Thursday Thoughts: What Do You Look For in a Technique? | Modern Manual Therapy Blog

Thursday Thoughts: What Do You Look For in a Technique?



This week's Thursday Thoughts was inspired by a guest to my blog last week. He's one of those EBP types (P standing for police).

The discussion was cordial, better than most of the argumentative types online these days, but the tone was definitely there. Posts like those always confuse me, when someone relies only on "evidence" are they talking about 1 RCT with a control group? Or do they need the RCT also to be validated?. Better yet, are they looking for a large sample with long term follow up, or a meta-analysis?

Do you need all that for a clinical pearl? I sure don't. If someone showed me a novel technique that made something I was using regularly better, or more comfortable for a patient, I'd be all over it. I certainly wouldn't accuse someone of wasting the patient's time, or instructing something that could hurt a patient. Any technique can waste a patient's time or hurt them, but it's up to the clinician, their expertise and clinical decision making to see if it is indicated. I think some people just like to be heard. A little googling is all it takes to know that some people belong to a forum that loves to debate and argue. That's alright for some, but not for me! Thoughts?

Either way, I'm happy to post Clinical Pearls for the thousands of you that find them useful, and not for the select few that think I am wasting a patient's time. Thanks for reading!


Keeping it Eclectic...

17 comments:

  1. Dr E,

    This post is spot on. It is definitely beneficial to be a critical consumer of information in general. However, that mindset must flow over to "research." A mental exercise i have always found useful is the following:

    If a body of research surfaced that disqualified the "effectiveness" of an intervention that has given me good clinical results: would I abandon that intervention?

    I personally do not care why my patient gets better. Truthfully, sometimes i have a good idea why snd some times I don't. In any skill based profession, (carpentry, plumbing, mechanic,etc) the practicioners of those professions have "clinical pearls." Some they can explain, some they can't. It simply works for their current problem regardless of the reason. Keep the pearls coming.

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  2. Dr E,

    This post is spot on. It is definitely beneficial to be a critical consumer of information in general. However, that mindset must flow over to "research." A mental exercise i have always found useful is the following:

    If a body of research surfaced that disqualified the "effectiveness" of an intervention that has given me good clinical results: would I abandon that intervention?

    I personally do not care why my patient gets better. Truthfully, sometimes i have a good idea why snd some times I don't. In any skill based profession, (carpentry, plumbing, mechanic,etc) the practicioners of those professions have "clinical pearls." Some they can explain, some they can't. It simply works for their current problem regardless of the reason. Keep the pearls coming.

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  3. Thanks Jeremy, one of my favorite critiques for clinical decision making from my friend Charlie Weingroff is "Does it make sense?" I don't need research to tell me to use something that enhances something in my toolbox.

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  4. Hi erson,

    What do I look for in a technique?

    I think any technique in manual therapy can be described in terms of four parameters of force application; 1. Intensity per unit of patient-therapist contact (pressure if you like). 2. Duration of force application. 3. Direction of force application. 4. Nature of force application (e.g. oscillatory, sustained). So if I were on the hunt for a new technique for my clinical tool box, and a mate suggested I learn technique "x", my initial inclination would be to have a think about technique "x" within the context of these 4 force parameters and to ask myself whether or not it makes sense to apply such a force profile in a manual therapy setting.

    I'd ask myself- Does the application of such a force profile carry any foreseeable risks in terms of causing tissue damage and/or increasing nociception and/or increasing peripheral or central sensitization? If not, I'm all for learning and applying the new technique. If it does carry such risks, these need to be weighed against the extent to which reported/purported outcomes for technique "x" are necessarily tied to any or all of these specific force parameters. In other words, could I reasonably expect an equally favourable outcome if I were to tinker with some or all of the force parameters that constitute technique "x" in a manner that mitigates any risks (outlined above)? If the answer is yes, I'll go ahead and modify the technique... Technique "x" may no longer resemble technique "x" anymore.

    I think that with a good history, and a good understanding of neurophysiology, anatomy and biomechanics, we should be able to analyze the patient before us and pretty much make up "techniques" with an appropriate depth, duration, direction of force for any given presentation by considering the following:

    1. Do I suspect that there is a nociceptive drive from injured tissue? Can I help the patient position himself to protect it, or unload it, or load it?

