Trends can be a good thing or bad thing. It’s a good thing if we define trend as an update or upgrade. Old things are abandoned as new paradigm shift is welcomed. In science, it means that new studies present a more scientific fact nullifying those that have been previously believed and taught. Or trend can be a bad thing when it is described as fashion or fad. Here today, gone tomorrow because they don’t have scientific studies to back them up. In physical therapy, there had been numerous techniques once used and now being abandoned. That’s fine too. Which medical science does not evolve and advance, and still use same method of diagnosis or treatment for decades?
I am happy to be in the bandwagon in this journey of new trends in my profession. Some therapists just want to stick to what they are used to in their practice but I am not some therapists. I refuse to be left behind. Thanks to all of those practitioners who constantly push researches and studies so that physical therapy and physical rehabilitation practices will truly be evidence based and treatments based on psuedosciences be contained or minimized. Thanks to clinicians and researchers who are bold enough to call out and challenge the charlatans who provide training and products with unproven effectiveness as a way of monetizing the practice.
I am forever grateful to everyone who keep supplying oceans of new information to the community of PTs around the globe through facebook, twitter, and online forums. Not only from physical therapists but also from related professions like atheltic trainers, strength and conditioning coaches and massage therapists. There’s always going to be arguments from different groups with different paradigms in the practice, Overtime, as I read discussions and sometimes join in these discussions, I have learned which side to choose. Yes, sad to say, there have been some inevitable divisions among physical therapists. But of course, we can all disagree with respect! Everybody is entitled to voice their opinions. At the end of the day, science wins by landslide.
So, over the years of following various clinicians and researchers, balancing the views of each one, I have come to embrace these trends in the practice, which form much of how I work on my clients and patients now – from assessment to explaining the what, why and how of my interventions.
1. Manual Therapy
Now, manual therapy is really not a new thing. It has been around for quite a while. Many manual therapy techniques are shared by a number of rehab professionals which includes osteopaths, chiropractors, physical therapists and massage therapists. Since manual therapy is simply the use of the therapist’s hands in treating various musculoskeletal conditions like soft tissue pain and injury, many have used these hand techniques in so many ways, some good and some plain ridiculous. I am not the one to point out which ones I think are unscientific but you can read some of them here!. Also, many manual therapists have given big claims on how can manual therapy works wonders, in which no substantial study to back them up. Stuffs like releases fascia, corrects malalignment, boost the immune system, among many others. How one can break up scar tissues and fascia when a surgeon needs to use an scalpel to do so?
I can say that if there’s anything new with manual therapy is it’s how we understand how it works. Manual therapy does not deform fascia, put back an out of place sacro-iliac, or release trigger points. Most of the effects of manual therapy are neural not mechanical or structural. We cannot mechanically deform fascia with hand forces but instead we stimulate skin mechanoreceptors which sends signal to the brain to allow a tensed muscle or soft tissue to “relax”. Most of the time it’s not the techniques that are flawed but how the mechanism of the techniques is explained [i.e., based on purely biomechanical models].
Also, manual therapy has been made a panacea in MSK [musculoskeletal] physical therapy by many practitioners. But manual therapy is really just a means to an end. Manual therapy as a tretment is mostly passive and thus can make the patient dependent on the therapist all the time. That is why many manual therapists in other disciplines like chiropratic can keep their patients/clients for years or even a lifetime. I also know some physios who became osteopaths who tell me that they don’t prescribe exercises anymore. But the goal of pain and injury rehabilitation is to make the patient/client functionally independent and be able to mange their symptoms. That is why I don’t stop with manual therapy in treating my patients. I use manual techniques to address symptoms of pain, stiffness and limited joint motion, after which I proceed to what physical therapists are known for – movement!
Here’s an excellent article by Greg Lehman on fascial treatment fallacy.
