So I’ve been involved in a few more frustrating discussions around manual therapy recently mainly about why some therapists justify using it. During these discussions, therapists often tell me they use manual therapy as a form of graded exposure to painful movements or tasks as it helps patients return to normal function and activities. Well, this is not actually correct and manual therapists need to find another excuse to justify their rubbing, poking, and pressing because it’s not a graded exposure treatment.
Now manual therapists often come up with some weird, wonderful and whacky reasons for using their techniques, some less plausible than others. Things such as releasing fascia, breaking adhesions, freeing up muscle knots, or reducing muscle spasm. So when some say manual therapy is a form of ‘graded exposure’ it sounds not only plausible but also scientific, evidence-based and contemporary. However, it’s just not true, manual therapy is not a form of graded exposure treatment.
Many therapists have poor understanding and some rather skewed ideas of what graded exposure treatments are. Often they confuse, bastardise or completely misrepresent graded exposure to explain or justify the use of their treatments.
For example, therapists often tell me that they use taping, dry needling, manipulation, or joint mobilisation to allow patients to do movements or tasks with less pain, fewer restrictions, and less fear and anxiety. They tell me that by performing some form of passive treatment to a patient in pain it opens the window of oportunity and allows them to move more frequently and therefore is a form of graded exposure therapy.
Graded exposure is a specific behavioural treatment designed to reduce or remove fear, anxiety, and avoidance by exposing a subject to the fearful stimulus. Graded exposure is performed by exposing the subject to the stimulus, not by removing or reducing as many manual therapists seem to think.
For example, if you have a fear of spiders, you don’t become less fearful of spiders by avoiding them, you need to be exposed to them. Also if you are fearful of spiders being exposed to some fluffy bunny rabbits also won’t reduce your fear of spiders, it has to be context specific.
This is no different with pain on movements or activities. If you are avoiding bending forward because it hurts your back and you are worried, scared, or afraid that it’s harming you, having some needling, massage, or a manipulation first and feeling less pain when you bend forward won’t reduce your fears of bending when the pain returns.
Likewise, if you are afraid to lift your arm up overhead because it gives you a sharp catch, having a nice young physio apply a Mobilisation With Movement or a silly Scapula Assistance Test as you reach up which reduces the catching sensation won’t help you with your reluctance to reach when they stop doing these things.
Symptom Modification ≠ Graded Exposure
Simply put manual therapy is not a form of graded exposure treatment, its a form of symptom modifying treatment which is completely different (ref). Now you may be thinking this is just Meakins being pedantic over semantics and yes it may be a little, but it is also an issue that is causing some misunderstanding and misuse of two very different approaches to patients in pain.
For example, if you have a patient who you assess not to be displaying any signs or symptoms of fear or avoidance to movements or tasks that hurt. That is they are continuing on with daily tasks, work, and sports despite their pain, and in the exam, they show no signs of apprehension or reluctance to move despite their pain, then I would say modifying their symptoms with some passive interventions could be useful, its not essential or necessary but could be an option.
However, for these kinds of patients, I now prefer not to apply manual therapy anymore but rather I prefer to discuss activity modification options, even advise some short periods of rest. Yes, you heard me, rest, it’s not a dirty word and it can be an effective treatment for some people in pain in some situations if not used for long durations (ref). And of course, I will look to load them in ways that don’t provoke or aggravate their current symptoms if possible.
However, if you have the more common type of patient in front of you who you assess is displaying some signs of fear, reluctance, or avoidance to movements and tasks because of their pain, then modifying their symptoms with manual therapy or any other passive treatments may not be the best thing for you or them to do.
Despite it being wanted by patients and despite it being far easier for therapists to do, removing pain when there is no need may actually be more harmful than helpful. If you want to help a patient reduce their fear of a painful movement, or if you want to get them to return to a task or an activity they have stopped because they are afraid, then they will need graded exposure to it without first reducing, removing or modifying their symptoms.
Hardest thing to do!
However, getting patients to do the things they most fear and are avoiding is the most challenging, difficult and unnerving thing to do. To be able to recognise who does and who does not need to be pushed into pain, when it is safe to do so, and how far to take it, takes a shit load more skill, effort, experience, confidence, and bravery than using any manual therapy or other symptom modification treatments.
Also, one of the biggest misconceptions I hear about therapists who don’t use manual therapy to reduce patients pain but rather push them to do things that hurt or are challenging is that they are reckless, cold, discompassionate and uncaring, this is complete and utter bull shit.
To be able to calmly and confidently get a patient to do something they don’t want to do requires far more skill in communication, rapport building, and motivation than anything else. Believe me when I say its no easy task to ask a patient to do something that hurts them, in fact its the hardest thing I do day in day out, with me always questioning and second guessing if I am pushing them too much, being too harsh, or just worrying about flaring them up and then losing their trust and confidence in me.
It was so much easier and simpler when I could just tell patients to avoid, reduce, or stop doing things that hurt, but this often didn’t get people any better or back into doing the things they wanted.
So that’s my two cents on how manual therapy is NOT a form of graded exposure but rather a form of symptom modification which works through completely different mechanisms. Manual therapy and most other symptom modification techniques will always have small effect sizes, last very short periods of time, be unreliable in who they work on and dont work on, and in my opinion are generally not worth the time and effort for most MSK issues.
So if you are using manual therapy and are telling patients, other physios, or yourself that its a form of graded exposure therapy, its time to find another excuse.
As always thanks for reading