just for the sake of keeping it easy to read.

Side note two: you can read the preceeding editorials by my lovely, former instructor & colleague Laura Ritchie; by Greg Lehman; and by Adam Meakins by clicking the hyperlinks in their names.

Is manual therapy a high skill technique? No.

As I’ve written about in my article “Simplifying The Manual Therapy Process” – many believe (and teach) the idea that manual therapy is a high skill technique that requires thousands of hours (and dollars) in training. Hell – in physio school we sometimes covered the same technique five times. It gets to the point where new therapists aren’t confident at all in their manual therapy skills in comparison to their bosses, mentors or instructors.

As I said in last year’s article

-          Motion & positional palpation techniques are not reliable

-          You can’t isolate manual therapy to one joint

-          Different techniques have shown the same effectiveness for the same condition

-          Manual therapy’s mechanisms are neurological in nature

Is there “no skill” required to do manual therapy? No. You have to provide enough force & contact to make it feel worthwhile and you have to emphasize the principles that I will discuss near the end of this article.

Is manual therapy the most effective treatment for musculoskeletal issues? No.

This area is more up for debate as studies have shown manual therapy has results ranging from placebo to even better than certain types of exercise. You can pick any PubMed study to support your stance so I’m not going to spend a lot of time on this other than to show that, looking at the evidence as a whole, manual therapy falls behind exercise & psychosocial therapies in the “hierarchy” of effective treatments.

Does that mean we should be 100% hands off? Hell no.

Some may argue with this but I do believe manual therapy has its place in certain situations such as

1) Highly irritable patients

This time of year (late spring/early summer) is when I quite often see patients in irritable situations – quite often due to doing too much too soon with gardening, sports, backyard/cottage parties, or other activities. Sometimes patients just do too much; or have an accident; and are pretty sore, inflamed, and sensitized to the point where they can’t tolerate much of any exercise. And at the end of the day there’s only so much education you can hit someone with & expect them to retain. That’s where manual therapy comes in.

Some would argue “I’d rather have a patient’s appointment cut short than do passive treatment” but if you’re in a clinic where everyone gets 20-30 minute appointment times, and you only give them 5-10 minutes of exercise & education, good luck hanging onto them.

2) Patients with medical contraindications to exercise

Occasionally, in orthopedic practice, you will get patients who have contraindications to exercise due to recent surgery … or cardiovascular or other medical conditions. Again manual therapy, and even (gasp) modalities, can have a time & place in these situations.

3) Highly deconditioned patients

Similar theme as above – we’ve all had those patients that do a few minutes on a recumbent bike or do a couple sets of a very remedial exercise … and are “toast.”

4) Building therapeutic alliance

I only do this occasionally – but I’d rather do a few minutes of manual therapy (or any passive therapy that isn’t contraindicated) to get a hard headed patient on my side & get them doing what I want – then see them go to another therapist who may provide them with a lot of negative language.

 Where do we go from here?

As someone who’s been formerly involved with the physiotherapy education system we need a paradigm shift. Instead of emphasizing pseudobiomechanical faults (that often can’t be reliably assessed and/or don’t correlate with pain), nocebo-ic language, and passive therapies we need a shift towards

-          Teaching professionals to be more effective communicators & build therapeutic alliances with their patients

-          Getting patients to believe in & trust in their bodies and their adaptability

-          Teaching manual therapy in a way that is in line with the evidence

-          Educating patients that pain is more than just tissue damage

-          Emphasizing an interactor vs an operator model (to quote Jason Silvernail)

-          Shifting from emphasizing predominantly passive therapies in practice (and having them on this high pedestal) to using them as an adjunct combined with exercise/movement therapies & education

-          Putting patients in the drivers seat to improve their quality of life

-          And teaching therapists to be competent and confident in all of these areas

This takes a lot of work in the physiotherapy (and rehab) education system, in knowledge transition, and in practice. This is a big challenge for us to take up – but is a must for us to improve the quality of patient care.

I hope this helps find some common ground because that’s my article – and as always thanks for reading.

How Louie Simmons Influenced My Approach To Training & Rehab (for Mash Elite Performance)

Over the last few weeks I have begun to put out content for strength coach & world champion powerlifter Travis Mash. I plan to keep the rehab-based content on this site and put my strength training content on his site (although I will have links to everything here).

In my first article I discuss how Louie Simmons, the coach & owner of Westside Barbell, has influenced my approach to training & rehabilitation.

