by Christine Petrides
Manual therapy is such a contested and debated topic in this field it can be exhausting at times. To me it seems strange to indoctrinate clinicians away from touching their patients, when touch can be such a powerful force, for so many reasons. I understand of course the attempt to help clinicians expand their use of manual therapy though and not to keep us potentially stuck in a limited (and potentially harmful) application of it.
As we read the 2nd paper this month (Bialosky et al. 2009), we see right off the bat, manual therapy seems effective, it’s just that nobody really understands exactly how. The mechanisms aren’t understood. However, it seems like the one of the things we can potentially use to determine when it might and when it might not on patients is the “likeliness to respond”. Which seems like a whole other can of worms to me.
It is said that manual therapy techniques are used to target MSK pain (what is that exactly, and how does it differ from other pain?), soft tissue (what does that include/exclude), or the nervous system. Yet other professions will say that manual therapy is targeting the lymph system or the organs, or the joints, or even the energy field. So who is deciding when which techniques are targeting what structures or systems? How can we ever separate these things from one another in a reliable way?
This all just reminds me a bit about dispositionalism (from the 'CauseHealth' book) in the sense that lots of things are going on yet, you can only measure or work with what you’re observing. And just because you’re observing something, is by no means a guarantee that that’s what is the working mechanism. Take for example a working lamp. When it’s working, you don’t think much about it. You see a lamp which gives light and it’s satisfactory to you that it’s that lamp that’s giving the light. It’s only when it’s not working that you start to investigate a bit. You look at the light bulb first, and replace that, if the lamp then gives light again you can happily assume that it’s the light bulb that gives light. But the next time the lamp stops working and replacing the light bulb doesn’t work, you need to investigate some more, and your original hypothesis is no more. You go to the plug to see what’s happening there, and so on and so on. I can see that this is what Bialosky is expressing throughout the paper, as he talks about the singularity of most research studies. Although useful for helping us understand the whole picture when put together, Bialosky highlights that “conclusions based on studies designed in this fashion may fail to consider other potentially pertinent mechanisms” (Bialosky et al, pg. 2).
I find it so interesting how so many of the things we think we know are in fact just stories we have been told. I don’t think the debate should ever really be about whether or not touching or manual therapy works or doesn’t work, but rather about when and when not and why or why not.
From the October 2022 Readings (Pain & Touch):
Bialosky, J.E., Bishop, M.D., Price, D.D., Robinson, M.E. and George, S.Z., 2009. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy, 14(5), pp.531-538.