Manual Therapy: Manual therapy, like exercise, has been demonstrated by countless articles to be an effective treatment, often when combined with other therapeutic interventions. A systematic review on the treatment of mechanical neck pain found that multimodal manual therapy care including exercise was superior to controls in improving pain and patient perceived outcomes. As you can see from part 2 , we have built a profession that utilizes some great, evidence-supported interventions but also one that routinely performs and bills for unnecessary modalities.
What task are we accomplishing if we are using modalities? As Physical Therapists, one of the most common symptoms our patients tell us about is Pain. And despite this, we have over-simplified pain by thinking of it as a bottom-up response, in which the tissues are injured and and therefore hurt. The true scientific explanation of the pain involves the neuromatrix , which is a brain-involved, top-down response, in which the brain and nervous system defend an injured tissue through sending a perceived signal, pain.
Ignoring that the brain is the ultimate player in ALL pain is a costly mistake. Below is a diagram of the neuromatrix which demonstrates all of the associated inputs into the brain which may cause it to respond by sending a pain output. Part 4: How do we overcome our barriers? We must agree as a profession to gently let go of interventions which have been demonstrated to be of little therapeutic value. Plain and simple.
But in the end it is the right thing to do. We should also re-educate ourselves in the scientific method and become aquatinted to new understandings of pain, fatigue, etc. Things evolve. So should we. I recommend we move forward through open discussion in the work place, online websites such as somasimple , etc. Discuss these thoughts.
Try to make sense of them. As I stated above, we must question what we think we are doing and what we think we are affecting. When we place are hands on a patient, how do you know you are touching anything but the skin? Our reliability in palpatory skills is inherently low. And this is because of human anatomy variability. But who cares. By adopting a neuromatrix explanatory model of pain, we understand that the human pain experience is much more than a tissue and determining the tissue at fault is not necessary after ruling out systemic involvement through symptomatic screening.
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Barrier 3: Too much emphasis on board examinations for new graduates. This is one barrier I do not see changing. But, if I had any influence on accrediting bodies, my idea would be:. Barrier 4: Unscientific Continuing Education Courses. I believe a peer-review process should take place for all CEU course applications.
All information included in the course should be well-cited and have scientific basis and plausibility. Alright, so this essay has been quite exhaustive but in my opinion, quite necessary. We must all work together in making this change. Are you willing to hang up the ultrasound head? Paris S. A history of manipulative therapy through the ages and up to the current controversy in the United States. JMMT Physical Therapy Review. Ultrasound therapy for musculoskeletal disorders: a systematic review.
Pain A review of therapeutic ultrasound: Effectiveness Studies. Physical Therapy Therapeutic ultrasound for osteoarthritis of the knee. Cochrane Database of Systematic Reviews , Issue 3. DOI: Carroll D, Tramer M, et al. Randomization is important in studies with pain outcomes: systematic review of transcutaneous electrical nerve stimulation in acute postoperative pain.
British Journal of Anaesthesi a Adie S, Naylor JM, et al. Cryotherapy after total knee arthroplasy: a systematic review and meta-anlysis of randomized controlled trials.
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The Journal of Arthroplasty Macedo LG, Latimer J, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical Therapy 92; Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military cluster randomized trial. BMC Medicine 9; Gross AR, Kay T, et al. Manual therapy for mechanical neck disorders: a systematic review.
Manual Therapy 2oo2: 7; The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Manual Therapy 17; French HP, Brennan A, et al.
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Manual therapy for osteoarthritis of the hip or knee- a systematic review. Manual Therapy 16; There have been a couple of randomized controlled trials demonstrating the efficacy of manual therapy for the treatment of knee OA.
These trials resulted in large effect sizes, decreased use of meds, and decreased surgical rates. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther ; Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med ; You have made some good points in my opinion.
However you have made very broad statements which require further investigation. The use of core stabilization may not be as important in the prevention of back pain, but does that hold true for individuals with back pain?
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I think that as a profession we must bring along the things we have found to be beneficial to our patients and leave behind the tools that we have found to be ineffective. However, there are a plethora of things that we still need to figure out through rigorous scientific study. Generalizations do not help us in this cause as they only swing the pendulum to extreme ends. We must not forget that not all research is of the highest quality. Physical therapists as a profession must learn how to digest the evidence properly and learn the difference between a well constructed study and a poorly constructed one.
Once that hurdle is cleared I believe the real discussion can begin. Thanks for the comment Alden.! Even though a couple of RCTs may have demonstrated some benefit of manual therapy for knee OA, the systematic review that I cited, published in Manual Therapy last year, took these into account, along with other studies on the subject. Maybe we can attribute this to regression towards the mean? Core stabilization is most definitely a hot topic which I expected would raise some criticism. My issue with core stabilization is this: 1.
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How do we reliably identify an unstable spine or individuals who would benefit from this treatment approach? Do these muscle fibers fire correctly after one has injured their back read: Macdonald D, Moseley GL, et al.
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Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. How can we justify that core stabilization is more beneficial vs. The articles that I cited, are all well-done, quality systematic reviews excluding the 2 RCTs in the exercise sections , and I think we at least know enough about modalities that we can leave them somewhat behind.
Have a good one! Good discussion and points! But, I think researchers and the academic PT community are just as much to blame. Researchers continue to perform trials investigating interventions with little to no regard of a deeper theory of mechanisms, pain, or treatment effect. Researchers continue to perform trials guided mis-founded theories, or with a potentially short sighted view of other data on impairments certain populations exhibit i. And yes, we need clinicians to be more scientifically and research minded. Excellent piece Joe, I hope this creates further discussion.
First off let me tell you this article was very refreshing. I most certainly agree with you. What am I going to do — I will think on that and save it for another post.
Thanks for the comments Tim! We need to drop modalities—at least for the majority of our patients. I agree that there are financial incentives to using junk, but morally and ethically speaking, that puts us in the same classification as physicians who prescribe medications for kick-backs.