A perspective of change

Definitions in the world of science continuously change. Just as our skin ages and changes so do our brains. The ideas and beliefs that we held to be true when we first learned about manual therapy in our undergraduate studies should also change and evolve as the understanding improves. When our understanding fails to evolve, we develop blind spots and strong biases.

Being 100% certain about something may blind us to other possibilities. You may have heard claims of certainty that ‘spinal misalignment’ is the cause of their pain or that a ‘weak core’ or a ‘pelvic tilt’ will cause you to have back pain. Many of these old ideas and misconceptions have been disproven and are not supported by science.

I often hear/ see statements from other therapist on social media stating, “I use x treatment for x condition, and I always get results”. “This is the best protocol for low back pain” or “apply this technique for 3 minutes to resolve shoulder pain” 

But these “specific protocols” and interventions are not supported by the literature. 

While we all know that research doesn’t have all the answers, if we can take what we learn from our experience with our patients and then add some well tested science, I think we can all agree that it can only help to improve our understanding and therefore improve what we can help our patients achieve. It’s not a case of research V’s our experience, it is a case of research AND our experience.

Each individual’s pain experience is highly variable and there is no one specific approach that will work for everyone. Anyone that gives you a recipe based treatment or a specific protocol to manage any injury is lacking a thorough understanding of pain and current evidence.

Practitioners from different modalities will usually tell you that their modality is the best and if you stick with it, you will get results…

Don’t get me wrong, people might improve with various different approaches and with different time frames whether we agree with them or not, but let’s dive in deeper about why.

Did they get better because of that technique you applied or that you apply your treatment in a specific order?

Perhaps it was the positive social interaction?

Was it because you gave them the best exercise program or maybe that they just improved their activity levels in general?

Did simple movement and exercise influence other lifestyle changes or improve their sleep and decrease their stress?

Did positive reinforcement and education decrease their fears and provide positive emotional changes?

Did they believe that your treatment was going to make them better?

Did you clarify understanding and improve their confidence and optimism?

Was it the empowerment that they are now able to be more in control of their pain?

Did this improved sense of control reduce the worry anxiety and stress?

Were they motivated to change, and your treatment was a component of their motivation and not the cause.

Was there a change in their lifestyle, job role, relationship, social circle etc?

Or did they just get better due to the natural course of healing?

It is far too difficult to pick out one and say THAT is why! and THAT particular treatment is effective. Because the more and more we understand mechanisms, the less certainty we have. There is no one size fits all approach, and it would be arrogant to say that we know what is going to work every time for every patient, and that we know the cause of their pain down to a single structure particularly when working with chronic pain.

I do believe the clinician can play an important role in the pain rehabilitation journey… But there is more to it than the techniques you apply.

Knowing that there are various other factors that can contribute to the success of your treatment is actually empowering. It means that we can utilise those factors intentionally. We can use them on purpose to amplify the effect of what we are doing with our hands or with our exercises. The importance of this therapeutic relationship can be powerful. By building this relationship of trust you are able to influence various other contributors to a person’s pain experience.

Pain is confusing and multifactorial and pain research still has a long way to go. 

I, just like many others, have evolved in my understanding over the years and begun to question things even more and ask the question “why?” rather than accept simplistic cause and effect rationales. 

I practiced this way for many years, mainly because I did not have an understanding of the complexity of pain, I had a simplistic biomechanical cause and effect view and viewed pain as a physical problem.

Much of what I learned in my undergraduate studies, served as a scaffolding to my knowledge because at the time it was the most accepted reasoning because the research had not quite caught up yet, or I was unaware of it and didn’t know what to look for or where to look for it. 

However, many of those fundamental principles, theories and rationales that I learned in undergraduate training are now very outdated. The techniques and therapeutic interaction etc may not have significantly changed but our understanding of what we think we are doing and the influence of that language we use has changed a lot, because we now better understand the mechanisms involved. 

It can be easy to become set in your ways and develop a strong confirmation bias, (Yes we all have our own bias whether we choose to see it or not) However being open to conflicting information and ensuring that our beliefs are pliable and have the ability to change when presented with new evidence is important.

Early in my career I certainly did not make everyone better, (I am still frequently faced with challenging patients where I face many road blocks) and so I was always confused as to why some patients would get better and others wouldn’t when you would apply the same approach and exercise for something like back pain. I knew something was missing, I just didn’t know what…

When people didn’t get better it was easy to create a counter argument and say, “Ah well it’s because of your posture”, or “you haven’t been doing your exercises enough” or “well you do have those degenerative changes in your back which can’t be fixed” or “you need to keep coming in for regular treatment to keep it under control…” This focus was on the physical, but pain is NOT a physical problem.

The more certainty we have about a particular treatment intervention, the more likely we are to develop a blind bias towards other possibilities.

As we understand more and more about pain, the less certain we are about what works. If pain and recovery was linear, we would expect that by removing the painful stimulus that the pain would go away or that minor tissue damage would equal minor pain and major tissue damage would equal major pain. But this also isn’t the case. Shifting the focus away from pain being a physical problem can be an insightful change of perspective.

I am not saying that you don’t get results with your treatments, but I am asking you to question is it really the technique alone? Or is there more to it?

The truth is… We still don’t fully understand pain very well and if we don’t understand it well, how can we be so sure about exactly what is needed to fix it.

Keep an open mind.