Over the weekend I was involved in a discussion on a forum site about active versus passive approaches in manual therapy. It was posted by some very sensible people, well versed in pain science and with further training in exercise approaches. My comment to them suggested that their understanding of active approaches was going to be different to a lot of other practitioners, still stuck in passive mode. I suggested that because these guys were well advanced on their integration of pain science into clinical practice, that it is easy to forget that there are large numbers of practitioners who have no understanding of these concepts and how they work in the real world – that things weren’t changing as fast as we might think they are. Someone replied to my comment that this was not the case, as in their experience, most practitioners were on board with prescribing a stretch or two as part of treatment or occasionally recommending someone do pilates. Job done.
It was a Saturday afternoon, I was wrangling 3 kids solo and trying to bake a cake for a four year old birthday the following day. PLUS, I am a massive chicken on the internet.
I hate the conflict, tend to take it all very personally and it seems to be rare that a good outcome results from these often heated discussions. Everyone thinks they are right and the lack of tone, body language and other social norms that would ordinarily govern such a discussion are lost – things tend to get said that ordinarily wouldn’t, if the discussion was face to face. Therefore I didn’t get back on and say what was burning and bouncing around in my head as I beat butter and sugar together – THAT IS NOT AN ACTIVE APPROACH!
All was not lost though! Through the therapeutic mechanisms of smashing eggs and more beating, I tried hard to define what actually IS an active approach. I believe that if we summed up the things that pain science teaches us, active approaches over passive approaches would have to be my number one take home point – simply because it underpins everything else. It puts the ball back in the patient’s court, gives them a sense of control and reduces helplessness. Together with education, it paves a lifelong pathway for patients to manage their own condition, instead of having to rely on someone else to take their pain away or help them out.
Further narrowing things down, I pondered that language is the most important thing when setting up active approaches.
Language helps us:
- Convey to the patient with acute pain that everything is likely to get better, that they should stay active and remain positive that things will settle in time.
- Educate the patient with chronic pain about the changes that occur within the nervous system that perpetuate a pain experience and hence separate out tissue damage from pain, empowering them to move more and be fearful less
Language hinders us when:
- Our diagnosis and subsequent explanation to the patient implies that something is wrong, broken, impaired, switched off, weak…… Eg. Your pelvis is rotated, your leg is longer, your core is weak, your cranial rhythm is imbalanced, your feet are flat, your gluts are switched off and even your neck is out (yes, it still happens)
- Our management approach implies that in order overcome these diagnosed problems, the patient NEEDS to see the practitioner in order to get resolution of their symptoms. In other words – you can’t do this on your own.
Using an active approach in manual therapy really has very little to do with what actual techniques, exercises or stretches you use. It is about the tone of the consult from the second the patient walks in the door – creating an empowered patient who is in control of their own health. It is a bigger picture approach and understanding of our role in helping this person on their journey. An understanding that what we do with our hands plays a very small role in that process and respecting that the power we have with our language is MASSIVE. This doesn’t minimise or reduce the importance of our role as manual therapists –it just changes the emphasis.