2. Functional Movement Therapy
Like I mentioned, manual therapy is not main intervention in many physical therapy treatment. Movement is. The goal in injury rehabilitation is not only to relieve pain but to improve movement. Injury, if not managed by movement therapy will impose risks of re-injury. Pain might be relieved but the abnormal movement patterns adapted thru the presence of pain or injury are not addressed. Thus, slight deviation in future tasks may trigger central sensitization causing pain to recur. Also injury not rehabbed properly has a higher change of re-injury. Proper rehabilitation cannot be done with manual therapy alone.
Movement, like manual therapy, is not a new thing. In fact it is as old as the physio profession itself. Physical therapy by definition, is all about movement. Just that movement had just got the attention it deserves in the recent past. Movement goes beyond prescription of therapeutic exercises to certain conditions [i.e., 3 best exercises for back pain, neck pain, etc]. They should be functional and diverse, addressing the specific goal of the patient/client – to continue with sporting activities, to be able to get back to dancing, to be able to carry out household chores pain free… the list goes on.
My movement therapy intervention starts with graded movement exposure. This process addresses patient’s fear avoidance of movement. Much of the rationale for graded movement has something to do wit pain neuroscience, which third but possibly most important in the list.
Once the patient/client has gained more confidence in movement, more complex movement patterns are taught and prescribed as next home exercise program. Movement matrices [movements in different planes and combination of planes], increased speed of movement, movement with resistances are developed and taught. For clients who have more active lifestyle or are involved in sporting activities plyometrics may be the final phase of movement therapy
3. Pain Neuroscience
Understanding pain neuroscience makes pain and injury management becomes so much simpler and easier. Instead of coming up with ridiculous and unscientific biomechanical paradigm like postural pain, muscle imbalances, spinal units called vertebrae and disc going out of place, increased anterior pelvic tilts, unequal leg lengths, and many other fear mongering biomachanical phrases which can cause more anxiety to the already suffering pain patient, explaining pain in the context of neuroscience gives a better assurance to the clients that their condition is not that bad. It may take time to “heal” but with excellent prognosis. Pain science paradigm is also cost effective as it eliminates, in most cases, the need for expensive scans and imaging like X-rays and MRI.
In a nutshell [as condensed from words by Jason Silvernail], pain neuroscience is grounded in the notion that pain is a conscious feeling that motivates protective behaviour, not a discrete biological event that occurs when tissue is truly in danger. Thus, the relationship between true danger and perceived danger is modulated by the sensitivity of our protective system. Meaning that pain and injury are more not necessaruly correlated. Understanding these things decreases perceived danger and therefore pain, and positions a biopsychosocial approach to rehabilitation as the best approach to rehabilitation.
Read this primer on pain science here.
4. Preventative Healthcare
To some, physical therapy as preventative healthcare is something new. Many still see Physios as go to professionals if someone has serous injury, physically handicapped or has neurological problems. But physical therapists, sometimes in collaboration with personal trainers and nutritionists can help in prevention of many chronic conditions like stroke, diabetes, osteoporosis, falls and fractures in the elderly, and obesity, among many others. Proper physical therapy assessment and training can also help prevent or minimize injuries in young and professional athletes, weekend warriors, performing artists and other active lifestyles.
Office workers and those whose jobs require them to either sit or stand for long hours can also benefit from the services of physical therapists. Moreover, children nowadays lack physical activity as they spend more time texting and playing computer games. Physical therapists can provide education and activity prescriptions to inactive populace, either children or adults.
So these are what comprise my approach in my physical therapy practice. In the past, I have been impressed with so many techniques my colleagues teach and use. I have tried to learn some of them. I felt sorry for the things that i couldn’t afford to learn. either through lack of money or lack of availability of the training. In some classes I attended, I was even taught a watered down version of what evidence-based practice is, just so they can justify the things they teach and do which lacks solid and strong scientific evidences.
As I stay within the scope of evidenced based practice, not only my interventions have become simpler but I have been seeing higher success rate, and happier, more satisfied clients and patients.