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A recent Dr. Spina Facebook rant on the importance of good manual care…

November 8, 2012

Here’s one of my now famous rants that I recently put up on Facebook.com/FunctionalAnatomySeminars:

@DrAndreoSpina:
“Working solely with rehabilitation exercises while omitting manual therapy application is NOT practicing Evidence Based Medicine”

….I don’t know when it started…nor why it is happening, but there is a ‘movement’ occurring in manual therapy world where it would appear that a number of practitioners want to abandon a HUGE amount of good evidence in o

rder to confine their usefulness to the prescription of “corrective exercises.” Of course, I am not denouncing the use of rehabilitative exercise…for those who know me you will know that I don’t believe that any condition is ‘fixed’ with manual care. Rather that manual care creates tissue alterations (or ‘cellular environment’) that will better ‘accept’ exercise…which is what ‘fixes’ problems. However to even imply that rehabilitation can be the ONLY way to manage MSK problems is not only contrary to the concept of EBM…it is in a way anti-research!

….stay with me for a moment…a person comes into the office with LBP. You may, or may not actually touch the person when assessing them (which actually is what is being done in some ‘circles’ now!!!) and you come up with a “brilliant” diagnosis of “Mechanical Low Back Pain”…which is to say, “I have no idea what is wrong with you, but I hope that with my next procedure….’movement screening’ I can fool you into thinking the contrary.” Thus the movement screen begins, which usually entails watching them do some arbitrary movements (which really lack scientific validation BTW)….and you conclude that there is a ‘biomechanical’ issue leading to the problem. NOW…if you truly believe this, then you are, by default, concluding that something is “wrong” with some of the tissues – ie. they are NOT functioning well. You may also come to the conclusion that because some of the pathological tissues (which you did NOT diagnose btw…but only assume to know about based on your ‘keen’ eye which apparently underwent some miraculous evolutionary leap not afforded to the rest of us) are not functioning optimally, that other tissues have compensated. Thus you have a ‘dysfunctional’ system where “things” are, or are not “firing” (Whatever that means…and while on the topic….what does ‘facilitate’ or ‘inhibited’ ACTUALLY mean?…..moving on) properly.

…..So what is your logical conclusion???? LETS GIVE THEM EXERCISES WHILST THESE COMPENSATION PATTERNS STILL EXIST AND CONTINUE TO ENGRAIN THEM INTO THE MOTOR PROGRAMS…FURTHER, LETS IGNORE THAT PATHOLOGY OR ABERRANT HISTOLOGY IS OCCURRING IN ANY OF THE TISSUES (because recall you didn’t even take the time to assess the person) THAT WOULD PREVENT PROPER FUNCTION ANYWAY. What?

Now you could justify what you are doing like some are by pointing to a lack of DIRECT research in many aspects of manual care…choosing only the negative, skeptical side of things….always looking for how to use the research to disprove what others are doing instead of spending your time using research to justify what you are doing. But if you are this ‘glass half empty’ person then you are STILL not scientifically justified by only prescribing general ‘exercise.’ Further, you really need a lesson in what EVIDENCE based practice really means. RESEARCH is only ONE component of EVIDENCE. Further, if you confine yourself to ‘manual care’ research, you are ignoring a plethora of applicable research (histological, cellular, etc) that you can use to create an evidence-based system of manual care. There is no (to my knowledge) DIRECT RESEARCH to prove that anti-biotics are appropriate for bacterial meningitis….does this mean that you will refuse taking anti-biotics if you were unfortunate enough to contract bacterial meningitis? “Sorry Mr. Emerg doctor…I don’t believe your ‘assumption’ that an ANTI-BIOTIC, which is known to battle BACTERIA, is appropriate for my BACTERIAL problem because there is no direct study done that PROVES that it is appropriate in this particular case”….now, if you lived long enough complete this ignorant sentence, someone needs to explain the difference between research & evidence, because apparently you are having a difficult time separating the two.

Getting back to the original point….ignoring the usefulness of manual care (which btw has been used successfully for thousands and thousands of years thus providing lots of CLINICAL evidence), ignoring research out of the ‘scope’ of manual care, and substituting it with another component of care which truly has just as little ‘research’ (according to your definition) is ANTI-SCIENTIFIC and is NOT EVIDENCE BASED MEDICINE.

Sincerely,
Dr. Spina

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3 Comments leave one →
  1. November 8, 2012 4:46 pm

    Awesome. I teach for MPI and have had numerous conversations with people (many self proclaimed experts) about this very topic. More and more docs and students are getting away from using their hands not only therapeutically but DIAGNOSTICALLY. Karel Lewitt and Pavel Kolar are two of the best I have ever seen and no one seems to remember how well they use their hands both diagnostically and therapeutically. It’s frustrating. Great post.

  2. ben permalink
    November 14, 2012 4:33 am

    nice post Dr Spina. I would not be entirely dismissive cos as you know, there are the so-called 5 levels with RCT being the ‘king’ of evidence and personal testimony or expert opinion being at the bottom. One can also go to two poles in approaching data – reductionist (cellular, biochem) vs holistic (entire person). In the case of manip, Gonstead chiro would usually never adjust a new patient unless an xray was taken and also claim to deliver specific adjustments. Inter-rater reliab is not that high to begin with when therapists label a segment as Cx, furthermore Xray may not even show partial displacements of vertebra, etc.

    I know that FMS, and other movement screening (Gray Cook etc) is quite popular nowadays but it is not necessarily bad instead of chasing subluxations. firing sequence evidence may not be that neat as Janda thought but we may not be able to deny that something awry (neural signals whatever) is causing the patient to recruit say the lower back muscles, TFL rather than glute medius in a sidelying abduction. You can give a hvla to the hip joints, ART, etc but that does not translate into being able to recruit the glutes. Here i feel that Gray Cook really excels (as I have personally tried) – in one video he coaches a client who has knee caving in during squats and then says he is “not that smart” to figure out using a micro approach (weak glutes, etc); so he proceeds to give feedback to the client by using resistance bands to drag the client’s knee and so the client is forced to abduct the knee and make more use of the glutes. Whether this trick is neural grooving i dont know, but it works!

    • November 15, 2012 6:05 pm

      Hi Ben….
      I don’t know that it is me who is being dismissive….rather, I believe that the point of the article that I wrote is to remind people NOT to be dismissive of utilizing manual care.

      I am not against any system provided that there is at the very least a scientific ‘chain’ that can lead to the conclusions that we made. That is not to say that there must be direct research on the topic…only a solid theoretical foundation with its basis in the literature.

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