10 Things I learnt From 10 Days With Diane Jacobs

Across the end of March and the start of April I spent 10 days straight with Canadian physiotherapist Diane Jacobs, who was in Australia to teach her DermoNeuroModulating (DNM) workshop, which I attended.

Twice.

The first event was held in Noosa, Queensland. It was hosted by Robin Kerr at her recently sold practice, Alchemy in Motion.

The second event was held in Melbourne, Victoria. It was hosted by me at the lovely Parkville hotel The Larwill Studio.

Each event started with a 3 hour lecture by Diane, which covered the theoretical foundation of her work, and was then followed by 3 full days of teaching the manual techniques and clinical reasoning outlined in her book.

I also spent a few days before and after the Melbourne workshop hosting Diane – we went to the zoo, some local pubs and restaurants as well as the Shrine of Rememberance and the National Gallery of Victoria. She even got to have lunch with my mum!

I thought the course was fantastic, overall one of the best courses I have attended, and definitely the best manual therapy course I have attended.

50 Years Is A Long Time

Diane is the same age as my mum. I won’t say what that is exactly (not that I think she’d mind), but she has been in practice for almost 50 years.

Her first years were spent in a hospital setting, which almost turned her off the profession. In fact, she did leave for a short while, but she found her groove, and has never looked back (mostly).

I think anyone who has lived a life, worked thoughtfully and experienced many interactions with people is worth listening to and learning from, and Diane proved me right.

Not David Letterman

In 2013, I took a visceral manipulation course. It was interesting, but implausible. I’d say that Diane’s explanations make more conceptual sense.

One of the benefits of the course was the location – it was in New York City, and while I was there I went to a recording of The Late Show With David Letterman.

His Top 10 lists were great.

I’m not sure I’m of that calibre, but here goes.

NEW YORK – APRIL 24: Dave reads the “Top Ten List” on the Late Show with David Letterman, Friday April 24, 2015 on the CBS Television Network. (Photo by Jeffrey R. Staab/CBS via Getty Images)

On Life

Life mostly works itself out over time. We worry about things we can’t control very much (like outcomes in manual therapy) and cause ourselves a lot of bother, but it mostly works itself out.

On Work

Being a manual therapist is a peaceful way to make a living.

On Not Knowing

It’s okay to not know something, and it’s okay to have a story that may be somewhat, or even entirely inaccurate, as long as you acknowledge it.

The first principle is that you must not fool yourself – and you are the easiest person to fool.


Richard Phillips Feynman 

On Listening

At the Noosa workshop, Diane asked the group if anyone had neck pain, as she was about to demonstrate techniques targeting the occipital nerves.

A man in his sixties volunteered, and she asked him about his pain.

What followed was a 40 minute implicit demonstration of how to listen to someone (not just a patient). Diane seemingly made him feel as they were the only 2 people in the room with her facial expressions, body language and most importantly, her quiet attention.

I really think we need to start considering listening as an intervention itself

Alison Sim

On Manual Therapy

It’s non-specific and n=1 and that’s completely okay.

Additionally, manual therapy can be optimal when it is used for certain presentations (and not very good at all when used for others).

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“For the treatment of pain, manual therapy is always OPTIONAL, but it can be OPTIMAL” – Diane Jacobs ~ So when is manual therapy likely to be optimal? According to Diane, when pain is: ~ ▪ Localised/discrete ▪ Changes with movement/position (ie mechanical) ▪ Changes with distraction ~ Manual therapy is not likely to help (resolve the condition) when: ▪ There are multiple sites of pain that are likely to be the result of central sensitisation ▪ Conditions like fibromyalgia and hyperpathia (basically anything which is highly centralised) ▪ Most (but not all) neuropathic pain ~ I think there is a dearth of research looking at indications and dosage for manual therapy, and as a result (and due to the non specific nature of manual therapy), a lot of research into effectiveness is poor and doesnt help clinical practice. ~ What are your indications for manual therapy? (if you don’t use it, don’t comment, as I know the arguments against, I’m interested in arguments for) ~ #integrativeosteopathy #osteopathy #physiotherapy #massage #manualtherapy #myotherapy #chiropractic #clinicalreasoning

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On Interoception

Often Diane would ask someone if they had pain in the region she was about to demonstrate techniques for.

