Musings from 2015
Wow the year has flown by quickly. I have to say that I feel disappointed that I haven’t posted much this year. My apologies for not doing so. I have great admiration for the physiotherapy bloggers out there who post such regular, well written posts.
To wrap up the year I thought I might reflect/muse on one of the useful approaches I have found particularly helpful in the management of patients. I am going to refer to some quotes by the late Max Zusman in this post as I think he sums up what I want to say in a far better way than I ever I could. Please see here and here for some must read articles by Max. For those of you who are unfamiliar with Max Zusman, there was a wonderful tribute written about him over at noijam.com.
I hope it is pretty clear to most people that manual therapy does not appear (yet anyway) to have any effect on structure. See here and here for more information. There have also been two fantastic posts recently on the subject over at Evidence Informed Physical Therapy and willcottphysio.
What manual therapy does seem to do is reduce tissue sensitivity i.e. it has a neurophysiological effect that, when done appropriately, can reduce pain in patients. It can’t reduce pain in all patients, but when it can reduce pain significantly or completely I think we can quite confidently say to patients that there cannot be something structurally wrong with their injured area. Why I hear you ask? Because we are probably not having any effect on structure.
Max’s views on this:
Research confirms that passive therapeutic movement has no lasting effect on tissue length, position, shape, or content. A reassuring (to both practitioner and patient) “click” notwithstanding, pain reduction with thrust or oscillatory passive movement would appear to be mainly for neurological rather than for mechanical reasons. It is also worth pointing out that, in more than 100 years, there has been no demonstrable evidence of anything resembling a spinal joint subluxation.
So lets use an example of poor John Citizen coming in with a sore back saying “my disc bulge at L4/5 is the problem”. If I can mobilise, manipulate and/or massage his low back and he gets up with zero (or at least significantly reduced) pain then how can his disc bulge be a significant structural problem? We should be explaining to John that we are having very little, if any, effect on his disc bulge with our treatment. If the structure of the disc was that badly damaged he would be no better from treatment, if anything he would probably be worse.
Max Zusman:
Patients should be encouraged to welcome the fact that their nonspecific pain problem is not SAB-based (Structural, Anatomical, Biomechanical based). If this were the case, the pain would not be modifiable in any clinically relevant way using existing hands-on treatment, and patients generally do not relish the idea of invasive procedures.
What might be contributing to John’s ongoing pain? Well it could be anything couldn’t it. Posture, muscle tension, stress, lack of sleep, de-conditioning etc. But quite clearly it cannot be completely due to his disc bulge because otherwise we wouldn’t be able to meaningfully change his pain.
So this year, whenever I have been able to meaningfully reduce someones pain I have used it as the opportunity to educate them around what manual therapy does (it doesn’t seem to change or effect structure). Given their pain is improvable, we just need to find out what they need to work on to improve it. They also don’t need my “magic” hands to do it all for them, because really they aren’t all that magic and it probably doesn’t really matter what I do with them. As long as it is not too vigorous or illegal!!
Max Zusman:
Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “biomedical” model.
So, the dogma behind the trial and error formulae that have dominated learning and clinical practice of therapeutic passive movement for decades is gradually being discredited. Even recommended guidelines and rationale for the once all important “selection of technique” appear to lack validity and reliability.
I use less techniques now than I ever have. I also have found patients very receptive, often quite relieved, when I have explained to them that we (physiotherapists et al) don’t have magic hands that can push disc bulges back into place and re-align spines. The problem I regularly see is many patients that are under the impression that this is the case. This is a concern in our profession and something that I feel holds us back.
Last words to Max:
If the physiotherapy profession wishes to remain a respected provider in the musculoskeletal pain area then it has no choice but to drop the “lip-service” and actually undertake serious philosophical change. To properly secure the clinical freedom and range of benefits the profession has/is seeking in many countries today it needs to abandon its arcane, outmoded empirically-based reasoning and influences.
I couldn’t agree more.
Wishing you all a safe, happy and healthy 2016! Thanks to all of you who have spent some time on this small blog of mine. I appreciate it greatly. See you next year.
Cheers
Mark
About the Author: Mark Gibson
Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.Subscribe
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Down the rabbit hole the profession goes, exploring smaller and smaller chunks. Like taking an orange, removing the peel, breaking the segments apart,deconstructing the pith, squeezing the juice, measuring, appraising all the way down to the most minute chemical contruction. At which point it’s no longer an orange, or maybe its a bit of an orange and part of something else also. And for what? So we can tell people that what they see is not an orange, what they taste is not an orange, what they smell is not orange flavour ? For them, it is an orange, its not a lemon. If they want lemons and get oranges, they know the difference. They know the difference between pain and no pain, its in their own lived experience. However what WE dont know, it what THEY see and taste and smell. We dont know what their system gives them as a representation. My son is blue green colour blind, yet he can differentiate between some shades and tones that I cannot discern. What he ‘sees’ is not what I see. I am synaesthetic, some tones in music stimulate a taste in my mouth, or brighten my visual field, or ‘tickle’ my brain and causes me to laugh. There is debate over the very nature of what is evidence based medicine. Is it the breaking down of the orange into the chemical components, analyses? Is it acknowledging that humans are hugely differentand all perceive the orange in a different way? That brains and systems work very differently? That we cannout have a simple solution as insurers, financiers, economists, accountants, administrators would have us generate. That on a spread sheet their 5 and 7 and 10 will always add up to a logical 22. But humans are not spread sheets, or some easy simple logical flat pack that bolts together. This is what makes us human
Thanks for your comments Mark, as well as for your great website. This seems to echo the thoughts of Adam Meakins (@thesportsphysio) in arguing that there is no skill in manual therapy. However, Bill Vincenzino was recently talking about how force application (I.e direction and magnitude) during an MWM was relevant in terms of producing pain reduction in lateral epicondylalgia. I suspect there are other examples of this. This seems to suggest then that specific biomechanical forces are indeed needed to activate/maximise pain relief, challenging the notion that no skill is needed. It would be great to hear your thoughts. Cheers.
Hi Michael,
My apologies for not getting back to you. For some reason I wasn’t notified regarding your comment and have just come it across it now. Happy New Year to you! Thanks for taking the time to comment.
I think there is certainly SOME skill in manual therapy. I seem to recall even Adam Meakins agreed there is some, just not as much as others think.
I think (based on my clinical experience and review of the literature) that the skill level is not as important as many make it out to be. It therefore probably doesn’t need to taught as laboriously and pedantically as what it often is. Instead the time could perhaps be better utilised to learn about other more important topics.
I don’t have a large amount of experience with MWM’s (I have done a couple of Mulligan type courses) but given that the research suggests we don’t alter structure with manual therapy I wonder if MWM’s simply change pain (when they work) because we are providing some sort of stimulus into the nervous system. Once again, there is definitely SOME skill required in doing these techniques. If you push too hard you might trigger pain levels, push too softly and you might not provide enough “input” into the nervous system to activate the neurophysiological mechanisms. I doubt that a beginner/novice would know how to “lay” hands on a patient as well as an “expert”, I just reckon the skill level plateaus out pretty quickly. There are also far too many other variables that come into play within a physiotherapy consultation that influence the outcome of the consultation.
I hope that makes some sense. Thanks so much again for taking the time to comment. Would love to hear any other thoughts you have. I am now off to have a look at my comment notification settings!
Cheers
Mark