Clinical Edge - Physio Edge 093 Manual therapy - evidence, effects and expectations with Prof Chad Cook Clinical Edge - Physio Edge 093 Manual therapy - evidence, effects and expectations with Prof Chad Cook

Physio Edge 093 Manual therapy - evidence, effects and expectations with Prof Chad Cook

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David: Hi Chad. How are you?

Chad: Doing very well. Very excited about speaking with you.

David: Thanks for coming on.

Chad: My pleasure. Thanks for thinking of me.

David: Beautiful. I'm really looking forward to exploring this topic with you. I think there's a lot of debate going on around this and I'm really looking forward to exploring with you the evidence and both sides of this topic of manual therapy and I'm really looking forward to exploring it. So yeah, got lots to talk about.

Chad: Let's get started. I, too, am interested in this. I'm a believer that you can't really talk about a topic unless you understand both sides and I feel like I do get both sides of the pros and cons of this.

David: Yeah. For sure. So, we're going to dive into manual therapy real shortly, but tell us a little bit about yourself. Where are you based and what's your background, that sort of thing?

Chad: Sure thing. I'm in the United States in a state called North Carolina, the beautiful city of Chapel Hill, which is the home base of the University of North Carolina. I am a tenured professor at Duke.

I'm also currently the program director of our academic doctorate physical therapy program. I have an appointment at the Duke Clinical Research Institute and I am a researcher. I have done a lot of research on manual therapy and other orthopedic-related conditions in the past.

And I'm proud and I feel very blessed that I'm part of this profession. Basically, that's my professional life.

David: Really nice. Is there anything about you that people that follow you on Twitter already might not know about you?

Chad: Personal things, I guess. I own a lake house. We bought one in the fall and in my free time, you'll find me at the lake with a whiskey in hand for sure.

David: Nice.

Chad: That's the smartest move I ever made. Historically, I used to be a competitive triathlete in my younger years and now I focus on not being a competitive triathlete.

David: So, you do a bit of biking, a bit of swimming and just for fun.

Chad: Just for fun.

David: Yeah. Yeah. Nice. You said before and I can see the trees out of your window, so you've got a little bit of countryside behind you. And you said before you do a bit of mountain biking, as well, through there.

Chad: We do. We live in the Carolina Forest, which is a reserve. It's owned by the University of North Carolina and there are only a couple of subdivisions that they've allowed to cut into this. We're in an old mining area, so this used to be an old iron mine in the 1800s. And then we're really lucky, a lot of trees, a lot of nature around. It's gorgeous. You may actually see in the background as we talk some deer walk by and raccoons and things, so it's very nature oriented.

David: Yeah. Really nice and peaceful. Beautiful. So, let's dive into a bit of manual therapy.

There's a lot of anti-manual therapy sentiment going on, that movement happening within the profession of physical therapy, physiotherapy and the health professionals. What do you think is driving that? Why do we have that sentiment or movement going on?

Chad: I think it's a number of things. First and foremost, I think there are some very well-followed, noisy social media individuals that have their anti-manual therapy stance and have made it recommended to really blast manual therapy, not necessarily knowing the pros and cons, but just focusing on the cons. And that part, I think, has really allowed a number of people who maybe haven't been drawn to manual therapy in the past or are looking for a reason to condemn manual therapy, it's been an easy avenue for them to jump on board with that.

David: There's definitely ... a fair few people talking about it. So, when you're looking at the arguments that are mostly put forward against manual therapy, what do you think, are the ones that actually have any merit?

Chad: Well I think probably the biggest argument is this assumption that what you do on day one… is going to influence somebody's health outcomes in six months. They're spot on there. I don't think that a particular mobilisation approach or manipulation is going to change someone's overall health outcomes at six months, one year or two years, but it's really not designed for that, either. So that's not a knock on manual therapy, that's just asking it to do something that it's really not designed to do.

In fact, most of what we do isn't going to influence a person in their totality of health outcomes and all the ingredients that make up health outcomes. Most of the little things we do in day-to-day practice are not going to influence that.

So, if that's your focus, if that's what you're saying that manual therapy doesn't work because it doesn't do that, well that is correct. But the majority of what we do doesn't influence outcomes in six months.

David: What is it about those long-time frames that's hard to change?

Chad: I think it's as much the outcome measure and how we measure our outcomes and what influences outcomes as it is the time frame. For starters, natural history, as we know from the majority of our studies, if we just leave people alone, the change that will occur with their condition will swamp any of the change that you may make that's related to the treatment intervention. And without getting too technical, it's essentially the way that an outcomes measure is created, it's designed to measure health status. And if you really look at the components that make up health status, it's social determinants of health, it's emotions and thoughts, it's comorbidities, it's all of these components. It's behaviors that aren't necessarily going to be influenced by a pain modulating intervention like manual therapy.

David: So, you think just looking down the track at those six-month markers or the long-term markers to see does manual therapy make a difference in six months' time if we do it or don't do it, then it's probably not going to give us a clear indication whether or not any of our interventions or most of our interventions are going to have big effect down the track. Is that what you're saying?

Chad: You know, David. If you look at the really well-designed trials that occur right now, the majority are null trials. The majority show no difference at six months. And there is a reason for that. It's because you really need to see major changes in health status of an individual at six months to really show those differences and outcomes.

And even our trials that we've used on manual therapy, we've never seen a difference in the outcomes with that and the exception of one study, but it was a multimodal study that also involved other features in addition to manual therapy. So yes, it's just how things are.

David: Any other arguments that you think against manual therapy that have any merit?

Chad: I think the arguments attacking any of the historical theories around manual therapy also have merit.

You know, there's a phrase "We were flying the plane as we were building it." And I think a lot of the manual therapy philosophies were born from philosophical constructs from osteopaths and chiropractors, and these were thoughts of individuals. And over time as these were studied, they really haven't borne out. We don't correct subluxations. We don't have to mobilise in a convex/concave rule, the bias law of coupling. You don't have to perform a mobilisation procedure with that particular concept. These have not borne out.

And unfortunately, this was such dogma mandated during one's training process, I think it really had a negative connotation to a lot of individuals. And it's easy to take shots at that because we've all been ... it's been trial by fire, right? You had to go through that. You had to get your union card. You had to listen to the guru berate you that you're not doing the technique correctly. All of those things, I think, are fair game, as well.

David: So, you think other theories behind all that we used to try and explain some of these things might not have been on the money when it came to trying to figure out why these techniques were working and a little bit of dogma about how you had to do specific techniques rather than you were doing something and it was working. They were trying to explain it and maybe it wasn't on the money.

Chad: Exactly. We saw things that worked in clinical practice. It's how we explained it then and unfortunately, that's a consequence of not really understanding the science behind manual therapy. If one actually looks at the science behind manual therapy, there are human and animal studies that do show that there is a mechanism, there are things that happen, but these things that are happening are nothing similar to what we claimed happen historically.

David: A lot about that explanation. So what sort of things would you tend to avoid? We're going to dive later into using manual therapy and the type of explanations we can use, how to rationalise it, how to clinically reason through if you are using manual therapy and how to explain it.

But what are some of the things that you would try and make sure that you're avoiding if you're describing it to a patient or if you're teaching this to a therapist or whatever?

Chad: That's a good question. I think there are two things that I really try to frame if I decide to use manual therapy. For starters, what I try to really impress upon the patient is that this is a pain modulation technique and that if we see pain reduction with this particular procedure that it usually has suggested really positive outcome, that there are multiple studies that show this. But it also suggests that the patient is pain adaptive, which is also prognostically a good sign, suggesting that they could endogenously modulate their own pain. And we've seen several studies that have reflected this.

I also really emphasise the components that can modulate their pain passively can also modulate their pain actively and that's especially important, given the short period of time that you're allowed to work with patients. In some countries it's maybe one visit.