One thing that really stood out was how she always wanted to get people aware and thinking about how their body felt, rather than the labels and diagnoses they’d been given.

“Does anyone have a sore back”

“I do”

“Tell me about your sore back”

“I had a disc injury”

“How does that feel?

On Beer

Dark beers are her favourite, but The Damned Pilsener by HopNation in Footscray was pretty nice as well.

On Lifespan

It’s mostly genetic.

People try all kinds of things to live longer, but it’s mostly down to genes, and maybe stress.

On Asymmetry

Asymmetrical structure is normal, common and completely okay.

Habitual asymmetrical use of our body is possibly a predisposing factor for mechanical pain.

  • Sleeping on the same side every night
  • Curling up in the same position on the couch all the time
  • Crossing arms/legs the same way all the time
  • Standing with your weight on one leg
  • Carrying bags/children on one side

Her rationale is that such sustained postures/positions/movements relatively tension and shorten the same neural tissues in the same way over time, impacting their fluid dynamics.

Better awareness leads to better use of our body, which leads to feeling better in our body.

On Diagnostic Errors

Everything is a type 1 error (when it comes to musculoskeletal pain diagnoses).

Most of the pain problems we see in clinical practice have been given structural or biomechanical labels.

Yet, often neither changes when the pain resolves.

Or on the other hand, many people walk around with these structural or biomechanical changes and experience no pain.

She is very comfortable with simply calling something “pain”, treating it conservatively and if it improves, not pursuing it further (she will refer for investigations if it doesn’t and she suspects pathology).

DNM: Just Another Acronym?

Manual therapy is full of acronyms and techniques.

Does DNM bring anything different to the table?

Yes.

DNM isn’t about the techniques, which are lovely, but often just rebadged osteopathic techniques.

DNM is about the clinical reasoning process in manual therapy.

It is about considering the role of the nervous system in pain.

It is about understanding what we can affect with manual therapy (nerves, the most excitable tissue in the body), and what we can’t (muscles, fascia and joints – at least not directly).

DNM was the first approach to manual therapy I came across that not only considered the skin (the only thing we can touch), but the physiology and potential therapeutic effects of treating the skin.

There are no rules for DNM techniques – it’s jazz, not classical music.

It’s not copyrighted.

It’s not a business.

It’s simply one woman’s interpretation of the literature on pain, physiology and manual therapy.

Clinical Reasoning In Manual Therapy

Touch is an important part of human interaction.

Pain is an unpleasant human experience.

Touch conveys meaning that words often cannot.

Pain is often hard, if not impossible to put into words.

It is not surprising that touching people in pain is a common ritual, and it has likely been performed for thousands of years of humanity.

Touching people in pain has now evolved into specialised forms of physical therapy, from massage to manipulation and everything in between. However, what it all boils down to is touch and narrative.

Many therapists, and particularly those who define themselves by what they do (like osteopaths), will be upset to hear that I don’t think manual therapy has to (or can be) very specific to be effective for pain relief.

Manual Therapy is Applied Force

In his excellent book The Science and Practice of Manual Therapy, osteopath and researcher, Dr Eyal Lederman describes the 2 types of force you can apply to a body with your hands, instruments or body:

  1. Tension forces
  2. Compression forces

He elaborates that combinations of these two forces can also be applied, yielding resultant forces such as:

  • Torsional forces
  • Shearing forces
  • Bending forces

When you consider the other variables relating to applied force:

  • Direction
  • Speed (technically velocity)
  • Duration
  • Rhythm/frequency
  • No of cycles

You can then begin to develop different techniques.

