You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.
I had a problem.
Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.
The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.
It’s a tough business.
The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹. Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.
Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
Nonmanual (including exercise and education) = 80%
Manual = 20%
Modalities = 0%!!!!!!!!!!!!
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
PRI manual = 14%
Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
I was recently at my home away from home, IFAST. Every time I go here the following occurs:
I have an amazing time with amazing people.
I learn a ton and realize how little I really know.
Prolific discussions are had.
I end up purchasing WAY too many books as soon as I get home.
As many of you know, Bill Hartman and I appreciate a PRI philosophy. When I go to IFAST, we inevitably experiment with many different things. This weekend, Bill and I were playing with how many different ways we could achieve full right shoulder internal rotation on my good friend Lance and the lovely IFAST intern Liz. Here was everything that gave these people full motion.
Soft tissue mobilization to the infraspinatus.
Manually assisted breathing.
Tickling the right side of the face.
Tapping the left hamstring.
Smacking the right glute max (yes, I spanked someone).
Having someone think about contracting their right glute max as hard as possible.
Having someone watch me breathe with a left sidebend.
Now of course, that does not mean you should be spanking your patients and clients with shoulder issues (but if you do make sure it is the right glute), but we have to ask why did all of these different techniques–even the weird ones– achieve the same outcome we wanted?
Why Things Work
Joseph Brence, a gentleman whose material I enjoy, recently posted a blog showing several different techniques and polling his readers if these interventions “made sense,” whatever that means to you.
While I am sure most if not all these treatments will achieve certain results, they likely are accompanied with flawed explanations. Why can we have erroneous rationale yet make positive changes?
I think that we get too caught up with what is occurring in the periphery. We can argue all day if we are breaking up scar tissue, mobilizing fascia or joints, stimulating skin, or releasing trigger points—but it does not really matter.
Forget about the periphery for now. Let’s keep things simple. Here is what we think is going on with our interventions. You ready? When I am performing treatment x, I am………………
Applying a sensory input
IASTM is a sensory input, manipulation is a sensory input, myofascial release is a sensory input, and your interaction with someone is a sensory input. All that we do—in therapy, fitness, school, socializing, everything—is a sensory input.
We apply a sensory input, the brain interprets this input, and a multi-system output is or is not elicited. This new output is itself a sensory input, which the brain interprets, thus affecting one’s perception.
This cycle explains why everything works in simplest terms. However, this process is complicated by the multiple variables that make one technique work for one person but not for another.
Take the examples above that we performed to increase shoulder mobility. What we did not account for was that Lance and Liz were very comfortable with Bill and I, thus are more likely to relax and be more receptive to the sensory input we apply.
Let’s look at ultrasound as another example. The literature is pretty clear that this modality is crap. But we have all had that patient who said ultrasound fixed them the last time and it helps so much. You try everything else to no avail, but as soon as you begrudgingly apply that ultrasound the patient rapidly feels better. The sensory input’s efficacy depends on how the brain interprets said input.
That is why patient interaction is so important. I can fathom someone who performs a treatment that is very much evidence supported, but does not get the outcome desired. Maybe the patient did not feel comfortable with the applied input, or maybe they did not like the clinician. These things matter and this is what makes our jobs so challenging. Everyone’s brain interprets the environment differently, thus requiring an individualized approach.
What should be in Your Skill-set?
If we operate on the above framework, we can apply pretty much any technique to someone. But again, that does not mean that all techniques will work, and some might be more effective than others. The short answer is that you need to provide the right intervention to the right person under the right context that has the lowest potential for harm and the largest potential for results.
It is also desirable and beneficial to utilize sensory inputs that either the patient/client can perform on themselves (i.e. exercise) or that can facilitate this process to occur quickly. The clinician’s ultimate goal should be to render themselves unnecessary for the patient.
All that being said, there are things that I look at when I decide to implement or learn a particular technique, in no particular order:
If there is some substantial support in the literature for or against something, it is a piece worth considering. This does not mean we must live and die by the systematic reviews. Even things such as case studies have merit. After all, it was Pavlov’s dog, not dogs. And it was an animal study at that!
Don’t like that case? Here is another example. Suppose I have a case study which involves a healthy man in his mid-twenties being seen for shoulder pain. I apply a brand new intervention that results in his instantaneous death. Will this influence your thought process in terms of using said intervention? Perhaps a higher level study is needed to make sure that this was not just a fluke. Of course, this will not happen because this case’s outcome is relevant. The big question to be answered by evidence is can I use the literature to support my treatment rationale?
2. The patient believes it will work.
This component is huge. There is more and more research being done on thrust manipulation, but what happens if the patient does not like it? In a clinical prediction rule recently done, one of the criteria was the patient’s belief that the intervention will work. Simply put, patient perception helps maximize the placebo effect and affects the sensory input interpretation.
3. The potential for harm is low.
Hippocratic Oath baby! Do no harm first and foremost. You do not want to ignite one’s pain neurotag if you do not have to, so I try to pick things that will not hurt someone. You want to use the minimal dose necessary to achieve your desired result.
That doesn’t mean I won’t use technique that are uncomfortable; especially if it helps me achieve my goal. This situation is where you have to educate patients that you may be sore during an activity, but safe afterwards.
4. The potential for success is high.
You want to use things that will work on patients. The ability to choose the right intervention comes with your philosophy, evidence, skill level, clinical reasoning, and a multitude of other factors.
5. The intervention works fast.
Suppose we take two manual interventions. You pick one that takes 10 minutes to perform to achieve a desired output. Mine takes me 30 seconds to achieve the same result as you. I will win every time because now I have an extra 9 minutes and 30 seconds to give the patient exercises to facilitate keeping that desired output. If something works incredibly fast and provides more opportunity for motor learning, I am going to use it.
6. The intervention gives the patient or client the power to change themselves.
This is the reason I like PRI so much. They emphasize non-manual interventions over manual. Minimal motor learning is going to occur with passive interventions, so the more active the patient can be the better.
7. I can provide rationale that the patient or client will understand regarding its efficacy.
If you cannot say why you are performing an intervention, you should not do it.
8. I can perform the intervention with skill and confidence.
This piece goes with maximizing patient’s expectations. If I come across as the cock of the walk with a selected technique, and I have done it enough that I can make it comfortable, that will reflect on the patient. Do all that you can to maximize placebo.
There are so many different techniques that we utilize, and we all have our biases as to which ones we like. The important thing to understand is that all the interventions we provide operate under a similar framework; sensory input to facilitate a desired output and perception. So when deciding which technique is best to apply, pick the one’s that you can perform the best, that the patient believes will work the best, and allows the patient to take care of themselves as soon as possible.