To Use All Ways And Be Bound By None

“We now find rigid forms which create differences among clans… Because of styles, people are separated. They are not united together because styles become law. The original founder of the style started out with hypothesis, but it has become the Gospel truth, and people who go into that become the product of it.” Bruce Lee 1940-1973.

Another Practitioner’s Opinion

As a relatively new physiotherapist (I graduated from University of Sydney in 2000), I was fortunate to have met or spoken to distinguished osteopaths such as Anne Cooper and Peter Green, physiotherapists such as Nick Stepkovitch and Alex Rtshiladze, and chiropractors such as Henry Pollard PhD and Phillip Bolton PhD. I feel I had learnt much from the conversations with these experienced clinician-and-educators.

I read Whitaker’s commentary (“Where do we go from here?” COCA News 2001) with great interest and was reminded of Pollard’s article (2000), which discussed the increased competition in the contemporary marketplace amongst providers of conservative orthopaedic treatments. I agree with Whitaker that there seems to be much overlap amongst the manual therapy professions. Education-wise, indeed if we are all taught evidence-based practice (EBP), we may end up getting taught pretty much the same things.

In terms of techniques used by each profession, the boundaries also seem more blurred than ever. There are advertisements for cranio-sacral therapy (Upledger Institute 2000) and muscle energy procedures (Hungerford 2001) in the physiotherapy bulletins. Courses such as the McKenzie protocols are offered in chiropractic newsletters (Dynamic Chiropractic 2001, June 18, p.54). The neural mobilization procedures developed by Elvey (1986, 1998) and Butler (1991) are also used by osteopaths (McClune et al 1998). Exercise prescription, manipulative therapy, and electrotherapy are taught in most if not all schools.

Furthermore, some concerns are universal to all manual therapy professions. For example, the risk of cerebrovascular complications associated with cervical manipulation is an important issue and each profession has introduced procedures to minimize these risks (Grant 1994, Terrett and Kleynhans 1992, McClune et al 1998).

As far as professional identity goes, I wonder that if now we had a large sample of patients blinded to the manual therapy professionals (chiropractors, physiotherapists and osteopaths) treating them and have them guess who belongs to which profession, would they have guessed it better than chance?

The current stance of the manual therapy professions reminds me of Bruce Lee’s commentary on the status of martial arts (see above). We are separated in some ways because of history but perhaps also our beliefs. Personally I welcome the current exchange among the manual therapy professions and feel that there is much we can learn from each other. It would not bother me either if in the year 2050 we are producing only one type of physical therapists. That means we are united (not necessarily uniform) and we can do better research by pooling together resources, and will not have to do similar projects multiple times for the purpose of justifying each of our professional standings.

Today the research in physical medicine, as in other health care disciplines, is characterized by technical sophistication and a strict quantitative methodology (a hallmark of EBP). Yet I feel somewhat ambivalent about these research methods. On the one hand, I appreciate the important contributions made by these researchers in the last few decades. Some assertions are proven and many assumptions were challenged. For example, the value of manipulative therapy in acute low back pain has been well established in guidelines and reviews (Bigos et al 1994, Rebbeck et al 1998). The somatovisceral relationships are continuing to be investigated (Dhami and DeBoer 1992, Grieve 1994, Sterling et al 2001). The validity of vertebral positional diagnosis and direction specificity of vertebral adjustments has been questioned (Hartman 1997, Burns and Mierau 1997), and accepted laws of vertebral motion coupling are under renewed scrutiny (Nansel et al 1992, Ruston 1994, Gibbons and Tehan 1998). Even the side of cavitation associated with manipulation may require re-considerations (Reggars and Pollard 1995).

On the other hand, I am concerned about the crystallization of the fluid art of physical medicine - resulting in prescription-based treatments (Curtis et al 2000), and the division of analysis in research. For example, in low back pain research treatments are usually performed in isolation to one another (Stankovic and Johnell 1990, Cassidy et al 1993, Hanten et al 2000). For “scientific rigour”, the dosage, frequency and intensity have to be standardized across the subjects and throughout the course of the trial. Yet clinically, the same patient may receive manipulative treatments, soft tissue treatments and exercises at different times depending on the assessment or patient tolerance (but equally frequently, clinician’s experience and preferences).

Furthermore, not every patient’s body responds to stimulation the same way and at the same rate, even if they had the similar structure-based signs and symptoms to begin with. Some respond fast, some slowly; some prefer firm pressure, some light; some prefer mobilization, some manipulation, etc. Some change their preferences to therapies within the session or between sessions. There certainly needs to be some guidelines, but it is questionable with what precision one can objectify and solidify the dynamism between the patient and the ever-changing illness, or properly fraction up a synergy of actions in treatment.

I feel much uncertainty when attempting to make “judicious” use much of the available “evidence” when we assume the trial patients are one and the same because of similarities in some structure-based markers at one arbitrary point in time (admittedly, I possess little clinical expertise). Yet despite the initial similarities (even “prognostic” factors accounted for), clinically there may be little knowing from the outset how or if an individual patient will respond to the “standard” treatment over time as outlined by the RCT or systematic reviews (most of their “conclusions” are inconclusive or require further research), whether he/she is going to be the 20% of positive responders, 50% of moderate responders, 20% of non-responders, or 10% of negative responders.

