Thursday Thoughts: We Know More About What Mechanisms Are Not Happening

Modern manual therapy should be based on what we know regarding biomechanics, pain, and movement.

Here are some facts

Pain and Motor Control

pain alters motor control
motor control is based on patterns stored in the brain, not in the muscles
therefore, you should probably not exercise or strengthen those who are in pain, until you can eliminate it through other means, OR significantly reduce the perception of threat

Pain and Sensation

pain alters perception of the body
this is based on cortical smudging seen on fMRIs of painful or immobilized body parts
proprioception, kinesthesia, and sensory discrimination are all all altered in areas of the body having persistent/chronic pain
sensitized peripheral and/or central nervous systems have lower pain thresholds, but are based on perceived threat and is a neuroimmuneresponse, often not a simple inflammatory response

Manual Therapy

mobilization and manipulation DOES NOT reposition bones, or move them and have them stay in whatever place you think you put them back into
mobilization does not come anywhere close to deforming joint capsules
soft tissue work does not come anywhere close to significantly deforming or stretching fascia

Repeated Motions

in many cases DO NOT reduce disc herniations (it may work on lumbar disc protrusions - intact annulus)
these also do not deform joint capsule, if they did, with simple end range motions, the body would be a fragie thing indeed

So when those of us who teach modern manual therapy say you should not cause pain, or hammer away on your patients, it's based on what we know is not happening, rather than what is happening. Fascia and manual therapy reserach performed on cadavers takes an intact and responding nervous system and conscious and subconscious perception out of the equation and are most likely not relevant to our living patients. The next time someone tells you that repeated motions reduce disc protrusions, performing certain 9 step exercises move your sternum, pelvis out of one rotated pattern and into another one, or using your hands or tools breaks up scar tissue, you should really question these things. From what we currently know, these things ARE NOT happening. Sure they are easy to understand, explain, and everyone seems to believe them.

Using newer explanations regarding manual therapy, exercise, and education's influence on the nervous system require practice on 100s of patients to get it to be as smooth as, "These mobilizations will stretch your joint capsule," or "This cross friction massage will help re-align your scar tissue like rolling your hand over twigs that are criss crossed." We have all said these things before, but it's misleading to patients and often makes our jobs more challenging to use completely different explanations.

Want to learn more? Read Todd Hargroves excellent, A Guide to Better Movement, and Therapeutic Neuroscience Education, two of my top text recommendations.

All is not lost, Pain Science fits neatly into any model you may be practicing if you are able to explain your interventions as novel inputs that reduce perceived threat and stretch/pain perception during positions or movements.

Want to hear me say it to live patients? Check out tons of live cases on The OMPT Channel!

Keeping it Eclectic...