Reflections of a Dinosaur: Big R’s, the patient narrative and a final thought on myths in the debate on manual therapy.

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Neil Langridge, Consultant Physiotherapist, gives his personal reflection on the latest Big R’s conference here:

I have just got back into work this week after the Big R’s event over the weekend in Manchester. I was wondering how it would go as I had been asked to provide a keynote talk on the place for manual therapy in contemporary MSK practice. On my panel was Karli Gibson, a very level-headed and forward thinking physiotherapist who I think has a lot to offer the profession, and Adam Meakins, a specialist physiotherapist in the management of shoulder conditions who has built up quite a following within the profession, and has developed many strong arguments regarding the case for change.

The event proposed some really innovative ideas, but most importantly brought together individuals interested in better care for patients, improving the MSK offer to the public and I felt, all in the spirit of working together.

I was fully aware that my presentation and the subsequent discussion was likely to be a bit stormy, the session was moderated by Mark Reid, who I thought did a really good job. I have to firstly tip my hat and really congratulate Jack Chew and his team, which also applies to the Connect team who equally supported the event. I can’t fail to be impressed individually with Jack, who undoubtedly “walks the walk”, he is very forward thinking, very passionate and very gracious in the way he works complex areas of discussion and debate. His work is fairly unique in my opinion within our profession, and more like him would only be a good thing. His team, Rob, Jack, Mark et al likewise, very sensible, but willing to challenge the status quo and build from within, an impressive group.

The Connect team were also very appropriately vocal and led some really interesting workshops which I thoroughly enjoyed, and there were some great discussions on orthopaedic triage, FCP and what advanced practice is. I am gladly linked in with them to develop further strategies concerning excellence, and I know it will be a pleasure to work with them. This felt a lot better than the last meeting where topics such as “eradicate ultrasound!” felt very narrow, so this experience was miles more positive.

The patient stories were really powerful and humbling, Joletta, Adrian, Pete, and Tina all contributed hugely, I think there should be a patient voice on every panel in the future. Martin, a very entertaining, driven, enthusiastic physiotherapist from Kenya gave a great insight into Physiotherapy away from these shores, a great perspective driving presentation.

So, I made my little speech and I addressed a few thoughts that run round SoMe and within the profession and also I learned what the panel’s view were, which was really valuable. So, what did I learn and speak about;

  1. The term “low-value treatment” applied to MT is not seemingly that true. It depends what you define as value and then if you base it purely on economics, surprisingly against usual care it fairs well against exercise and better than usual GP care in many MSK conditions. Societal value tends to suggest that applied hands on to certain patient groups are valuable to those individual personally. So, when individuals speak of high and low value, ask, what do you mean, valuable to whom, and by what measure? Try it, you may find the answer is not as clear as you thought.Value Price
  2. The “Window of opportunity” – I know many are not fans of this term when applied to MT, but it is my opinion it applies to every intervention, whether education, exercise etc. The break in the pattern behaviour, belief, understanding, or a change in the perception and emotional response. We then use this to set the scene differently for the patient. So, when individuals say MT inappropriately uses the “window of opportunity” analogy, then ask do not our other interventions use similar processes?Open windows
  3. MT disempowers patients? I heard the patient stories relaying powerful messages they heard about being “weak, unstable, needing a stronger core, things being in and out”. Its always cringing and saddening on the part of a professional to hear those stories. It’s therefore in the message and the clinician behaviour that disempowers, and of course, you can plainly disempower by just talking to someone, it’s not unique to MT. Of course MT has the potential belief system associated with that as it can lead the patient to believe they need to see someone to fix them; once again, that’s the clinician, not the treatment. The disempowering therapist can lurk under any treatment system.
  4. Adam was asked what he doesn’t agree with regarding MT, all of it, some it etc? I was in total agreement that massage should not be an NHS offer. In terms of well-being if individuals wish for that then I see no problem with them accessing this outside the NHS. Handshake
  5. He didn’t agree with techniques being used even in the clinical context when the patient is lying on the treatment plinth. He did, however, seem concordant with the use of hands-on in the facilitation of movement, which seemed to be in some conflict with the strong message “Manual therapy sucks”.
  6. The panel discussed Harm; Adam stated that MT was “harmful”. I was conflicted with a previous statement that suggested all MT should be in a spa, whilst then saying it was harmful, I was also not sure what is meant by harm in this context. If it is harmful then ensuring it is within a clinical context would be key and moving that out to your local hairdresser (as suggested) might not be such a good idea. I would agree that the language around MT could be harmful to the process and perception of recovery, but the vast majority of MT physically is not, and no evidence was proposed that supported the perception of MT as a treatment method being harmful to patients.
  7. So, MT in the sense of relaxation and well-being – keep it out of the NHS, use as part of ongoing health and well-being if that is something the patient values.MT in the clinical context I propose can be used when patients are fearful, limited by pain and have tried initial education, reassurance, and exercise. Then you can “play with some processing” aiming to give the patient a different emotional perspective towards their condition.
  8. MT will get challenged about – “what are the mechanisms?” Well, the simple answer is we don’t know. My proposal is that there is no single mechanism, and multiple mechanisms will be at play, their effect on a socially constructed individual cannot be just down to the mechanics or basic physiology. The really important point for me is that this (IMO) is the case for all interventions. Some have a greater physiological and anatomical understanding of the effects than others but in Physiotherapy do we really know all the mechanisms at play after exercise, education, reassurance? Two people can say exactly the same reassuring commentary and the receiver of this could react in totally different ways to that advice. Therefore, a “truth” in these interactions is a pretty tough call. We can suggest them, but we don’t really know the interactions of all the possible neurobiological, emotional, physiological mechanisms and that is not unique to MT, so some sense of perspective is needed regarding this argument. So, we base the nature of success on some theoretical proposals and patient-reported outcomes. The same for any Physiotherapy MSK intervention. Maybe it looks a little like the picture below?

Tangled

In the end, I really found the 2 days inspiring. Within the panel, Karli brought pragmatism to the debate which resonated well with me, whilst Adam was considered in his responses and I have said this before, I agree with many of his proposals, but for any argument, for me to be convinced, I need strong positions of belief to be flexible in how they respond to differences of opinion, so we can all see the multiple perspectives rather than the singular one. I feel this was a common theme of how we move forward, gaining the multiple views and then finding common-ground to help in professional growth.

So, many voices were heard, and disagreement will always remain, but that’s Ok and very healthy. I think without individuals who push the questions then the conversations would not be where they are, which is so much better as we move away from strongly held doctrines, philosophies of our practice and consider the future for an evidence-based profession which is grounded in the patient story.

Neil Langridge.  Consultant Physiotherapist.

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3 comments

  1. It’s encouraging to see the development of more critical discussions of manual therapies than used to happen.

    I think that it’s probably pretty hopeless to think in terms of mechanisms. I’d settle for knowing how much regression to the mean contributes to the (apparent) effectiveness of procedures.

  2. A really considered and interesting summary. There seems to be lots of hope for a progressive profession to encompass the whole patient. Thanks

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