One of my teachers in college used to say “what’s wrong with massage?” The wisdom in that statement took me 8 years to understand. We don’t need to make fancy explanations. For the most part they simply aren’t defensible, and plain old massage with a bit of understanding of how psychosocial variables play into the patient’s pain experience is more than enough.
I have noticed a lot of resistance in our community (massage therapists) to resign to the fact that we were just plain wrong about a lot of our assumptions. Mostly, I’m talking about how we have inferred causality regarding the mechanism of actions to explain treatment outcomes. Let me be clear…just because it doesn’t work *how we used to think* it worked (myself included), doesn’t mean that it doesn’t work. It just means that it works, but not for the reasons that we used to think.
I’m so tired of the misconception that skepticism is cynicism.
Another important challenge is that some people aren’t quite aware of how to recognize the difference between criticizing a person’s character (ad hominem), and criticizing an idea. If I have faith in manual therapy (which I do), it doesn’t mean that I need to be attached to the reasons why I think it works. If someone challenges my beliefs it doesn’t need to feel like a personal attack or an attack on the quality of practitioner that I am.
Before I begin deconstructing a couple of commonly held beliefs among manual therapists, I want to lead with a huge disclaimer.
You help people. You are there for people. You maybe even get amazing results. I give you the most sincerest of high fives. You are awesome, and doing important work. We are all a family, united on the same side of the line here. Where it starts to go sideways is when we begin challenging the proposed reasons why you get the results that you do. Challenging the reasons is important. The gift of scientific inquiry will hopefully give us the tools to both teach assessment and treatment techniques that are far more reliable than what we currently have, and maybe we can use that information to be able to reproduce treatment results more consistently.
I take no issue with practitioners who practice in a certain way. Whether you’re a DC, PT, or RMT. Whether you practice with anatomy trains in mind, or you’re a CST, visceral, or Reiki practitioner, I’m not going to stand toe to toe with you and argue about the results you get. Heck, I might even take a CST course because man…when those people put their hands on me, I feel enormously comforted, and I’m sure I have a lot to learn from that community. I also have no problem with learning from gurus. They often have a lot to offer. They have what I would call wisdom. Although the proposed mechanisms are often highly speculative, or even verifiably untrue, there’s still lots to learn from them, like different ways to touch people. Since everyone likes to be touched a little differently, having variety of approaches and touch in our treatment tool-box is a good thing. Regardless of how questionable the proposed mechanisms of action are for explaining treatment effectiveness, the phenomenon gurus produce in the form of treatment results generates important questions for the scientific community. We need each other. From one end of the spectrum to the other. From bench scientist to guru whose techniques border on (or are) energy work. We need each other.
Let’s make a clear distinction here…it’s okay to challenge the reasons why we think it works. It’s uncool, unproductive, and adds nothing to the conversation to attack a person’s character. We need to challenge ideas, but if you find yourself taking it personally, or unable to back up what you’re saying with any supporting evidence, just bow out. Ask questions, go read, and come back to the conversation. Let’s all learn something! I enter every challenging professional conversation with curiosity, and an open mind. I am ready to be convinced! Lay it on me! Heck, if I heard a plausible argument for the earth being flat, or the existence of the Easter bunny, I’d be all over that.
First I’m going to start with deconstructing some easily debunkable, yet commonly held beliefs among manual therapists. Then I’m going to explain why it’s totally okay, why manual therapy is still awesome, and it’s therapeutic use is totally defensible.
Here we go with the debunking…
It’s important that we abandon the unsupported ideas of tissue specific treatment. It’s clear that the effects of manual therapy are general, and non-specific, and that they are also mediated by patient beliefs, and expectation.
It’s crucial for progress, and our credibility as a profession that we support our beliefs with more than inferring causality based on nothing but conjecture tied together with logical fallacy. We can do better than that. The public deserves better than that.
Let’s start with the easy one. If you think you can identify, and treat a specific spinal segment, (never mind a heart ligament) you have nothing but your own beliefs to support that notion. In order to accomplish this, we would need to be able to first identify restrictions, and then be able to treat them. Neither of those ideas is defensible.
Reliability of segmental motion testing is controversial at best. (1, 2, 3).
This study (2) found that interrater reliability (greater than just chance) is less than 20%. Professionals agree on what segments are stiff or not with an accuracy of less than a coin-flip. This review shows that Interrater agreement only rarely exceeds poor to fair agreement (3).
Let’s try something easier then. How about detecting motion of the PSISs? None of the studies included in this review (4) showed interexaminer reliability. Training (even among experienced Osteopaths) does not seem to improve consistency. “Those examiners who attended training sessions achieved a marginal increase in intra-examiner and inter-examiner reliability, but concordance was still less than acceptable for a clinical test. The osteopathic profession should reconsider the use of these clinical tests purported to indicate sacroiliac dysfunction in view of their unestablished validity and poor inter-examiner reliability”.
Even if we were able to identify specific structures that need mobilization, we can’t seem to make the application specific. In these studies (5, 6, 7), we can see that we’re simply not targeting specific vertebra. Real time interactive MRI shows force applied to *any* lumbar vertebrae resulted in all of them moving, and they don’t even all move in the same direction. Yes, we can use joint mobilizations to improve ROM, but not because we’re mobilizing specific vertebrae. Less than ½ of the time do cavitations take place in the intended vertebral level, and they don’t even occur on the intended side of the spine with any accuracy.