You can check it out at the link below

https://www.mashelite.com/how-louie-simmons-influenced-my-approach-to-training-and-rehab-by-eric-bowman/

Advice I Would Give A New Physiotherapist Or Physiotherapy Student

              

            Before we get started I am going to be writing for Travis Mash’s website in addition to continuing to post content here. My content for Travis’s website will be more strength training focused whereas this site will be more rehab focused.

One of my favourite podcasts is Karen Litzy’s Healthy, Wealthy, Smart podcast. At the end of each episode she asks her guests “what would you tell your younger self” (or something of a similar nature). It made me think –  almost three years out of PT school – what would I tell my younger self.

                With that in mind, in no particular order, here are some things that I wish I would have known in PT school and when I started….

1) You probably know enough in your exercise & manual therapy knowledge to help a lot of your patients no problem. So be confident when assessing them and interacting with them.

Which brings me to….

2) There are a lot of things you should learn that aren’t taught in school so take the time to do continuing education and take the time to critically reflect on your practice & what needs to be improved.

3) Learn a system of rehabilitation such as Maitland, McKenzie, Mulligan, McGill (why do these all start with M?). You don’t need to be a strict Maitland, McKenzie etc therapist but I believe in the importance of having a base system to work with and to consolidate the info you know. I see too many therapists that are overwhelmed with information, have a hard time consolidating it, and end up throwing crap against the wall to see what sticks.

 4) Understand that you’re never going to be able to cure everyone. Sometimes patients won’t do their exercises or sometimes can’t modify exacerbating activities. Sometimes the patient needs surgery or medical management. Sometimes there are other health issues or psychosocial factors. Sometimes it’s a chronic issue that may not get that much better. Sometimes it’s not the right match of patient & therapist and sometimes, no matter how evidence-based it is, it’s just not the right input to reduce threat.

5) In physio school they teach that every exercise should be painfree. I believe you should do the best you can to make exercises painfree but in some situations (e.g. chronic pain, post-surgical) that may not always be possible. In those cases you need to educate patients that hurt doesn’t always equal and to do exercises in a way that may slightly increase symptoms but achieves their goals and doesn’t worsen them in the long term

Which brings me to….

6) One trick I learned from listening to Greg Lehman is to do “less more often” when working with people with signs of a central sensitization/more widespread pain. I anecdotally find 1-2 low dose exercises done frequently through the day more advantageous than the traditional 3x10 or 3x15 for helping these clients achieve their goals without as high of a risk of flareup.

7) Following on the heels on #5 – pain science education is great but it does need to be tailored to the individual in terms of

- Whether you do it or not and

- How much information you provide

Some will want to know all the details and some patients will be put off by it. A fellow therapist said it best – ask the patient if they want to learn more about pain. If not, no harm no foul.

8) One mistake that I made was subconsciously being in a hurry with my assessments. It’s tough to do this after being put through rigorous, time crunched exams but its important to really slow down your assessment in order to build better rapport with your patients. You may very well be the first one person in the healthcare system that’s actually listened to them.

Also – many objective physiotherapy assessments lack reliability, validity, sensitivity and/or specificity. Towards that end you can really hack down your objective assessment to what’s essential.

9) Take the time to learn how to progress, regress, coach and modify exercises. I learned most of what I know about exercise coaching, cueing, progressions & regressions from strength & conditioning coaches.

 10) When it comes to managing athletic/training injuries I believe workload management is the most important thing. Tim Gabbett’s research has shown that the “sweet spot” for increasing workload lies at about 10-25% at a time. I tend to stick to the “10% rule” of increasing workload in a week as a start and then go from there.

11) Understand that a patient’s recovery (or lack thereof) from pain or disease can be influenced by a multitude of factors including non-specific effects (I hate the word placebo), natural recovery, and other factors in addition to the treatments provided.

The last two points will be familiar if you’ve read my work….

12) Probably the most important point: use positive words with your coaching, cueing & communication. If you tell your client they got 20 things wrong with them, need you to fix them, and will hurt themselves with everything than that may set them up for chronic issues.

Sometimes yes – if you have a client that’s repeatedly doing activities that worsen the issue (despite advice to modify those activities) than you may have to come down heavy – but that should be a last resort. Read on the magnitude of the nocebo effect and the impact of clinician words.

13) If you’re reading this site you probably value continuing education and improving yourself (and others) as a therapist. My big advice – take it slow and don’t rush it. I poured myself into long weeks during and after school with writing, curriculum work, and other side ventures … and burned myself out more than once. Understand that you’re only as good as what you can recover from. Know that line and stick with it.

If you’re a new therapist or a student I hope this provides you with some useful tips. As always – thanks for reading.