Commentary on “Placebo Mechanisms of Manual Therapy”
- June 2, 2017
- Posted by: Pieter Kroon
- Category: Uncategorized
In this blog post I want to discuss a viewpoint article that was published in May, 2017 JOSPT entitled “Placebo Mechanisms of Manual Therapy: A Sheep in Wolf ‘s Clothing?” Click here for the article: http://www.jospt.org/doi/abs/10.2519/jospt.2017.0604
The article in essence implies that we do not really know what makes a manual therapy treatment efficacious. The role of a placebo might be bigger than we have previously anticipated. The effectiveness and improved outcomes associated with manual therapy treatments might not strictly come from “precise application but rather from improved contextual factors related to reputation, confidence, and therapeutic alliance.”
If we follow this type of reasoning, it ultimately does not matter if physical therapists are fellowship trained or not. All we need to bring to the table it is a good amount of confidence, a good reputation, a therapeutic alliance, and presto, the patient has a higher likelihood of improving.
This line of reasoning bypasses important aspects of manual therapy treatment. Being fellowship trained in manual therapy is not about the almighty manipulation, applied after subjecting the patient to “an elabo¬rate ritual involving the evaluative and application process.” As a Program Director in orthopedic manual physical therapy, the most important concept that we teach our students is advanced problem solving and the ability to differentially diagnose. Manual therapists are first and foremost advanced problem solvers. The ability to differentially diagnose is our most illustrious quality and the reason that seeing a fellowship-trained therapist is worth your time.
It is true that no one knows exactly what happens during a joint manipulation. Increasing bodies of evidence are explaining that the main effect appears to be a neuromuscular driven response. However, that applies more to spine problems, and not so much towards extremity problems. In extremities we tend to see true mechanical joint dysfunctions, which can be fixed with a mechanical solution. In these cases, precise evaluation methods, and skillful application of a joint manipulation to the appropriate joint will make the difference between a good treatment and a lousy one. For example, when treating a runner with midfoot pain, we must perform a skillful evaluation to determine what the painful structure is. Is it the bone? Is it a tendon? A muscle? A ligament? Or a joint? For example if I examine the foot and find that it is the cuboid that is at fault. I find restricted motion and a positional fault, as well as tenderness over the cuboid/MT 4-5 joint line.
I better be able to manipulate the dysfunctional cuboid. Manipulating the talocrural joint in this case, is not going to fix the problem. And this has nothing to do with “priming the nervous system to augment the effectiveness of manual therapy.” If there is a true mechanical restriction, the appropriate joint manipulation, when performed correctly, takes care of that.
Following the line of reasoning that the effectiveness and better outcomes of manual therapy might not strictly come from precise application but rather from “priming neu¬rophysiological capacity for endogenous pain modulation” or “active central ner¬vous system effects” is a slippery slope. It implies that it does not really matter what we do manual therapy wise. Any sensory input will do the job, and that gives physical therapists license to be sloppy in our evaluation and treatment process. And before we know it we are back to how we treated 30 years ago when I first got out of PT school. You found the spot where it hurt, and you just rub it, push it, move it around a bit (since motion is lotion!), throw some holy water over it and pray that when the patient comes back next time, the nervous system is sufficiently primed to the point he is better. I mean, I have a good reputation, I am likeable, and I do not lack in the confidence department. What possibly could go wrong?
By no means do I want to downplay the advances in pain science that have been made over the last ten years, and its implications on our treatment. However, we should not throw the baby out with the bathwater. And don’t tell me there is no baby in the bathwater. Reasoning like that is not good for our profession.