Techniques have historically been name in anatomical terms (myofascial release, joint articulation) or by descriptors of what the technique involves or a proposed mechanism (high velocity-low amplitude – HVLA, counterstrain, muscle-energy technique/proprioceptive neuromuscular facilitation).

Clinically, most therapists will say that different techniques (aka different applications of forces) result in different clinical effects and outcomes.

While there is some research to suggest there are different descending modulation pathways that are stimulated with different manual therapy techniques, overall, our current body of knowledge suggests that the effects are non-specific.

The (Non-Specific) Effects of Manual Therapy

Referring back to Lederman’s book, we can describe the effects of manual therapy in 3 main areas:

  1. Tissue effects, which are primarily local
  2. Neurological effects (yes, the nervous system is tissue, but this relates to function of the nervous system)
  3. Psychological effects

You Can’t Change Tissues, Directly

One of the big misnomers surrounding manual therapy is that it directly changes tissues like muscles, ligaments and fascia.

This is not the case – and it doesn’t make biological sense for it to be.

Imagine, if a pair of hands touching you for a few minutes could stretch out your muscles. What would happen to your muscles as you sit down, or sleep?

Manual therapy can possibly stimulate some cellular responses via mechanotransduction.

  • Mechanotransduction is the physiological process where cells sense and respond to mechanical loads. It is independent of the nervous system.
  • Mechanotherapy is the therapeutic application of force/load, used to differentitate between homeostatic mechanotransduction.

A 2012 study, Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage, demonstrated this.

While it was quite a small study, with only 11 participants, it shed light on some cellular effects as a result of massage.

The researchers induced muscle fatigue/damage via exercise (stationary cycling) and then massaged one thigh and used the other as a control.

They found that massage activated the mechanotransduction signaling pathways:

  • Focal adhesion kinase (FAK)
  • Extracellular signal-related kinase 1/2 (ERK1/2)
  • Potentiated mitochondiral biogenesis signaling [nuclear peroxisome proliferator-activated receptor γ coactivator 1α (PGC-1α)
  • Mitgated the rise in nuclear factor κB (NFκB) nuclear accumulation

However, whether at all this is clinically relevant remains to be seen. It is one small study, and most other studies demonstrate a very small effect as well.

What is relevant, is that there is a benefit to tissue repair, particularly in the first 2 weeks after injury from harmonic articulation. This is outlined further in Lederman’s text, but considering that pain often leads to decreased use of tissues, this should be considered as a potential therapeutic option.

So it is fair to say that tissue effects, via mechanotransduction are not relevant to the clinical outcomes resulting from manual therapy.

In part, this is because of the way force is distributed by the body.

The Frictionless Skin-Fascia Interface

Between the skin/subcutaneous fascia exists a frictionless interface. That is, the skin will slide over the fascia below it. Think about this, if this didn’t happen, you could pull your subcutaneous tissues around (this would not be good).

As a result, only force applied perpendicular to bone affects bone – tangential force is dissipated.

This knowledge has implications for manual therapy: can you really shear a fibula or radius? What about a vertebrae?

It’s not possible.

Again, thank goodness.

NeuroModulation?

The most likely effect of manual therapy on pain seems to be facilitating “the drug cabinet in the brain” by descending modulation.

Descending modulation is an important biological process that is protective of us in times of threat, but also helpful in managing pain.

It is known that manual therapy, and even touch can cause the brain to release inhibitory neurotransmitters that modulate pain, most likely at the spinal cord level.

As mentioned above, different types of manual therapy seem to evoke slightly different modulation responses.

Psycho(social) Effects of Touch

Touch is the most important sense we have. Without it, we cannot entirely feel pleasure or pain – we are less than human. – David J. Linden

Psychological effects have some crossover with neurological effects, and tend to evoke:

  • Descending modulation
  • ANS changes
  • Pleasant feelings (positive affect)

People can discern meaning from touch – thus can create therapeutic context with touch.

Think about this, if you caress a loved one, versus firmly grab them around the forearm, does the evoke different thoughts and feelings?

