Explaining Manual Therapy: The Road Less Traveled

You put your hands on a patient and begin to press, guess, mob, thrust, manipulate, needle, scrape, and “release” their tissues, and then it happens…your patient asks you to explain exactly what you are doing with your techniques. Surely you’ve been asked this question hundreds of times, and maybe you’ve come up with a generic response, or maybe you’ve taken some sort of IASTM course that preaches adhesion breaking.  Maybe you even revert back to some homeopathic minded explanations of “like cures like” that you learned with the archaic cross friction massage techniques in your entry level coursework. Maybe you talk about the ever elusive trigger points that you are un-triggering. Maybe you were taught that bones get out of place and you are strategically relocating them. Regardless of what your answer currently is, I assure you that in this situation you have reached a crossroads in how you can proceed with your patient education. 

It is becoming progressively more evident that the words we choose to use when speaking to our patients may be just as important if not more important than our interventions in some cases. We all know the positive powers of the placebo effect, but often tend to overlook the equally powerful and negative effects of the nocebo effect. As research tends to mount, we see that explaining topics to patients from an overly biomechanical perspective with words that carry negative connotations such as stuck, degenerated, broken down, herniated, scarred, out of place, poor alignment, weak, etc lead to poor outcomes. This is demonstrated well in a 2015 study by Darlow et al titled Easy to Harm, Hard to Heal: Patient Views About the Back, and again here by Darlow in the paper The enduring impact of what clinicians say to people with low back pain. Additionally, we see in the study Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review that fear avoidance behaviors lead to decreased outcomes. Considering we now know how directly we can push patients into fear avoidance behaviors with wording, it is easy to see that what we say directly influences outcomes through increasing or decreasing fear avoidance behavior and patient’s ideas about their bodies.

Both Joel Bialosky and Andrew Vigotsky have written extensively on the mechanisms of manual therapy here and here. Additionally I have broken Bialosky’s article down in a blog post here. What we see from these works, is that the vast majority (if not all) manual therapy work through various neural mechanisms both centrally, in the spinal cord, and peripherally to alter threat perception. Simply put, if there is no perception of threat by the nervous system (centrally or peripherally) there won’t be pain. I would like to take that thought process a step further and suggest that feelings of tightness our patients report and we often treat with manual therapy are very likely also a derivative of pain. Pain is an unpleasant sensory experience based on real or perceived danger. Tightness is also an unpleasant sensory experience likely based on a perception of threat in most cases. It is very real to our patients, however it is an output of the CNS based on perceived threat which can lead to very real alterations in muscle function and guarding (mediated by the nervous system). This can be observed by the ballerina with incredible flexibility yet reports significant tightness in her hamstrings, while the 70 year old man who can’t touch his knees reports no feelings of tightness. One of these people’s nervous system is perceiving a certain degree of threat which gives them the experience of tightness, yet they have very different objective physical exam measurements.

What I didn’t do in my previous post was leave readers with examples of how they may be able to word their response to the questions posed by the patient about what their manual therapy is actually accomplishing. When a patient poses this question to me, I very simply initially reply with “I’m trying to change your nervous system a little bit by activating different receptors in your skin, connective tissues, and joints. I explain that their muscles are most often employees of the general manager nervous system. Just like any good employee, they do what the manager tells them. The reason they have pain and feel tight is due to the perception of danger their CNS feels. At this point you can diverge into both acute and chronic pains by explaining normal guarding and pain after an acute injury/surgery, or beginning to broach the subject of both peripheral and central changes in chronic pain states. Explaining the mechanisms of manual therapy is the absolute perfect gateway into educating on pain. 

When you choose to use different manual therapies it gives you the opportunity to talk about novel stimuli. A patient may ask why you choose to use IASTM one day and HVLAT that next. This gives you the opportunity to explain that the nervous system is good at building patterns and can even get better at making pain when it has done it so frequently over the course of their condition. Just like if you practiced shooting free throws every day you would get better at shooting free throws, if you practice pain every day you can get better and producing pain. The novel and changing stimuli allows the CNS to perceive something different, take their pain out of context and possibly break the pain cycle. This subsequently allows for increased movement and active therapies which are the true drivers of long term change.

Occasionally, patients don’t want to buy in because they have been told quite the opposite from previous clinicians. In this case I will often use a simple demonstration of contract relax stretching or set of nerve glides to show just how quick of a change you can make in the body by affecting the nervous system. Seeing such a dramatic change in ROM after 10-30 seconds of basic motion or contracting is often just enough to them realize there is something to this nervous system is king thing. Other times I may use a strong isometric contraction to decrease pain or even a demo of post activation potentiation. Building your patient’s trust and gaining buy in is imperative to a successful treatment path.

So in closing, I ask you. The next time this situation arises are you going to take the well-worn path of those before you, or are you going to instead to take the less traveled path and use what you now know about pain and mechanisms of manual therapy to continue to grow the road system for your patients and those clinicians after you to travel? Use explanations of manual therapy to lead into explanations of pain. Create an environment that doesn’t promote structural nocebos, and help patients to understand that their bodies are robust.

  

 

As always, thanks for taking the time to read

Jarod Hall, PT, DPT, CSCS

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