Our website noigroup.com is getting one very big overhaul. In fact, we’re rubbing it out and starting again. We can’t wait to show you the brand new website in a few months. With the old website being put out to pasture, we want to make sure that the years of collected content don’t get lost, so we will be re-posting some classic old NOI notes to ensure that they have a new digital home. It’s been an interesting process reading back over material from over a decade ago – where have our ideas changed, where have they stayed the same, and so on. We think some of these posts have aged like a fine wine and are still as relevant today as they were when they were written.
What do you think?
Meet Fred
Fred was a patient of mine. He was about 55 and came from the far north of South Australia and only came to the city once a year. He used to call in to see me for a bit of physio and he frequently brought a present – usually a piece of lamb, but occasionally a lump of beef that I am not really sure which part of the animal it came from.
Anyway, Fred used to say “the second and third are out in the neck, have been for a few months since I came off the motorbike; I reckon the L5 is out too and the hip might be going out too. Can you whack them back in. By the way, I have half a sheep in the truck for you. Mind you with the drought they are a bit dry, but you did say once that you liked mutton. And another thing – don’t give me any exercises, like you tried last year. I get too much bloody exercise on the place these days”.
Share my quandary
I take a breath and reflect “but these days I am supposed to be evidence based and offer more self management, graded exercise and neuroscience education. I even wrote a book on what you are supposed to do. How did I get it so wrong with Fred? And what would my students be thinking now if they were watching this clinical encounter?”
Judge my therapy
I assessed Fred, I was interested in the motor bike accident so I checked him out as best I could for any contraindications to “whacking things back in”. There was a bit of stiffness in the upper neck and low back and I “whacked them back in” (grade 5 rotation for the lumbar spine, and lateral flexion grade 5 for the C2-3 joint or thereabouts). “Beautiful”, says Fred, jumping up and playing with his new neck movement. “Did you hear that neck go back in…still a bit out in the low back. Give it a bit more of a whack will you.” I did just that. Fred handed over the half a sheep, shook my hand and said “see you next year”.
What’s in a whack?
Was I wrong? I know that my therapy doesn’t follow any recent guidelines for chronic spinal pain and I know that the efficacy of manipulation is not that strong. I have got Fred addicted to me from years of successful annual treatment (at least I call it successful as I don’t know what might have gone on in the previous 12 months) and I have little chance of initiating an education and exercise based approach.
I don’t think anything goes out except fires and me on occasional Friday nights. Joints may get a bit stiff or rarely, locked, but that is about it. I am happy that I probably manipulated Fred’s perceptions as well as perhaps doing something to the joint structures. You could call it a placebo treatment but then again I am reminded by a Patrick Wall comment “In the end if many treatments are shown to be placebo, then we should work out what it was in the placebo that was the active ingredient.” There may have even been something helpful in the swapping of the sheep and the manipulative techniques.
-David Butler
My dear friend David.
You commentary on Fred & half a sheep was very telling about what often happens in our profession. What you DID do – in spite of thinking of evidence-informed practice, was LISTEN to your patient! Fred truly felt he knew what he needed, and because it was not contraindicated or outside our scope for practice, you did him a service that will keep physiotherapy as his first choice for treatment in the future. Goodonyamate!
Warm regards from Ottawa Ontario Canada.
Sandy Rennie, PT, PhD
I’m thrilled with you David, while we continue to interact with humans we must meet them where they are. When robots come to see us for treatment we will have more chance to follow the recipes prescribed by ‘evidence based’. Please could we all learn to LOOK & LISTEN and use our experience.
It’s my observation that manual therapy inevitably develops a dependent attitude, or, in other words, it fails to teach a person how to help himself. This is why Fred returned to you–you had made him dependent on you, just as any guru would desire of a devotee. This is a horrible thing to do to another human being! We need to revolt against this take-over of PT by manual therapy! I hope that NOI will decide to lead the way in this revolt. Regarding any help or apparent help that the manual therapy achieved with Fred, I’ve observed that whenever manual therapy has helped, it was either the placebo effect that you mentioned, or it was an accidentally but correctly applied mechanical force on a joint tissue, which Fred could have applied himself, any time, if he had only been taught. And this does not mean a long routine of general exercises to burden this busy rancher, but only one self-performed, mechanically correct movement now and then, and a lifestyle of avoiding the recurrent mechanism of injury or re-injury. Perhaps it’s still a placebo, but at least Fred would be independent. (But then you wouldn’t get your annual dose of mutton!)
HI, David! I practice near a farming community and agree with all your points. we must listen to our patients and balance out their requests with safe treatment. “Medicine is the art of amusing the patient while nature cures the disease” comes to mind. just keep doing what you’re doing!
Sylvia,
“Medicine is the art of amusing the patient while nature cures the disease”
This is a really funny quote.
Fabulous piece David! You really love stirring it up don’t you? The question I often ask myself is does that deeply ingrained model this person runs on keep him trapped? Is he suffering for it? People oftentimes really expect, want and feel they ‘need’ their manual Rx’s. Would he be open to learning new and more evidence based stuff? Can I do both? How can I best pace the delivery of the new if deemed necessary? Great everyday challenge and one to sink our teeth into! Cheers from Germany
David,
A wonderful story and so true to life in our practices over the years. Mine 40yrs!
Listening and reassurance is golden with a little safe technique and education thrown in.
As long as our patients return to their “happy and functional normal “ lives we should be happy too.