In their paper, The Skin As A Social Organ, the authors argue

However, because the skin is the site of events and processes crucial to the way we think about, feel about, and interact with one another, touch can mediate social perceptions in various ways.

The authors cite 3 mechanisms by which the skin can convey social meaning:

  1. Through affiliative behavior and communication
  2. Via affective processing in skin-brain pathways
  3. As a basis for intersubjective representation

I have never heard this described in any manual therapy course, or through my years of university study, yet it is arguably a bigger factor than mobilising joints or stretching muscles.

The Devil Is In The Dosage

There is scant (read: no) good research on dosage for manual therapy.

Practically, dosage is often constrained by patient/practitioner availability and resources (time, money etc).

Within a session, we can do more manual therapy or less. That much is obvious. However, it is hard to prescribe a dosage for intensity, unlike say, exercise.

That is because, as discussed above, the effects of manual therapy do not rely on mechanical stimulation, but rather contextual facilitation, affective change and possibly (probably) expectation.

So a simple way to gauge the response to manual therapy for dosage reasons is:

In other words, if you can gauge a response (within session changes) and measure the adaptation (between session changes) you can reverse engineer the dosage.

Within Session Changes: What to Look For

The responses we are looking for are often subtle, and if missed, can easily lead to overstimulus.

These are (tanks to Barrett Dorko for a couple of these):

  • Softening: a subjective feeling from either patient or practitioner of the tissues softening
  • Warmth: a noticeable increase in superficial warmth, typically explained as an increase in cutaneous blood flow
  • Movement: this is often spontaneous and effortless (think of a person “adjusting” themselves on the treatment table), but it can also be improved movement based on pre/post clinical assessment.

It is important to realise that within session improvements do not suggest resolution, only that there as been a response to the implied stimulus.

Is It Effective Though?

None of this matters if manual therapy isn’t clinically effective.

Here’s the rub (pun not intended): there is low quality evidence to suggest manual therapy can help certain conditions, while there is high(er) quality evidence that shows a smaller effect.

There is evidence (of varying quality) to suggest manual therapy can also influence the following processes:

  • Affects ANS
  • Affects tissue tone and ROM
  • Affects lymphatic system
  • Affects immune system
  • Affects haemodynamics
  • Descending modulation

Hence I favour a process based approach over a condition based approach to clinical reasoning.

This means that you aim to influence processes that are involved in the patient’s presenting complaint.

Putting It Altogether

In order for manual therapy to have a positive clinical effect, we have to apply the right dosage. In practice, underdosing is preferable to overdosing, as you can always do more, but you cannot take away work that has been performed.

We also know that manual therapy is non-specific, but different techniques potentially effect different descending modulation pathways. With this in mind, using a variety of forces (tension, compression, twisting etc) with a variety of variables (direction, duration, magnitude, frequency etc) will provide a hedge of sorts when an individual’s response and preferences are not fully known or understood. This can be modified over time as the practitioner-patient relationship develops.

Finally, we know that we can’t affect tissues, but we can affect processes, so again, as a hedge of sorts, it is preferable to treat a large proportion of the physical body over a localised approach. The exception to this is harmonic style techniques in the early stages of injury to enhance repair.

Conclusions

Two governing quotes govern my thinking around manual therapy for the treatment of pain:

When pain is the primary complaint, treatment of pain should be primary. – Barrett Dorko, PT

And the second:

Manual therapy is optional, but it can be optimal (for the treatment of pain). – Diane Jacobs, physiotherapist

If we understand the likely processes involved in manual therapy, and we acknowledge what we don’t know, along with what we know with a high degree of certainty is unlikely, then I can see well explained and well executed manual therapy continuing to play a role in therapy for many years to come.

If we continue to “treat anatomy” in relation to pain, then over time, funding from health systems and insurers will dry up, as the link between anatomy and pain is tenuous at best.