So, spending time looking at augmented exercises which are often active that also modulate their pain, that really compliment what is done with a manual therapy technique, I think that's imperative to teach a particular patient and to impart on them so that they know they need to continue to do that.

What I'd really try to stay away from are some of the crazy theories about correcting a subluxation or some sort of biomechanical dysfunction or that I'm fixing scar tissue or any of these older theories out there which have not really stood up well.

There are small studies, small biomechanical studies suggesting that there are some things that happen to the tissue, but these are not permanent things and these are not ... you're not changing the position of a structure. You're not fixing some malalignment and that never comes up in the conversation with the patient.

David: And what about the therapists that argue that you could pretty much achieve the same results with exercises you could with manual therapy to no treatment sessions and you might be better off spending your time performing exercise instead?

Chad: Yeah. It depends on two things, I think, about that. First of all, they're probably right that if a person is pain adaptive and they can endogenously modulate their own pain and this would be your non-fibromyalgia-type patient that if you're trying to frame what is a pain-adaptive patient, this is a patient that needs very little external means to pain modulate. They don't need a lot of drugs. They don't take high levels of pain analgesics. They can modulate their own pain. That type of person probably would benefit from a number of different clinical analgesia-based approaches, whether that's an active approach or a passive approach.

So, if that's the comment, that's probably correct. With respect to we should spend more time on that, I would argue that if we're doing a traditional outcomes-based study, we're probably not going to see a difference in the two groups, again because the natural history and all of the other elements that reflect outcomes are going to swamp any of the treatment that's provided. So, I really think we'd have to measure something differently.

Some of the arguments I've heard for an active approach is autonomy and that person continues to self-treat afterwards and I think something like that needs to be measured. It would be a very interesting study. And if indeed that's the case, then we should absolutely consider that.

David: And have there been any studies that show that performing manual therapy does actually create some sort of reliance on passive therapies or create that therapist reliance?

Chad: David, I asked the same question on Twitter, primarily because I'm unaware of any. The comments I received from a lot of very intelligent people were that they were unaware of any.

I am aware of studies that looked at characteristics of patients who seek a physical therapist versus seek a chiropractor. And chiropractors tend to provide more passive-based approaches. I think they are morphing across the world to really compliment more of a rehab-based approach.

So, I'm not trying to ... I'd hate to stereotype a whole profession. But at the time of the study, even the authors of the study and I do not remember the author names, I apologise, but there are differences in characteristics of people that seek a more passive approach versus an active approach. But that's not consequence of the treatment provided, that is a characteristic of the individual who seeks care and to me, those are two different things.

David: Yeah. Okay. So there hasn't been any studies that you are aware of that have shown that if you're performing some sort of manual therapy that it results in more of a reliance on those therapies or on passive treatment as opposed to someone that receives an active treatment?

Chad: I've never seen a study like that. No.

David: Yeah. Okay. Fair enough. Is there any other evidence against manual therapy?

Chad: Against as in a negative outcome?

David: Yeah, showing that there are negative outcomes to it.

Chad: Yeah. So, there are adverse effects and as you know, those can be categorised at different levels. There are high percentages of individuals that will have soreness or minor adverse events or harms, but with respect to when I encapsulate harms in the whole value-based care mechanism, there's harms, there's outcomes and there's patient experience all packaged together, along with cost.

And I think that's ... to me, there's a balance there because one would argue well why don't you just give them Ibuprofen because that's pain modulatory, too?

There's actually a high percentage of harms associated with Ibuprofen, including eventual death in some individuals with GI disorders. So that's a whole different level of harms with another type of intervention. But with respect to everybody can pick and choose one or two studies where someone has a severe harm or a severe adverse event, but all in all, in total it's actually pretty low. And even on the cost side of value-based care, overall the cost is actually pretty low.

David: Okay. So, the costs haven't been shown to be a more costly exercise to get treatment that involves manual therapy, as opposed to treatment that involves exercise.

Chad: Yeah. I haven't seen a comparison of that. What we would really have to do is not only look at the time that they were in care because it's going to be such a small window, but the downstream costs and the health seeking costs with the assumption that an active approach may lead to less health seeking, more self-efficacy, more self-treatment. But again, I haven't seen something like that. Indeed, I have not read everything. There are ... just in low back pain there are about 30,000 papers a year that are published, so it's impossible to be on top of everything. But I read almost everything that comes out on manual therapy and I haven't seen a direct comparison like that.

David: And so, what about is there anything looking at worse outcomes for performing manual therapy than not performing manual therapy when you compare those treatment groups to say if you include manual therapy you're likely to have a worse outcome than if you didn't?

Chad: Off hand, nothing is coming to mind. I've seen where adding manual therapy has not improved the outcome in general, but by comparison and you may know of some that I don't know, but by comparison in a well-designed trial, I can't think of any that show that one particular approach is better than manual therapy, but then again, I would argue that comparing two different techniques in isolation, that's not reflective of how the management should be performed. So, a study like that wouldn't tell me that much.

It's the same with pain education. Pain education has received a knock recently because they said pain education and isolation doesn't seem to make a difference. Who would do that? Pain education should be combined with your other treatments in a management approach and not completed in isolation. And I really think manual therapy should be packaged in that process, as well.

David: Most people aren't just performing the pain education and saying see you later. They're doing it as part of their entire treatment and incorporating it with whatever it is that they're doing in their treatment sessions, as well. So, you're saying when you look at just comparing one technique to another, you're probably not likely to see a ton of difference because that's not really a reflection of what really happens in practice. Is that right?

Chad: David, you're spot on and first of all, we've done that before and I can quote our studies that looked at that. The most recent was we performed just a nongeneralised, nonspecific technique for the back versus a very specific technique targeted to comparable region. And at short-term and long-term six-month outcomes, there was no difference. But when we asked the patient if they thought they were better, the group that received the specific treatment thought they were better, even though the way they scored their outcomes measures and their pain intensity measures, there was no difference.

In all the studies that we've looked at, manipulation versus mobilisation, we have never found a difference between those two particular techniques or between one technique versus another. And I think it reflects the fact that it isn't the technique that matters, it's whether or not the patient is pain adaptive, then you can modulate the pain. These techniques by themselves are not going to be the silver bullet that makes a big difference.

David: And so, you can understand why some of these arguments come about because when they're looking at that and saying do they have worse outcomes if you just perform manual therapy?

And you think it seems ridiculous to compare or you're unlikely to see differences when you compare one technique to another sort of thing often times.

But you see patients coming, I've had patients coming in myself where they've seen a therapist. They might have had 20 sessions in a row of just the same mobilisation or the same soft tissue release of their hip or whatever it might be and that's been the bulk of their treatment. And it could be manual therapy, it could be ultrasound, whatever it might be, but it does raise questions about what's going on in these with therapists that are just doing the same thing over and over that aren't getting any changes in pain modulation within that session or between sessions, just going, "Well, we've got to do another session because I think that's what's going to make the difference."

I don't know about you, but you can understand where people are coming from seeing this and getting frustrated that doesn't seem like an effective way to treat when there's potentially other therapies that they could be using instead.

Chad: Oh, I 100% agree. That's a management issue, though. Like you said, that could be any treatment approach that isn't working for that patient. What is the definition of insanity? Doing the same thing over and over and expecting something different. I think at best, manual therapy should be used two to four maximum sessions to modulate the pain, to show the patient that their pain can be modulated because it can have a very strong psychological approach that's actually prognostic, suggests they're pain adaptive and then progress on to something else that's more active, more progressive and certainly something that's more autonomous for that patient so they can self-manage.

David: Definitely.

Chad: That's a management issue and it just makes me sad when I hear stuff like that. But to label that as a knock against manual therapy, that could be a knock against anything. That's a knock against opioids, right, just giving people opioids over and over and over and expecting something positive to occur from that, whereas opioids actually have a very positive effect in selected individuals. That's a management issue.