When reading research papers, I also feel that we design our research treatment in ways akin to making gloves (of identical digit lengths) by averaging the lengths of the digits. If they fit 60% of the population (eg. the 3 middle digits) moderately well, we consider them good enough treatments. Is standardization of treatment truly valid or just an assumption we make in research for statistical convenience? Having supposedly done all these evaluative studies, I find it amusing but have to suggest that with regards to the efficacy of most treatments, in the past we didn’t know, and now, we are not sure. Such is the truth about our “evidence”…

There is little dissent of the need to do further research. However, rather than testing discrete treatments, there may now be a rationale for combining of treatments. For example, it has been shown that movement gained by manipulative therapy is lost within 48 hours (Nansel et al 1990). On this basis Jull (1998) suggests that active movements may be useful in maintaining the movement gains. Another approach is to tailor treatments based on the assessment of symptom response to loading (Delitto et al 1995, Fritz 1998, Maluf et al 2000), and putting the clinical algorithm itself to the test. Thus there is a framework of clinical reasoning for treatment selection, individualizing and staging therapies according to the progress of the each patient. It also reflects more closely to the clinical practice of physical medicine.

One possible area of research may be the management of upper limb musculoskeletal dysfunctions. Cervical manipulative therapy (Vincenzino et al 1996), movement system balance (White and Sahrmann 1994), myofascial release (Leahy and Mock 1992, Leahy 1995, 1999), and the neural mobilization techniques (Elvey 1986, Butler 1991, Elvey 1998) are some of the potentially useful (not mutually exclusive) concepts. They may be organized into an algorithm and put to test to see if outcomes are improved over individual treatments.

Furthermore, we ought to be wary not to throw the baby out with the bath water when assessing techniques. Certain techniques that are not powerful as a singular intervention (Cassidy et al 1992) may be useful as an adjunct or a preparatory treatment to other interventions. For example, the post-isometric relaxation procedures may be useful in obtaining some relaxation in tense patients with acute wryneck before manipulative treatments are performed.

In addition to being a muscle stretching technique, for those who have a poor awareness of their muscles, the clinician facilitated contract-relax procedures may help to bring about the awareness (EMG biofeedback may be an additional option) before incorporating the particular muscle group into task-specific training.

Tai Chi, Kung fu (such as the Wing Chun style) and Yoga training often call for contraction of the pelvic floor muscles and lower abdomen. In terms of exercise-based treatments, they may be useful as supplements to specific retraining exercises (Richardson et al 1999, Sapsford et al 2001) or adjuncts for patients inept with the scientific gibberish of multifidus, internal oblique, and thoracolumbar fascia. I wonder if we would improve compliance by giving salience to movement rehabilitation (make it interesting and understandable to the patient) so it is not such a labour?

In practice methodology, I rather envy that of old time Chinese Medicine doctors. Firstly, signs and symptoms of the patient are carefully assessed. For treatment, the core of tried and tested herbal remedies is there, but the “recipe” itself would frequently be modified according to each individual’s constitution (Contrary to popular beliefs, Chinese Medicine uses herbal “recipes”, not “formulae” set in stone - an unfortunate modern translation). If the herbs are poor to taste despite their therapeutic value, the doctor may complement them with some soothing ingredients so they are not intolerable. On each return consultation the patient is reassessed, and the herbal ingredients are further adjusted to better suit the patient’s needs at the particular stage of recovery. Obviously they knew not of the science in standardization. Furthermore, these ingredients are designed to work in synergy, rather than as individual active substances, which diverges from the reductionist thinking that dominates modern health research.

Such practice recognizes healing as a fluid and dynamic process and that each individual is unique. It requires of the clinician a sound judgment of the patient and a thorough knowledge of available remedies. At the same time, the clinician has much latitude to modify the treatments to cater for the specific needs and preferences of the patient as afforded by their clinical experience and expertise. He is at liberty to use all ways, either singularly or in combination (herbs, acupuncture, manual therapy, diet, exercise, counselling, etc) and be bound by none. In amongst the search for well-defined and evidence-based treatments, I believe there is much room for human ingenuity and clinical artistry in our work yet.

In conclusion, it is suggested that we be mindful that the currently favoured research methods are excellent but not without their own intrinsic limitations. One challenge for physical medicine is how we can continue to shape evaluative research design to better reflect the clinical scenario and cater for patient differences and the different recovery rates, rather than assuming homogeneity by virtue of selective biologic markers. The evidence thus derived may be more clinically useful.

The exchange of ideas and increasing overlap among manual therapy professions seem inevitable now due to the availability of literature and information technology. I believe that collaboration may help foster better treatments and clinical research projects. At the same time, we also have to keep an open mind regarding the potential use of available techniques and that these techniques need not be mutually exclusive from each other in practice.

Mark Wu, Physiotherapist

Footnote: I would like to thank Dr Pollard whose kind encouragement prompted the writing of this article.

Editor’s note: References supplied by the author. Contact the editor for a copy.