Finally, we have to give patients a voice. If patients determine they receive a benefit that is meaningful to them, we cannot discount that, as long as they understand the nature of the benefit (i.e. often transient and part of a bigger picture approach to health and pain management).

Workshop

If the topic of clinical reasoning and evidence informed practice with manual therapy interests you, come along to the 3 and a half day DermoNeuroModulation workshop in Melbourne at the end of March (presented by author and developer of the method, Diane Jacobs, who I’ve referenced throughout this post).

Details via the embedded link below.

Comments From Past Attendees:


Nick Efthimiou Osteopath

This blog post was written by Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

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References

A Process Model in Manual and Physical Therapies http://www.cpdo.net/Lederman_A_Process_model_in_Manual_and_Physical_Therapies.pdf

Mechanotherapy: how physical therapists prescription of exercise promotes tissue repair https://bjsm.bmj.com/content/43/4/247

Mechanotransduction: use the force(s) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491211/

The frictionless properties at the thoracic skin-fascia interface: implications in spine manipulation https://www.ncbi.nlm.nih.gov/pubmed/12034123

The relationship between the application angle of spinal manipulative therapy (SMT) and resultant accelerations in an in situ porcine model https://www.mskscienceandpractice.com/article/S1356-689X(08)00170-7/pdf

Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy http://jaoa.org/article.aspx?articleid=2093620

Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage https://www.ncbi.nlm.nih.gov/pubmed/22301554

The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/

Pain https://www.ncbi.nlm.nih.gov/pubmed/26304172

Mobilization and Manipulation of the Cervical Spine in Patients With Cervicogenic Headache: Any Scientific Evidence? https://www.ncbi.nlm.nih.gov/pubmed/27047446

Manual therapy, exercise therapy or combined treatment in the management of adult neck pain – A systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pubmed/28750310

The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814665/

Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs https://bjsm.bmj.com/content/51/18/1340

Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis https://www.thespinejournalonline.com/article/S1529-9430(18)30016-0/abstract

Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial. https://www.ncbi.nlm.nih.gov/pubmed/29088393

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. https://www.ncbi.nlm.nih.gov/pubmed/29686479

Manual lymphatic drainage for lymphedema following breast cancer treatment. https://www.ncbi.nlm.nih.gov/pubmed/25994425

Manual Therapy Influences on the Autonomic Nervous System https://www.otago.ac.nz/physio/research/otago363201.html

Acute electromyographic responses of deep thoracic paraspinal muscles to spinal manual therapy interventions. An experimental, randomized cross-over study. https://www.ncbi.nlm.nih.gov/pubmed/28750955

Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis https://www-sciencedirect-com.wallaby.vu.edu.au:4433/science/article/pii/S246878121730067X

Assessment of skin blood flow following spinal manual therapy: A systematic review https://www.ncbi.nlm.nih.gov/pubmed/25261088

The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695672/

Further Reading

The Science and Practice of Manual Therapy – Eyal Lederman

DermoNeuroModulating – Diane Jacobs

Clinical Neurodynamics – Michael Schacklock

Touch – David J. Linden

How Specific Do Treatments For Pain Need To Be?

Specific; On TargetPain is what drives people to consult a medical professional more than any other symptom.

The vast majority of pain is benign, somatic (musculoskeletal) in nature, though some somatic pain has a visceral component.

Most of the time, complex examinations and treatment rituals are performed, in order to diagnose and treat said pain.

Patients feel like they are getting good value, practitioners feel like they are providing it.

But is it necessary to go through all these examinations, and aim for all these specific hands on, taping and exercise techniques to help people get better?

I’m going to argue, that no, it isn’t.

Can We Be Specific With Assessment?

A typical assessment of someone in pain consists of the following:

  • History
  • Neurological and orthopaedic testing
  • Active movement
  • Passive movement
  • Palpation/provocation

It can also include

  • Functional/task specific assessment
  • Capacity testing: strength, endurance etc

Based on all of this, a clinician then formulates a diagnosis, which dictates a management plan.

However, and this is a massive “however”, it could very well be that we are wasting our time.