David: Yeah. For sure. And I like the way you described it there. You said it's not that silver bullet. You're looking to incorporate it, you often won't be using it more than two to four sessions and you're developing patients management onto a more active approach as you progresses through their treatment.

Chad: That's good management. That's good therapy right there. And again, I will absolutely state this in the court of law, wherever, with a gun to my head, whatever you want. If a person is pain adaptive, the approach for modulating their pain is less important than the fact that they're pain adaptive. If there's an active approach that modulates their pain, that will be as effective as any passive approach. And which passive approach you use it doesn't seem to matter. Manual therapy, there are a lot of different types of manual therapy.

David: When you're looking at choosing between your exercises and your manual therapy, are there any things that help to guide you as far as what you might choose for that particular patient? If they are likely to be one of these patients that is going to respond with some pain modulation, then why would you choose manual therapy, as opposed to some sort of exercise-based program?

Chad: I think a lot of it is going to be expectation-based and there's a wealth of research, most of it out of University of Florida here in the United States where you tie a person's expectation to their treatment management.

And we're seeing more and more of this where a person's expectations about their treatment effectiveness tends to be the largest predictor of the outcome, whether it's a conservative approach or a surgical approach. Specifically, at the shoulder, we're seeing it in the low back.

I spent some time and talk about the patient. What do you think will help in your particular condition? We have a number of options to select. Which of these have worked for you in the past or which of these do you think is going to be most effective for you? Then I get the biological mechanisms associated with that management approach for that pain adaptive patient, but I'll also get the psychological piece to that, as well.

David: So, you use patient preference to help guide you there?

Chad: Very much so. And I've actually a number of times on Twitter, I've said I don't understand why it's so powerful, but patient expectations are incredibly powerful. And we're actually in a randomised trial right now where the goal of the study is to change patient expectation. So, we spend ... It's a telehealth study and I spend six sessions over six weeks with the patient's talking about the conservative approach for management of the shoulder and trying to change their expectations.

And I'll be honest with you, I have never been so challenged in my life to try to accomplish that. It is indeed a complex and challenging issue.

David: Any tips for that? It's a little bit of a branch-off, but it would be interesting to hear.

Chad: Yeah. So first of all, it's a slow drip. You're not going to change expectations with some single statement, some wild, crazy statement that the patient just flips a switch and they're going to change their expectations. It's very similar to changing behaviors. It's something that has to come from the inside of the patient.

They have to have the epiphany. So, you really have to flip the script so that the patient is the one making the revelations from the information that you provide them, from the experiences that you give them, from the homework that you give them to challenge their beliefs, their automatic thoughts.

It's very similar to cognitive behavioral therapy, but instead of changing behavior, you're changing expectations. But expectations are rooted into a lot of past experiences and those tend to be the most difficult patients to re-convince that a conservative approach works if they've had a negative past experience.

David: Yeah, interesting. It seems like a pretty tough study to be involved in.

Chad: It is and we've had psychologists involved. We've had a number of really learned individuals that help build the six-week strategy. And it's going to be interesting. I'm very keen to find out once we complete this trial if it's made a difference or not. We are going to attempt to write a qualitative paper about the health coach sessions because we've learned so much in the process of just talking to patients and walking them through their expectations and why they think the way they do.

David: These are patients that are thinking that they're going to need surgery and you're taking them through, showing them, or trying to help them come to the conclusion that they might not be better off with surgery, they actually might be better off with a conservative approach. Is that right?

Chad: Very much so and also, recognising that when it comes to some sort of imaging anomaly with the shoulder, it's more the norm than it is the exception and the fact that almost everyone has a rotator cuff tear above the age of 60. A lot of our folks are older.

And then disconnecting that tear on the image with their current symptoms is a real challenge, too, and getting them to recognise that there may or may not be a relationship between those two particular areas.

Patients are rooted into pathology. They're rooted into the biomedical aspect of it. They want an answer and because they're given that answer often by their medical provider, for us to go in there and exercise that, exercise the demons of their thoughts, that's not an easy thing to do.

David: Yeah. For sure. And how do you help them come to the conclusion that because everybody else is likely to have results on their MRI of the shoulder, as well, that what's showing up on their MR or whatever imaging they happen to have is probably not requiring surgery. What sort of tactics do you tend to take to help them come to that conclusion?

Chad: Covert tactics. Very much you give them information. You query them a lot. What do you think that means? There are multiple studies that show this, what does that mean to you? I'd like you to reflect on this. What if I mentioned to you that tear has probably been there a decade? Why do you think now it's a problem where it wasn't before? What are your thoughts on ... It's a slow drip. It's very much you can't just tell them because they immediately turn off when you do that. So, it's very much that they have to come to that conclusion themselves.

David: And I think that does tie in a lot with the manual therapy discussion because you can use that with your patients, as well, and I'm sure you do this sort of thing where you perform some manual therapy and they have got some relief, asking them what does that tell you that we've just done a little bit of manual therapy and it's settled your pain? What do you get out of that?

And patients are able to come to those conclusions, well it mustn't be that bad. Whatever it might be, you can actually use those little experiences or questions and get them to come to those conclusions to help to understand what's going on.

Chad: For a person that's been suffering from pain whether it be an acute with a high intensity or if they've been dealing with mechanical pain for a long time without chronic pain syndrome overlays, the fact that you can modulate pain is a very powerful thing. I think you almost see the light bulb in an individual's head that hey, there must be a light at the end of this tunnel. And then if you can augment that with some form of home program, some active movement, some mechanism that you do with the patient that they own themselves, that's a powerful thing.

The nice thing about it is I'm aware of nine studies that have actually looked at that and does it suggest a good outcome? The answer is yes. Those individuals that are early pain modulators, pain adaptive individuals tend to have better short and long-term outcomes than those who don't demonstrate that behavior with manual therapy. It does not mean that manual therapy is the only way to do that. It just means that those people have demonstrated early pain adaptive behavior. And those particular individuals are likely to do well in the long run.

You can bet that's the first thing I tell the patient. This is a good sign. Wow. The fact that we've made this much difference in pain suggests that your outcome is very favorable. And the people that I've seen, that there are nine studies and we couldn't have had a better result. And again, it doesn't mean it has to be manual therapy. It could be an active approach. If you're following McKenzie, it could be a McKenzie-based approach. But the studies suggest that it is going to be a favorable outcome.

David: It's a great experience for people to have and then get that understanding that if they can get that change then and they've got a change in their pain, it's likely to have a positive outcome. They almost feel proud of themselves sometimes.

Chad: Yeah. And they buy into the treatment, too. I was in Spain one time and I was teaching a workshop and it was a manual therapy workshop. And I'm very honest where manual therapy fits within the management and the care of patients. It was very interesting. During the lunch, one of the Spanish physios said, "You do realise that most of the people here pay out of pocket? So, I'm going to use those techniques that make a difference, but also what the patient wants." So, it gets people back into my door. It keeps them in that management cycle so that I can see them for two to three weeks instead of just one visit and they never come back. And there has to be a value that's placed upon the care that the patient assumes and sometimes putting your hands on a patient and modulating their pain is that perceived value that allows you to further manage that patient.

David: Yeah. For sure. And I think when you're looking at trying to get them in for just a few sessions and they're getting that buy-in, I think that's great. I guess some of the detractors would argue when you're using that as a business model to keep people coming back 20 or 30 times or whatever it might be just for manual therapy, then that's when it's starting to be heading down the wrong track. But once again, that brings us back to what you mentioned before, that's a management approach and that's what we're looking at here is more using it for that shorter length of time. You're only using it for a few sessions and you're heading people down that active approach after you've got that buy-in.

Chad: That's the right management approach. And I will never defend someone, again, that is using any approach that isn't making some progression continuously over time. That's just not the right approach and that's whether that's manual therapy, whether that's the wrong exercise, whether that's the wrong cognitive behavioral therapy. All of these mechanisms fall into that.

