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?
––– Comments
Felix
Commented • April 18, 2018
Low to moderate effect size for pain modulation offered inconsistently across make conditions, manual therapy is the modern day equivalent to blood-letting of days of old. Too many disciples too brainwashed to progress, to let go of what just doesn't work well enough. Time for the manual gurus to have their nonsense exposed. It's become a cult.
Felix
Commented • April 18, 2018
The Emperor has no clothes might be far closer to tbe truth.
Jarrod
Commented • December 6, 2017
Thanks for your comments Brian. I agree with you that when if comes to treatment, what is most effective and efficient should be emphasized. Though this emphasis must be purposeful. If all we do is passive treatments because that is what the patient wants, or it is what is deemed have the most effective immediate results, can be a slippery slope. I have witnessed in many patients an over reliance on passive treatments that develops an attitude of becoming fully reliant on a particular treatment leading to a dependence mindset where they believe that the only thing that will help them is to get a certain treatment over and over until forever. This emphasis of passive and active treatments should always be thoughtful and well reasoned and always striving for the long term; ie more active than passive. To your next comment, "I am not even sure what the term manual therapy means", well that is one of the ideas I tried to define in my definition. Manual therapy can be many different kinds of techniques. There are hundreds of techniques for many reasons and some techniques appear to be more helpful that shifting protective responses than others. But why is it I can do the same technique to 10 different knees with similar presentations but be only 50% effective? It likely has less to do with the technique being performed correctly, and much more to do with the individual response to the technique. I find nothing wrong with taking theory of current research and using to to reconcile and marry the best of manual therapy and pain research. I am certain my definition will continue to evolve over the coming year. At the end of the day, I perceive you and I are on the same page that manual therapy is a vital part of our profession and is an important part of our continued effort to help patients who come to PT each day. Jarrod
Jarrod
Commented • December 6, 2017
Thanks for reading Bob and continuing the conversation. I appreciate the feedback. I agree that a major part, maybe the biggest part, of the manual therapy is all about having a sound reasoning process. I was told by a smart manual therapist a long time ago that you are never wrong with your manual therapy technique application if your reasoning is sound. It may not work, but it is not wrong. I love your phrase "dynamic reasoning for a dynamic organism". That is awesome! Thanks again Jarrod
Bob Schroedter
Commented • December 6, 2017
Jarrod, I appreciate your contribution and think it strikes the right tone regarding the balance of several contrasting factors...active versus passive, acute versus chronic, efficacy versus effectiveness, research versus practice. Unlike others, I am not disconcerted by your definition of manual therapy as a dynamic intervention part of a dynamic reasoning process for a dynamic organism. As you emphasize throughout, the patient-centered focus is critical to all we do with our words, minds and hands. Hopefully, this isn't interpreted as political.
Homemade Solutions in Hindi
Commented • December 4, 2017
Manual therapy is skilful. But very cautious
Brian D'Orazio DPT, MS, OCS
Commented • November 28, 2017
Thanks for your comments. I wish to apologize for misinterpretation of some comments related to disparaging research on manual techniques. On a re-read, I think the recent downgrade of reimbursement from CMS was negatively influencing my read of your blog. I also wish to state that I admire your attempts to advance our thinking of manual techniques and their application to pain management. I still contend the statement that active treatment outweighs passive treatment is too general. Whatever is most effective and efficient should be emphasized in the treatment. Early in the treatment, perhaps passive is more effective and leads to active, but the profession has been stuck on this concept of ignoring passive. Usually both are employed to some extent. As for your definition, I have several objections. First, manual therapy isn't a single " thing ", just as PT or exercise aren't specific things. As such, when someone uses the term manual therapy, I'm not even sure what that means. Second, I HATE the use of the term " manual therapist ", which seems to be derived from manual therapy. Though technically not part of your definition, your definition seems to seek a unifying theme that argues for use of the title "manual therapy" versus recognizing there are many techniques used under many circumstances. Not all of these circumstances are for pain management. So manual therapy should be replaced with the term manual techniques, or even better with use of an operationally defined technique without use of theory in the definition of that technique. Your interpretations of studies and what they mean for pain processing provide for interesting debate, but they are just that...interpretation of results and development of theories. It's important not to conflate theory and fact and I think your definition may begin to cross that line. Dr. Cook's 5 points are very general and I'm sure he goes on to define what he means. However, taken as single sentences, I think in number 1, in which he states "manual therapy is a better choice for pain modulation than the alternatives". I would add the caveat that select manual techniques MAY be a better choice for pain modulation in specific circumstances. I do like 3 and 4. Thanks for the opportunity to debate an important aspect of our profession and to argue that it deserves greater respect in the field of medicine. These techniques are labor intensive, intelligently chosen and delivered by highly trained professionals that deserve the respect of our medical colleagues.