Let’s have a look at each of those components, and see how specific they can be.

History

The clinical history is probably the most important part of an initial consultation. Combined with general information about a patient (age, occupation, family status etc) and how they carry themselves, a clinician can hypothesise a working diagnosis prior to any further assessment, which usually serves to confirm or refute the diagnosis.

For certain presentations, the history is quite diagnostic.

For example, neuropathic pain occurs when there is damage to a nerve, causing it to have what’s called an ectopic discharge. Without going into too much depth, when patients complain of burning, lancinating pain, often that will point us towards a diagnosis of neuropathic pain.

On the flip side, a recent study questioned whether commonly held true concept of clicking in the knee being related to meniscal damage. It was shown that equal numbers of people with and without meniscal injuries experience things like clicking and catching. (1)

Neurological and Orthopaedic Testing

The neurological examination consists of things like a cranial nerve examination, reflex testing, sensory testing and motor/strength testing, along with neurodynamic testing.

Unfortunately, neurodynamic testing often yields false positives (so not that specific).

Strength testing, at least the manual version, is very unreliable, and thus not specific.

Isokinetic strength testing is more reliable, however most clinics do not have this equipment. Some clinics have hand-held dynamometers, which increase reliability of strength testing. (2)

Additionally, strength testing only tells us there may or may not be a weakness, not why. Additionally, strength is not related to pain, though it is important for both injury risk and activities of daily living.

Sensory testing is helpful, while reflexes don’t really tell us much except that reflexes are there or not.

Orthopaedic tests, those which clinicians use to rule in/out certain tissue based injuries are notoriously unreliable. Even those which have demonstrated high sensitivity and specificity are subject to error as a result of neurological changes when we are in pain.

Active Movement

Okay, by now you should be sensing where I’m going with this.

Active movement tests the ability to perform that movement. Yes, certain tissues/structures are involved in certain movements, but that doesn’t mean that movement is a specific test.

For example, raising your arm out to the side as high as you can involves multiple muscles acting at the shoulder joint. If it hurts to do so, it implicates all these muscles involved, as well as the tendons, ligaments, joint, nerves etc.

Is it helpful to know? Most of the time.

Is it specific? No.

Passive Movement

See above.

Yes, passive movement takes muscles out of the picture, at least from a contractile point of view. That doesn’t mean that if active movement hurts, and passive doesn’t, that the problem is with a muscle.

Thus, not specific.

Still valuable, but not specific.

Palpation

Most practitioners, especially osteopaths, believe their palpation skills are reliable means of assessment.

They’re wrong. (3)

Palpation is not reliable, and thus definitely not specific.

Still valuable, but not specific.

Can We Be Specific With Treatment?

The short answer: it depends on the treatment.

Let’s look at my common methods of treating pain:

  • Education
  • Manual therapy
  • Graded exposure
  • Movement therapy/exercise rehab

Can any of them be specific?

Education

Education can address specific themes and topics, but the challenge with education, as is the case with any communication, is that what is heard and understood is not always what is intended. We are at mercy of the interpretation of the receiver. Language is more than words. It is influenced heavily by our social circles and our cultural experiences. (4)

But because teaching people about their pain, how to manage it and how to prevent future flare ups is a hugely important part of practice, this means these are simply challenges to be overcome.

I’ve said before, that education is the only thing that stays with a patient after they finish working with me. The caveat to this is, education that is effective. Saying things is not educating. Helping someone understand is educating.

As important as it is, I think it is a stretch to say it has a specific effect on pain. We can’t measure the effect it has, and say what amount of pain reduction was attributable to what amount and type of education.

Manual Therapy



I’m going to upset a lot of my colleagues by saying you can’t be that specific with manual therapy.

But it’s true.

Think about it, all we can truly touch is the skin. Not muscles, not ligaments or tendons, and not bones. The skin.

We can direct force to deeper lying tissues, like those mentioned previously, but this depends on the magnitude and direction of the force, as well as where the target tissues are situated.

