Blog for Remedy Physio!

Well, how lucky do I feel??Just through supporting a podcast that I believe is invaluable by being a patreon, I won a free place on Dr Toby Hall’s Manual Concepts course!

So, before coming on the course, I would not have described myself as a manual therapist. In recent years, I had moved away from most forms of manual treatment as I didn’t feel very effective and I questioned the mechanisms by which some people stated they worked.   I.e., we were correcting positional faults and specifically mobilising individual segments. I was aware of the research surrounding the neurophysiological benefits, but hadn’t explored this fully and felt I was doing a pretty good job without needing to use it anyway. In hindsight, I think I had done this without a good enough exploration of the current research surrounding manual therapy. I think part of this was due to not fully understanding the techniques, meaning I could realistically read the research appropriately critically. So, when I won the course place, I decided to look on it as an opportunity to immerse myself in the concepts of manual therapy for 8 days to see if my preconceptions were correct, or if I was missing an element of patient care that could add to my patient outcomes.

In part 1 of the course, we started with the lumbar spine…for a full 3 and ½ days! Straight away I was impressed with the research that Toby presented in terms of being able to categorise lumbar spine patients to then guide the most appropriate treatment to make it more effective (Hall 2009 among others). He presented a pretty impressive case for being able to identify specific clinical findings such as central sensitization with questionnaires such as the LANSS and OREBRO, and neural sensitization with neuro dynamic tests. It all seemed very logical, which appeals to my methodical brain! I now want to go away and try and see if I can use the system with patients! What I also liked though, Toby didn’t pretend that this and other models were perfect!   And that many patients will fall into more than one category. People are complicated! However, I came away with a clear framework that I could try to use to assess lumbar spine patients that I feel is supported by the available literature. This includes techniques such as PPIVMS and combined movements. I really didn’t want to believe that I could feel intervertebral movement on a PPIVM, but I definitely could feel something! I was working with a lovely thin lady with good spinal movement, so believe I could feel tautening of soft tissues around the vertebrae as I moved to the end of passive range globally. So is it just a good test of passive range of movement? Useful in reasoning if your patient has a general restriction in movement when relaxed or more of a motor control issue if range in lying is hugely different to range in standing? However, since trying this on “real” patients, I’m struggling to get anything meaningful from them again and not sure using them is adding to my objective assessment. I’m finding the using PAIVMs as a pain provocation test more useful in homing in on the potential area of dysfunction. I’m obviously still learning the techniques in terms of handing and confidence, so I intend on continuing to use them with patients for now and just reflect on how useful I’m finding them.

Then we progressed to the manual treatment techniques. I got a little bit more frustrated at this point. There just isn’t the same volume of well-designed studies out there! Probably because they are impossible to design! The rational for some of the Mulligan concept techniques for a radiculopathy, such as the Gate technique, seemed very vague. Other techniques seemed more based in clinical reasoning, such as using mobilisation techniques designed to open up the lateral foramen in compressive type pathologies. However, these were still presented as being able to be localised to a specific level by handling techniques, which I don’t believe is possible or necessary.   Ross, Bereznick, & McGill, 2004) demonstrated thoracic manips caused cavitation at the target level just 50% of the time and caused cavitiation at multiple levels.   I now realise however, that that doesn’t mean I stop using the technique all together! It could still have a beneficial effect in a nonspecific way. I had been throwing the baby out with the bathwater, as they say! Then we explored several SNAGS for the lumbar spine to improve movement impairments; We were taught to facilitate flexion facilitating an upward glide of the lower vertebrae. I straight away thought that this was just never going to happen as I believe that we can only produce movement if we apply force perpendicular to the bone following reading a paper by Bereznick, Kim Ross, & McGill, 2002) So, I took the opportunity to question Toby about this and he was very open to the fact that the more likely mechanism of action is neurophysiological, such as reducing fear of movement or increasing proprioception. So, my conclusion has been that the techniques are still worth exploring, but my clinical reasoning as to what I am doing and why needs to be based in the best available evidence.

I thoroughly enjoyed the 4 days and met some great physios and enjoyed many a debate over what we were doing! Dr Toby Hall presented a very compelling case for the benefits of manual therapy if you pick your patient and technique using the best available evidence. He certainly managed to get me to question some of my preconceptions and acknowledge that there are people out there that manual therapy is appropriate and effective for. I am looking forward to exploring the assessment and techniques over the next 2 months and probably reading a few more papers to try and come to some sort of balanced conclusion!

Finally, but not least, the Remedy Physio team are a very friendly bunch, even taking us to the local pub quiz one night! The facilities were good, both at the Sheffield Hallam Uni campus and at the Jesus Centre for the last 2 days! I am looking forward to part 2 and exploring the thoracic and cervical spines. So, thanks again Remedy Physio and PhysioMatters for the opportunity!

Bereznick, D. E., Kim Ross, J., & McGill, S. M. (2002). The frictional properties at the thoracic skin-fascia interface: Implications in spine manipulation. Clinical Biomechanics, 17(4), 297–303.

Ross, J. K., Bereznick, D. E., & McGill, S. M. (2004). Determining Cavitation Location During Lumbar and Thoracic Spinal Manipulation. Spine, 29(13), 1452–1457.

Schaffer, A., Hall, T., & Briffa, K. (2009). Classification of low back-related leg pain-A proposed patho-mechanism-based approach. Manual Therapy , 14 (2), 222–230.