By Carey Wheeler
A couple of years ago I was on a holiday with my family in Bali. On one of the days we went for a trip to the Bali Zoo and we asked our taxi driver if we could take the long way there by seeing some of the surrounding sights and sounds. Religion plays a very large role in daily life for the Balinese, and being the inquisitive type that I am, I was interested in learning about the different rituals and beliefs of this vibrant culture.
One thing of particular interest was how so many religions all got along so well in such a small part of the country. The metaphor that the driver used was perhaps the most succinct and intelligent answer I could ever imagine. Conveniently, it can also be used as a metaphor for physical therapy and pain science.
As we navigated the narrow streets of the outskirts of Seminyak, his story went something like this: “The Balinese people are very welcoming. We are very humble and understanding. For us, God is like this van. If you look at the van from that side (motioning to the left), all you can see is what you see from that side. If you look from the front, that’s all you see. Look from the top and the van looks different again. But you are always looking at the same van. The Balinese people understand this. We understand that even though we may be looking at religion from different angles, we are all celebrating God in our own way.” Wow!
This is not the first time that physical therapy has been likened to religion. The secular, isolated and reductionist models that pervade and divide the manual and exercise therapy worlds see us bickering between manipulative and non-manipulative therapies, between hands-off exercise based therapies and hands-on therapies. There is constant back and forth between the fascia fanatics and trigger pointers, the craniosacral pulsers and lymphatic drainers. The question has been asked before and needs to be asked again: How can they all be right?
When we are faced with a question like this, Occam’s Razor usually cuts to the point pretty well; “the simplest answer is usually correct”. The only way that all of these approaches can be correct is if the mechanisms by which they propose to have their effect are the same. Therefore the posturing, postulating and bickering is unnecessary and frivolous. The specifics and the details of each branch of physical and manual therapy are no longer contentious. We are all looking at the same van from a slightly different angle. Like the Balinese, we can actually all get along in this small world of ours. So rather than argue about what we can see from where we stand, we need to discuss what it is that we are actually looking at.
In physical therapies, the engine, chassis and interior of our van are built from the non-specific effects of what we do. Formerly known as the placebo effect, the non-specific effects of physical therapies include aspects such as expectation, conditioning, descending inhibition and, in some cases, diffuse noxious inhibitory control (1). All of these very real and very interactive mechanisms of physical therapy are at play with everything that we do. The likelihood of us finding more and more relevant non-specific effects is far greater than us chancing upon the elusive specific effects we have been searching so long for. Rather than debate which modality provides the strongest specific effect to a certain tissue we should discuss how we can maximise the role that the non-specific effects play in our interaction with our patients and clients.
The caveat here is that when we have enough evidence to show that a modality or an approach holds no clinical benefit beyond the non-specific effects, we need to seriously consider the ethics of continuing to use that modality (i.e stop looking at the van from that angle). The retort, and one that I acknowledge is very valid, is that when interacting with patients it is the magnitude to which we can influence the non-specific effects of an intervention that will ultimately determine the effectiveness of that intervention (2). This means that we have to acknowledge the role of the patient’s beliefs and expectations in their outcomes, but to not let patient beliefs dictate an implausible or non-evidence based approach.
However, if we can all agree that the immediate and short term outcomes that our patient’s see are based largely on the non-specific effects of our interventions then we can also agree that it is what happens outside of the clinic that is most important to long term outcomes. Long term structural, psychological and social or behavioural change doesn’t occur in a single session or with two sessions per week for six weeks. We need to stop the bickering over beliefs, shake hands, and acknowledge that we all have the potential to have an effect on pain in the short term. Then we can sit down together and help each other to ask better questions.
What biopsychosocial factors have led this person to be here today? What can I do to give this patient the power they need to make the changes that are necessary for long term change? How can I best communicate this information to this patient to make sure they understand what it is we are actually trying to change? Who else in their circle of influence needs to understand this so they can be the best support for this patient? The questions go on and on but they are infinitely more meaningful than asking from what angle does the van look the best!
1) Bialosky.JE, Bishop.MD, George.SZ, Robinson.ME, 2011, Journal of Manual and Manipulative Therapy, ‘Placebo response to manual therapy: something out of nothing?’, Vol.19, Iss.1, pp.11-19
2) Kalauokalani. D, Cherkin. DC, Sherman. KJ, Koepsell.TD, Deyo.RA, 2001, Spine, ‘Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects’, Vol.26, Iss.13, pp.1418-1424
Carey Wheeler is a Clinical Myotherapist (BHSc) and has been in private practice for 5 years. He lives and works in Geelong, Australia. Carey’s clinical approach has always been movement based with a strong focus towards active therapy which developed from a background in strength and conditioning as a personal trainer. One of his main practice goals is to help patients bridge the gap between rehab and training. www.baycityspinalsports.com.au