Usual Care Physiotherapy – Say what?

Usual care physiotherapy for chronic musculoskeletal pain, does anyone still do that?

I recently read a single – blinded randomized controlled trial article (Domingues et al., 2019) discussing the effectiveness of combined Manual Therapy with Exercise compared to “usual care” physiotherapy for the treatment of chronic non-specific neck pain (CNSNP). The first cynical thought that came to my mind was, “Are we still doing usual care physiotherapy for chronic musculoskeletal pain?”

I will openly admit that manual therapy (MT) is not my go to these days for managing CNSNP, only because there is a heap of evidence to show that it’s not recommended as a standalone and that it ‘could be’ used as part of a multimodal approach (Lin et al., 2019). Before I decided to explode into a rant about why these papers continue to be published (more on this later), I thought to myself, “no, why don’t you read the article and try and understand the authors reason’s for writing it?”

So, let’s start with the conclusion.

‘This study’s findings suggest that a combination of manual therapy and exercise is more effective than usual care on disability, pain intensity and global perceived recovery.’

Wow, big call I thought, good for physiotherapists who do manual therapy (and who just read the conclusion).

Sorry, I admit there’s skepticism in those previous lines, and rightly so. Reading through the article there are so many inconsistencies I don’t know where to begin, but let’s try anyway:

1. The frequency and duration of sessions – two 45 minute sessions of manual therapy and exercise for 12 weeks for chronic neck pain?! Is there justification for that, considering we could argue that just being validated is enough to generate treatment effects (Edmond & Keefe, 2015; Linton, Boersma, Vangronsveld, & Fruzzetti, 2018).
2. What’s the cost of a 24 session program of manual therapy and exercise? The cost effectiveness of manual therapy for the management of musculoskeletal conditions lacks support in the literature (Tsertsvadze et al., 2014).
3. Interestingly, a similar study byLópez-de-Uralde-Villanueva, Beltran-Alacreu, Fernández-Carnero, & La Touche, (2018) compared two treatment groups and an MT standalone control group. Treatment group one consisted of MT plus therapeutic patient education (TPE). Treatment group two was similar to treatment group one but added therapeutic exercise (TEX). The treatment protocol in the second group reduced the time period of MT after the introduction of TEX at session 5. The treatment duration was about 20-25 minutes of MT from session one through four and then reduced to 12-15 minutes from session 5 through 8. The entire intervention lasted for a duration of 8 sessions twice a week for 1 month. The second treatment group was most effective for reducing pain intensity and perceived global improvement.
4. That manual therapy as a means of treatment for “mechanical dysfunctions” has been refuted and that treatment effects are more likely down to placebo and therapeutic alliance (Bialosky et al., 2017; Bialosky, Bishop, Price, Robinson, & George, 2009).
5. How can you truly separate the specificity of manual therapy compared to that of usual care massage (Bereznick, Kim Ross, & McGill, 2002)?
6. Do clinicians still use the chattanooga pressure biofeedback device? I confess to doing a bit of a lit search and was surprised to find positive findings for its use.
7. There are potential risks of experimenter bias evident in the study
8. The usual care group didn’t receive an equal number of sessions to the manual therapy group
9. Are we unfairly comparing usual care physiotherapy with manual therapy and exercise to unreasonably justify manual therapy
10. Did usual care physiotherapy involve all the approaches? or just some of the approaches at the same time? Or perhaps at different times?

A reasonably extensive list. Plus, I’m no academic. So, I do wonder what else I missed. What stood out most prominently for me was the paragraph below:

‘Second, it is possible that important variables related to the outcomes may not have been assessed, such as anxiety, depression, pain catastrophizing and environmental factors. Previous studies have found a relationship between psychosocial factors and self-reported disability.’

Right… So why wasn’t this assessed then? We know from the research that psychosocial factors are stronger predictors of pain and disability in a variety of musculoskeletal conditions, including the neck (Costa, Maher, McAuley, Hancock, & Smeets, 2011; Dimitriadis, Kapreli, Strimpakos, & Oldham, 2015; Menendez, Baker, & Oladeji, 2015; Piva, Fitzgerald, Wisniewski, & Delitto, 2009; Thompson, Urmston, Oldham, & Woby, 2010) and that individuals with chronic musculoskeletal conditions, a multimodal approach is recommended (Lin et al., 2019). It bemuses me that in 2019, with the abundance of research supporting a multimodal approach for chronic musculoskeletal conditions, we continue to get articles like this, for which the only reason I can think as to why they are published, is to justify the continued need for manual therapy.  Of course, anyone reading the paper or this blog might say, “so what’s your point, because the results show it works”.

I can only say that looking at the evidence, manual therapy just isn’t that effective at helping people in pain for the cost, and yes whilst I agree it does demonstrate some short term effects that may be increased to moderate effects with a multimodal approach, it isn’t significantly better. Yes, we can argue that exercise and CBT compared to manual therapy is no more effective (Fredin & Lorås, 2017; Monticone et al., 2013), but there is a wealth of research to support exercise and cognitive behavioural approaches for addressing other factors that play a significant part in persistent musculoskeletal conditions.

