We’re writing this blog to explore the right, the wrong, and the grey when it comes to using manual therapy.
Manual therapy (MT) has become a four letter word in some circles, and there are reasons for this. For a long time, clinicians and researchers have searched for magic bullets to cure musculoskeletal pains; in doing so, we’ve created overly complex models with the trappings of theoretical plausibility to help us make sense of our world. Unfortunately, these misguided theories likely caused as much harm as good, and contributed to growing disability and medical costs as patients were labelled as having instabilities, rotated pelvises, upslips, downslips, subluxations, and other nonsense that needed to be put back into place. So where does this leave us? Do we toss MT, do we change our paradigm, or do we just flounder onwards?
To start the conversation we should explore what modern EBP physiotherapy should look like?
- Care should reflect and recognize the elements that make us human: the biopsychosocial approach.
- Instilling and/or restoring patient self-efficacy using active treatment strategies is paramount.
- Healthcare interactions should utilise principles of therapeutic alliance and shared decision making.
- Patient preferences and clinical experience should then guide what evidence-based treatment we apply and how we apply it.
Navigating the Pitfalls of Manual Therapy
There are some good arguments against the use of manual therapy:
- It’s effects on pain and function are short-term and deemed low value.
- Language surrounding manual therapy can be nocebic.
- Manual therapy can lead to patient dependency and may reduce self-efficacy.
- It interferes with natural history leading to prolonged disability.
Some arguments against manual therapy usually begin with its transient nature, discuss its low value and continue to point to its minimal effectiveness over the long term. However, this is by no means conclusive. In a well conducted trial for cervicogenic headaches, Jull et al. found that manual therapy and exercise were both highly effective in reducing headache frequency and intensity1. Similarly, Abbott et al. conducted an RCT which found that a manual therapy group and an exercise group had similar benefits on function and other physical performance tests in patients with knee and hip osteoarthritis that was sustained at one year2. Additionally, it has been demonstrated that patients with neck pain only receiving manual therapy recovered faster and more cost-effectively compared to GP care or physiotherapy. Despite these findings, what is very clear from the research is that manual therapy is not a magic bullet cure for, well, anything. That said, manual therapy can still have a place in multimodal musculoskeletal care; however, significant changes need to be made to the way it is typically implemented.
Traditionally, the clinical reasoning and language that has accompanied manual therapy has been complicated, confusing, and far from falling in line with the evidence. Past paradigms have focused on specificity, pathoanatomy, tissue changes, scar tissue... the list goes on. For the most part, these models were developed to help clinicians make sense of a MSK world of uncertainty. There’s a seductive complexity to some of these explanations, and it often takes earnest clinicians down a rabbit hole to a wonderland far away from what physiotherapists are supposed to be best at - exercise/activation and education. This kind of complexity has been known to take the ‘physical’ out of ‘physical therapy.
Clinicians who embrace these complex models often transmit this knowledge to their patients in an attempt to ‘educate’ and justify the use of their interventions. We’ve all heard patients tell us about how their physio told them they had twisted hips, a rib out of place, a shoulder that sits too-far forward, etc. These examples are seemingly benign, but they seed a belief system of physical fragility, and can grow into thought processes that lead to increased threat. A thought virus under the influence of genetics, previous exposures, the environment, and stress may easily manifest into a real and recurring problem.
Language, Clinical Reasoning and Decision Making - An Alternative Approach
Education delivered by well-intentioned therapists based on outdated patho-anatomical clinical reasoning models does not help explain pain, it can make it worse. The previous anecdotes from the clinical trench (twisted hips, rib out of place, etc) are all too common and the language that accompanies old school manual therapy is likely in part, contributing to a growing culture of pain and disability in developed nations.
The words we use can harm patients and we must consider what narrative to construct in order to explain someone’s pain. Not only can patients adopt these words as their new truth or in some instances their new self-identity, they often tell their friends, family and colleagues to keep the ‘thought virus’ fed, watered, alive, and well. These are just anecdotes, but consider the following study.
In a qualitative study by Darlow and colleagues, it was demonstrated that words from one or multiple healthcare practitioners had the potential of affecting a patients beliefs about their pain for years (up to 30 years in one subject) in a sample of subjects with chronic low back pain4. One of the subjects reported, “basically all I’ve kind of been told to do by physios is to work on my core...I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak....I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it...carrying it, and having extra weight on my stomach.” While this likely represents an extreme outcome, it does highlight the potential to impart a fragilistic narrative and brings meaning to the old saying that ‘negativity is a place for pain to flourish.’
To this same end, a recent article by Stewart and Loftus delivered a very clear message: language can impact the clinical outcome. Language has the power to tip the scale in favour of recovery or non-recovery as “words are capable of corrupting or enhancing thoughts…[they] can generate good or bad emotions and prompt actions that can lead to positive or negative behaviour change5.”
Let’s pause here and review. First, it is clear manual therapy provides short-term changes. Hopefully there is some doubt now that MT is conclusively ineffective in the long-term too (sorry for the double negative). Next, the language we use creates the context and narrative for all our interventions in some cases for the better, and in some cases for the worse.
With some of the potential pitfalls discussed what should manual therapy look like in a modern physiotherapy practice? Stay tuned for part 2.
1. Jull et al. A randomized control trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002.
2. Abbott et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage. 2013.
3. Ingeborg et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ. 2003.
4. Darlow et al. The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine. 2013.
5. Stewart and Loftus. The Impact of Language in Musculoskeletal Rehabilitation. JOSPT. 2018.
References:
1) Bialosky et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy. 2009.
2) Rabey et al. Reconceptualising manual therapy skills in contemporary practice. Musculoskeletal Science and Practice. 2017.
3) Lluch et al. Preoperative Pain Neuroscience Education Combined With Knee Joint Mobilization for Knee Osteoarthritis: A Randomized Controlled Trial. Clinical J Pain. 2018.
4) Luque-Suraez et al. Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. BJSM. 2018.
5) Louw et al. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial, Journal of Manual and Manipulative Therapy. 2016.
6) Vlaeyen et al. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clinical Journal of Pain. 2002.
7) Bunzli et al. Making Sense of Low Back Pain and Pain-Related Fear. JOSPT. 2017.
8) Craske et al. Maximizing exposure therapy: an inhibitory learning approach. Behavioral Research Ther. 2014.
9) Chen et al. Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain. 2018.
10) Walton et al. Risk factors for persistent problems following acute whiplash injury: update of a systematic review and meta-analysis. JOSPT. 2013.
11) Jakobson et al. Long-term prognosis for neck-shoulder pain and disorders: a 14-year follow-up study. Occupational and Environmental Medicine. 2018.
12) Cook et al. Does early change predict long-term (6 months) improvements in subjects who receive manual therapy for low back pain? Physiotherapy and Practice. 2017.
13) Cook et al. Is there preliminary value to a within- and/or between-session change for determining short-term outcomes of manual therapy on mechanical neck pain? Journal of Manual and Manipulative Therapy. 2014.
14) Lehman, Gregory. The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice. JOSPT. 2018.
15) Mintken et al. Manual Therapists - Have you lost that loving feeling!?. Journal of Manual & Manipulative therapy. 2018.
16) Louw et al. A clinical perspective on a pain neuroscience education approach to manual therapy. Journal of Manual and Manipulative Therapy. 2017.
17) Nijs et al. Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Manual Therapy. 2010.
18) Cleland et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multicenter randomized clinical trial. Phys Ther. 2010.
19) Lucado et al. Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis. Journal of Hand Therapy. 2018
20) Kraus et al. Tactile communication, cooperation, and performance: an ethological study of the NBA. Emotion. 2010.