Hi Dave,
Thanks for the “oldy but a goody” found in NOI archives. Having just come back from teaching “up-to-date” (at least I hope so) physiology of pain within OMT training courses in Germany this blog hits a note. How much of a biomedical hands-on treatment are we still allowed to endorse within a bio-psycho-social framework without having a bad conscious or being judged by colleagues? To be honest – I envy your ability to still safely “wack L5” here and C2-3 there…. (at least still in 2008 you were). Being trained in Manipulative Therapy in the heydays of that concept, I left this camp nearly 20 yrs ago for the bio-psycho-social multidisciplinary pain management realm. Within this concept I found myself skilling up on running interdisciplinary session on education, communication, pacing, relaxation etc. However, nowadays I have frequently noticed that I seriously regret being “out-of-date” with the MT skills and admit to my lowered self-efficacy which prevents me from applying such techniques due to lack of practise. So, do we really need to choose either camp?
This might be a good time to refer to two papers by the late Max Zusman, who has always been somewhat of a healthy conscience of MT: “There is something about passive movements” (2010) and his legacy paper in 2013 “Belief reinforcement: one reason why costs of low back pain have not decreased”. We have seen the pendulum of clinical reasoning swing from fully endorsing “hands-on” therapies to only “hands-off” therapies (at least in LBP) but in my humble view the truth, as so often, is somewhere in the middle. We just need to use our skilful assessment and hands-on treatment techniques in a “person (not patient)-centred- approach” to whoever comes into our clinics (with or without half a sheep in the back). They might just be able to provide a reasonable “window” of short-term pain reduction to free up some working space memory for modern neuroscience pain education, and to get the active treatment movement going after confidence and trust have been restored for the person in their body by experiencing that “pain can be changed” (even if short-term). We should never forget that while we work on tissues, we also address proprioception, reduce nociceptive stress concentration, improve preciseness of cortical representation, open internal drug cabinets through placebo…. We could even argue in the benefit of an annual MT check-up for preventing any more sinister, costly and potentially disabling other treatments.
Tschüss from Melbourne
Ref
Zusman M (2010). There’s something about passive movements… Medical hypotheses, 75 (1): 106-10.
Zusman M (2013). Belief reinforcement: one reason why costs for low back pain have not decreased. Journal of Multidisciplinary Healthcare, 6 197–204.
Hi, I’ve been an osteopath for 30 years and have gathered, a hundred percent unapologetically, quite a few British equivalents of “Fred”
What you did was not wrong unless in your desire to placate you exceeded your technical scope. Large numbers of patients over the past few years have made their way to me somewhat disillusioned by yet more ‘exercise programmes’ having been given them to no avail.
Those of us who still favour manipulative techniques are not always ignoramuses lacking finesse and knowledge, incapable of reading research papers; we just know what helps people.
Hi Michael, well said. I’m a Physio who works in a Chiropractic Clinic and as such, an absolute convert.
David! Sounds to me like an excellent therapy session by a skilled clinician using the best tools in his toolbox to suit the job. We sometimes forget that “evidence based practice” is supposed to include the patient’s perceptions and experience, and the clinician’s knowledge and experience, not just what’s in the literature. Your story reflects the sort of interactions that make physio such a unique profession. It never gets boring!
I absolutely love this and feel so reassured that such an eminent member of the Physiotherapy profession can admit to sometimes just giving patients what they want and need. How refreshing! It makes me feel so much better – only today I sent a patient out with taping that he won’t see in any book 😉 Those who treat by rote would do well to read this.
From the start of my career…
I always aspired to be an elite manual therapist.
Imagining people parking in cars outside my clinic as far as the eye could see to sleep overnight in order to see me.
…the great healer and helper of people.
Thankfully, I developed absolutely no confidence in this skill and, as a result, did not become accomplished in it. Manual therapy is a good tool (one of many) to be used to help others, while they gain understanding from us that their best help is themselves. Unfortunately, we may have not realized this until recently that the passive coping resulting from “being wacked back in” is not healthy neurologically.
Instead…God in His wisdom made me…
* an average technical clinician but also a good listener.
* compassionate to a fault.
* keenly interested in helping others be able to help themselves.
* motivated to work myself out of a job with each client.
* see early on that pain and damage were not the same thing.
* value the wisdom in learning from mistakes.
* learn — over and over again — that I do not know it all.
* interested/inquisitive in the thoughts of others…especially as to “why”.
* see the inherent value of each person, gifted to them from their Creator.
* understand the life-giving force of being driven by true Truth.
There is no judgement in the actions of the past (especially the actions of others) as we look back. Only wisdom to learn and tolerance to hope that, as we look back, we note first that we did the best we could with what we believed to be True…and that we are now different than we were then because of our relentless pursuit of Truth.
Hindsight is always 20/20 vision.
Look back and learn. Use that wisdom to direct your direction forward. Tell as many as will listen all you have learned.
I, for one, appreciate your pioneering spirit. The first plow through the field is always the hardest dig. Continue forward.
In deep respect for all you have done…
Paul Leverson, MSPT, TPS
Hey… thanks everyone for resonating with “Fred and Half a Sheep”. I wrote it some years ago, but on reflection I would still do the same and maybe even with less guilt. By the way, my “addicted patients” are now much less in number as I hope you’d hope.
A couple of other issues arise. The treatment could be defended on the grounds that treating the representation or symbol of a person’s malaise may be more powerful than a material offering to another component of the problem, such as strengthening a weak bit.
I was thinking of Fred as I read about sacred values in conflict resolution in Robert Sapolsky’s “Behave” (2017). These values are defended hard, they define the person, are hard to shift and maybe we shouldn’t try. “I go in and out” may be such a value for Fred. Such values need respect.
I am not suggesting we should all become manipulators and I should mention that I became quite adept at manipulation though intensive training over many years, allowing gentle, mid- range thrusts, which is some cases may loosen something in and around a joint and/or provide a thrilling input into the CNS which in some cases may then rejoice at the offering to the representation. Gotta keep up your skills!
David