David: Tell us a little bit about the patients that you avoid using manual therapy. What are the patients do you definitely go, "Right, you are not likely to benefit from it," or "We want to stay away from doing manual therapy on you."?

Chad: Those would be nonpain-adaptive patients. And these would be individuals. If you read the literature, the pain literature, they just simply don't have the same endogenous pain modulation capacity that you see in normal individuals and I hate to stereotype a group, but individuals with fibromyalgia fall into that group. These are folks that really require more external means to modulate their pain. They are seekers of high doses of pain analgesics. They tend to be on opioids. They're always looking for some external means to alleviate their pain because they are less functional within their internal means. They tend to have poor conditioned pain modulation responses. They tend not to have success with gaiting pain. They tend to, with respect to pain adaptive behavior, they tend to just demonstrate nonpain-adaptive behavior.

Those are folks that I really don't spend time with manual therapy because generally what you don't see are those within sessions or in that single session pain modulation responses with movements or any other type of pain relief-based activity. I move straight forward into a different management style with that patient.

David: What about, do you notice anything with patients that are sensitive to cold or are allogenic to cold or ice or any of those sorts of things? Does that affect your judgment if they've mentioned that within their history?

Chad: It does. When I look at someone who is nonpain-adaptive, it's a full package of things that they'll describe. It'll be a lot of ... Not all people with central sensitisation fall within that category, but a larger percentage will fall into that category, a lot of those with the central sensitisation syndromes who have symptoms affiliated with that. And there’s a litany of different symptoms associated with that. But it's also individuals that just behaviorally will describe to you what they've had to do to manage the pain.

And whereas it's not necessarily just a chronic component to this, certainly the chronicity of their symptoms plays into that particular package, but I think the thing, though, that's important is that during your assessment process and hopefully, everyone is doing both an active and a passive movement assessment process, that movement does not seem to modulate their pain. So, during the active physiological movements or the passive physiological passive accessory movements, there doesn't seem to be any combination or single set of movements that really modulate that particular individual's pain. It almost seems what historically we've called nonmechanical. That's a bad description, but what it is, is that movement does not modulate the pain.

Those individuals tend not to respond to manual therapy. In particular in 2014, in “Manual Therapy” we looked at using PAs if a person responded positively with a pain modulatory approach to a PA for the low back.

Was that prognostic for a good outcome? It absolutely was. So, there is evidence to support this approach in quite a few studies and clinically, that's what I look for.

David: Yeah. Okay. You're looking for a change in their pain within the session.

Chad: Yeah.

David: To performing some sort of manual therapy. And after you've gone through those, you've looked are they fibromyalgic, do they have any of the pain modulation responses or are they opioid-dependent and then central sensitisation or fitting into those sorts of categories, you're less likely to be thinking that those are going to be helpful. Whereas if they're not fitting into those categories and you're getting that nice change with your manual therapy, then you're thinking this is a good direction for now.

Chad: Yeah. I think the risk of simplistically dichotomising patients, when you look at the pain-adaptive literature, they dichotomise patients.

They basically say they're either pain-adaptive or not, and there are characteristics associated with both groups. And I think a really good clinician can tease out those characteristics enough to know where to start. A movement-based examination, I think is a very telling feature to drive a person's management approach.

David: What about our specificity when it comes to a manual therapy assessment? How specific and reliable are we when it comes to assessing?

Chad: If you're looking for the feelings of stiffness or pathology in the tissue and things like that, it's pretty poor. If you're looking for whether or not you can diagnose a tissue lesion of some sort or a particular area, there is some suggestions that some PAs, things like that are reflective of a facet-related problem, that's Jeff Schneider's work, 2014, in “Archives”.

But in essence, specificity of technique, it doesn't seem to matter even if you're not really that close to the area that your technique that you apply to a given area. First of all, it moves all of the structures around it. It moves things besides joint. It moves soft tissue. It's very nonspecific. So that's probably another older myth that we have to be very specific, very directional with our techniques and further effectiveness and that doesn't seem to be the case.

David: Right. So probably, if we're thinking we can pick up, say an L3 stiffness or whatever, probably not totally reliable when it comes to assessing with our intratherapist, so assessing it again ourselves or between therapies. Is that right?

Chad: That is correct. And you tell that to a really seasoned manual therapist, they don't like to hear that. That's fine. That's essentially what the research suggests that's not the case. I think if you dial into that patient and you look at a patient response, then your accuracy is better at localising where the probable lesion is, if indeed there is a lesion at all; however, the most important thing is that person's response. And whatever you use to get the response that you're driving for is probably the right technique. And that technique is probably going to look different from every ... from person to person.

David: So, you're tuning into what the response is to the person that's on the treatment table at that time while you're doing it and then you're seeing how they respond to different pressure or different directions or locations of mobilisation. Chad: You've encapsulated that perfectly. That's exactly what I do. If I had to put a 100% profile on it, 98% is the response of the patient and there may be 2% of the cases where I might feel something odd and I will adjust based on that. But the majority of what I do is completely based off the response of the patient.

David: Yeah. If you press in different directions or whatever, you can often feel where they actually let go or you can actually get some ... whether that's ... that seems to be a technique that the patient is happy to receive and maybe that's a lot of the response, too.

But you can actually pick that up with your hands or from looking at the patient and seeing how much they stiffen up when you do different techniques, as well, can't you? Chad: I have a number of people have said, "Hey, I had so-and-so work on my neck and they're a master clinician." I can tell the difference between that clinician's techniques versus a newbie or a person that's learning." And I think what we're getting with that is expectations. There's probably a placebo element that's baked into that. We're expecting that really talented individual to provide a technique that probably has more value than somebody over here that's fumbling around with your neck. But in reality, if you look at technique-to-technique with the same provider, the same level of expertise, it doesn't seem to matter.

I think there is a physiological element and hopefully we'll get a chance to talk about that, to manual therapy. There is a physiological outcome that's measurable. But I think there's also a psychological component that is pretty powerful when there's a high degree of expectation from that provider. There is comparable medical research. For example, if a physician is standing next to the machine that's providing the analgesic in a hospital room versus the machine alone, when the medical provider is standing next to the machine, the pain relief is actually significantly stronger than when the machine provides it even at the same dose. So, these are expectation things, right?

David: Yeah.

Chad: The Parkinson studies that actually show that placebo is so strong that when people are randomised in two groups between an active versus a control group, the strongest effects are in those who actually expected or felt they received the experimental group. And so, the expectations pieces are really what's driving that. The master clinician bit has a psychological component to it and it may be that there's a confidence in how they manage that patient with their manual therapy or something, but the technique itself is essentially standard across the board.

David: Yeah. Okay. When you're looking at your specificity of technique, it sounds like you're not just moving L3 for instance, that there's a whole lot of movement going on at all the levels above and below and all the tissue around that area. We're probably not having as specific effect as we once might have thought from in this case, say mobilising L3. It's going to have a more of a general effect with the focus around that area, but it's creating movement above and below.

Chad: It is. And it may emphasise movement in one particular area, but you're getting movement everywhere. So, the assumption and again, you probably…where you had to sit through these grueling courses where you had to lock the segment above and below so that you only had movement in one particular area, that just doesn't exist.

David: It's interesting seeing those videos where they have done CT where you perform mobilisation, seeing how much movement actually occurs all around that whole area with mobilisation. I think that's pretty ... I'll see if we can post some links here in the show notes to that, but it is definitely pretty interesting to see how nonspecific techniques end up being in that area.

Chad: Very much so and again, it has a physiological component to it. It's nonspecific.

I think probably the techniques across the board, it doesn't matter which technique you use, it's going to have the same effect. I think if there is an added effect, it's probably a psychological effect.

David: When we're looking at manual therapy and we're diving into some of the things that might be supporting it all and how we use it, we've talked a fair bit about some of those positive effects. Do you think there's a future for manual therapy within physio, physical therapy, osteopathy, chiro, that sort of thing? Is it a valuable addition to our profession do you think?

