The Power Tool in your Tool Belt

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Working in musculoskeletal practice, it’s easy to forget the scope of the issues that we are dealing with. Low back pain is a leading cause of disability in Canada, with 1 in 5 Canadians suffering from high intensity low back pain over a 6 month period (1). Nearly 1 in 5 Canadians suffer from chronic pain lasting more than 3 months (2). In Ontario alone, over a year-long period, 22.3% of people saw a physician for a musculoskeletal issue; that’s 2.8 million people! (3). So the natural next question is what as physiotherapists can we do to help these people in pain? What is our most potent treatment tool for managing musculoskeletal pain? While we have a number of tools in our toolbelt, is there a tool that we should be bringing out a bit more often than the rest? 

There are a few reasons why I think there is a general answer to that question. The answer is not a newly minted manual therapy technique, nor is it ACT, CBT, MDT, ART, PNF, or any other 3 letter proprietary intervention, and it’s not even anything that gets plugged into the wall… In fact it’s humble, well known, and called EXERCISE. A recent systematic review of treatments for the most common musculoskeletal pain sites – neck, back, hip, knee and multi-site pain – found that exercise had the strongest recommendation – greater than other modalities such as manual therapy or oral pharmacological management (4). This was corroborated in a huge number of reviews: 10 Cochrane reviews, four clinical practice guidelines and 3 policy documents. Bottom line – we are very confident that exercise is a highly influential and effective treatment tool that physiotherapists are well positioned to administer. While there are issues with these reviews and they can’t inform all of our practice (they don’t give us specific recommendations for specific patients), they can inform us about what our power tool might be. 

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To zoom in on a specific treatment area let’s look at a review of lumbar spine pain where the authors compare active versus passive care. A massive review of lumbar spine treatment in the US of over 750,000 individuals looked at whether people received “adherent” versus “non-adherent” care (5). How did they categorize adherent care? This was defined as having over 75% of the treatment being active – either “exercise therapy” or “neuromuscular re-education”. The authors found that patients that received adherent (aka active) care had a significantly lower rate of going on to have advanced imaging, spinal injections, lumbar surgery, and had lower medication costs over the subsequent 2 years. 

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Importantly, this review is not saying that we can’t or shouldn’t use manual techniques or therapeutic modalities. Indeed, the authors state that manual therapy in the first 2 weeks of care is part of clinical practice guidelines based on research of positive effects with early manual therapy in acute low back pain (6). I would suggest that the thesis is that exercise shouldn’t get left out, and that it should usually make up a large portion of a treatment session. 

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So how can we best implement our exercise programs? There’s no use in having this “Power Tool” if patients don’t understand why we’re getting them to use it. Exercise can be uncomfortable. It’s hard work, and it’s sometimes painful. We need to employ considered strategies to motivate patients to engage and adhere to their exercise prescriptions.  

So what are patients saying about exercise for musculoskeletal pain? Patients prefer individualized exercises that are tailored to their normal activities (7). Interestingly, this review of patient feedback emphasized the value of demonstrating exercises, observing their performance, and giving feedback based on technique. Patients seem to have a bias against cookie-cutter approaches, which is echoed in treatment guidelines for lower back pain (8). I’m not saying that perfect technique is necessary for an exercise to be effective – rather, technical tips and instruction seem to increase patient buy-in and enthusiasm.

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There’s another major tip that I personally think is critical— keep it fun! Our exercise programs should try to match the intensity and type to the patient in front of us, but also introduce variability and a good bit of fun to the process. It’s often the case that many different types of exercise will achieve similar benefits. For instance, with low back pain treatment, core stabilization, moderate-intensity aerobic exercise, strength programs and flexibility programs, lead to a similar magnitude of benefit (9). That leaves us in a position to pick what exercise resonates with our patients. If there’s an exercise that the patient finds meaningful or fun, their adherence will go up and they will realize the benefits. I’d argue that a good deal of the art of exercise prescription is making it fun and meaningful. 

