Replicability in Manual Therapy Studies for Back Pain

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the gap between social media and actual clinical practice, seeking real mentorship from real clinicians treating in the clinic instead of social media influencers, and the importance of having a healthy sense of humility regarding manual therapy treatments.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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ZAC MORGANGood morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty here with the cervical and lumbar spine management, teaching both of those courses on the weekends. And if you have not had those courses, both of them involve a decent amount of manual therapy. So we enjoy kind of teaching manual therapy, doing manual therapy on one another those weekends and kind of reframing how you might frame that manual therapy intervention with your clients. in the hopes of maybe creating a little less dependence on manual therapy and instead a lot of independence in our patients and kind of pushing them towards a more fitness-forward lifestyle. For those of you that have been to the courses, you know that's a big deal to us here at ICE and we love doing that. And this morning's podcast is titled Manual Therapy Misconceptions because I think this is definitely an area in the manual therapy world, physical therapy specifically, where I see a lot of disconnect between what happens in the clinic and then what happens on social media. So I want to start out by talking about over the last several years of spending a lot of time on the weekend, you know, teaching manual therapy techniques, fielding questions in those settings, as well as spending a lot of time in the clinic treating a lot of clients with acute back pain, with acute neck pain, with persistent back pain, with persistent neck pain. I see a lot of misconceptions and at our clinic we spend a lot of time training younger clinicians and bringing through students and then also on the weekends working with a lot of seasoned clinicians And I just see that social media has had an influence on our profession's willingness to use manual therapy and our understanding of everything. And so I think that's what today's podcast is about, is sort of how that has been influenced and maybe just reframing some of our thoughts around it. THE GAP BETWEEN SOCIAL MEDIA & REAL CLINICAL PRACTICE There's one thing that's for sure. If you spend a lot of time on social media and specifically follow a lot of the conversation that happens in our profession, you'll see a huge gap between what a lot of people say out there on social media and what actually clients want and what drives people to seek out physical therapy. So there's a huge gap there. And that's where I want to kind of start is with the social media conundrum. Obviously, social media platforms have become such a popular way for us to get new clients, for us to educate the public, and for us to educate one another within the profession. But there is a conundrum here. And the conundrum is that all of the platforms, really regardless of which one you spend time on, they are built specifically for the reason to drive engagement. The goal of those apps is to keep you on them for longer. That's why they exist. So within that, the content that typically keeps people's eyes on it for longer is generally framed more contrarian or more negative, that tends to drive engagement more frequently. So if you post something negative or if you point out something negative, often you will see a lot more engagement, a lot more comments, a lot more likes, a lot more just overall view of that content. And I think that this can cause a lot of issues in clinicians and has caused a lot of issues and I've seen it firsthand and that's a huge issue in our profession. So I kind of want to talk a little bit about those issues specifically and then what we might do to sort of reconcile them. SOCIAL MEDIA DRIVES CLINICAL CONFUSION So the biggest issues that I see and this is really regardless of whether it's a younger clinician or somebody who's a little bit more of a seasoned veteran What we see is when people spend a lot of time kind of intaking some of that negative information from social media, it drives a lot of clinical confusion. People are confused about what they should do with their patients. It drives ethical challenges. Some of these posts call into question how ethical manual therapy is, and it makes people feel like maybe it's a little unethical for us to be doing hands-on care. And they definitely often drive further away from expert opinion. So when I say expert opinion, I mean things like our clinical practice guidelines. So you think about what that is, like how those are formed, and it's really the foremost experts in our profession getting together, synthesizing all the data that exists, synthesizing clinical experience as well, and then making evidence-based recommendations. To get a clinical practice guideline published, it requires a lot of work, a lot of experts to communicate with one another and develop expert opinion. And here's what we think. This is a grade of A, this is a grade of B, and so on. To get a social media post out requires nothing other than an internet connection and a device that can do it. sometimes we're reading these opinions from non-experts and those non-experts could wind up being very loud and have a large platform and that doesn't always equate to someone that actually spends a lot