I attended a pancake breakfast today (Sunday). It’s a Calgary Stampede tradition, and our 100-year-old community hall hosts one every year. It’s nice to see neighbours and relatives from around our rural community, some that you only see once a year!
Such was the case with Deanne. I tend to only see her at the Pancake Breakfast every year. She was once a human patient of mine as well. I’ve not treated her since 2005! She always had a ‘bad back’.
So, in chatting with her, she had told me that since the last time I treated her, her back has been good. She’s never needed physio for her back since then! (How’s that for an Outcome Measure that Matters!!!) Anyways, she had mentioned that she had been to one other physiotherapist since she had seen me for a neck issue. He had asked her, where’s the pain. She pointed. He acknowledged. Then gave her a sheet of exercises to do and said, “Go home and do these exercises and you’ll get better.” Deanne said that he never even touched her! No manual therapy at all!
As you can imagine, she never went back!
Here’s the trouble. There is plenty of research to back up exercise therapy. There is a whole trend towards working on the ‘psychosocial’ aspect of pain management (in the human field anyways). And, there is a disturbing trend away from ‘passive therapies’ such as manual therapy (and also modalities, I’ll add).
I have heard the complaint by seasoned practitioners, that new physiotherapy graduates are not receiving enough training in manual therapy in their physio school curriculum. This complaint has been heard from different areas of the world, not just here in North America. Despite this commentary, research has shown that manual therapy service utilization has increased throughout a ten-year period from 2008 to 2017 in Australia. Yet harkens an additional message that the RATE of annual growth for this service has declined over the years.1
Is it because there is less research to back up manual therapy? Not exactly… What is coming to light is that the ‘biomechanical’ model for manual therapy (i.e. this is the problem joint, and it’s not moving correctly in this or that direction, and requires XYZ-specific technique to fix it) does not stand up to rigorous research testing. Does that mean it doesn’t work? No. It means that the manual therapy forerunners, didn’t have the mechanism of effect of manual therapy quite right! Manual therapy has a neurophysiologic effect and an impact on pain.2
Say what? Essentially, the mechanical force from a manual therapy intervention results in systemic neurophysiological responses leading to pain inhibition. Basically, manual therapy impacts the nervous system and that creates a cellular response within the tissues… and all of that helps to reduce pain.
So, while some groups, professions, or schools are teaching from the same old play book (biomechanical approach), others are shifting away from manual therapy altogether! Both are wrong!
On top of that, what I don’t understand is why we have to pick ONE technique? Does exercise help? Does laser help? Is exercise better than manual therapy? Is laser better than manual therapy?
Research often shows us that a combination works best!
Manual therapy plus specific exercise is better than either alone for treating non-specific neck pain.3 Spinal manipulation combined with laser therapy and conventional exercise is more effective than laser therapy and conventional exercise alone in chronic non-specific low back pain.4
Wiggling the joint helps with pain. Reduction in pain allows for movement or exercise to be more effective. If movement feels better, people can function better. If exercise is more effective, then muscle get stronger… and function gets better!
So, to sum up my ramblings… get your hands on the dogs. Mobilize things. Wiggle the joints. Wobble the spine. Do manual therapy. Add it to your exercise prescription. Add it to you modality sessions. And if you don’t do it, learn it… (or figure out who to refer to!)
Let’s keep getting those dogs better… maybe faster and maybe more effectively as well!
1. Lystad RP, Brown BT, Swain MS, Engel RM. Service utilisation trends in the manual therapy professions within the Australian private healthcare setting between 2008 and 2017. Chiropr Man Therap. 2020 Sep 21;28(1):49. doi: 10.1186/s12998-020-00338-1. PMID: 32951611; PMCID: PMC7504850.
2. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18. doi: 10.2519/jospt.2018.7476. Epub 2017 Oct 15. PMID: 29034802.
3. Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017 Nov 6;30(6):1149-1169. doi: 10.3233/BMR-169615. PMID: 28826164; PMCID: PMC5814665.
4. Nambi G, Kamal W, Es S, Joshi S, Trivedi P. Spinal manipulation plus laser therapy versus laser therapy alone in the treatment of chronic non-specific low back pain: a randomized controlled study. Eur J Phys Rehabil Med. 2018 Dec;54(6):880-889. doi: 10.23736/S1973-9087.18.05005-0. Epub 2018 Apr 24. PMID: 29687966.