When it’s fun, it gets done

 A few caveats before we adjourn... While the review on musculoskeletal pain mentioned above found moderate to large effect sizes with exercise treatment (this would indicate these treatments are showing large changes in pain), other reviews have found smaller effect sizes on pain and disability particularly in the lumbar spine (10,11). Exercise is not a panacea for pain, and we will need to consider all the things that are sensitizing the patient in front of us to have optimal outcomes. This could include factors such as biomechanics, sleep, stress, kinesiophobia or pain beliefs (12,13,14). In chronic low back pain there is some promising evidence that combining exercise or a graded-exposure approach with ‘Explain Pain’ education leads to the better outcomes in pain and function (15).

When we’re talking about musculoskeletal pain in these broad terms we can only make broad recommendations. That said, there are some guidelines that have been suggested for chronic presentations that I think are helpful to keep in mind when we are treating patients, which I’ve included below (16). These recommendations and guidelines offer a starting point when implementing our exercise programs. 

  1. Understanding contemporary pain biology and ‘explaining pain’ are key competencies required for biopsychosocial treatment.

  2. Frequently reassure patients that it is safe to move/pace-up despite their symptoms.

  3. Exercise prescription should be time, as opposed to pain, contingent using a tolerable/not tolerable dichotomy.

  4. Having ready‐made responses to flare‐ups can reduce severity.

  5. Exercise should be individualized, enjoyable, meaningful, and related to patient goals.

  6. Many patients with CMP will respond to lower exercise dosage than recommended for healthy individuals (i.e. graded low to moderate intensity). 

  7. Closely observe and monitor exercise then provide feedback and correct poor technique.

  8. Encourage patients to self‐monitor exercise (diaries, activity trackers, etc.).

  9. Place emphasis on developing/restoring movement confidence and quality.


This excellent article was written by Nathan Hers and originally published in PABC’s February 2019 Directions Magazine.  

Nathan Hers BSc MPT

Nathan Hers BSc MPT

References

  1. Cassidy, J. et al. (1998). The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine

  2.  Schopflocher, D. et al. (2011). The prevalence of chronic pain in Canada. Pain Research and Management

  3.  MacKay, C. et al. (2010). Health care utilization for musculoskeletal disorders. Arthritis Care & Research

  4.  Babatunde, O. et al. (2017). Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLOS One

  5.   Childs, J. et al. (2015). Implications of early and guideline adherent physical therapy for low back pain on utilization and cost. BMC Health Services Research

  6.  Childs, J. et al. (2004). A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Annals of Internal Medicine

  7.  Slade, S. et al. (2014). What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain?: A systematic review of qualitative studies. The Clinical Journal of Pain

  8.  NICE. (2016). Low back pain and sciatica in over 16s: assessment and management. Retrieved from https://www.nice.org.uk/guidance/ng59

  9.  Saragiotto, B. et al. (2016) Motor control exercise for chronic non-specific low-back pain. Cochrane Library.

  10.   Rainville, J., et al. (2004). Exercise as a treatment for chronic low back pain. The Spine Journal

  11.  Searle, A. et al. (2015). Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation

  12.  De Oliveira Silva, D. et al. (2018). Kinesiophobia, but not strength is associated with altered movement in women with patellofemoral pain. Gait & Posture

  13.  Osteras, B. et al. (2015). Perceived stress and musculoskeletal pain are prevalent and significantly associated in adolescents: an epidemiological cross-sectional study. BMC Public Health

  14. Bonvanie, I et al. (2016). Sleep problems and pain: a longitudinal cohort study in emerging adults. Pain

  15.  Pires, D. et al. (2015). Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial. Clinical Rehabilitation.

  16. Booth, J. et al. (2017). Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care

PART 2: In with the new … What should manual therapy look like in a modern physiotherapy practice?

In part one of this exploration, we looked at the pitfalls of manual therapy and the power that language and narratives have to either push patients into these traps or sidestep them completely. 

manual therapy does not cause specific structural tissue changes

In part two, we’ll explore ideas on how to create a healthy context for manual therapy. We’ll figure out how to use it in a way that’s consistent with modern EBP Physiotherapy. 

