Monday 25 June 2018

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.

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