of time in the clinic. So I think this is where some of that confusion can come into our practice, whether again, whether you're a younger clinician or someone that's more seasoned, it's kind of who we're choosing to listen to because of who's the loudest on social media and that being where we get most of our information. "MANUAL THERAPY DOESN'T WORK" So the narrative specifically, the misconception specifically that I'm addressing in today's episode is this manual therapy doesn't work narrative. So a lot of people have that feeling that manual therapy doesn't work and there are certainly studies that have challenged the efficacy of manual therapy and you see those studies get talked about a lot on social media again because they're negative and they drive engagement. But that narrative is one that I have heard often be challenged either on the weekend or in the clinic where people are just confused about whether or not manual therapy works. And that's a huge disconnect between clinicians that you talk to that do treat a lot of these issues. Those clinicians typically feel strongly that it does work and again our experts If you look in the clinical practice guidelines for back pain, for instance, you're going to see that really regardless of the presentation, there's some expert opinion that we should use manual therapy, that it should be used almost regardless of acuity or stage. Manual therapy might be something that should be included in back pain. And that's not just profession-specific. A lot of clinical practice guidelines make those suggestions, but ours certainly do. The updated ones from 2021 from Stephen George and colleagues make a lot of recommendations surrounding manual therapy. So I think that disconnect is driving a lot of clinical confusion for us. The reason this podcast kind of came up in my head, the topic, really came to me when I was looking through the recent JOSPT and there was a systematic review from, forgive me if I butcher the name here, but I think it's Ruzick et al, and this was just a couple of weeks ago that this one was published. You might have seen it in Hump Day Hustling, our newsletter. But essentially, it was a systematic review. It was done over at Bellin College. So the DSC program and the fellowship there at Bellin went in and they did a systematic review, kind of analyzing the literature, looking at manual therapy for low back pain. The question they were trying to answer was, are the methods in these manual therapy studies, the way they're described, are they repeatable? So in other words, if you read these studies, and you're an independent researcher outside of the group that just did that study, could you read through that and then actually replicate the findings? And the way they were looking at that is, are the methods described well enough for us to replicate the interventions? The answer was no. There was poor reporting in manual therapy intervention studies, and that limits the reproducibility of those findings. This is a big issue because one of the major tenets of science is that it needs to be replicable. You need to be able to check your work. If you're not able to do that, I would call into question whether or not it actually is science. At the end of the day, science has to be described well enough that an independent researcher could then come in and replicate the interventions to see if they can replicate the findings. If you then get a lot of data pointing in one direction, we start to say, you know what, I think there's some merit here. But if the methods aren't described well enough that we could even replicate them, you have to call into question whether or not that's actually science. And I guess my point here is a lot of these conclusions that are drawn on social media posts are of an independent study where maybe the methods aren't even described well enough to where you could apply them to the clinical cases you're seeing. And so we're drawing a huge conclusion that manual therapy doesn't work Meanwhile, the studies aren't even replicable. I think this is a massive issue. There's a huge disconnect there. And so I don't just want to point out the issue, I also want to talk to you briefly about what we might could do going forward, given that the studies don't guide us that well, given that they're not super replicable, and given that we can't draw those big conclusions off of non-replicable studies. And so let's address those problems. CLEAR UP CLINICAL CONFUSION WITH ACTUAL MENTORSHIP I think that the confusion here can be sured up by seeking mentorship. expert opinion and just time around expert practitioners. So what you will find often when you're actually seeing those people treat in the clinic, when you're working alongside of those people, is they're not confused about whether or not manual therapy works. They often have some type of a framework that they're bringing forward to the patient and they feel confident that they can often help patients because of their skill set. So I think we, as a profession, need to lean more on the empirical side of the scenario, given that our data is a bit confounded by lack of replicability. So what I mean by empirical is things you can witness, things you can see. The test-retest model, actually spending time around clinicians that utilize that and frame it positively for patients. That's what I think we should be seeking out as our evidence-based practice right now, because I think a lot of our actual evidence is challenging. That is the