Chad: Yeah. I get asked that a lot. I just, I guess I'm a little thick or slow, but I don't know why we would want to remove something that is pain modulatory that could be included in our arsenal of caregiving. It would be if somebody said, "You know, we need to remove centralisation from our management process." Well why? Centralisation can be a powerful short-term relief mechanism and it usually is prognostic. It means a person is going to get better probably if you do or don't do centralisation.

So, I think it is an addition. It's a treatment component within a larger framework of management processes that we provide our patient. I do not think we should remove it from our care. I just think we should be careful about how we manage our patients and how we use it in that management process.

David: When we're looking at the evidence, is there anything that actually supports using manual therapy?

Chad: There is evidence and it's even health-related outcomes, which it has to be pretty strong to change an outcome measure, its health status based, but this suggests that manual therapy and exercise combined tends to be better than just exercise alone and is certainly better than just manual therapy alone.

So, as part of a multimodal mechanism, it seems to have some effect in the spine, it certainly has an effect in the knee. There is some evidence to support it in the back. It's mixed in the back. And our own work has shown that if you provide manual therapy and exercise to the hips, you will see a better outcome in patients with back pain versus just treatment of the back alone. So yeah, there is evidence to support it.

David: Any references particularly you think would be good for listeners to look at or that we could link to in the show notes?

Chad: I typically go to the systematic reviews because they capture everything. But with respect to the low back, there's actually mixed results on systematic reviews, which is an interesting issue on its own. So, I won't even go there. There's a recent JAMA article that suggests that spinal manipulation has benefit in a meta-analysis, whereas the Cochrane says that it's no better than any other interventions. I would probably lean more toward the Cochrane paper, suggesting that it has equal benefit to other interventions. And that's really where I stand on manual therapy.

It is a form of pain modulation and there are other forms of pain modulation, and what matters most is probably whether the person is pain adaptive. So, it's less about the technique and more about the patient. And if you can identify those patients that are going to respond well with some movement-based approach, it really doesn't matter what movement-based approach you give them. The Anita Gross' work in the neck is probably worth looking at her systematic reviews, the Cochrane, and then Gil Dahl's work for the knee. He's done a couple of really strong randomised control trials, really well-done RCT for patients with OA and manual therapy that are certainly worth reading.

David: Let's dive into, we talked about some of that evidence and there's good reasons to continue to use it within our practice as physios going forward or physical therapists or whatever our profession is, but how do we go about actually using clinical reasoning when it comes to manual therapy? What sort of tips and how can we go about using it here Chad?

Chad: I think the first step and we've talked a little bit about this is that understanding how you plan to manage a patient and then looking at each patient individually and what you're dealing with the most, does the patient need pain modulation? Is it something of value? Is this something that's going to potentially lead to a better outcome for that particular patient? And if so, what are the pain modulation methods that I might be able to impart on that patient and communicate this in a way that it's not going to be detrimental, that it'll actually be positive.

Whether a person needs active or passive, that's up to them. But using that early in the process to give the patient an understanding and hope that hey, my prognosis is going to be good, I'm moving in the right direction, what I have experienced in my physical therapy visits are positive and then I'm not afraid to exercise and move more actively and I can self-manage my own pain. I think if manual therapy is embedded into that then that's a positive.

I do look early from the clinical reasoning management approach at whether the person is pain-adaptive or not and again, we've talked about that, too. Pain adaptive means they respond very well to movements during your clinical assessment approach. They don't seem to have all of these overlays that are related to central sensitisation disorders or nonpain adaptive disorders or a significant need for external pain modulation through drugs or other forms of pain analgesics.

All of that is packaged into my clinical reasoning process. And then at that point, I may decide and it's often borne out from my treatment of what types of movements seem to be pain modulatory, at that point I may decide and then communicate with the patient here's what I'm thinking. Which of these do you think will make the biggest difference for you? Which do you think is going to help and what has helped before? And then after all of that, I will decide then to use a particular technique or an active approach or skip it and move straight to a more strengthening-related approach or a cognitive behavioral therapy approach.

David: You mentioned that you're looking at communicating with them about what you're actually going to be doing, understanding how to use that pain modulation and then figuring out if they are actually going to respond and if pain-adaptive or not and then the movements, what movements are likely to be pain modulatory for them.

So, coming to that part of it, when you get into the piece where you're identifying which movements are likely to be pain modulating for them, how does that help you decide on what treatment to use or whether that's techniques.

It's not just to say the patient doesn't have a preference for a particular technique.

They haven't really had any treatment before, but you feel like they've got change with particular movements so they might be painful into say flexion…the lumbar spine and they might be painful in flexion or lateral flexion and not into other movements. You have decided that they are likely to be pain modulatory or pain adaptive. How does that help you decide on your techniques that you're going to do?

Chad: Often the same things that are pain modulatory during the assessment process will be the treatment techniques that I choose.

And a lot of people will describe this as almost a Maitland approach or a Mulligan Approach if you wanted to label it with a philosophy. I just think it's more of a pain-adaptive approach. Those same processes during the assessment that reflect pain modulatory behavior in that patient will often be the techniques that I choose for that patient.

The active pieces often are the augmented home exercise program and the passive pieces might be the pain modulatory assessment processes that I'll use. And I use very simple manual therapy techniques like PAs, like UPAs, CPAs, UAPs. I don't feel the necessity to get into the complex biomechanical blocking the segments approach that maybe a Scandinavian model or a Netherlands model will use. I don't think we need to go in that direction unless that patient requires a ceremony of some sort to really get the buy-in of the pain modulatory behavior. And this is not a knock toward dry needling, but the ceremony associated with dry needling is probably one of the biggest reasons for its pain modulatory effectiveness. Patients, they look for that.

The biggest ceremony of all is surgery, right? A person has to go through that whole process and by golly, the outcome is going to be great because of it. So, it really depends on the patient, but often, it's the simplest procedure during the assessment process that I will use as that pain modulation component as a segue toward an additional approach in the future. I just don't use manual therapy by itself.

David: It sounds like you've gone through that if we're coming back to say in this case a low back plan as a bit of an example, but you've gone through the movement assessment.

And it sounds like you then moved on to assessing them passively and done any other tests that you might want to do and then you've gone through potentially palpation whether that might be a PAIVM assessment or something like that and then seeing if that has a pain modulation response. Is that the sort of approach you tend to take through this assessment or is there, am I missing something there in the middle? Chad: No. That's a piece of it, but I also do strength and endurance-related assessments, as well, to dial into whether or not a person needs that part because I feel that there is a strong benefit in showing someone that they have an impairment. If I think there's a strength or endurance impairment it's important to be able to show them that, but also to be able to show them progress as they move on. There are other pieces into it other than just the pain modulatory components.

David: So, you assess their movement. You're assessing strength, range of movement, possibly movement control, all those types of things and then one of those components you're looking at is do they have a pain modulatory response? And then you're looking at some of those what you've identified there, those impairments as your assessment/reassessment type of findings, as well.

Chad: Indeed, and I also ... and I don't want to forget about the cognitive behavioral component, too. I think that's a big part of it. So, the intake forms, the significant queries that may be borne out from getting to know that patient a little bit more. I may decide at the end of it, “Hey, do you mind filling out the central sensitisation inventory. I'd like to get your perspective on this,” or a PEG3 to understand how pain interference may interfere with their activities, not just pain intensity.

So other things that ... I reserve the right to adapt to what the patient shows me and I reserve the right to go in and look at the cognitive behavioral components, primarily because the research does show that we're not that good at sorting that out through our own gestalt and being able to understand the totality of what's going on with that patient. I do use a lot of pen and paper tests to get a perspective about that patient.

David: And do you tend to do these before the session or during? Or how do you tend to put those in ...

