A recently graduated manual therapist feels a little frustrated after a busy week seeing patients – some of them aren’t getting better like she had hoped. Or, they do really well initially, boost her day with praise and adoration, and then the following two weeks they haven’t maintained the initial changes, and are disappointed, hinting that she has done something different in the second two treatments that haven’t worked as well as that magical first treatment. She beats herself up, worrying that her techniques are not up to scratch.
A professional development course run by a fellow manual therapist comes to town, scheduled for the following week. It promises a new and fantastic approach to treating a classically recalcitrant condition – one that doesn’t respond well to manual therapy in either the literature or the clinic. Despite it being drilled into her at university – “don’t believe any claims without asking for the evidence”, she thinks this could part of the solution for her current slump – perhaps I just need to learn how to do it right.
She rocks up to the course, excited to see what magical wonders are going to be taught. The Guru rises and speaks of the many, many patients he (lets be honest, they are mostly blokes!) has cured with his patented technique.
Case study after case study, miracle after miracle. He shows his eager audience the magic – be careful, you need to do it exactly this way, or it just doesn’t work. Not feeling it? Do less. You need to do it in the correct order or………, your hands need to be exactly here not there, you must do it x number of times or hold for exactly x number of seconds……..
Inspired and excited, she goes back to work, and lo and behold on the Monday, in walks a patient with exactly that condition. Brilliant, she thinks and gets to work, her workshop notes hiding in the top drawer of the desk. Technique delivered as per the recipe – job done. Unfortunately for everyone involved though, the patient does not get better, even with repeated treatments following the exact described protocol. The patient is devastated – this is their fourth failed treatment and they had really felt positive this time – after all, the practitioner was so confident and enthused that she could make a difference. As for the practitioner, disillusionment is settling in hard and fast. Underpinning it all is a thought that keeps rearing its ugly head – “I am just not good at the techniques”.
What this poor disillusioned young lass has missed as she plummets head first into her first career crisis are a few key issues:
- If it sounds too good to be true, it probably is!
- If the literature has repeatedly demonstrated than manual therapy is not an answer for this condition – run very fast in the opposite direction
- While he may have helped many patients to get a good outcome, he failed to present all the cases where things didn’t go so well.
- The ones that cancelled their appointment because the treatment wasn’t working and they couldn’t be bothered paying to go back and tell him that. He is unlikely to ever know that this is what happened because he doesn’t have the time or need to call the patient to follow up – he is busy enough in clinic so doesn’t need the patient to return, and the administrative tasks he needs to complete each night are a much higher priority. Even if he did get the chance to call the patient, it is possible that they may not tell him the truth – upsetting a charismatic practitioner by telling them that they haven’t helped feels a bit icky – better not to say anything
- The ones who weren’t getting better, but did come back in – and look at him with sad puppy dog eyes, confused as to why they aren’t getting better as he said they would. He is likely to refer them on to someone else if they are persistent enough and hang around – nobody likes to feel that uncomfortable!
- The ones who claim they feel better, swept up in the practitioner’s enthusiasm and repeated claims that things are feeling or looking better in their opinion, despite the fact that they have no functional improvement. Let not take any objective measurements in these cases – why spoil a good story?
- The ones that were spontaneously resolving or healing on their own anyway – who doesn’t want to take credit for that and who is definitively going to know?
Pain science is continuing to paint us a very clear picture about the management of chronic pain conditions – any single modality approach is unlikely to be the answer the patient is looking for, especially if that answer is a complete cure. Pain is complex – there are lots of factors that come together to cause the brain to create pain as an output. The tissue factors are just one of those factors and therefore solely directing our efforts towards “fixing” those tissues is going to be an exercise in futility more often than not, particularly in the chronic pain setting.
In an ideal world, the practitioner might have spent time with the patient validating their pain experience and previous failed treatments, gaining an understanding of what they believed was wrong with them, helping them to set expectations and educating them about the neurophysiology of pain. She could easily then have delivered the treatment protocol as part of her bigger picture approach – after all, there is plenty of evidence to say that therapeutic touch can be helpful…… just not on its own! She then might have spent time setting out some active management strategies and giving plenty of reassurance. If both practitioner and the patient have a better focus on how they define success, they are more likely to be happy with the progression of the therapy process – and our practitioner might last a few more years in practice!
Got a favourite guru story? Tell us in the comments on the facebook page. Might be best to keep identities out of it though…..