Let’s start with what we’re doing; manual therapy seems to impart neurologically mediated changes including analgesia and changes in psychology (1). This can help to:

1.    Facilitate exercise.

2.    Facilitate exposure to a feared movement.

3.    Develop a healthy narrative about how pain is readily changeable. 

4.    Meet patient expectations. 


So how do we take advantage of this and at the same time avoid the pitfalls?

The first thing we can do is set the stage of patient expectations. By prefacing a bout of MT with a comment along the lines of: “we’re going to do some manual therapy which may help improve your symptoms and allow you to move better; to be clear, we are not putting anything back in to place or freeing anything up, but simply interacting with the nervous system.”

For many, manual therapy related reductions in pain are often transient and the favourable results are likely attributed to changes in neurophysiology (1), not biomechanical miracles. 

It should also be stressed to the patient that manual therapy is being used to decrease sensations such as ‘stiffness’, ’tightness’ or pain in order to facilitate an increase in activity and load tolerance. Finally, and perhaps most importantly, any positive short-term change in pain or function after manual therapy must be used to further reinforce positive messaging in the form of “Explain Pain” style education which may be as simple as suggesting “pain is a protector and not a barometer for tissue damage.”

Some authors have described situations using vignettes to help decide how to use or not use contemporary manual therapy (2). Despite these articles and other research recommendations, the evidence-base is limited and to our knowledge there are only two randomized trials examining the effects of manual therapy combined with a neurophysiological versus a biomechanical/biomedical explanation. 

First, a group of subjects with osteoarthritis and evidence of central sensitization were randomized to receive 4 sessions of modern or biomedical pain education in addition to knee joint mobilization before their surgery (3). Pre and post-operative results showed no significant group differences except for one clinically important difference: subjects receiving modern pain neuroscience education (PNE) with manual therapy achieved greater improvements in psychosocial variables (pain catastrophizing, kinesiophobia). Pain catastrophizing and fear of movement are two big predictors of non-recovery (4) and perhaps this study suggests that modern pain education can co-exist with manual therapy without compromising clinical outcomes.

Another study from Louw and colleagues randomized subjects with chronic non-specific low back pain to receive one of two explanations (neurophysiology or mechanical) with manual therapy applied to the lumbar spine (10 minutes of central PA mobilizations - not an intervention that would typically be used in clinical practice) (5). The only significant finding that met the minimal detectable change (MDC) was the group receiving a neurophysiological explanation for their symptoms experienced an immediate change in the straight leg raise test immediately post-treatment.

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Unfortunately when we consider these two studies we cannot build much of a compelling argument for manual therapy. Worth a mention though is that manual therapy and PNE did not use an inhibitory learning approach which could be an important component in creating clinically meaningful change. To elaborate a bit, the roots of inhibitory learning come from the psychology literature and it has been adopted into physiotherapy practice, most typically in the treatment of chronic low back pain (6,7). 

So how does inhibitory learning work? Well the patient first identifies a salient movement, perhaps one where there is pain-related fear (let’s say: forward flexion). They then make a prediction about the outcome (ex. It’s going to be painful) after which an intervention (i.e. a symptom modifier, for example MT) is introduced, followed by re-testing of the movement. If after the intervention the movement has changed (i.e. is less symptomatic) then a prediction error has occurred (i.e. the expectancy violation) which seems to be an important observation to reduce pain-related fear between a coupled stimulus and an expected outcome (8). 

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This uncoupling of fear of pain, pain, and movement could allow for further graded exposure to fearful activities. It could also lead to a graded path towards more meaningful activities of daily living. What this approach provides is an opportunity for the patient to see in real-time that the painful movement can be changed, which can help to form an expectation of recovery and enhance the therapeutic relationship with the clinician. It is worth noting that these expectancy violations could also be induced by education, advice or movement cues.

