TREATMENT CONTEXT, NON-SPECIFIC EFFECTS

My take on why manual therapy "works", part 7.

OLDER POSTS IN THIS SERIES

Part 1: IS MANUAL THERAPY EVEN NECESSARY?  

Part 2: NEUROTAGS! YOU'RE IT!  

Part 3: ABOUT "LEARNING"  

Part 4: SKIN STRETCHING AND MOVEMENT ILLUSIONS  

Part 5:  TACTILE DIRECTION DISCRIMINATION IN THE DORSOLATERAL PREFRONTAL CORTEX 

Part 6: MORE ABOUT DORSOLATERAL PREFRONTAL CORTEX

NEWER POSTS IN THIS SERIES

Part 8: SOME FINAL THOUGHTS ON NON-SPECIFIC EFFECTS

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The next statement in the SomaSimple post is: 

"7. Even if you think you have to mobilipulate people (i.e., engage in manual therapy overkill), you still have to properly set a patient's expectation, because no matter WHAT you think you're doing, it still all boils down to non-specific effects being the crucial variable."

I linked to the Bialosky paper from 2008 (1), to include all those at the far end of the manual therapy spectrum, the extremes of the operator mentality endemic in manual therapy. To their credit, these manual therapy researchers took what I like to call the "operator model" of manual therapy to its limit, analyzed the method, and, according to this paper at least, concluded that it's not the method, it's the non-specific effects that are important in pain resolution.  Effects that happen to correlate with a technical application of force into an alive awake person's body being protected by an alive awake nervous system, but still don't "prove" that the method is important, only that people will get better with manual therapy because... brain.*

Some Canadian PTs from Edmonton's University of Alberta have the right idea (according to me, at least). One is Jorge Fuentes(2), whose PhD thesis demonstrated that  "how a physiotherapist interacts with a patient verbally, through eye contact, body language and listening skills is almost as important as the treatment itself."

Another is Maxi Miciak(3) who says,

"[Jerome Frank's] (4) "..conceptual framework includes four common features: (i) an emotionally charged confiding relationship with a helper, (ii) a healing setting where there is belief the therapist can help and is acting in the client’s best interests, (iii) a rationale, conceptual scheme or myth that plausibly explains the symptoms and prescribes a procedure for resolving the symptoms, (iv) a ritual or procedure that requires active participation of both patient and therapist and is believed by both to be the means of restoring health."   

Be sure to read her blog posts on the topic, Finding Freud in Physiotherapy Part 1(5) and Part 2 (6).

I'm pretty confident these two are on the right track.
If they are, one can extrapolate that the heavy-duty-industrial-strength kinds of manual therapy can be allowed to go extinct. So can any of the professions or branches of the human primate social grooming tree that support them. Those branches can come crashing down for all I care but I hope the tree will live on. We are still primates, after all, needing physical contact for our brains to grow, then periodically thereafter. Until or unless we become fully cyborg-ed.. fully wired up to/into/chemically controlled by the society we depend on... but this isn't about that, so I'll leave that topic alone at this point.
 
*In a later paper they tried to revert to saying, "Yeah, we said non-specific in that earlier paper, but really people, we should all do high-velocity stuff, because... evidence." Whereupon Jason Silvernail and I protested in a letter to the editor(7) which was published (resulting in my one and only citation), thanks entirely to Jason Silvernail who spotted the incongruence, because he follows all that mobilipulation literature, whereas I think outcome studies, although necessary I guess, are mostly tooth fairy science, so I let my interests travel elsewhere. The letter was built around a google doc I wrote, trying to analyze what therapists do in terms of doing things "to" people as opposed to doing things "with" people, that I called Operator/Interactor models of therapy(8). Will Stewart interviewed us following its publication. (9)

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1. Joel E Bialosky, Mark D Bishop, Michael E Robinson, Josh A Barabas, and Steven Z George; The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders 2008, 9:19 (open access) 

2.  Richard Siemens;  Physiotherapy patient interaction a key ingredient to pain reduction, research says. U Alberta via Medical Xpress June5 2013

3. Miciak M1, Gross DP, Joyce A. A review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice.  Scand J Caring Sci. 2012 Jun;26(2):394-403

4. Frank JD, Frank JB. Persuasion and Healing: A Comparative Study of Psychotherapy, 3rd edn. 1991, The Johns Hopkins University Press, Baltimore.
5. Miciak M; Visioning Practice Through a Psychotherapeutic Lens. IgnitePhysio.ca blogpost May3 2014 6. Miciak, M; Contextual Theory –An Unexpected Ally. IgnitePhysio.ca blogpost May 9 2014


7. Diane F Jacobs, PT and Jason L Silvernail, DPT, DSc, FAAOMPT; Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. May 2011; 19(2): 120-121

8. Diane Jacobs; Operator/Interactor: Manual Therapy and its Treatment Models. Google doc 2011

9. Will Stewart; Moving Beyond the Technique: From Operator to Interactor. Podcast interview with Diane Jacobs and Jason Silvernail, 102:26 minutes, 2012.