The last monkey-wrench I’ll throw into the archaic theory that we can detect, and treat specific vertebral restrictions is quoted nicely from this paper (8) “A clinician attempting to palpate vertebral motion would be misled by assuming that perceived restricted joint motion universally represented a finding potentially amenable to manipulation. For spine palpation to be a valid indicator for manipulation, the clinician applying it must first be able to differentiate between asymmetrical motion caused by vertebral fixation and that caused by asymmetrical joint anatomy”.
How can we magically tell with only our hands that this joint is stiff, and requires mobilization when there is significant variation in facet geometry between segmental levels, and it is normal (9,10)? In other words, funny shaped vertebrae are normal, and how han we tell if a joint is stiff, or is it just a funny shaped vertebrae?
As far as we know, we can’t.
Just because our theories about treating specific spinal segments, (never mind a pericardial ligament) are *clearly*debunked this does not mean that manual therapy as we know is useless. Far from it!
Now it’s time for the good news.
Massage therapy may exert an effect on the spinal cord, acting as a counter irritant to modulate pain (Boal & Gillette, 2004) and joint biased MT is speculated to “bombard the central nervous system with sensory input from the muscle proprioceptors (Pickar & Wheeler, 2001). So…if someone is having an unpleasant sensory experience…we give them a pleasant one. What’s wrong with that? Neurophysiological effects of MT may be related to changes in the opioid system, dopamine production, and central nervous system changes in descending modulation of pain. (Sauro & Greenberg, 2005; Fuente-Fernandez et al., 2006; Petrovic et al., 2002; Wager et al., 2004; Matre et al., 2006). One of my teachers in college used to say “what’s wrong with massage”? The wisdom in that statement took me more than half of my career to realize. We don’t need to make fancy explanations. They aren’t defensible, and plain old massage with a bit of understanding of how psychosocial variables play into the patient’s pain experience is more than enough. Throw some joint mobes in there…why not… Joint based techniques may act on the dorsal horn to decrease/modulate/change the nociceptive input the spinal cord receives (Malisza et al., 2003).
Maybe the ritual of assessment, a complicated treatment explanation and perceived effectiveness of treatment matter too. So as long as we don’t hurt people, and practice with confidence, we can enjoy the use of non-specific variables such as placebo, expectation, and psychosocial factors which may be pertinent in the mechanisms of massage therapy (Ernst, 2000; Kaptchuk, 2002).
In closing, I would like to say that massage therapy is awesome. We as a community have strengths that are unique to our profession, and we enjoy advantages that other practitioners do not. We are the best when it comes to hands on work (that’s right, I said it *playfully*), and we spend more time with people, allowing us the opportunity to discover and perhaps treat for psychosocial variables relevant to the patient’s symptoms.
We don’t need to prop ourselves up on fancy explanations that aren’t defensible. Doing so damages our credibility, and does not serve the best interest of the patient.
Thank you, and remember that if someone challenges an idea, it says nothing about the quality of practitioner you are. Are you willing to change your mind when the evidence is compelling? Or are you going to be obstinately adhered to your beliefs, even when the available evidence contradicts them?
Change is here…what side of it are you going to be on? The side of growth, and integration of evidence, or the side of myth and folklore?
We don’t so much have to change what we’re doing, as we have to change our explanations. Practice however you want. Personally, I want to aim for thinking like a clinician, and treating like a magician.
With love, respect, and an open mind…provided that you defend your argument 😉
- Hardy GL, Napier JK. Inter and intratherapist reliability of passive accessory movement technique. NZ J Physiother 1991;19:22-4.
- Inscoe EL, Witt PL, Gross MT, Mitchell RU. Reliability in evaluating passive intervertebral motion of the lumbar spine. J Man Manip Ther 1995;3:135-43.
- Huijbregts PA. Spinal motion palpation: a review of reliability studies. J Man Manip Ther 2002;10:24-9.
- Fryer G, McPherson HC, O’Keefe P. The effect of training on the inter-examiner and intra-examiner reliability of the seated flexion test and assessment of pelvic anatomical landmarks with palpation. Int J Osteopath Med. 2005;8(4):131
- Lee RY, Mcgregor AH, Bull AM, Wragg P. Dynamic response of the cervical spine to posteroanterior mobilisation. Clin Biomech (Bristol, Avon). 2005;20(2):228-31.
- Ross JK, Bereznick DE, Mcgill SM. Determining cavitation location during lumbar and 5. thoracic spinal manipulation: is spinal manipulation accurate and specific?. Spine.2004;29(13):1452-7. (https://www.ncbi.nlm.nih.gov/pubmed/15223938)
- Assessment of Lumbar Spine Kinematics Using Dynamic MRI: A Proposed Mechanism of Sagittal Plane Motion Induced by Manual Posterior-to-Anterior Mobilization Kornelia Kulig, Lee, R.Y.W., Evans, J.H., 1997. An in-vivo study of the intervertebralmovements produced by posteroanterior mobilisation. Clin. Bio-mech. 12, 400–408.
- Atlas–Axis Facet Asymmetry: Implications in Manual Palpation Ross, J. Kim MSc, DC*; Bereznick, David E. MSc, DC*; McGill, Stuart M. PhD*Spine: June 15th, 1999
- The effect of facet geometry on the axial torque-rotation response of lumbar motion segments. Ahmed AM Spine [01 May 1990, 15(5):391-401]
- Facet Orientation in the Thoracolumbar Spine: Three-dimensional Anatomic and Biomechanical AnalysisMasharawi, Youssef PhD*; Rothschild, Bruce MD, PhD†; Dar, Gali MSc‡; Peleg, Smadar MSc‡; Robinson, Dror MD, PhD§; Been, Ella BPT*; Hershkovitz, Israel PhD‡Spine: August 15th, 2004 – Volume 29 – Issue 16 – p 1755-1763