There is quite the debate these days about how manual therapy works and particularly what types are best or get different/better results or is it all just placebo. Here is a case, n=1.
I’m evaluating a patient with upper back pain, medial to the scapular border and lateral to the spine, around T5-ish. We all know where this spot is, right? The complaints are approximately 8 months in duration, 5/10 pain secondary to increased breast tissue (20 lbs) during pregnancy and post-partum time periods, per the patient.
So, after a thorough evaluation including subjective statements from the patient like “it feels like it needs to pop” I throw down a super-boss pre-technique education session and set up a nice high-dog, mid-dog and low-dog supine thoracic HVLAT. Clickity poppity. 0/10 pain. High fives. For real, she threw up a high five.
This patient was seen 5 more times, not on my schedule (I’m an intern, not in control of my schedule!) She came in about 5/10 pain (so no real long lasting effects from HVLAT, she reported an 8 hr relief after the above encounter) and would perform specific exercises and get soft tissue mobilization and scapular mobs and spinal mobs and leave in 5/10 pain. No one at the clinic where I intern was trained in the HVLAT technique. I saw her again on 6th treatment visit; was able to get some good cavitations, and got 0/10 pain again. High Fives.
The point of the case is not that I’m magical, or that HVLAT is magical… but that it was magical for this patient. Adam Meakins wrote a very interesting and thought provoking post here titled “There is no skill in Manual Therapy..?” I agree that across the board manual therapy is interactive and engaging and involves touch and therapeutic context and a lot of things cannot be parsed apart from one technique to the next. The ectodermists certainly have my attention as far as interacting with the brain through the skin, love that idea. In this case (n=1), however, other attention giving touching techniques were provided with no benefit to the patient. That gets me to thinking that there was something about the HVLAT… or about the provider or the context.
The other providers at the clinic I intern in are caring and interact just fine with patients and there was therapeutic touching going on. But perhaps the ol’ concepts of ‘expectation’ and anchoring and priming are at play here. She came in wanting “the thing that makes my pain better” and was not able to get it. Using this idea, if she had gotten grade 3 spinal mobs at evaluation and got relief, then other techniques, such as soft-tissue or HVLAT, would not have been successful.
Was it just attention? Many will say that manual therapy is simply placebo, or no better than placebo. Perhaps they are right, I suppose research nerds are working on it now. Placebo is one of the most powerful forces in medicine and should not be under estimated. Erik Meira has a great post here at PT Podcast titled “Why I’m not a manual therapist” that makes some very nice points about all of this uncertainty.
Now, I don’t get caught up in the “It seems to make the patient better, so why not just do it?” mindset. I like to have evidence to support my clinical reasoning; the three pillars and all. (If you will note above the patient preference pillar was kept in high regard in her treatment approach. Mix that with what I’ve seen clinically and some evidence for immediate effects from HVLAT, and there we go).
That being said, I am OK with some unknown placebo influenced outcomes. I’m mean, heck, I’m not sure I can control for all that anyway. I may look like a guy who played a doctor on a TV show that a patient saw when they were a kid and now they are more likely to get better, etc,etc. We don’t live in a bubble, non-specific effects surround us, no doubt.
Now , as mentioned above, I’m not going to provide craniosacral treatment or rub peanut butter on it because it “just seems to work.” I chose Physical Therapy… I will use the placebo treatments within my scope! (don’t fall into the sar-chasm) In all honesty, that’s kind of true. I’m not a physician providing pills that may have a stronger placebo effect that their specific biological agents. I’m not a chiro who is providing life-saving vertebral re-placement adjustments, which work off placebo. I’m going to be a practicing PT, who will maximize the science and the placebo behind the treatment approaches we employ. (Note: I don’t find placebo a bad word; it is simply providing a positive environment wherein actions take place. I do not support deception or fraud in any manner.)
Now all this above writing is an exercise in reflection, a chance to try to work out how and what happened with my patient. I hope it spawned reflection with you as well.
Why did one thing work and not another? What was the causal agent? Was it the technique, the education, the provider? If another patient presents like this again, what will I maximize? Will I consider HVLAT? Will I consider maintaining the continuum of care within one provider?
To the untrained brain the HVLAT looks like the major change in treatment for this patient. But perhaps, as mentioned above, there are many factors which changed from provider to provider, day to day. In all I am happy to have been a part of some relief for this patient… now to figure out how all that happened…