One argument against using manual therapy under the inhibitory learning model is that manual therapy and even education could act as an ‘inhibitor’ or a ‘safety signal’ which can disrupt the size, strength and efficacy of the expectancy violation.

What could be more powerful?  The patient explores and learns about the symptoms on their own through movement hopefully coming to a self-realization that ‘hurt’ did not lead to some expected ‘harm’ and continue to push the symptom edges from there. Unfortunately many do not take the ‘perceived’ risk of challenging symptoms and end up in avoidance cycles. For a more in-depth review on pain-related fear and inhibitory learning check the brilliant works of Johannes Vlayen, Jeroen de Jong, and Michelle Craske.


 
PREDICTING PATIENT OUTCOMES

Baseline pain and disability scores are important to collect on the first clinical interaction as they have been shown to be useful prognosticators across many different musculoskeletal populations (9,10,11). However, it may be important to consider what happens within the first few treatment sessions to determine if manual therapy and response to treatment might have predictive capabilities. 

Cook and colleagues have looked at the prognostic value of this phenomenon. In a retrospective study, a group of subjects reporting chronic low back pain on average for 345-weeks received four treatments of manual therapy and exercise within a 2-week time period. For those subjects who experienced a pain reduction of 30% within the session, there was a predicted 50% improvement in Global Rating of Change scale and the Oswestry Disability Index at 6-month follow-up (12). 

Similarly, another study analysed within and between-session changes in group of subjects with mechanical neck pain who received manual therapy. Those subjects who experienced a within-session change in pain and function of 30% often experienced a 50% reduction in the Neck Disability Index at 96 hours (13). Further, the between-session changes in pain were associated with a 50% change in disability and Global Rating of Change scores at 96 hours (13). These findings may suggest that early positive changes indicate a favorable prognosis, and taking it one step farther may help us identify who is likely to be a rapid, slow, or non-responder to treatment. We must remember that even if dramatic symptom modification does not occur, a favorable outcome is still possible. This point and a good deal more information surrounding symptom modification was recently discussed in an article from Dr. Gregory Lehman (14). One highlight: Dr. Lehman suggests that symptom modification procedures have the potential to reduce pain and improve function, allow an entry point for PNE thereby creating an opportunity to “reduce the impact of negative influences, such as reduced self-efficacy, catastrophizing, [lost] locus of control, fear avoidance, and kinesiophobia.” 

A long story short: manual therapy, when used responsibly within a salient context, could have the ability to demonstrate that movement is safe and that change is possible. This gives hope and facilitates an active treatment approach. Manual therapy can remain a part of clinical practice when the clinician stays up to date with current research (15) and can coexist with pain neuroscience education (PNE) even in patients with evidence of central sensitization (16,17). 


WHAT WE DO: 

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We use manual therapy in our practice, but not on every patient. Yes, this means we impart mechanical forces to the skin and the underlying tissue in effort to create a neurophysiological response that may lead to a pain inhibition or even a prediction error. It may also give us some insight into prognostics. We use it with full disclosure to our recipient that an active approach is paramount for recovery and then we also pair it with PNE as appropriate. 

As biopsycholosocialist physiotherapists, we check-in with other salient features that may be a part of the clinical picture such as past experiences, sleep, unmanaged chronic stress, diet, negative beliefs, training loads, total life loads, other comorbid conditions, and physical activity habits to name a few. We also look for things the patient is already doing well, highlight them, encourage and positively reinforce it. An acknowledgement of these variables help our patients see the vast complexity of pain. More pragmatically, it serves to highlight the many avenues for change. 

In this view, manual therapy falls into the category of symptom modifying procedure (SMP) (alongside: education, repeated movements, isometrics, exercise induced analgesia, etc). It is used to encourage to the uncertain patient that movement, specific exposures and loading is good, and will be part of their recovery. Our choice of whether or not to use it depends on the evidence, patient preferences and expectations, along with our training, and the context of our practice setting.