Jarrod
Commented • November 28, 2017
Hi Brian, Thanks for reading and taking the time to comment. I believe it matters on many levels if a treatment is active or passive. A big reason is that active treatments have the tendency to better develop self-efficacy, confidence, and an internal locus of control than passive treatments. I am all for passive treatments as part of the bigger picture and plan of care, but at the end of the day active treatments should far outweigh passive treatments in an individuals plan of care. Also if I can make an inherently passive treatment more active I will do it every single time. The evidence for making manual therapy more active on the patients part continues to grow. Seeing you found my definition of manual therapy too "political", I would love for you to share how you define it. This was one of the points within the blog to consider and develop a modern definition of manual therapy. Finally, in no way was the blog was asking to wring the hands of research, but to instead consider alternatives and a reconceptualisation of research to allow more meaningful relationships between research and clinical practice (as Kerry's article suggested) Thanks Jarrod
Jarrod
Commented • November 27, 2017
Dave, Thanks for reading and glad to hear your thought process has been challenged. Manual therapy is not about going 1/2 way and then backing out to go another direction. It is about setting the pace with goals and a solid plan of care day one. Manual therapy is best used after you find singular direction the patient needs to go after listening, physical exam, and assessment of their entire story. I am always open to beginning manual therapy day one, but I am also open to not initiating it until the 3rd visit or not at all. It depends on the direction I feel the patient needs to go. Getting stuck on manual therapy becoming the crux of the entire PT plan of care is only a a concern if there is not a unified direction that begins day one. You are right on when considering manual therapy as one way to show a patient that pain is changeable. Manual therapy that changes the context of movement and reframes the possibility that movement does not equal pain is powerful. Keep up the good work.. Jarrod
Lisa Maczura
Commented • November 25, 2017
As a chronic neuro patient and a proponent of MT I find that my particular hx supports the frequent use of MT, though not often for pain management. I have serious and protracted functional concerns, complicated by a lot of neural "noise" Patient ed is not the same MT or PNF. There is much that I understand intellectually from things my PT has taught me that have *zero* effect on my body's ability to response appropriately. I need the hands on for cueing, and to help my body understand what my mind already knows.
Brian P. D’Orazio DPT, MS, OCS
Commented • November 22, 2017
Who cares if a treatment is passive or active? It either works or it doesn’t. An injection is passive, a pill is passive...who cares? Engaging the “sensory and motor homunculus” sounds as political as the definition of manual therapy offered in this blog. A second point; we need to stop wringing our hands because research fails to demonstrate consistently great results. Until we have effective imaging tools, neuro-measurement tools and other tech needed to produce a gold standard in measurement, research will continue to be inadequate. In the 1980’s, faculty and researchers relentlessly criticized isokenetic measurement research. They launched into ivory tower arguments about the definition of strength, the applicability of specific force production protocols and a failure to correlate measures with function. In reality, much of the research was credible and use of this tool was enormously beneficial for the patient but the ridiculous academic debates led to insurance companies discontinuing payment for testing. Now, we don’t have this essential tool. CMS has just decided to reduce payment for MT AND TE! We know these are essential tools in patient treatment. I recommend that we don’t continue down a path of criticism of everything we do or our entire profession will go the way of isokinetic testing...if it hasn’t already. How much less can we be reimbursed before students stop applying for admission? Let us engage in meaningful debate on treatment, but not disparage our inability to produce the perfect research study that will validate all treatments. After all, musculoskeletal medicine...like golf...is not a game of perfect! Dr. Brian P. D’Orazio
Dave
Commented • November 21, 2017
Jarrod, thanks for the thoughtful blog. I struggle with manual therapy because it is hard to go half way. Human touch is powerful (I like the odd massage) but with certain patients that touch easily becomes the crux of treatment. Even with our best intentions it is hard to explain our way out of manual therapy (MT) towards a more active approach. There is efficacy and evidence to support MT in acute scenarios but it is not uncommon for acute scenarios to become chronic. If a patient is accustomed to MT it can be difficult to explain to them that MT is no longer useful and exercise is better. On the flip side, If MT with movement can show someone that pain is changeable and they can do it themselves - awesome. I like thinking of physical therapy as a profession that promotes movement, education, and advice. I don't really think we need MT as one of our badges. Thanks for challenging my thought process and getting me to dig a little deeper on how I practice. Dave
Jarrod
Commented • November 21, 2017
James, Thanks for reading and taking time to comment. You are correct that one of the regular knocks on manual therapy is the thought that it is purely a passive intervention. Though one of the biggest changes in the way I now practice manual therapy is engaging the patients active thought process targeting the sensory and motor homunculus . (http://www.tandfonline.com/doi/abs/10.3109/09593985.2015.1060656) Intentionally engaging the patients mind changes manual therapy from a passive intervention to one that the patient is part of. Adding that to your solid list of physical therapy backbone treatments and you are doing some awesome work helping improve function and lessening pain. Thanks again Jarrod
James E Glinn Sr
Commented • November 20, 2017
Love your post and your thoughts Jarrod. Having used manual therapy since my coursework from Stanley Paris back before there was an OCS, or even an Ortopaedic Section APTA, I have come to the following simple conclusions: A decent clinician needs a big box of tools, and manual therapy is but one tool. The "backbone of physical therapy" remains Ther ex/activities, functional training, and, Perhaps most importantly, patient education. After all of our clinical research over the past twenty years, it would, I think, be useful to reexamine the basic science of exercise physiology, and continue to research the emerging science of how neurotransmitters affect far more than mechanical factors. The biggest negative regarding manual PT is that it is a passive rather than active intervention, and as such, should always be an adjunct to an active, patient-centered program.