    2. Do I suspect there is a nociceptive drive from metabolically stressed but uninjured tissue (e.g hypoxic peripheral nerve secondary to defensive motor output, perhaps, but not necessarily secondary to current or previous primary nociceptive event)? Can I help the patient position or move himself to resolve either or both the secondary nociceptive drive or the defensive motor output?

    3. Do I suspect that there is no nociceptive drive, and that central sensitization mechanisms are dominant?

    4. Regardless of the suspected presence or absence of influence of nociception, does the patient have an unhelpful/erroneous understanding of their injury and/or pain? Can I alter this with education?

    I think the thinking/reasoning that should precede and accompany the application of treatment is jeopardized by the passing around of "clinical pearls" such as the one you referenced above. "Clinical pearls" are essentially technique tips that keep us bogged in the mindset that we treat anatomy. But as David butler said, we treat physiology, not anatomy.

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  5. Hi Erson, I though to share some thoughts here since it seems that I’m the guest that you are referring to. As I said in previous posts, there is nothing wrong with exploring variations to traditional techniques to maximize comfort. But given what we know from the manual therapy literature, to generalize a specific variation as ‘clinical pearl’ just because of ‘perceived effectiveness’ (actual effectiveness being unknown) can be misleading. This can be simply avoided by acknowledging the uncertainty involved and the risks of confirmation bias in clinical reasoning/practice. I did not accuse you of wasting the patients time, I simply asked how do you know that you are not? I’m not playing “evidence based police” but I highly value science based practice and critical thinking. 'Science based' considers the blind spots of ‘evidence based’ as there is much bias in research studies and many of them do not even consider prior plausibility or construct validity before jumping to conclusions. This also applies to the Mechanical Diagnosis and Treatment (MDT) model, positive trials do not necessarily suggest that the construct is valid. Furthermore, you can’t have it both ways with ‘evidence based’. In other words, you can’t take pride in being ‘evidence based’ just because you subscribe to the MDT model, and then complain about others being ‘evidence based police’ and just argumentative when you base your practice on ‘expertise’. Thank you for your time.

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  6. The problem is that perceived effectiveness =/ actual effectiveness. Also, "Does it make sense?" implies that everything is OK to do as long as it makes sense to the practitioner. We can't subscribe to this mentality and then criticize CAM practitioners for doing the same exact thing.

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  7. Evan, again, you don't even regularly read this blog. I use the treatments and education of the MDT model, along with the assessments for alleviation, but NOT the disc model. I use them within the context of neurophysiologic changes, and Explain Pain education on what pain is, and is not... I like MDT because it's simple, does not require many of the OMPT tenets, like special tests, diagnosis, palpation... etc...


    I see no difference between perceived effectiveness and true effectiveness. Should we not be maximizing patient expectation? I tell all of my patients that the effects of our treatments are neurophysiologic, very much transient, and not mechanical.


    You're making broad assumptions about the way I practice and interact with/educate my patients. I'm know I am not wasting my patient's time if I am giving them a modern interpretation of our assessments and treatments, plus giving them variations on techniques that were improving their pain and function, and making them not reliant on passive treatments.

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  8. Patrick, I agree with much of what you wrote, but I would have to say you must not be a regular blog reader, like Evan. If you read regularly, you would know I place a high emphasis on modern explanations of pain science education and the neurophysiologic/transient effects of all of our interventions from manual therapy, to MDT and corrective exercises.


    I do not see why the "pearl" I posted has any emphasis on pathoanatomy, the basis of MDT, which I have strayed far away from keeps those roots, but nowhere do I state you're reducing a cervical disc. I explain to patients about the directional preference, how it leads to centralization, and loss of ability to load.


    Btw, if any of your techniques are actually causing tissue "damage" you're using way too much force. I'd assume you'd know we're not actually deformation fascia or joint capsule from the sound of your excellent clinical reasoning, but I can't be sure because of your first paragraph about forces.

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  9. Thanks for your reply. I agree that your clinical pearl post was not suggestive of a pathoanatomical mechanism of effect. The post stopped short of speculating either way. I think that is a step up from clinical pearls one might read elsewhere (with fanciful purported mechanisms). My beef with technique tips (that stop short of providing any sort of reasonable accompanying explanation for the reader), is that they promote thoughtless treatment practices... "Just do x,y and z, the patient will get better- trust me." In the absence of an accompanying explanation for the mechanism of effect of your clinical pearl, your readers will inevitably use their existing (possibly erroneous) understanding of manual therapy mechanisms. Maybe within the broader context of your website, a neurophys mechanism is implied. I think you could be more explicit.

