Manual Therapy and Big Bastard Spiders!

an 6 min read

I've been involved in a lot of discussions about why therapists use manual therapy, and many tell me it's because it's a form of graded exposure to painful movements. Well, it's not!

I've heard manual therapists come up with all sorts of excuses to justify rubbing or poking someone in pain. Some are weird and whacky like realigning chakras or balancing energy, some are biomechanical but implausible such as releasing fascia, breaking adhesions, or freeing muscle knots.

So when some say manual therapy is a form of 'graded exposure' it sounds not only plausible but also scientific, evidence-based and contemporary compared to the other explanations. However, it's just not true, manual therapy is not a form of graded exposure treatment.

Many therapists have poor understanding and skewed ideas of what graded exposure means. Often they confuse, bastardise or completely misrepresent graded exposure to explain or justify the use of their treatments.

Therapists tell me they use taping, dry needling, massage, manipulation, or joint mobilisation to allow patients to move with less pain, less restriction, and less fear and anxiety. They tell me that performing some form of passive manual therapy treatment on a patient in pain opens a "window of opportunity" and allows them to move better and more frequently and therefore is a form of graded exposure therapy.

It's not!

Big Bastards!

Graded exposure is a specific behavioural treatment designed to reduce or remove fear, anxiety, and avoidance by exposing a subject to a fearful stimulus. Graded exposure is performed by exposing the subject to the stimulus, not by removing or reducing it first as many manual therapists think.

If you have a fear of big bastard spiders, you don't become less fearful of them by avoiding them. Instead, you need to be gradually exposed to tiny little bastard spiders and work up to the big bastards.

Also if you are terrified of big bastard spiders being exposed to some big bastard snakes won't help reduce your fear of big bastard spiders, it has to be specific.

Bastards!!!

This is no different with pain on movements or activities. If you are avoiding bending forward because it hurts your back and you are worried or concerned that it's harming you, having some massage or manipulation first and feeling less pain after when you bend forward doesn't and won't reduce your fears of bending when the pain returns.

Likewise, if you are afraid to lift your arm up overhead because it gives you a sharp twinge having a nice young physio apply a Mobilisation With Movement or a Scapula Assistance Test as you reach up which reduces the catching sensation won't help you with your anxiety or concerns about the pain as you reach overhead.

Symptom Modification ≠ Graded Exposure

To put this as clearly as I can manual therapy is NOT a form of graded exposure treatment, it is a form of symptom modification (ref). Now you may be thinking this is just being pedantic over semantics, but it's an issue that is causing some misunderstanding and misuse of two very different approaches to patients in pain.

If you have a patient who you assess not to be displaying any signs or symptoms of fear or avoidance to movements or tasks that hurt, and they are continuing with daily tasks and activities despite their pain, and they show no signs of anxiety or reluctance to move despite their pain. Then modifying their symptoms with some passive interventions could be useful, it's not essential but it could be an option to consider.

However, if you have a patient who you assess is displaying some signs of reluctance, anxiety and avoidance of movements and tasks because of their pain, then modifying their symptoms with manual therapy or any other passive treatments may NOT be the best thing for you or them to do.

Despite pain-modifying treatments often being wanted by these patients and it being far easier for therapists to do this, giving treatment that removes pain before movement can help in the short term but may make things worse in the long term.

Thats becuase if you want to help someone build confidence, reduce fear of a painful movement, and help them to return to a task or an activity they have stopped, then they will need graded exposure to it... but without first reducing, removing or modifying their symptoms.

The hardest thing to do!

Getting patients to do the things they fear or are avoiding the most is, without doubt, one the most challenging, difficult, and unnerving things a therapist has to do, and why I don't think that many actually do it.

Being able to recognise who does and who does not need to be pushed into pain, when it is safe to do so, and how far to take it, takes a shit load more skill and experience than using any manual therapy or symptom modification treatments or techniques does.

One of the biggest misconceptions I hear about therapists who don't use manual therapy to reduce patients' pain is that they are cold, discompassionate and uncaring, this is complete and utter bullshit. Just becuase they don't focus on short-term fixes and are looking at long-term solutions it doesn't mean they care less... if anything it's just the opposite

Getting a patient to do something they don't want to do also requires far more skills in communication, rapport building, and motivation than any manual therapy does. Asking a patient to do something that hurts them is the hardest thing to do, with you always questioning and second-guessing if you are pushing them too much, too hard, and worrying about flaring them up and then losing their trust and confidence.

Its so much easier and simpler to just push, poke and rub people in pain and tell them to avoid, reduce, or stop doing things that hurt. But I find this doesn't help many in the long term and this approach doesn't sit well with anymore. 

Summary

So that's why manual therapy is NOT graded exposure treatment but just short-term symptom modification which work through two completely different mechanisms.

Manual therapy and most other symptom modification techniques will always have small effects and last short periods of time. They are also notoriously unreliable in who they do work and don't work for, and in my opinion, are generally not worth the time and effort for most issues.

So if you are using manual therapy and are telling patients that its a form of graded exposure therapy, its time to find another excuse.

As always thanks for reading

Adam