Remember the first two terms of college?
I remember it being REALLY stressful; in fact, they always said if you could make it through term two, you would be okay because it was the toughest.
However, this was when we learned most of our technique classes. For us, term two was when we had a class called “Myofascial Release II .”
We learned a technique in that class that I still use today. The “Occipital Hold,” and we were taught how this was releasing the fascia around the occiput.
Then five terms later, we had two more technique courses. One was MLD, and the other was Craniosacral. I don’t remember who taught us Craniosacral, but I probably owe them an apology. I was a bit of a jerk in that class because…well, I couldn’t feel the rhythms and pulses as it was being taught. As other students would exclaim how they felt these rhythms, I’d look across the room and say, “you’re full of s#*t you can’t feel anything!”
It wasn’t my finest moment; clearly, my ego and lack of palpation skills were at play, and I’m sure I owe some classmates an apology as well.
The interesting thing is one of the techniques they taught us in that class was an occipital hold. With this technique, we were supposed to be altering the rhythm or flow of cerebrospinal fluid (I’m saying this strictly from memory as I haven’t studied any craniosacral since that time) along with possibly altering sutures in the skull.
Now, I wish I could say I was some forward-thinking student that realized this at the time, but I only came to this revelation a year or two ago.
Those two classes taught me the exact same technique but with wildly different explanations of what was going on.
So, which one was right?
The Mechanisms Of Manual Therapy
An excellent paper was done, which looked at modelling a new approach to how studies in our field should be designed to understand better how to advance what works in our profession and what doesn’t.
Part of the problem with many of our profession’s modality courses is how there seems to be a one-size-fits-all approach. That one technique can work on anyone for almost anything.(1)
Well, there’s a lot more to a treatment than just the technique we use. So we can’t justify saying there is a “single thing’, or “single technique” that works exclusively on any given subject.
We know the mechanical stimulus from any manual therapy technique regardless of the intervention (joint mobs, spinal manipulation, Swedish massage, myofascial release, etc) results in neurophysiological responses in both the peripheral and CNS to help with pain inhibition. (1)
This helps demonstrate why we can’t take a mechanistic approach to treat patients. As the paper points out, to have a mechanical based approach, there are two prerequisites needed:
- A mechanism contributing to a clinical population or subpopulation.
- Biological effects of treatment have to be established.
If both of these are met, a patient could then be matched to appropriate treatment (or technique), allowing for targeted application of that specific treatment. (1)
The issue here is there is no way to identify the main mechanisms of how any technique works.
Now, I know that will ruffle some feathers as we quite often become attached to our favourite technique (and in no way am I saying you have to stop using the said technique; I encourage you to keep using it). Still, much of the research behind many of these techniques aren’t reliable. Often, the study is being done by the person who created said technique to prove its validity. And most of the time, they have excellent outcomes to prove their efficacy.
However, what they aren’t taking into account is the contextual effects of what they’re doing. As this paper points out, this is a crucial part of any manual therapy intervention.
How Our Treatments Are Multi-Faceted
There is far more than just our hands-on techniques that influence treatment outcomes.
Just some of the non-specific factors to include are:(1)
- Patient beliefs
- Provider beliefs, confidence, demeanour
- The environment the treatment is provided in
- Therapeutic relationship
- Influence of community factors on the patient
There are many more but with this brief overview, let’s consider how this could influence research outcomes when strictly focused on a technique.
If a patient believes the technique will help, well, it probably will.
If the provider is trying to prove the efficacy of a said technique, chances are they are very confident of their proposed outcomes. They have probably also used the technique often, so they are quite capable and confident with the hands-on portion of using it. This would also influence their demeanour during their interaction with the patient, which also helps with a therapeutic relationship.
Even the setting where the treatment is delivered can influence the outcome. For instance, an athlete would likely have a better result receiving treatment within the facility of their chosen sport. Someone with headaches would probably have a more significant effect in a darker room with less noise.
So many of these contextual factors come into play; it demonstrates how we can’t strictly focus on one intervention or technique to show its effectiveness.
As well there is this other wonderful thing called “Clinical Equipose.”
We have touched on this in the past but essentially, what it means is a clinician having no preference as to what modality or technique they use.
This is very important because bias towards a treatment is also associated with clinical outcomes. Because if a clinician believes a technique works and their expectation is that said technique always works, their expectations influence the outcome.
Clinical Equipose is essential in a research setting because if the provider doesn’t care or isn’t invested in a particular technique, there can be no bias towards the intervention. As we have seen, this bias can influence outcomes.
When we look back to my story from college and ask which technique description was right, the reality is neither one was right, but this is still a great technique.
We know that what we do with our hands is a mechanical stimulus that results in neurophysiological responses to the nervous system. Everything we do is an influence on the nervous system. When we look at the occiput, this is an area that is HIGHLY innervated with nerves, and being nicely touched in the area feels really good! This is why an occipital hold is such a GREAT technique. So while we challenge the premise of some modalities (honestly, I wasn’t trying to pick on MFR or CST, it’s just a good example), it doesn’t mean we have to stop doing them.
However, we have to look at the reasons why these work with the people we see. First off, your patients like you, and you do a good job. You’re confident with your skills. They come to your clinic with an expectation that you’re going to help them (and you do!). Their preference is to see you because they like what you do. Their belief system is that you’ve helped them in the past, so you’re likely to do so again.
What we do have to change is the narrative behind some of these techniques. They’re not doing what many of us were taught, but they feel outstanding. So, if it feels good, you’re confident with them, and your patients believe you will help them, isn’t that better than a description that isn’t really plausible?
Oh, and to all my classmates and that teacher, I apologize.
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- Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unravelling the mechanisms of manual therapy: modelling an approach. Journal of orthopaedic & sports physical therapy. 2018 Jan;48(1):8-18.