So, yes there are schools of thought that would argue that manual therapy as a standalone is ineffective, that neurophysiological effects are likely, that it creates dependency, that it costs too much compared to something like exercise alone, that we can’t be specific with grade of mobilization etc etc. What I think we can all agree on is the futility in claiming mechanical effects and the nocebic effects of the accompanying narrative.

I recall something my mentor said to me when I first graduated. Physiotherapy is about health promotion and self-management. As an underpinning philosophy I still stand by that. Physiotherapy is not about maintenance or encouraging external locus of control or continuing flawed outdated concepts. It is a progressive evolving profession that embraces an evidence based patient centered approach. I’m sorry but 24 sessions of manual therapy for CNSNP is not patient centered.

Thanks for having a read

TNP

References

Bereznick, D. E., Kim Ross, J., & McGill, S. M. (2002). The frictional properties at the thoracic skin-fascia interface: Implications in spine manipulation. Clinical Biomechanics, 17(4), 297–303. https://doi.org/10.1016/S0021-9290(02)00014-3

Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2017). Unraveling The Mechanisms of Manual Therapy: Modeling an approach. Journal of Orthopaedic & Sports Physical Therapy, 48(1), 8–18. https://doi.org/10.2519/jospt.2018.7476

Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model. Manual Therapy, 14(5), 531–538. https://doi.org/10.1016/j.math.2008.09.001

Costa, L. D. C. M., Maher, C. G., McAuley, J. H., Hancock, M. J., & Smeets, R. J. E. M. (2011). Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. European Journal of Pain, 15(2), 213–219. https://doi.org/10.1016/j.ejpain.2010.06.014

Dimitriadis, Z., Kapreli, E., Strimpakos, N., & Oldham, J. (2015). Do psychological states associate with pain and disability in chronic neck pain patients? Journal of Back and Musculoskeletal Rehabilitation, 28(4), 797–802. https://doi.org/10.3233/BMR-150587

Domingues, L., Pimentel-Santos, F. M., Cruz, E. B., Sousa, A. C., Santos, A., Cordovil, A., … Branco, J. C. (2019). Is a combined programme of manual therapy and exercise more effective than usual care in patients with non-specific chronic neck pain? A randomized controlled trial. Clinical Rehabilitation, 026921551987667. https://doi.org/10.1177/0269215519876675

Edmond, S. N., & Keefe, F. J. (2015). Validating pain communication: Current state of the science. Pain,156(2), 215–219. https://doi.org/10.1097/01.j.pain.0000460301.18207.c2

Fredin, K., & Lorås, H. (2017). Manual therapy, exercise therapy or combined treatment in the management of adult neck pain – A systematic review and meta-analysis. Musculoskeletal Science and Practice. https://doi.org/10.1016/j.msksp.2017.07.005

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. P. B. (2019). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med, bjsports-2018-099878. https://doi.org/10.1136/bjsports-2018-099878

Linton, S. J., Boersma, K., Vangronsveld, K., & Fruzzetti, A. (2018). Painfully reassuring? The effects of validation on emotions and adherence in a pain test. European Journal of Pain, (2011). https://doi.org/10.1016/j.ejpain.2011.07.011

López-de-Uralde-Villanueva, I., Beltran-Alacreu, H., Fernández-Carnero, J., & La Touche, R. (2018). Pain management using a multimodal physiotherapy program including a biobehavioral approach for chronic nonspecific neck pain: a randomized controlled trial. Physiotherapy Theory and Practice. https://doi.org/10.1080/09593985.2018.1480678

Menendez, M. E., Baker, D. K., & Oladeji, L. O. (2015). Psychological Distress Is Associated with Greater Perceived Disability and Pain in Patients Presenting to a Shoulder Clinic. Journal of Bone and Joint Surgery, 97(24), 1999–2003. https://doi.org/10.2106/JBJS.O.00387

Monticone, M., Cedraschi, C., Rocca, B., Fiorentini, R., Restelli, M., Gianola, S. E., … Moja, L. (2013). Cognitive-behavioural treatment for subacute and chronic neck pain. Cochrane Database of Systematic Reviews, 2013(8). https://doi.org/10.1002/14651858.CD010664

Piva, S. R., Fitzgerald, G. K., Wisniewski, S., & Delitto, A. (2009). Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome. Journal of Rehabilitation Medicine, 41(8), 604–612. https://doi.org/10.2340/16501977-0372

Thompson, D. P., Urmston, M., Oldham, J. A., & Woby, S. R. (2010). The association between cognitive factors, pain and disability in patients with idiopathic chronic neck pain. Disability and Rehabilitation, 32(21), 1758–1767. https://doi.org/10.3109/09638281003734342

Tsertsvadze, A., Clar, C., Court, R., Clarke, A., Mistry, H., & Sutcliffe, P. (2014). Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: A systematic review and narrative synthesis of evidence from randomized controlled trials. Journal of Manipulative and Physiological Therapeutics, 37(6), 343–362. https://doi.org/10.1016/j.jmpt.2014.05.001