If I am to use an analogy - Manual therapy is a little like Mc Donalds in my opinion. I believe I heard this on a podcast by Adam Meekins and Chad cook. It will provide some nutrients (pain relief) in the short term, but the nutritional value and overall longevity and carry over is poor. Is too much massage bad for you??-- probably not in terms of the actual physical contact but if this contact is coupled with narratives that create a reliance on the therapist for passive treatments with patient with poor self efficacy well then it can be very harmful.
I would rather coach and empower people to enhance their own endogenous opioid and endorphin systems and their own natural healing abilities. Ironically this can be done with manual therapy, but it should be practiced more like a course of medication of three to four sessions only, if at all and only to show that pain can be modulated. This can then be used as a powerful tool. Somewhere along the line this became the keystone of treatment in private clinics around the world which I believe was heavily driven by patients wants and not their needs. What patients want and what they expect are not always what they need and likewise what patients need are not always what they want.
The reason manual therapy sells is because people may have come to expect hands on therapy in private practice, and it feels good with some pain modulatory effects. It is probably because gurus have pedaled manual therapy as the magic bullet of treatment and it does help with pain relief for most people with non serious injuries. When you reduce someones pain you can also improve their movement as the pain is now less limiting and they may move further when you recheck their range of movement on reassessment. What I mean here is--someone has pain in their back for example--they come to clinic and they can touch their knees on lumbar flexion --they get massage and after the treatment they can now touch their toes(their baseline -pre injury). What has happened here is pain was limiting the movement, you have interacted with the nervous system ( physical touch) and this has altered their perception of pain allowing them to move further. (Pain gate theory and/or diffuse noxious inhibitory control theories) --Some patient can become allodynic (pain now felt to a usually non painful stimulus) and/or hyperalgesic (pain increased to a painful stimulus). So massage in this case may very well be much more painful than helpful. Like everything in our world nothing is that cut an dry
Having a Mc Donalds meal is fine in the short term. Sometimes we do just crave a Mc Donald's meal even though we know it is off poor nutritional value however it does taste nice and on occasion this is okay.
It is my belief that patients may not even need manual therapy to improve and some patients do not even need proof that their pain is modifiable. Most strains and sprains have a very favorable natural history and my role here will be to educate and guide and perhaps inform clients of best practices to enhance their own innate healing abilities. Some pain, some times is okay. We must not always demonize pain. This would be like saying to someone " you will never be upset in your life again". This is totally inaccurate. Pain is a normal part of being human. We all experience it however on occasion it can persist and these are the people that need our help and guidance the most. Their is a huge dependence in modern society that we must eliminate pain at all times. This where big pharma comes into play. It is my belief that maybe we need to realize that some pain sometimes is okay. Of course there is times where we need to check with our doctor but that is my job to decipher sinister things for non sinister things. This is where we have the upper hand on doctors as we are specialized in these injuries but we also know when to refer to the doctors for imaging and further testing.
So, the decision the patients should ask themselves is "would you rather cheap, quick food or would you like a gourmet meal. This is especially important when people have tried Mc Donald’s on many other occasions and are still struggling with their symptoms and/or when their pain has persisted for longer than 2 months. Food for thought literally.
If you want massage, I think physio is poorly placed in the health care system to provide this service. It is a tool that we can utilize but it is in my opinion over utilized and sometimes it can be connected with outdated and harmful narratives of what it is actually doing.
I am all for making patient feeling cared for, listened to and making them feel good but if all that the therapist is providing is passive treatment because the patients like it and just want it then we are providing more entertainment and poor-quality care in my opinion. If the patient is equipped with the correct narratives and like massage then it could work but this is best given in an RMT space in my opinion.
We could argue that the patients who seeks passive treatment have poor self efficacy in the first place and do not like to complete the active components of rehab and that is fine however this is where an early on discussion must be had in relation to further treatment planning and goal evaluation and narratives attached to treatments.
Two examples to close –I have a friend that loves to smoke cigarettes---they just love having a cigarette in the morning, just like having a coffee---they feel they need this to start the day. They are aware of the health consequences, but that person enjoys the feeling, perhaps the stress relief that a cigarette gives---I am not there to change her mind rather just to explain my point of view and health consequences, if she chooses to continue to smoke after that, my job is done. I can only bring the horse to the water, but I cannot make it drink. You could argue that this person is getting some valuable effects from smoking and if it is in moderation then it may be like the occasional Mc Donalds meal or dare I say, the occasional massage.
Opioids are another example ---people love them. However, we know they can be addictive and one can become opioid tolerant after a while which means one needs increased doses of opioid to get the same pain relief –this can, as we know lead to addiction. There is also the theory that naïve opioid users can become hyperalgesic after opioid use. The theory here is that you take opioids, you get a huge dump of dopamine and opioids release and this dampens your pain response. However, the levels of opioids in your system remains high for a certain period so when your body is trying to return to its normal opioids baseline the body stops making its own endogenous opioids meaning the stores are not being replenished on their own. When we encounter a painful stimulus in this period the argument here is that there is reduced opioid reserves in the bodies stores to down regulate the painful response therefore, we feel more pain than we should to a painful stimulus. Not only are you now not building your own stores of opioids (bodies natural pain relievers) you are blunting your receptors to opioids meaning we need more of a hit, and these substances are addictive:
Caveat---Am I saying never take opioids-absolutely not, they are necessary for some people at some times in certain situations
So, the doctors and pharmaceutical companies are trying to help perhaps by giving these medications, but we all know about the opioid epidemic is now. Are we causing more harm than good?? Quick fixes are not always the right fixes. It can be like plugging a water leak somewhere, but the water will eventually find another way in.
In conclusion we can provide short term relief with all of the above methods but once left unchecked and once it becomes clear that these methods are not working, we must act quickly. Patients can develop heavy reliance on these methods and in fact this may lead to addictive behaviors and cause people to scratch an itch that may not even exist.
My goal is to empower people to build up their own opioids reserves and pain reliever hormones and stores and instill movement optimism with education, exercises and guidance.
What do you choose –Mc Donald’s or Gourmet Organic meal.
Comments