THE PRACTICE “CONTEXT”

Practice context is often left out of the conversation between pro and anti-manual therapy advocates. Given a context that is publicly funded, with long wait times to see a provider, as well as short treatment sessions, manual therapy clearly falls off the list of priority interventions. We would suggest this hierarchy of interventions:

1.    Education - set the expectation for recovery early.  Positively reframe the issue as something that will or can change while highlighting the resiliency and adaptability of the human body. Consider “impairments” as opportunities for positive change and not “dysfunctions.”.

2.    Exercise - those that are preferred by the patient and supported by evidence for their specific condition, and staged appropriately (i.e. if pain control is needed - initial exercises that focus on SMP; building to exercises that progressively load the body, and provide the patient with “proof” of their resilience).

3.    Manual Therapy.


With this triage in mind, manual therapy may be helpful if the context allows sufficient time, when pain control would be useful for reassurance, a positive patient expectation is present, and when using manual techniques that have demonstrated analgesic effects in the literature for the patients presentation (examples - thoracic manipulation for mechanical neck pain (18); mobilizations with movement for lateral elbow pain [19], etc). Typically these practice settings are privately funded. Now, there is an obvious issue here, why use something that hasn’t been shown to consistently change long term outcomes regardless of funding? Please understand, that we do not object to this question. However, in a privately funded setting, patient expectations appear to be very important to assist buy-in and encourage a patient to return to a provider. If the patient does not return because they didn’t receive the passive intervention they expected, there is a risk that they will find someone willing to provide it, and that person may provide a nocebic message and promote dependency. This is a slippery slope of logic and could be used to excuse high volume repeat visits (which we’re not on board with), but this becomes the job of the physiotherapist - to prove to the patient that they don’t need you (the provider) to get better!


THE TAKE HOME MESSAGE

So how can manual therapy be married with the evidence based framework? Given the ideas discussed above, we should:

1.    Consider our language when explaining our current understanding of how manual therapy works, to help build positive expectations of recovery. We must remember that all the elements that make us human are at work in how we recover from pain or injury.

2.    Leverage any changes in pain or movement tolerance with manual therapy to discuss our current best understanding of pain as relating to protection and sensitivity. Additionally these changes can be used to refute concerns for long standing damage as the cause of pain (“if we can change it for a moment, we change it long-term”), to plant and water the seeds of self-efficacy.

3.    Use of manual therapy should be done in a transparent way by informing the patient of its transient effects, and allowing the patient to voice their values as part of the shared decision making process. Such discussions will also help build therapeutic alliance. 

If manual therapy is used to aid short-term goals of pain relief, then it should always be paired with an active approach. Additionally manual therapy should be left behind as soon as possible, giving way to a fully active approach designed to help achieve the patient’s long-term goals, which empowers the patient to improve with the tools they have learned during the course of care (appropriate education and progressive exercise loading).

attributing successful spinal manipulative therapy outcomes solely to the identification and correction of biomechanical faults makes as much sense as crediting a beard for winning a hockey playoff series. - Joel Bialosky
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As a final consideration, why does it feel good to receive a firm handshake or a hug? Is it a coincidence that sports team who provide regular pats on the back or high fives to each other have better performances (20)? Touch is a part of being human and of our evolutionary background. We use touch to explore our environment and to also establish trust, connectivity and cooperation with others. This is social grooming, a behaviour that results in significant reductions in blood pressure, heart rate and other stress responses, something neuroscientists such as Dr. Robert Sapolsky have studied for years. 

Using touch paired with words that harm does not mix with our biology. However, therapeutic touch provided by a warm, empathetic therapist that listens, empowers, reassures and instills hope is definitely biopsychosocial-sanctioned. 

If we are to continue using manual therapy, the ego must be ‘left at the door’. We are not “fixing” anyone! If leveraged well, manual therapy can demonstrate a form of “proof” to our patient that they are changeable. Let’s be responsible with manual therapy. Let’s stay up to date with science, use positive language, build self-efficacy, use shared decision making and focus on a meaningful active approach.



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.