Physics dictate that the only force that can be efficiently transmitted to bone has to be perpendicular to bone. Any horizontal or tangential force is dissipated by the frictionless interface of the skin/fascia. (5)

Another strike against the blow of specificity is the way the body is innervated. No one section is supplied by a single neurological level. Hence, because of convergence of multiple levels, we end up with less specificity.

Finally, when it comes to spinal movement, there is a plethora of research showing that you cannot isolate movement to a single vertebral level. Even neck manipulations, which allow the best contacts compared to thoracic and lumbar manipulations, result in movement of adjacent interverterbal joints.

So strike specificity off the list of things manual therapy is.

Graded Exposure

What about graded exposure? Many people conflate graded exposure with exercise rehabilitation. There are similarities, in that they are both (should be) progressive. However, graded exposure borrows from psychological research, and in theory, addresses psychological factors relating to pain and activities just as much as the physical factors. It’s kind of obvious when you think about it: gradually doing the things that hurt, or that you are worried about hurting makes it easier to do them over time.

Worried about bending over to garden all day? Let’s start with kneeling for a short period of time. Then you can gradually (the graded part) do more (the exposure part) until you are bending over gardening all day

There are two arguments about whether graded exposure is specific:

  1. It works for the specific task/scenario, hence it has a specific effect
  2. The same can be achieved in other means, hence it doesn’t

In my experience, the former holds true more so than the latter.

Here’s an example:

A patient of mine who was very active injured himself playing hockey. The injury came about because he wasn’t physically prepared for the demands of hockey, despite being physically fit and active. That and plain old bad luck – he simply moved in a way that loaded his back too much, which was in part due to the circumstances of the game at that moment.

After history and assessment, I was able to narrow it down to a diagnosis of “acute low back pain, without referred pain” (remember, we can’t really be that specific).

Treatment was manual therapy (didn’t really make a big difference), stay active (kind of hurt, but didn’t make things worse), some gym work for posterior chain (was able to train, but didn’t help pain), time (definitely made a difference) and gradually increasing hockey load (really helped).

Does that mean it (graded exposure) has specific effects that cannot be achieved any other way? I really don’t know. Let’s call this a maybe, at best.

Movement Therapy/Exercise Rehab


Like manual therapy, the fact that so many approaches can work holds the answer: if everything works, then nothing works. 

Or less cynically (and this is my position, because we know this works for many pain presentations), if everything works, the effects are non-specific.

Honestly, aside from the specific adaptations of exercise, which can definitely be important to an individual based on their capacity (power, strength, endurance, mobility etc), or lack thereof, when it comes to pain, the most important thing is to do something, do it appropriately (not too much, not too little) and continue to do it (consistency).

This can shatter the hearts (and wallets) of professionals who espouse a specific approach as “the only approach”. Of course it works. But not because of the reasons you say it works.

Do We Even NEED To Be Specific?

So here is the big question, or rather two questions:

  1. How specific do we need in order to be effective?
  2. Can we be that specific?

We could argue that currently, we are not very effective at treating low back pain, for example. Most of the time we can help people manage it, and the condition takes it’s natural history, which for most, is a resolution over a long enough time-frame.

But could we be more effective if we were able to be more specific?

There is still so much unknown about pain, that it is very difficult to answer.

We do know that pain typically has a blend of biological factors, including local tissue factors and central nervous system factors. We also know that pain consists of psycho-emotional-social components, which play a large role in the nature and course of pain.

We can’t measure the exact contribution of each, and nor can we isolate tissue factors – even evidence of tissue damage on imaging or surgery is at best, correlated with pain. Sacreligious? Perhaps, but, if we go “full academic”, you can’t separate the non-tissue factors from the resolution of pain. For years, surgeons thought sub-acromial impingement improved because of surgical decompression (it didn’t) (6). Same with arthroscopic surgery for arthritic knee pain (7).

