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 and it helps patients return to normal function and activities better. 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 graded exposure.

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 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. Also if you are terrified 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 attractive physio apply a Mobilisation With Movement or a Scapula Assistance Test as you reach up which reduces the catching sensation this won’t help you with your anxiety or 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 a completely different argument (ref). Now you may be thinking this is just Meakins being pedantic over semantics, but its 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 anxiety, apprehension or reluctance to move despite their pain, then I would say modifying their symptoms with some passive interventions could be useful, it’s not essential or necessary but it could be an option.

However, for these kinds of patients, I prefer not to apply manual therapy but rather I prefer to discuss activity and exercise modifications, even advising 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). Of course, I will also look to load them in ways that don’t provoke or aggravate their current symptoms if possible.

However, if you have a patient in front of you who you assess is displaying some signs of fear, reluctance, anxiety and avoidance with 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 these patients and despite it being far easier for therapists to do this, removing pain when there is no need may actually be more harmful than helpful. If you want to help a patient reduce their fear, anxiety or apprehension of a painful movement, or if you want to give them control, confidence and get them to return to a task or an activity they have stopped, then they will need graded exposure to it… but without first reducing, removing or modifying their symptoms.

Hardest thing to do!

Getting patients to do the things they fear or are avoiding the most is without doubt one the most challenging, difficult and unnerving things a therapist has to do, and why I don’t think that many actually do it.

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 symptom modification treatments.

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 them a little or are challenging them is that they are 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 to do with you always questioning and second-guessing if you are pushing them too much, too hard, 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 push, poke and pamper all my patients, telling them to avoid, reduce, or stop doing things that hurt, but I found this didn’t sit well with more but more importantly it don’t actually help many people get any better or back into doing the things they wanted. 

Summary

So that’s my two cents on how manual therapy is NOT graded exposure but 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 for and don’t work for, and in my opinion, are generally not worth the time and effort for most 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