This next tough question comes from a former mentee, all around great guy, manual therapy fellow, and absolutely terrible cameraman.
Paul aka "James Cameron" asks...
"Hey Erson, In the past couple years I have changed my thoughts on the mechanisms of manual therapy and soft tissue etc. I do believe the interaction between clinician and patient is the biggest factor in success aka therapeutic alliance. In reading several blogs such as Greg Lehman's it seems as if all we do as manual therapists is apply placebo effects and there is no such thing as correct or incorrect movement etc. I feel there is incorrect movement patterns and when corrected after a "reset" with manual they feel better as well as decrease threat of movement. If a patient squats like crap or has no idea and you are able to instruct on the "proper" way they tend to move better. Are you on the same page? In reading Greg Lehman's blog post on fascia I get it our explanations are a farce and we are not breaking up anything but in his response to your comment on the blog he says there is no such thing as incorrect movement. I use an impairment based approach/patient response method and try to find the concordant sign and it seems to work well and apply manual as needed and watch with my explanations as to not initiate a thought virus. Sometimes PA's work, sometimes manips work etc. But in reading Lehman's post he says Pavims are crap etc. I respect your opinions and thoughts because it makes sense. What are your thoughts on this? I hope this makes sense."Well Paul, I'd certainly have to say there is no easy answer to your question. While research that the SFMA and FMS presents state that asymmetry is a predictor of future injury. Several studies have shown (in populations other than military and firefighters) that lower scores on the FMS do NOT correlate with increased injury risk.
I would say if you're using asymmetry alone as a predictor of future injury risk, you may not be on the right track. However,
At some point, as clinicians, we all have to make concessions with what research we apply, and what research we think "needs more research." In other words, we all cherry pick. These are my suggestions.
- easy to screen several joints at once
- in some cases mimic function (squat, single leg squat, hurdle step)
- are reliable (just about the least you could ask for in any test)
- clearing a patient with a movement screen does not mean they have the capacity or skill required to repeatedly perform
- telling someone they move "incorrectly" may or may not be true - perhaps as my pal Chris Johnson says - it's a viable strategy for them
- as a side note, Chris presents several great slides of world class athletes winning marathons having pretty moderate genu valgus collapse in stance - are you going to tell them to correct it if they're winning?
I "clear" a joint only when it has full threat free mobility - meaning it can handle passive overpressure and load
- if someone has cleared whatever your screen of choice is, it's time to "Watch them do things."
- there are certainly more efficient ways to lift and perform skill based sport movements
- someone may have perfect movement patterns according to the screen, but lose that control under load, with a deadlift, or even simple hip hinge
- I start with mobility, and then move onto skill and capacity if they repeatedly come back complaining of pain/injury
- in the presence of performance altering or pain causing dysfunctional asymmetry, then you want to intervene
- I "clear" a joint only when it has full threat free mobility - meaning it can handle passive overpressure and load
- this is a perfect time, if working with athletes to start consulting their coach
- i.e. I don't golf, so after restoring mobility and stability (able to keep mobility under load) - I have their coach look at them
- a coach's eye is going to pick up things you missed if you're just using your screen or not familiar with their sport
It's a direct way to the patient's nervous system and if ready, you can dissociate threat associated with movements and positionsPros
- specificity isn't possible for localizing a structure (nerve, fascia, or spinal level)
- that makes manual therapy conceptually much easier
- using placebo is great!
- we do this every time we say we can help someone with a technique or exercise
- it's a direct way to the patient's nervous system and if ready, you can dissociate threat associated with movements and positions
- if their nervous system is not ready to green light movement, positions, activities, manual therapy helps it feel safer
- the technique doesn't matter either - in line with current research pitting technique x vs y, both normally have similar positive outcomes compared to the control group
- you trained for years wasting time trying to learn how to isolate spinal levels and be specific with manipulation
- too many camps either proclaiming a certain technique is the best way to treat a patient or the worst way (i.e. the vehement hate for dry needling on the net - seriously, give it up)
- patient preference
- your ability to perform a technique comfortably, confidently, compassionately, and you can "sell it"
- so P/A aren't "garbage" if you get results with them, no technique is really garbage, it's how you present them (as either a fix or a temporary change that must be reinforced)
- i.e. selling a technique as "I just learned this technique last weekend" may work 2 ways
- patient 1 - That's exciting, I can't wait to see if it works
- patient 2 - Um... I'll pass on being a guinea pig
The only thing I am sure of is that I'm not sure about how anything really works, but I know what works for me and my patients.
The only thing I am sure of is that I'm not sure about how anything really works, but I know what works for me and my patients. It's based on what science says is not happening, what current guidelines recommend, and yes, my experience. Those who discount experience are often newbs who quote research stating it doesn't affect outcomes. While that may be true, my question to them is always, "In 20 years, your younger self will have the same outcomes as your future self?"
I hope this answered some of your questions. I basically said, do what works for you, use science to back it up, but don't let any one post or research article make you change what you're doing completely.
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
Keeping it Eclectic...