Part 1: Shhhhhhhh! I use manual therapy.

Shhhh! Don’t tell anyone… I still use manual therapy with some of my patients.

We’re writing this blog to explore the right, the wrong, and the grey when it comes to using manual therapy.

Manual therapy (MT) has become a four letter word in some circles, and there are reasons for this. For a long time, clinicians and researchers have searched for magic bullets to cure musculoskeletal pains; in doing so, we’ve created overly complex models with the trappings of theoretical plausibility to help us make sense of our world. Unfortunately, these misguided theories likely caused as much harm as good, and contributed to growing disability and medical costs as patients were labelled as having instabilities, rotated pelvises, upslips, downslips, subluxations, and other nonsense that needed to be put back into place. So where does this leave us? Do we toss MT, do we change our paradigm, or do we just flounder onwards?

 To start the conversation we should explore what modern EBP physiotherapy should look like?

  1.  Care should reflect and recognize the elements that make us human: the biopsychosocial approach.

  2. Instilling and/or restoring patient self-efficacy using active treatment strategies is paramount.

  3. Healthcare interactions should utilise principles of therapeutic alliance and shared decision making.

  4. Patient preferences and clinical experience should then guide what evidence-based treatment we apply and how we apply it.

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NAVIGATING THE PITFALLS OF MANUAL THERAPY

There are some good arguments against the use of manual therapy:

  1. It’s effects on pain and function are short-term and deemed low value.

  2. Language surrounding manual therapy can be nocebic.

  3. Manual therapy can lead to patient dependency and may reduce self-efficacy.

  4. It interferes with natural history leading to prolonged disability.

 Some arguments against manual therapy usually begin with its transient nature, discuss its low value and continue to point to its minimal effectiveness over the long term. However, this is by no means conclusive. In a well conducted trial for cervicogenic headaches, Jull et al. found that manual therapy and exercise were both highly effective in reducing headache frequency and intensity1. Similarly, Abbott et al. conducted an RCT which found that a manual therapy group and an exercise group had similar benefits on function and other physical performance tests in patients with knee and hip osteoarthritis that was sustained at one year2. Additionally, it has been demonstrated that patients with neck pain only receiving manual therapy recovered faster and more cost-effectively compared to GP care or physiotherapy3. Despite these findings, what is very clear from the research is that manual therapy is not a magic bullet cure for, well, anything. That said, manual therapy can still have a place in multimodal musculoskeletal care; however, significant changes need to be made to the way it is typically implemented.

Traditionally, the clinical reasoning and language that has accompanied manual therapy has been complicated, confusing, and far from falling in line with the evidence. Past paradigms have focused on specificity, pathoanatomy, tissue changes, scar tissue... the list goes on. For the most part, these models were developed to help clinicians make sense of a MSK world of uncertainty. There’s a seductive complexity to some of these explanations, and it often takes earnest clinicians down a rabbit hole to a wonderland far away from what physiotherapists are supposed to be best at - exercise/activation and education. This kind of complexity has been known to take the ‘physical’ out of ‘physical therapy.

Clinicians who embrace these complex models often transmit this knowledge to their patients in an attempt to ‘educate’ and justify the use of their interventions. We’ve all heard patients tell us about how their physio told them they had twisted hips, a rib out of place, a shoulder that sits too-far forward, etc. These examples are seemingly benign, but they seed a belief system of physical fragility, and can grow into thought processes that lead to increased threat. A thought virus under the influence of genetics, previous exposures, the environment, and stress may easily manifest into a real and recurring problem.

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LANGUAGE, CLINICAL REASONING AND DECISION MAKING - AN ALTERNATIVE APPROACH

 Education delivered by well-intentioned therapists based on outdated patho-anatomical clinical reasoning models does not help explain pain, it can make it worse. The previous anecdotes from the clinical trench (twisted hips, rib out of place, etc) are all too common and the language that accompanies old school manual therapy is likely in part, contributing to a growing culture of pain and disability in developed nations.

The words we use can harm patients and we must consider what narrative to construct in order to explain someone’s pain. Not only can patients adopt these words as their new truth or in some instances their new self-identity, they often tell their friends, family and colleagues to keep the ‘thought virus’ fed, watered, alive, and well. These are just anecdotes, but consider the following study.

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In a qualitative study by Darlow and colleagues, it was demonstrated that words from one or multiple healthcare practitioners had the potential of affecting a patients beliefs about their pain for years (up to 30 years in one subject) in a sample of subjects with chronic low back pain4. One of the subjects reported, “basically all I’ve kind of been told to do by physios is to work on my core...I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak....I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it...carrying it, and having extra weight on my stomach.” While this likely represents an extreme outcome, it does highlight the potential to impart a fragilistic narrative and brings meaning to the old saying that ‘negativity is a place for pain to flourish.’

To this same end, a recent article by Stewart and Loftus delivered a very clear message: language can impact the clinical outcome. Language has the power to tip the scale in favour of recovery or non-recovery as “words are capable of corrupting or enhancing thoughts…[they] can generate good or bad emotions and prompt actions that can lead to positive or negative behaviour change5.”


 Let’s pause here and review. First, it is clear manual therapy provides short-term changes. Hopefully there is some doubt now that MT is conclusively ineffective in the long-term too (sorry for the double negative). Next, the language we use creates the context and narrative for all our interventions in some cases for the better, and in some cases for the worse.

With some of the potential pitfalls discussed what should manual therapy look like in a modern physiotherapy practice? Stay tuned for part 2.

