What a funny time!
Where does the strange tendency to vilify approaches that are similar rather than compare the types of patients who respond to these approaches come from? Does the literature really robustly contest these approaches? Could social media be blamed for this inability to tolerate open discussion and sharing?? The impression of being better than our predecessors: fact or fallacy? The following text is a humorous reflection, flavoured with a little sarcasm, on the progress made by our professional practice over the past decades.
There was a time, at the very beginning, with the great wars, when physiotherapists treated their patients with exercises AND massage AND time AND compassion… And it worked quite well. Several years later, without warning, some of our peers decided to change everything to offer electrotherapy and hot packs instead of exercises, massage, time and compassion. And it worked… well for business, but well for patients too. So strange that human biology could evolve so quickly.
Soon after, it was manual therapists who took the floor and who, it is said in some circles, threw everything else out the window. What power! Of these manual therapists, some opted for British techniques (J. Cyriax, J. Mennell, G. Grieves), others for Scandinavian techniques (F. Kaltenborn, O. Evjenth), others for Australian (G. Maitland) or New Zealand (S. Paris, B. Mulligan) techniques and others still, for American or Canadian techniques (D. Palmer, A. Still, C. Fowler, J. Meadows, D. Lamb, E. Pettman, D. Lee). It was a beautiful period when everyone exchanged ideas rather than condemning the ideas of others. Moreover, we were free to mix approaches without being dichotomous. This was particularly true in Canada where, in 1974 in Montreal, IFOMPT was founded by several “greats” of the time. Some said that with magical hands, exercises, education and compassion were no longer necessary. To be honest, I’ve never personally heard nor seen this exclusive “magic hands” technique in clinic, but I’ve read about it a few times in recent years…on the “internet”! Did I misread?
Almost simultaneously, a certain Robin McKenzie, a manual therapist himself, is said to have developed a very interesting approach which included self-treatment, and according to several contemporaries, touching the patient could now be potentially harmful. Some recent studies, (obviously infallible and with perfect methodology according to some influencers), have even confirmed this hypothesis; a little puzzling when one considers that Robin McKenzie got along fantastically with his manual therapist friends and colleagues and even actually manipulated his patients daily with some success…
Soon after, strangely, everything became neurologically driven! Two charismatic and kind Australian gentlemen (D. Butler and M. Shacklock) are said to have “popularized” this new vision, this new panacea of physiotherapy, spawned from the observations and research of Bob Elvey. First, neural mobility and then mechanosensitivity became essential concepts for any self-respecting physio to implement! Ignoring those concepts meant being outdated and being stuck in prehistoric times.
In the wake of Shirley Sahrman’s muscle imbalances, the 90s also brought to the world the motor control theory of Dr. Paul Hodges, Dr. C. Richardson and their apostles. Thanks to some original studies, a new “star” was born and two very small muscles, transversus abdominis and the multifidus, became the center of attention of physiotherapists across the planet; yet another revolution that would potentially eradicate low back pain from the universe, just as activation of the longus colli would have done for neck pain (G. Jull). Since this was not quite achieved, we replaced motor control exercises by squats, deadlifts and planks (S. McGill) … with similar results (i.e., average). A few well-meaning people sought to understand which types of patients would best respond to different exercise approaches, but the complexity of the subject made this question almost impossible to solve. Back to square one.
Thankfully, Groundhog Day came around once more and made us understand that the neuroscience of pain (NOI Group and L. Moseley) and cognitive and behavioral approaches (P. O’Sullivan) were now THE thing to discuss with our patients, especially those suffering from chronic pain. Manual therapists and motor control “geeks” could forget about everything else and go back to square one. The great era of “hands off” and simplicity had won the battle and therapies behind a Zoom screen would dominate the world for those who were suffering. Victory! Everything would now be easier and simpler, brought directly to you in the comfort of your own basement.
The best physiotherapists had just discovered the power of words, communication, metaphors and patient education. Something that, according to social media, had been completely ignored by physiotherapists until now. And yet, the following sentence from G. Maitland, was already famous in the 80’s: “If you listen well to your patient, he will tell you what he has and if you listen to him a little more, he will tell you what to do to help him”. Stranger still, until recently, this phrase was heard mostly in manual therapy circles.
Had physios known that before, they might have shared in the current successes of these “hands off” therapies. As we say, statistics don’t lie. Indeed, there has never been so few people with low back pain, neck pain and persistent pain, than in this moment in time… right? Considering the evolution of the profession and the gradual elimination of inappropriate interventions, there should have been a worldwide reduction of the symptomatic population.
Add to this, strengthening, strengthening and strengthening, “because you can’t get wrong getting strong” (A. Meakins) as well as a dose of mindfulness (J. Kabat Zin) and we’ve reached the perfect therapy! The human being is great when he keeps it simple.
And I forgot, load management (LM), popularized by Blaise Dubois and « The Running Clinic ». Many years ago, I was taught that when exercises were prescribed appropriately, a pain level of 1-2/10 could be tolerated and that it even allowed for adaptation and progression. This concept had not been branded at the time so it did not get the attention LM has received. And since manual therapists apparently did not prescribe exercises nor educate their patients in LM, they fell short of empowering their patients. But wait! Could it be that mobilizations, with their progressive grades, were a way to introduce movement in the context of LM for patients who had developed kinesiophobia or catastrophization, by exposing them gradually to positive movement experiences and getting them back to active movement and exercises?
Voltaire said that «The art of medicine is to distract the sick while nature heals them. » Am I to understand that when you run out of distractions, you invent a new one and throw the baby out with the bath water? Had I known, I would have become, a few decades ago, a hypnotist or a doctor of charisma as Nick Bogduk suggested in the 80’s. It also seems to work in the quest to rise to the rank of “influencer” and reap its rewards!
Has the objective clinical presentation of pathologies really changed in the last 100 years or is it the reasons people suffer that have evolved? If so, do we currently have a real grip on the various modifiable prognostic factors (personal, environmental and functional)? As such, are we better than “life coaches”?
“Stronger together” sounds good in theory, but how do we translate this into concrete actions? While we wait for mentors who will unite rather than divide, the era of true prevention and resilience, I can perhaps simply continue to help my patients with interventions selected and based on clinical reasoning, well-selected articles from the literature and the needs and expectations of my patients, as suggested by my predecessors and evidence-informed practice!
Marc-André graduated from Laval University and works in a private clinic with an MSK sports clientele. He completed the AIM Physiotherapy Program and became a Fellow of CAMPT in 2009, and went on to teach from 2010 to 2020. He has a strong interest in knowledge sharing and the evolution of our practice.
You can find him at http://masphysio.com/.