    I think that every clinical pearl you provide on your site could also be an opportunity to educate your readers about the likely mechanisms by which manual therapy is effective, which would provide an opportunity to consider what is necessary and what is sufficient with regards to the force profiles of various techniques. I think your skin stretching clinical pearl for cervical extension was an opportunity lost. Having said that, I also understand that debating, challenging, and changing the worldview of PTs is unpopular, difficult, tiring and mostly thankless. Just about any PT blogpost could be diverted to a debate about the "how and why" of manual therapy. It would be exhausting... That's why I don't run a site like yours.

    All the best

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  10. Patrick, I take for granted that my regular readers already know I advocate for all that you already mentioned. It's not the traditional poke and hope without clinical reasoning or discussion on mechanisms. Neither are my courses. In fact, I repeat it a lot. Here's the thing, looking at my metrics, the longer the post/video, the shorter the time spent on my site. The ones who get it after much repetition and I go on and on about neurophysiologic mechanisms, using OMPT as an cheat to make the HEP easier, and the ones who do not possibly refuse to believe it or are stuck in pathoanatomy. It would be TOO repetitive if I went over it every post. Thanks... you write well, and your thinking, while modern, is not shared in most programs, whether entry level or fellowship.


    I maintain that in my blog and courses, you can go about challenging the tenets of our profession without being coming across as angry, cynical and negative, none of which you did, so thank you for the discussion.

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  11. Erson, in my lexicon there is a difference between perceived effectiveness and true effectiveness in that we can have perceived effectiveness without true effectiveness. Moreover, perceived effectiveness by the practitioner does not always coincide with perceived effectiveness by the patient. My definition of true effectiveness is that the intervention can accelerate pain resolution vs. not having it. Perhaps I'm wrong, but I’m not convinced that manual therapy has such capacity for most msk manifested conditions. The story that the mind constructs because of anticipation of favorable outcome in combination with time/ regression to the mean and temporary relief during/shortly after the application of the intervention can lead to perceived effectiveness. Now there is a gray area here as perceived effectiveness (theoretically speaking) can lead to physiological changes and true effectiveness, but this cannot be predictable. Temporary relief (which MT can achieve) may partially depend on parameters , but the effectiveness of parameters depends on context and ability of the patient to adapt to them positively. IMO we cannot generalize parameters to all patient population or even subgroups, and clinical reasoning in parameter selection is a lot of guesswork influenced by cognitive biases. The parameters that each therapist thinks are optimal for each patient vary, yet everyone seems to be arriving to the same general outcomes (at least in controlled trials).

    About MDT, I was criticizing the model which claims ‘cause and effect’ between ‘mechanical syndromes’ (postural, dysfunction, derangement ) and the pain experience.
    not how you choose to interact with your patients. Nevertheless, I was trying to stimulate a good discussion about the concept of ‘clinical pearls’ which I find interesting. Please do not pay attention to 'tone', I have nothing against you personally.

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  12. The way I explain it to patients is the transient improvements are real, but up to them to keep the improvements going. If thru HEP they manage to keep them going long enough, the threat level reduces, and the pain and activity threshold remains high. But seriously, everything else you said, I don't think of anything that complex, I view everything as much easier. That's why I stay away from your forum, and not your tone, but the overall forum's tone. Hope you have a good holiday weekend.

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  13. I think we are in agreement for many things reading through some of your recent blog posts and comments here. And for the things that we do not agree, I’m always happy to engage in discussions with people who view things slightly different, there is usually something to be gained. I assume that the forum you are referring to is soma simple. It’s not my forum (I’m a regular but not the owner or moderator) but you are very welcome to join and participate if you ever change your mind. People there are aware of your blog (that's how I found it, and I believe Patrick here as well) and I think they’ll be happy to see you participating. I see SS as a place were people actively address their concerns about therapy and receive useful feedback. I hope you and your family a good holiday weekend as well.

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  14. Thanks for taking some of your holiday time out to read some of what I write. I've already been invited to SS several times, but it's just too much thinking for me. I agree that critical thinking is important, but I've already been bashed enough in the "rubbish" header and done enough SS bashing myself to ever join with any good will from most of the top contributors.

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  15. It stands for ‘complementary and alternative medicine’ which is mostly based on belief systems vs. the scientific method (eg. the meridian theory, subluxation theory, homeopathy).

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  16. Your welcome. Cheers.

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