Is Manual Therapy a Gateway Drug?

Living in the great State of Colorado has been interesting the past few years.  It was not too long ago that we voted as a State to allow each county to legalize marijuana for private use and for distributors to do so under scrutiny and taxation by the State.  As I travel domestically and internationally to teach therapy concepts, it is always a hot topic to discuss regarding our laws, and of course, discredit or educate the misconceptions and distortions of the truth.  Topics like: Pot is legal everywhere in the State! You can smoke and drive! If you are carrying more than the federal law on an interstate you still OK because the State passed a law! You can still consume and work because State law precedes employer policy or regulation! 

All of these are mistruths,  developed by hearsay and passed down from mistruth to mistruth.  But by far, the biggest topic is one of Marijuana being the “gateway drug”.  This is the idea that consumption originally is harmless and fun.  But over time, it leads to experimentation with other drugs, addiction, dependency, altered thought process, and crime.  All of these have two sides to the coin, but it got me thinking about my profession…Perhaps Manual Therapy is the “gateway drug” of physical rehabilitation?

There is pretty big debate currently on the effect of Manual Therapy and its place in rehabilitation medicine. In fact, several research articles have called into complete question of any efficacy of various manual treatments.  The Powers that Be have continually shown that manual medicine takes second fiddle to exercise, rest, or placebo effect.  So why continue with manual medicine techniques?

Any treatment of choice, but especially manual rehabilitation techniques were always (in my opinion), meant to be a treatment accelerator;  A way to get short-term immediate improvements that were enhanced by pain modulation by-products, self-empowerment by the client, and then return of functional/meaningful movement.  Now of course, I have seen some tremendous immediate results over the years that required nothing further (and this doesn't imply that the technique itself was the culprit.)  But most often, it has provided a gateway to move on to other procedures more quickly than without.

Too often I read research topics that, in methodology, are inherently biased and not clinically applicable.  Structured to mandate that a specific technique or treatment be repeated for a set number of repetitions and sessions to determine an outcome/effect.  I always end up asking myself “who would do the exact same thing for 4-6 visits regardless of outcome or result?”  The reality of clinic practice is that there are far too many factors (controllable and non-controllable) to expect that the situation or environment is the same each time you see a patient.  As an example, if we apply a manual based treatment, and there is a noticeable positive outcome, doesn’t it stand to logic that the next step is some type of progression or advancement?  In contrast, if there is a neutral or negative result, why would doing the same thing again make sense here?  Hence, back to the “gateway drug’ analogy.

Published research has given us significant insight into the vast array of physiologic changes that happen after manual medicine and other treatments.  But why stop there?  Maximize those short-term results by enhancing movement patterns, empowering the patient, performing functional activities or even non-specific exercise.  Start moving again!

There should not be battle between current research and past models of applied therapy.  Individuals who insist on swinging the pendulum to the opposite side are just as likely to see failures and pushback as their predecessors.  Lorimer Moseley was recently quoted at the recent IFOMPT 2016 “…the biopsychosocial model rejects the biomedical model because the medical model is not concerned with the person. But it does not reject the role of structural, biomechanical and functional disturbance of body tissue as potentially powerful drivers of protection.”

Embracing the middle of a multi-modal therapy has always seen success because it places the patient interest first…. psychology, empathy, hands on care, movement, pain.  We should stay open…to staying open. 

Stop condemning other models of therapy.  Rather, I employ my colleagues to understand that just because we may not know how something works, in the end…it worked for an individual…and that changed their life in a positive way. Explanations of techniques may need some adjusting, as from the biopsychosocial leaders we know we can positively or negatively influence patient’s view on their situation by the words we use. We don’t need to tell people we are going to put their rib back in place, or tell them their nerve is smashed because of their degenerative disc disease. We can use verbiage that alludes to an adaptable body, a resilient one, that may just need a push in the right direction. Just a puff.  Instead of abandoning techniques because their effects are non specific, we can change the framework of explanation, educating the patient that there are lots of ways their body can experience movement, and we want to attempt to do our best (with perhaps both manual therapy, specific or non specific exercise) to shape a context where the patient is succeeding in something meaningful to THEM (be it pain levels, specific task, or just strength).  If it doesn’t work, move on, try something else, be willing to be open…to being open. EVERY model of therapy, no matter what the basis or theory is, fails for someone.

Chad Cook was once quoted, “I am a manual therapist, but first and foremost, I am a physiotherapist.”Well said, Sir.  Sometimes we do not need understand exactly how we make success, but rather that we focus that we simply have successes.  And be willing to stay open to ideas and expansion of our treatment models.

Eric M. Dinkins