Chad: The ones I use before which are automatics are more related to social determinants of health. And this is really understanding where that patient is in the spectrum of their health and their health status because there's essentially comorbidities and social determinants of health and behaviors are the strongest predictors of how somebody is going to score on their outcomes form regardless if that's a spotty or …a neck disability. All of it is completely swamped by those components. So that's the intake information before I really get to see a patient. Then that gives me a perspective of where they are on their health status.

I don't think there's a single battery that you can give somebody that's going to give you the full perspective of their cognitions and their emotions and how those may contribute overall to their condition. I think you have to tease that out as you build that particular relationship with that patient. So that may come after the fact.

David: You're getting more of the screening questionnaires initially and then you're identifying anything within your session and then having follow-up questionnaires to identify things like that cognitive behavior component or whatever else it might be, you can give them additional questionnaires to follow that up within the session or later on.

Chad: That's correct and I really appreciate the people that are creating the screening questionnaires to really drive care. I think that's a wonderful idea, but those are also not a silver bullet and to really outline the care processes for patients sometimes we need more information, that particular screening tool to really dive in and better understand the totality of that patient's condition.

David: Tell us a little bit about the mechanism. This is one of the ... we put this out on social media to find out what sort of questions people had about manual therapy and people really wanted to know how is it actually working, what are the mechanisms or likely mechanisms? So, what's actually happening that's modulating pain in patients that are having a pain modulatory response?

Chad: Yeah. So first of all, that's the big knock, I think, against manual therapy is that nobody understands the mechanisms. And even if you look at narrative reviews like Bialosky has done, I think which is the most referenced narrative review and he said that it basically is neurophysiological. But what's of interest, and something that I didn't have full grasp of the information on was that there's actually quite a few animal and human research studies that show that there is a true biological mechanism that occurs with a manual therapy technique. If you don't mind, I'd like to frame this because it's actually quite interesting.

So first of all, these mechanisms are short-term. They're probably anywhere from 20 minutes on max that you'll see these changes that occur, these biological changes in individuals, in animals and humans. And secondly, some last up to five hours. It really depends. But most of them if you think about this, we're talking about a 20-minute thing. It's something that lasts about 20 minutes.

There's a wonderful story about there used to be a bike race across America, since we were talking about bikes earlier. And this particular cyclist, his neck gave out about two-thirds of the way through the bike ride, because we're talking thousands of miles, right? And he had a chiropractor in his sag van and every 20 minutes, he would lie on the ground and the chiropractor would manipulate his neck for pain modulation. He would cycle for 20 minutes and he would stop and he would lie down. And in the book as he was telling his story, he said it's interesting. It only lasts about 20 minutes.

That's because biologically, neurophysiologically the techniques only last about 20 minutes. So, there is something that happens, but it's 20 minutes.

The second thing we need to consider is these are essentially animal-based studies and basic science studies. So, we can't make this giant leap of faith that a mechanism, a measurable mechanism is related to a clinical effect. A clinical effect is something that influences health outcomes because that's how we've measured it. So, I'm not sure if changing someone's pain biologically is going to have a clinical, a long-term clinical effect and that's generally what we see and what was on trial. So, I want to make sure and point that out straight away. But if we look at the studies, there is a measurable effect. And if you look at the way and pain and nociception is modulated in the body, there's the gait control theory. There are studies that support that. There is a conditioned pain response on an individual that if you perform manual therapy, you can actually modulate the perception of pain short-term. There is amino acid response, the way that pain is modulated in the body. Thus far, there aren't any studies that I'm aware of that have shown the influence GABA and a lot of amino acids that influence neurotransmission of pain.

There is adrenergic response that includes dopamine, serotonin an others and manual therapy has been shown to influence blood chemistry levels of those in animals and humans. There are expectations of placebo/nocebo. Some of the strongest literature is related to that, that it does influence those components in individuals. There are cannabinoids. Manual therapy does influence endogenous cannabinoids and the most research is actually related to endogenous opioids and that increasing endogenous opioid response in patients after application of manual therapy.

The strongest dopamine literature with soft tissue mobilisation, which I would argue is a form of manual therapy. There is literature to support that, as well. So, the folks that argue that there's no mechanism, actually there is. There's quite a bit of research on this.

Most people don't know about it, but what we have to be careful about is assuming that mechanism is what is going to lend itself to a clinical effect. And right now, we haven't been able to bridge that gap. And I'm not sure you can bridge that gap without a better designed study. But basic science studies do suggest there is some mechanism.

David: It seems like there's a ton of mechanisms there, including those biochemical ones. Tell us a little bit about the neuromodulator effect. How would you break that down and explain that in simple language?

Chad: For a patient, I would basically say that the body has its own mechanisms within how it perceives pain. So, if I was telling it to a patient, the body modulates pain. Everybody has their own neuro matrix. Everybody is unique in how it does that, but there's almost a standard biological process and part of that process involves blocking the pathway of pain and there are six different ways of doing that. And this particular approach will target probably four of those six mechanisms. So, it can target nociceptive pain.

The pain experience which is expectations, placebo/nocebo, really that, that's probably only a mechanism that has been shown in the literature on how manual therapy works. I actually think that's a pretty strong mechanism when it's tied to that person who has high expectations, that they need that particular treatment.

So, I describe it that way for an individual. I say look, it's a biological response. It tends to be short-term, but the positive thing about this is that if we do see a modulatory approach or a modulatory success with this, it suggests that long-term you're going to do well and it suggests that movement is something that actually can work in your favor as a modulatory management approach. So, I frame it that way for the patient.

David: If they ask you ... Some of the follow-up questions that people might ask, probably less frequently would be what are the six mechanisms. But they also most likely want to know how long is it likely to work for or help me for?

Chad: Yeah. I mention to them, I say look, it's short-term, but the nice thing about it is these augmented exercises that we provide you that we found in your examination that also modulate your pain, that's how you're going to get those carry-over effects for modulating your pain until we can do longer-term issues and until we give time and natural history the opportunity to allow you to heal.

David: So how do you explain the manual therapy to them in the context of those exercises? How do you say we're going to use this and then we're going to use some exercises? What's your explanation consist of there?

Chad: I often frame it very similar to the way I would describe how to use Ibuprofen to modulate pain. And it depends on the person in front of me obviously, but when I do workshops or I speak at a conference, I give this analogy a lot.

Let's say you go out, you drink a few too many with your friends, you wake up with a pretty significant hangover and you can either do nothing and if you're pain modulatory eventually that will phase off. It'll take a day maybe and it goes away or you can take Ibuprofen knowing that can modulate short-term your pain to get you through that.

Manual therapy is essentially the Ibuprofen for management. It's just something that allows a person to get through those initial stages to pain modulate before you can do the long-term things, the long-term thing being natural history, which is the most powerful thing that we have, but the long-term thing that's going to make a difference with that patient.

David: And how do you then describe what's going to happen throughout their treatment session as far as progressing through and using manual therapy in those initial sessions and starting exercise and progressing it? How do you set up their initial expectations in that initial session of what's going to happen throughout the course of their treatment?

Chad: I tell them straight off the bat that most people, they only need a couple of sessions of this, maximum of four, but after that, it probably has run its course in effectiveness and it's not needed. For us, our most valuable use of your time will be building more autonomous things that you can do and working on those things that are going to have a longer-term contribution to your recovery. I tell them straight up, right up front.

David: You've set them up. They know what's coming. They're not just thinking that they're going to be coming in for a session of manual therapy every time, but you're going to be doing some manual therapy and they're going to be moving on to those other things, as well.

Chad: Yeah. And I don't get any pushback from patients with that. They're very open to that.

I think they're really looking, you know, they're looking for answers, right? They're looking for what's the right approach to manage this. I think there's a study, a systematic review came out recently. They're looking for diagnosis, they're looking for prognosis and they're looking for what they can do to manage their care.

And if you give them hey, we need to do this a little bit, but I'm going to give you the tools that are going to allow you to self-manage, that's going to be received well by the majority of the patients. Those patients that don't want that approach are probably nonpain-adaptive and they probably don't need that type of approach in the first place.

