Find another excuse…

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.

The entertaining but no less wrong @wokephysio on Instagram… go follow him!

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.

It’s not!

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.

They all freak me out… bastards

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

Adam

11 thoughts on “Find another excuse…

  1. When I see “I’m being pedantic”, I actually read “I’m paying attention to detail because it fucking matters”. Simplicity and a lack of detailed understanding is how we ended up with and still have people believe in pain receptors and poor posture as a cause of pain.

    Good post.

  2. My God you are a hard bastard Adam!
    Mate! consider a cervical facet jt, say C01 or 12.
    If these have capsular thickening and shortening, and are currently loaded with nociceptive inflammatory exudate, and reactive upper cervical extensor contraction….give me an exercise that’s going to get that pain settled as quickly as manually mobilising them in a spirited manner.

    • Ok first things first… how do you know that some neck pain in a patient is coming from a thickened or inflammed C0/1 or C1/2 facet joint, and dont say with palpation or I’ll go for ya… Next why do you think you can not exercise or mobilise these areas as effectively as you can manually? Finally does manual mobilisation settle pain quicker than non manual mobilisation, if so please show me some evidence of this.

      And you’re right about one thing, I can be a ‘difficult bastard’

  3. Hi Adam,

    How often do you accidentally push someone too far, or lose rapport when trying to convince someone that they need to do something that hurts them? What does the process look like when you’re trying to regain their trust?

    -Nick

    • Hi Nick

      Great question and its hard to quantify exactly how many patients I flare up or lose rapport or trust with as some dont return when I do. However, over the years one of the things I have learned that reduces the negative effects of a flare up is to pre-empt them before they occur and explain to all patients who I am pushing into pain what they are, why they occur and more importantly what to do when/if they occur. I find being proactive rather than reactive is far more effective.

      Cheers

      Adam

  4. Question Adam – how do you see yourself as being different to an Exercise Physiologist?? I work with EP’s and they are a great recourse, they have covered much more exercise management in their training than we have as Physios and in a hospital setting they are taking on more of the exercise based rehab, group classes and hydrotherapy. I have years worth of experience using both manual therapies and exercise and have definitely seen many benefits in the use of manual therapy. Anyway, I am wondering, if Physios stop using manual therapy all together aren’t we all just EPs? Are we wiping out our profession by neglecting this effective form of treatment? Anyone can write a blog or get an article published these days saying what they wish so the good studies that show good evidence for these things get lost in the white wash

    • Exercise physiologists are a relatively new profession and only an Aussie thing as I know of, and from my travels and interactions with Aussie physios and EPs, it seems they were needed becuase physios mostly abandoned robust simple straight forward exercise as a treatment option in favour of the passive modalities such as manual therapy, electrotherapy, tapes, and needles and other crap that does little and no more than theatrical placebos. If physios in Aus were any good at using exercise as a treatment for pain and disability and disease then EPs would not have been needed… If Aussie physio is ‘wiped out’ they have only themselves to blame, due them being a laughing stock when it comes to exercise and even perhaps will lose the ability to use exercise at all the way they are going. Doing more manual therapy isnt the answer for physios… reconnecting with exercise is!!!

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