Is the Manual Therapy World Still Flat?

The discovery of the new world by Columbus and others who challenged the prevailing theory of the world being flat was a massive discovery that has paved the way to many more discoveries in our world.  It seems that some continue to see the manual therapy world as being flat, yet science and research are are giving us compelling evidence that it likely is round and that major discoveries may be on the horizon. 

I love manual therapy.  I have spent a career learning and pursuing further education in it.  I use it every day in the clinic and likely carry some bias towards it.  The big thing for me that has changed and evolved as I practice it is how I conceptualize it and most importantly how I explain it to a patient.  No longer does every patient have to receive manual therapy.  (Shocking to hear that from a FAAOMPT I know).    As I have done my best to search and listen with unbiased eyes and ears, it seems science and the literature have been telling us that, at a minimum, we need to be questioning some of the traditional mechanical theories and methods we are using to help people in pain.

 Pain, of course, is the reason we apply manual therapy in the vast majority of cases.  Why then, do we still allow theories that strictly look at it from a peripheral tissue-based view to exist without question?  Our improved understanding of pain and its complexity tells us that looking at it strictly from the bottom-up as we have traditionally done, while helpful in some cases, is grossly inadequate to explain complex pain states that out live tissue healing time frames.  When we treat pain after these time frames have passed the response becomes much more variable.  We see this in the clinic daily when a successful treatment is repeated and instead of improving the patient’s condition, as it had our first go around, it worsens them on the second.  How can this happen if we had performed the exact same treatment?  If this was strictly a mechanical phenomenon then this should not happen as the mechanics did not change in our treatment.

We need more complex models?

Our treatments can have amazing success with some people and in others it can fall flat leaving us scratching our heads as to what the heck to do with these patients.  What has been our professions’ response to this in the past with its continued dominant bottom-up view on pain?  In many cases, we have decided that the answer must be to make our models more complex.   Our training programs gain more levels of complexity to where you have to get to level 10 to be certified and reach the Jedi-level of skill that is required to help these difficult patients.   To explain the failures to our students and mentees we say you must have 10,000 hours to develop hands to be able to feel the millimeters of movement that are being missed and preventing the patient from achieving an outcome.  If we see a clinician fail or even worse yet, DARE to question us, we sit in our manual therapy circles and discuss how they just can’t do it due to their substandard hands,  haven’t hit their 10,000 hours, or maybe they aren’t a member of our tribe so everything they are doing is all wrong to begin with.   Could Occam’s razor be the solution?

We need more models?

Another response to  the variable response to mechanical treatments in complex pain states is that we simply have created different models.  We have models of all kinds that are hugely variable in what they propose to be the driving force behind pain and the reason for these patients whose pain outlives healing.   They aim to arm the clinician with the missing piece in their practice that will allow them to help these people.  As we bring these new techniques or models back to the clinic we experience some new found success.  As time passes and our excitement fades we find that the same patients continue to baffle us.  Pursuing education in these models does give us comfort though, as we now have a group of people who share our belief in them and allow us to feel we are doing the right thing.  I am confident if we traveled to clinics where these models are practiced we will find happy patients who gladly shell out a copay or even cash to pay for them.   My big question that I think we are LONG overdue as a profession to ask ourselves is:  are really doing very similar things and not recognizing it? And is it this that is truly driving the outcomes we all get?  Maybe it’s time to stop creating new models and instead come together.

Ben Cormack had a great post on Facebook that spoke to the commonalities we share that allow us all to achieve outcomes regardless of what theory or method we have decided to saddle up on. To me this is exactly why we have a huge amount of explanatory models, theories, and treatment methods  (many of which directly oppose each other) that all have happy clinicians and patients who sing their praises.  I would argue that it is these factors that, as Ben so eloquently points out,  clinicians wrongly attribute to their mechanical views that drive outcomes and fall victim to the post hoc ergo propter hoc fallacy where correlation does not necessarily mean causation.

Based on the above common factors it would seem that all methods or theories have the potential to positively modulate the patients’ pain experience.  The question we must ask is why does this modulation occur?  Is the modulation unique to the specific treatment or is it due to the commonalities discussed above?  When we consider the complexity of pain: in what patients,  in what presentations, and in what contexts are mechanical tissue-based treatments best applied if at all?

 There are some out there who think we need to stop doing all passive mechanical tissue-based care in persistent pain and some who continue to apply it to every patient who walks through the door without consideration of the other possible mechanisms behind their outcomes.  The answer likely lies somewhere in the middle and it likely differs for different patients.  Tissues will continue to get injured and benefit from mechanical care to improve healing.  Acute flexion-based back strains often can use a break from flexion just like our inversion sprains can use a break from inversion for a short time.  We need to own the understanding of tissue healing and be able to convey it to our patients.  We also will have acute injuries with overlying yellow flags that take more than a mechanical treatment.  Let’s also not forget that there may be some patients where pain is minimally about the tissues and any effect from peripheral treatment and has more to do with conditioned pain modulation versus any local tissue effects.

 Research in our profession needs to stop getting excited about RCTs that show an intervention is better than doing nothing or to a worthless sham treatments.  We need to start controlling for the commonalities in treatments we’ve discussed above and let’s start answering the questions of which interventions produce unique effects.    Let’s also not forget that a patient’s behavior and response in a safe clinical or research setting can be a lot different than what they display in the context of their unique social and environmental settings.   Creating change that can live on in the context of a patient’s life is what we are after and it will take us looking outside a patients biology, pathoanatomy, and biomechanics if we truly want to do better in treating the patient in pain.

 Amazing discoveries were made when we decided to change our view that the world is in fact round and not flat.  I see the same potential for discoveries our profession can make if we question some of the traditional theory that continues to drive our inability to help some patients in pain.  I see opportunity to unite methods and models in a common model of effect.  As a profession let’s set sail and see what amazing discoveries lie ahead.

 What do you all think?

Mark Kargela

Mark has been practicing physical therapy since 2003. He spent the his career pursuing expertise in manual therapy treatments. When he recognized that manual therapy had limited success in chronic pain he began intense study of pain neuroscience and advanced training. He practices in Glendale, Arizona where he is a Clinical Assistant Professor and runs Midwestern University's Physical Therapy Institute. He also teaches nationally for Modern Pain Care and lectures across the country on spine care and persistent pain.