Those that are looking for a massage, those that are looking for just somebody to work on them each time, it's unlikely that the marriage of that treatment approach to that patient is a logical marriage. That's going to take additional conversations with that patient.

David: And if we have time, we might dive into that a little bit, but yeah, patients are there, and they want to get better and they're not there to say we want to do some manual therapy on you every time. That's not what they're looking for.

If we can give them the tools that they need to actually get better long-term and this is giving them that opportunity to do that or you're helping them to progress to that active approach that they can self-manage, that's really the outcome that they're looking for. They want to get better and get back to all the stuff they want to do, really, most times. Chad: I agree with that completely.

David: Yeah. It's lovely to be loved, but that's not really our job. Chad: Yeah. Sometimes you have to be the bad person and to me, those people that you have to take that approach are really those that are not candidates for manual therapy.

If they don't have a demonstrable pain modulatory presentation in that assessment approach, they're not going to benefit from manual therapy, whether that be short-term or at all. So that just takes the conversation with the patient.

David: Tell us a little bit about, you mentioned before that there's different ... you'd class soft tissue release as part of that manual therapy group, so what sort of techniques generally does manual therapy consist of? People have asked when people are looking at the studies and manual therapy all gets classed together, they say what's manual therapy? Is it mobilisation with movement? Is it PAs? Is it soft tissue release? What would generally be the thing that's studied and what would you classify as manual therapy and tend to use? Chad: It really suffers from an appropriate operational definition, I think, and I have actually seen this discussed a lot in different papers. I have a textbook and I talk about it in chapter one, but it really suffers from the weird techniques in combination with the more legitimate, scientific techniques. The APTA, which is our professional body here in The States and AAOMPT which is the manual therapy academy, they both have adopted a general definition that involves skilled hand movements. A lot of things can fall into that.

Yeah. I would argue that it's ... To me, manual therapy, it's a muscle energy technique, the manual therapy is manipulation. My answer is yes. It's mobilisation with movement, yes. It's soft tissue mobilisation, yeah, I also think that's manual therapy. Manipulation, mobilisation regardless of its form. I would even argue that selective stretching techniques fall into the realm of manual therapy. So, I think it is a wide definition. I almost wish we could define it by a passive pain modulatory technique. I think that has a hand-applied, pain passive pain modulatory technique. I think that's what manual therapy is about. The skill part? There probably might be a placebo piece to that, but I think even bad application of manual therapy techniques on the right pain modulatory person is going to work. So, the skill part is probably to be debated.

David: So if a patient comes in for treatment and you said you tend to ask them about their preference and what they feel like is going to get better, would you tend to include soft tissue release in your treatment or if they say yeah, I really feel like I need a massage or how do you tend to approach it in that sort of case or what sort of manual therapy would you tend to use?

Chad: I tend to be more joint-related. I am a victim of my background, so I am a product of my training. So, it tends to be more joint-related. I have no qualms about referring out for a longer session of soft tissue mobilisation on a person that I think may benefit from that, some high-tension, high-anxiety, a person who could benefit from a massive dopamine release that I have no qualms about it. In our particular setting, we just don't have the time to do that, to put the time into it that it really is going to get the maximal benefit for that and massage itself, massage technique is not really covered under any insurances here. Soft tissue mobilisation is considered in the same CPT code as a joint-related manual therapy-based technique.

I tend to lean more to the joint-related techniques, knowing that it also gets the soft tissue-related techniques.

I also do some muscle energy techniques, as well, and I'm a for the most part equal opportunity employer of techniques. There's not a particular one that I think is better. I try to match it to the patient preferences, try to match it to the patient in front of me. I'm very cautious about doing an aggressive manipulation technique on a fragile person.

Just to be on the safe side, I'm a believer that there's no difference in the biological outcomes between the different types of techniques.

Again, I'm a product of the research studies that we've done that show there isn't, if health-related outcomes are our tool of measure. But if patient expectations are tool of measure in the patient experience, then it's really about matching the preferred technique to that patient.

David: Do you have any examples of how you ... any recent patient examples where you might have chosen one technique over another, for instance, based on anything that popped up throughout their assessment or their subjective or their preferences or whatever?

Chad: Sure thing. There was a patient that came in and was actually a relative of one of the patient's that I was treating and he was a medical student, high levels of stress, was having some neck-related problems, reported a pretty high pain intensity for an individual and he came in and we worked him through and he was pain modulatory or pain adaptive. The movements really reduced his pain and I really emphasised that the active movements, these are things you need to do especially during your training because this isn't going to go away for years. And then he voiced to me that, he goes, "What I really would like is if someone would just pop my neck." He goes, "I've had success with that in the past, I seem to get some residual relief from that. Would you consider doing that?"

And I said, "Sure. That's certainly well-within our boundaries of what we do. Let's give it a try. Let's see if it reduces your pain."

He requested that versus a stretching approach versus a mobilisation approach versus whatever and since the majority of his pain was in the lower cervical region, since I was able to reproduce a lot of the symptoms during the clinical examination with the passive accessory motions in the lower cervical region, it's a fairly safe technique, it's an easy technique and if I matched it to what the patient preferred.

David: Nice. That makes sense. Any other examples that you might have used or other times, other case studies or where you've matched your technique to the patient presentation?

Chad: Yeah. I'll give an example of an active approach. I had an elderly gentleman that came in. He was having some problems in his mid-to-left thoracic region and he had reported he has had these problems a long time and that his preference was not to be popped. He says I don't like that. I've had that before. My preference is, is there something I can do myself to modulate that pain? I showed him some self-physiological movement techniques that seemed to pain modulate his problem and some active exercise, a resistance exercise that also modulated it. So that's another way of just matching request.

If somebody tells me I've had that before, I don't like it, I tend to steer away from that because I'm a believer that the technique is certainly not as powerful as the expectation in that placebo/nocebo in that patient.

David: Definitely. If they've had a negative response to it in the past, then not generally going to respond too well to it this time.

Chad: Yeah. Not going to try to talk somebody into that. No.

David: No. They don't ... They tend to ... If they've negatively responded, they're probably going to do the same this time. So, it sounds like you matched it.

In this case, he wanted some physiological movements and he wanted some self-management stuff. What specifically with that in this case you did some physiological movements or did you do some rotations with him and what sort of resistance stuff did you do with him?

Chad: We had to do combined movements. So yeah, we had to match movements up before we'd actually ... and I tend to see that mainly in the thoracic region more than ... well I see it sometimes in the cervical region, too. But the thoracic region, it's often difficult to really isolate and it's pretty powerful if you can really get the familiar concordant pain of the patient then you can modulate that. So, to really target that particular individual's pain, if I remember correctly, we had to side bend to the left, we had to rotate to the left and then go into extension and that gave him that mechanical spike. And if he repeated that movement it actually modulated his pain and dropped his pain intensity.

And he was just as excited as can be because he had this dull, toothache-like pain in the left side of his mid-thoracic region for a long time and he was able to modulate it himself. So that's an example of matching, but it was a combined movement to answer your question.

David: Using that combined movement you found what reproduced his pain. In this case, it was that rotation, lateral flexion and then into extension.

Chad: Yep.

David: To reproduce it and then use repetitive movements into that position and that helped to reduce the pain that he was experiencing, his pain.

Chad: Correct. And also, just for clarity, when I talk about augmented exercise, we actually studied that a while back and we showed it does have a clinical therapeutic effect. And what we mean by augmented is that home exercise program, that program that you give the patient to do themselves actually addresses their concordant pain, their familiar pain. It has a movement-related modulatory component to their concordant pain. So, you match the importance of identifying that person's pain, so you get the buy-in of the patient, the expectations of the patient. You give them an activity that they do themselves that modulates that pain so they know that they're in control of that and we feel it's a pretty powerful thing. It has a small effect overall on health outcomes, but it did show an effect.

David: Tell us about some of the resistance exercises that you got him to do, as well, with that.

