Herein lies the main question: Are you really even a physio, massage therapist, chiro, etc. if you haven’t forced your hands into the very sensitive structures of at least one person all while assuring them that it is what they need and will make them feel better in the end?
Whether it was the dreaded psoas release, digging the heel of the hand (or elbow) deep down into the IT band, blasting the pec minor with a reinforced thumb, scraping with a tool until a person is red and bruised, pistoning a needle sadistically, or performing the people’s elbow into multiple tender spots of the mid back, most all of us have been there.
Over the years, many manual therapy models and schools of thought have educated young clinicians that at certain times, we need to work, or even force, through pain in order to see results. Depending on the model, this could be in order to release trigger points, break up adhesions, stretch out soft tissues, or relocate shifted bones. Some models even ascribe a positive value when bruising or other signs of tissue injury occur along with their treatment. The practitioner often sends the message of “the target was hit” and associates it with healing and successful treatment.
But, neuroscience has progressed. Our understanding of pain and injury have progressed. The science of tissue adaptation and load capacity has progressed. So, now the real questions are, do we really need to be performing painful treatments to help people get better? And subsequently, is there ever a place for painful treatments?
Inspired by Podcast Episode 48: Is Painful Manual Therapy OK?, this blog is an extension that relays the thought processes and ideas based on the two questions above. If you have not listened to it yet, I highly recommend you do so first HERE.
Do We Really Need to Be Performing Painful Treatments to Help People Get Better?
Pain can be annoying, frustrating, debilitating, and exhausting. Some people are willing to do anything to get rid of their pain. That may mean taking medications, having surgery, seeking out a faith healer, doing exercise, changing diet, addressing sleep disturbances, or seeing a practitioner who digs their hands into tissues, scrapes fascia with a blunt object, or mobilizes joints beyond a comfortable range of motion. At face value, these aggressive manual therapy approaches may seem barbaric to some of us, but the fact still remains that some people actually do feel better in the end, at least in the short term. The argument could even be made that these interventions wouldn’t still be performed today if there wasn’t at least some PERCEIVED value. The other edge to that sword however, is that many people (patients and providers alike) feel these types of treatments are needed even if the patient doesn’t objectively get better.
Often, when I think of the various models that have been used to elicit more pain or intentionally hurt people, my first thoughts go to the movie “Major Payne.” If you have not seen it, it is a classic kids movie where a US Marine Corps Major, played by Damon Wayans, is discharged from the military and takes on a job training Junior Reserves, the “green boys,” back in the States. At a few points in the movie, when someone would get hurt or have pain, Major Payne would take their finger and say “I can show you a little trick to take that mind off that pain.” If the person obliged his offer, Major Payne would proceed to break one of their fingers (he didn’t with any of the kids!!!). Surely they wouldn’t have that pain they had before, they would have a brand new pain to focus on!
It can be quite easy to jump on the correlation train and assume that when people feel better after a painful treatment, it is because we are rubbing, releasing, or “fixing” the source of their pain. But, at this point, that just isn’t what science tells us is happening.
As the evidence continues to mount, we find that by placing our hands on patients, we are not realigning any bones, we are not “releasing” any tissues, and we are not placing near the amount of force to lengthen any muscle, connective tissue, or fascia. So what exactly are we doing?
“Regardless of what fancy model or theory you want to throw at it, if you just strip it down to the simplicity of it, you're fricking causing pain! And the body, if it has intact endogenous mechanisms, is going to shut down some stuff. Then, when you put a white coat behind it, a fancy theory, and a relationship that you've developed with the patient, you can do get away with a lot of painful stuff”
~ Mark Kargela
Our body is well suited to adapt to its environment, and by creating several sources of noxious input, and in a normal healthy body scenario it will begin to dampen your original symptoms through multiple processes (gating, DNIC, endogenous opioid release, attention diversion, etc). So, in the case of a normal functioning nervous system, one could possibly make the argument that creating pain with manual therapy might have some justification in very specific circumstances and explanations to the patient. However, we must also consider that research has supported other methods that can produce similar responses, that are much more comfortable, and do not necessarily require a clinician’s hands.
So if you have the thought, or have ever had the thought, that some of your techniques NEED to be painful to obtain meaningful improvements, you are not alone. This message is for you. Based on the history of manual therapy, the way we were taught, and the concepts of pain that are most prominent, most of us have been there with you. Everyone at Modern Pain Care surely has. In truth, many of us have created bruising or possibly even produced some small soft tissue tears with the belief that we were actually helping. We just hope at the very least that you don’t willfully and intentionally caused significant tissue damage while informing the patient “It’s for the best.”
“Luckily, you know, at least to my knowledge, I never did any serious damage. But we can get into this in a little bit. I've actually worked with a couple of patients who did have some pretty serious damage, serious issues after aggressive bouts of manual therapy.”
~ Jarod Hall
Is There Ever a Place for Painful Treatments?
You may be thinking to yourself, most of this does make sense but there are times in specific cases where some pain is elicited, or may need to be elicited to best prepare and guide treatment interventions. With these particular cases, it all comes down to the narrative you use and how you communicate before, during, and after provoking symptoms.
“I like to think of myself as a little bit more in the middle, where I am not going to be sadistic towards people and try not to have unfounded thought processes around how manual therapy works. I'm never going to just cram on people's tissues or cause pain during manual therapy, but at the same time, if we have a narrative in clinic, that pain doesn't mean damage and that pain is OK to bump into…and if I want to test how well somebody's conditioned pain modulation and endogenous mechanisms are working, I think it's OK to press into just a little bit of discomfort or mild pain, to see how a person's body responds and show that pain is ok and doesn’t necessarily mean damage.”
~ Jarod Hall
A patient’s pain experience is often shaped by the words we use, the interaction we make, and the way we respond when symptoms increase. With this, our goal may be to help patients reconceptualize any fear related movement into an activity that is less threatening.
If that means placing the patient on the table in a safe and comfortable position where they can relax and gently introduce non-noxious input into sensitive structures that will inherently create several neurophysiologic mechanisms that down regulate their pain experience and prepare them for movement, then that can be completely justifiable. However, it ultimately boils down to the amount of effort and time you spend with them in a passive manner and how efficient you can be with guiding their interventions towards a more active approach.
In this manner, performing manual therapy becomes more of a process rather than a product. By delivering manual therapy in a patient centered manner, you are able to gain a better understanding of the patient’s beliefs and expectations, reduce the perception of threat, and improve trust. This may theoretically set your patient up for success if and when they experience pain with a particular exercise or activity.
“This is the cognition targeted manual therapy that we talk about in Modern Pain Care. Where you're really getting a good understanding of what the patient's perceptions, beliefs, expectations are as you're doing the technique and then again afterwards. You constantly assess this so you can really maximize that encounter when you’re putting some of these hands on techniques on people and hopefully moving them in a positive direction”
~ Mark Kargela
If you are eager to learn more about our views at Modern Pain Care on the use of manual therapy we have a few courses you are able to take advantage of. Our Complete Clinician Course involves an entire section on manual therapy and we also have had the pleasure of hosting Matt Low as one of our guest lecturers for our masterclass events where he discusses utilizing a patient-centered approach in manual therapy.
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