 

1. Jull et al. A randomized control trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002.

2. Abbott et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage. 2013.

3. Ingeborg et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ. 2003.

4. Darlow et al. The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine. 2013.

5. Stewart and Loftus. The Impact of Language in Musculoskeletal Rehabilitation. JOSPT. 2018.

The importance of therapeutic alliance

Physiotherapy has long focused on identifying specific treatment interventions for patients in the hopes of maximizing clinical outcomes. Despite our best efforts, specific treatments often demonstrate modest improvements when compared with competing interventions. This lack of consistent results has led to therapists developing complex treatment models in an attempt to make our clinical world make sense.  

Could it be that we have been looking in the wrong direction for far too long and need to make a paradigm shift where the process by which we interact and deliver our healthcare interventions is as important as the intervention itself? Are some of the significant treatment effects seen clinically the result of the therapist and patient relationship, rather than just a specific treatment intervention?

There is emerging evidence that a significant component of clinical outcomes is shaped by the therapeutic alliance (TA) established between patient and therapist. How do we go about maximizing these effects?

TA is defined as the collaborative and affective bond, or the positive social relationship between the physiotherapist and the patient. It’s believed that there are many aspects that contribute to the establishment of a therapeutic working relationship that include active listening, nonverbal behaviors, demonstration of empathy, respect and collaboration.

Accelerated Motion Physiotherapy

Although the research into this area is still limited with respect to physiotherapy, the results are promising. In one interesting study, patients with low back pain were randomized to one of four groups: standard encounter with IFC, enhanced therapeutic alliance with IFC, standard encounter with sham IFC, and enhanced therapeutic alliance with sham IFC with short-term pain relief as the outcome of choice.

As you might guess, those patients who received the enhanced therapeutic alliance (which simply consisted of listening to the patient and the story behind their pain), had greater pain relief than those who received the standard encounter. Now, the argument could be made that these were only short-term changes in pain, but what about the big picture? Fuentes et al. recently published a trial exploring the relationship between therapeutic alliance and outcome for patients with persistent low back pain. At visit two, a higher therapeutic alliance predicted better outcomes for pain, disability and function at eight-week follow-ups, and the effect size was not small.  Those who scored high on therapeutic alliance rating could expect a 20% improvement on their disability outcome scores compared to those with a low therapeutic alliance rating.

If these changes are not enough to convince you that it is worthwhile to foster a therapeutic alliance, consider some of the other benefits that come with a high therapeutic alliance. Patient’s satisfaction with physiotherapy treatment is generally based on their relationship with the clinician, not the clinical outcome. Heck, patients sue their physicians typically because of a fractured relationship with the clinician, not based on the clinical outcome. Finally, there is evidence that clinicians find their interactions with patients more satisfying when there is a higher level of therapeutic alliance.

One long held belief is that bedside manner is an innate quality that only some clinicians are born with. Although some individuals may be predisposed to having higher abilities to form a therapeutic relationship with their patients, there is good evidence that clinicians can be trained to improve their skills in this area. In one study, physicians were randomly assigned to either serve as a control group or provided with three hours of training that focused on improving awareness of the neurobiology of empathy, communication strategies and the ability to decode facial expressions. Not surprisingly, at one month follow-ups, those receiving the empathy training intervention demonstrated significantly improved empathy scores from their patients.

Curtis Tait, Accelerated Motion Physiotherapy

So what are some simple things that you can do to start improving therapeutic alliance? Here are three easy things to get you started:

  1. Shut up! Well maybe I’m being a little harsh and not achieving therapeutic alliance with the reader……  But every patient has a story to tell and it is imperative that they are heard and validated. I start most of my first assessments with the words, “so, tell me your story,” then I put my computer off to the side, lean in and listen. In a classic study, when observed, physicians only allowed their patients to complete their solicited reason for the visit without interrupting about 25% of the time, and the average time until the physician interrupted their patient was 18 seconds. Interestingly, no patient spoke for longer than 150 seconds if allowed to complete their opening statement, and they would often leave psychosocial components of their history to the end of their discussion. Based on our evolving understanding of pain sciences and its relationship to the psychosocial, I’d suggest that great value can be placed on not interrupting the patient and listening for an extra 132 seconds on their first visit!

  2. Ask patients what they are hoping to get from the clinical visit. Not meeting a patient’s expectations, or naively believing that they simply want what you are trained to provide, is often a recipe for disaster. Patient dissatisfaction occurs when their expectations are not met, irrespective of how reasonable those expectations may be. If we know what patients are expecting, we have an opportunity to help shape expectations and provide the exact service they are looking for.

  3. Practice shared decision making with your patients; this is the act of the clinician and the patient making a decision regarding treatment together, based on the best available evidence. After an assessment, summarize your findings and then give your patient potential treatment options with the possible costs and benefits of the interventions. Shared decision making does a few key things to help improve the clinical process; it increases patient self-efficacy as they actively participate in decision-making regarding their care.

Accelerated Motion Physiotherapy

Interestingly, shared decision making may also help more patients utilize physiotherapy than other more costly and invasive interventions. There is evidence that patients choose more conservative treatments when given the opportunity to participate in shared decision making.

This is by no means an exhaustive list, and the application of soft skills needs to be modified and altered appropriately with each individual patient. I would argue that the true “Art” of physiotherapy is not the ability to poke a patient with a needle, manipulate a joint or teach a fancy exercise, but rather the skillful interpersonal communication skills required to establish therapeutic alliance with our patients. It is time to get away from being enamored with just interventions and looking for that magic bullet treatment that will serve as a panacea. Regularly reflecting on our communication skills, and spending time learning how we can foster therapeutic alliance, is well worth the effort both from an outcome-based perspective and personal satisfaction as clinicians. A great place to start is with the timeless paper the four habits model.