Chad: I do the supine resistance exercise because I've had less compliance to prone-related resistance exercises. So, we’ll put a person in a supine position, have their arms out at 90 degrees and what I'll ask them to do is actually raise their chest off the floor. The beds tend to be too soft, but off the floor, which really performs a very powerful contraction to the extensor muscles, eventually working that individual into contact points of the neck, the elbows and the ankles in moving into an extension-based movement. It's actually more vigorous than doing the prone-based techniques and quite challenging and completely safe for individuals regardless of their age.

David: Yeah, I can imagine. Especially if you're moving towards supporting weight through the head and neck and the ankles, then you're really getting a whole-body extension going, aren't you?

Chad: Yep. There are many ways to skin a cat, right? But this particular way is especially beneficial, I think, in older individuals who maybe have some respiratory discomfort while lying on their stomach. Most people can still lie on their back.

David: But it sounds like you progressed him through what was comfortable to start with and then you gave him those things to modulate his pain and you started that strengthening approach and then you gradually progressed by the sounds of it.

Chad: Correct. And the obligatory TheraBand where you can do the arm exercises while he's performing the extension-based approach, and those things tend to be enough. And then it's about involving them into the community resources, right, and then talking to them about how he can join a wellness center and modulate his pain through resistance exercises. All of those pieces, I think, are going to be the touch points for the big things that influence health outcomes like social determinants of health and behaviors. And if you can get them to buy into that, then we're really going to see differences with our patients.

David: When we're looking at making sure that our manual therapy is effective, do you have any tips or tactics or strategies that we can use? Therapists out there are going feeling more confident there is some evidence supporting this when I start including this for those two to four sessions, getting people active, as well. Any tips you've got to help them make sure that their manual therapy is effective? Chad: I think the big thing is how you package it to the patient and the response that you're looking for. I think the technique is just a byproduct of your management approach. Technique is going to matter less than the overall what happens during that process.

If you talk to the patient and you tell them, “Hey, what we're looking for here is we're trying to target the complaint, the pain complaints that you're dealing with and we're going to see if we can modulate that pain”. My interest here is whether or not this particular movement combination is going to reduce your pain because that is a very positive finding. That has a solid prognosis. If you package that to a patient, then they buy in equally. They're a partner in that process and then you look for those procedures that make a difference.

In totality, if a person is pain adaptive, they're going to have a positive response to their outcome.

And even if you're a lousy clinician, just natural history is going to carry that patient forward and they're going to do better. And that's information in itself, right? That tells you that they're going to do well and you can celebrate with that patient when you find out hey this is a really good finding. This suggests you're going to do really well. Patients I've had in the past, patients in the research, they all demonstrate a really positive outcome. There are many things you can do. Movement is going to be your friend. Exercise is going to be your friend. I can't give you a better prognosis.

And to really sell that message to the patient and that the technique that is being used is not the reason for this, it's internal to the patient. It's the way they endogenously manage pain. That's congratulations, your body is doing you a favor. This technique is just a vehicle to allow that celebration. I think that is the most important thing with respect to manual therapy and being successful with it.

David: Anything else that you think will help people to ensure they're maximally effective?

Chad: I think, I'm hesitant to say this, but part of that sell job is the same as part of the sell job with exercise.

It's part of the buy-in and commitment and getting the patient to be an active participant in this recovery process is getting them to recognise that this particular approach has value. The technique is just part of an approach and that all of this is a puzzle piece in a larger framework. So, getting the mental buy-in so that the patient knows you know exactly what you're doing, that you have a plan, but that you're not spit balling it and you're not just throwing a wet piece of paper upon a wall and seeing what sticks, that this is a process and this process involves this which will then involve this and which you will then do this. I think if you frame that for a patient, they appreciate it and they're more likely to have success with that because you're not just getting the biological pieces, you're getting the psychological pieces.

David: Great. Anything else that may continue to make this even more effective?

Chad: Opioids. No that's not true. I'm sorry. In essence, I'm not scared if somebody is taking medications. I don't try to pull somebody off of that. I think the bigger picture has to be taken into account and I've mentioned this a couple of times. If you really look at the studies and what influences health status and health recovery, its behaviors, its comorbidities, its social determinants of health.

And having the person understand that these are things that really do influence their overall outcome and doing what little you can do to make sure they understand what resources are in the community or why it's important to listen at a reasonably good diet and exercise and reduction of stress and all of these things, being a contributor to the health community as a whole and delivering that message, then you're going to make a bigger difference on health-related outcomes and health status and health recovery. Those are the things that really make a big difference.

So, we're not going to change that ourselves in that single session or collection of sessions with the patient, but we can be a common voice with others in the health industry in supporting that piece.

David: Perfect. And is there anything else you want to add before we wrap this up, Chad?

Chad: Well I want to thank you for the opportunity to actually talk about this because I think there's a lot of misinformation about manual therapy. Manual therapy is just a treatment selection and it's not a demon. It's not a silver bullet. It's none of that. It's just a treatment selection. It does have a biological value to it. There are mechanisms that have been measured in studies. Whether or not those mechanisms really influence long-term outcomes, that's to be determined. My guess is they probably don't. I think that's asking too much of one piece of a management process. But I just wanted to thank you for the opportunity to talk about that and hopefully, your podcast listeners will resonate on that, too, and it is what it is.

My colleague, Phil Sizer, says, "I don't get it." It is what it is. It's not that big a deal. It's not something to vilify. It's not something to celebrate. It's just a management approach. It's part of a management approach.

David: And yeah, you're approaching it from that scientific point of view, I think. You're looking at the positives and the negatives and the evidence for and against it and then deciding which direction to go based on that. Chad: Exactly.

David: I think that's great because I think it's good to have discussions and I think it's good to look at everything we're doing, analyse it through the microscope and say is this actually an effective way to work or to approach something. And then if it is or it isn't, we're analysing it and making the best decisions. And I think it's good to have these sorts of open discussions and look at all sides of the issues and then figure out what the best way for each therapist there is and for the patients that are coming in front of you, what's the best approach for each patient there, as well.

So, it's been a really enjoyable discussion. I really enjoyed exploring all these areas and diving into the evidence, diving into mechanisms, practically how it can be applied and yeah, it's been a thoroughly enjoyable conversation.

Chad: I've enjoyed it, too, and I think your questions were great. And I truly appreciate it.

David: Awesome. Well tell us where people can find out more about yourself and what you've got going on?

Chad: I am only on one social media platform and I'm barely on that. And I'm @ChadCookPT. No. I actually am fairly active on Twitter and I enjoy that platform. I actually appreciate the fact that it gets information out quickly. And so, @ChadCookPT for those who care to check me out there.

David: Great stuff. And any other websites or places that you run courses that people can check out, as well? Chad: I independently do courses. I've been very lucky in my career. I have been able to speak in over 24 different countries to these amazing physios throughout the world who no matter where they are, their common purpose is just to do better and to help people, and it's amazing how similar everybody is in every country. I do them independently. So, I do workshops. I do a lot of keynotes and taught a lot about the research that we do. I'm on PubMed, do a lot of research, so it's on PubMed if you're interested in looking at some of the studies that we've done.

David: Awesome. And you're on ResearchGate, as well?

Chad: I am not. I'm a lazy researcher. I let PubMed do all the work for me.

David: Good stuff. Spending time on the research rather than updating ResearchGate.

Chad: Exactly. Yeah.

David: Fair enough.

Chad: Writing grants that I don't get. So yeah.

David: Fair enough. So, if people are interested in your courses, they can contact you via Twitter I imagine.

Chad: Absolutely.

David: Yeah. Awesome. Well thanks again, Chad. It's been really great to have you on and everyone let Chad know what you've enjoyed about this conversation. Any questions you might have, I'm sure he'd love to have a bit of discussion with you, as well. So, thanks again, Chad. It's been awesome.

Chad: Thank you, David.

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