Clinically, I have seen people with total and partial knee replacements still experiencing pain, more than 12, and in some cases 24 months post surgery. This doesn’t mean there is no effect of the surgery, but we aren’t 100% sure what it is.

Anyway, I digress.

With most non-specific pain presentations, by nature, we can improve people with non-specific interventions.

Neck pain for no apparent reason? Here’s a scientific valid approach:

  1. Rule out serious pathology.
  2. Rule out tissue injury (via history and assessment).
  3. Rule out complications/comorbid factors.
  4. Educate.
  5. Provide coping strategies
  6. Neuromodulate with chosen intervention, if desired (see above).
  7. Improve function (see above).
  8. Let time and physiology do the rest.

We can apply this concept to nearly all non-specific pain and be evidence based.

In fact, you can apply this to many instances of specific pain too.

Let’s Get Critical

Earlier this year a study on managing lateral hip pain (gluteal tendinopathy/trochanteric bursitis) was published in BMJ:  Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial (8)

 After critiquing this study, you could easily come to the conclusion that there was a lot of confirmation bias taking place in how much effect these interventions were having, and how much of that effect was due to the specific nature of the intervention (there was no general exercise arm as a comparison).

The methods of intervention were pretty generic:

  1. Education (basically, avoid compression of the tendons by not sitting and moving in certain ways) and exercise (a standardised hip exercise protocol) was one group
  2. Corticosteroid injection was another
  3. Wait and see was the third

Everyone got really excited on social media when this was published, because “exercise works!”, and “I do exercise with my patients” so there was lots of back patting and confirmation bias all around.

However, in my opinion, the interventions didn’t result in that much improvement over a wait and see approach in the main outcome measure (Visual Analogue Scale or VAS, a numerical pain scale). In fact, average pain intensity (score out of 10) changed from 5 to 3 in the wait and see group, while the intervention groups (education + exercise or corticosteroid injection) improved from 5 to 2 on average (there was only a minor difference between the two groups).

Consider the cost for that 10% improvement over wait and see:

  • The education + exercise was 14 sessions, which, if we take an average of $80 per consult, is $1120.
  • A corticosteroid injection under ultrasound guidance, ranges from between $150 and $300 on average.

So was all that effort of exercise, expense of education and injections worth it? Yes, in the short term, there was a big difference at 8 weeks over wait and see. However, if you told someone they had to spend $1000 over 8 weeks to end up 10% better than doing nothing at a year, how many people would still take that option?

Now let’s look at the other main outcome measure, the Global Rating of Change or GROC. The GROC is a single-item instrument that asks each patient to indicate whether and to what extent they perceive change has occurred, typically relative to the date of the initiation of care. The GROC uses a Likert scale to indicate the direction of change (ie, worsening or improvement) and the extent of change (ie, “tiny” to “very great”).  (9)

However, there is contention that the GROC doesn’t reflect functional changes (9), as it is a subjective assessment, but unlike the VAS it isn’t assessing pain, which is subjective, but the participants perception that something has changed. The problem with this, is the recency illusion and the availability heuristic inherently skew the results.

So when we look at the GROC scores: we see that at 8 weeks there is a big difference between the education + exercise and wait/see group, which makes sense, because the education/exercise program was 8 weeks long. But over time that difference was reduced, which is explained as follows:

Our data showed that a patient’s current FS exerts a strong bias on perception of change, even for short recall periods (fewer than 30 days), and this effect increased as transition time lengthened. (9)

So where does that leave us? Time to draw some conclusions.

Conclusions

That was really a long winded way of saying, no, we don’t need to be specific, because even when we try, we can’t be.

The constituents of good care are listed above. This much is clear, though some will debate the manual therapy aspect, others debate the exercise aspect, the moderates will say these 4 interventions are all good in various degrees.

What is emerging, is that what you do isn’t as important as how you do it, and who you do it with (the therapeutic alliance is a big predictor of outcomes in pain). It is also important to not do the wrong things – i.e. those that are clearly ineffective, but moreso, those that actively do harm.

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.