short-term solution. In the short-term, I would suggest if you're a younger clinician or a seasoned clinician who has some disconnects surrounding manual therapy, seek out mentors that have an understanding of manual therapy, who see a lot of back pain, who have busy schedules, busy caseloads full of patients with back pain looking to get better and see how they handle those scenarios. I think that is a much better route than seeing social media posts and drawing a huge conclusion from those posts. Meanwhile, the evidence that they're analyzing isn't that great. RESEARCH METHODS MUST IMPROVE The second thing would be a more long-term solution, and this is more speaking to the research going forward. We have to improve the methodology. That's what that systematic review from JOSPT That's what they suggested, and I couldn't agree more. In the future, our methodology has to improve. We have to get better at describing our techniques so that we can, over time, whittle down what is the most effective. But the problem is, that doesn't help you today. When you go see that patient that comes to see you with five days of low back pain, and they're really looking to feel better quickly, and they're starting to lose a lot of functional capacity because they're not doing much, because their back hurts so much, and you're confused about whether or not you should use manual therapy, long-term improvement of methods won't help you. You need to fix the short-term problem and get some understanding by spending time around clinicians that are used to seeing that and that can help you move that patient forward. And again, our practice guidelines are pretty clear here. they make a lot of suggestions surrounding utilizing manual therapy. And most of my colleagues that also treat a lot of back pain, that's basically my whole caseload is back pain and neck pain, occasionally shoulders, hips, knees, but a ton of back pain and neck pain. and I utilize a lot of manual therapy. And I don't feel bad about that. I feel like framed in the right way, it's so helpful to help that person reduce their concern and improve their activity. I agree that there are some ways you could frame it that might challenge someone's belief system in their body, but just don't do that. Just frame it correctly. And so that's my call to action. Seek credible mentors, contribute by pushing our profession forward with the use of these techniques that patients are going to seek out and they're going to get regardless of whether they see you or someone else. So let's be good at it so that they do seek us and then reframe the methods in future studies so that that way we can actually get good scientific data moving forward and understand what works and what doesn't. SUMMARY Team, in summary, I think a lot of clinical confusion comes down to a mismatch of understanding the quality of the information you're receiving. Social media has made it very easy to get your opinion out there, and often there will be opinions coming from folks who may or may not even be experts, who may or may not even be treating in that region, and challenging your belief system on whether or not an intervention works. And I see that confusion manifest as confused young clinicians who have a challenging time deciding whether or not they should utilize manual therapy. Spoken from someone who treats a lot of those problems and who has spent a lot of time around experts who also treat those problems, I've been very lucky to get a lot of time on board with experts. there's not that much confusion on the other side of the coin. So I think that mismatch of where you're getting the information from is huge. So my call to action is let's improve our manual therapy skill set. If that's what you're looking to do and this message is resonating with you at all, I'm going to tell you about a handful of upcoming courses because this is huge for us at ICE. This is why we don't hire people who aren't clinicians. It's really important to us that at ICE, when we bring forward a message to you, you're getting that message from people who actually are in the treatment room. They're behind the walls. actually trying to eradicate these problems over time. UPCOMING COURSES If you're looking for that in the cervical spine, May 18th and 19th, Casper, Wyoming, that one's filling up fast. So if you're in that area and you need a spot there, Casper, Wyoming only has a few seats left, make sure you jump into that. At the end of June, the 29th and 30th, will be in Kent, Washington. And then in July, the 13th and 14th, Charlotte, North Carolina. So a handful of options there for neck. If you're looking for low back, this weekend we've got two course offerings. If you want a last minute ticket, you can certainly jump into one of those. Carson City, Nevada, and then right here where I'm at in Hendersonville, Tennessee. Still seats left in both of those. And then next weekend, April 13th and 14th, near Boston in Braintree, oh I'm sorry, yeah, in Minnesota. I think I've got that down wrong. I think it's Braintree, Massachusetts and that's actually over in the Boston area. So if you're looking for either one of those and you're liking these narratives for reframing manual therapy, jump in with us. We're excited to bring forward some different ways of framing manual therapy. Thanks, that's all I've got for you team. We'd love to hear some interaction here in the comments throughout the day. Keep an eye on the thread.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.