??? Different responses to manual therapy?

[Lachlan]

When perfoming manual therapy (whether its mobilisation, skin stretch etc) im sure we all see some patients who get up and feel alot better, whilst for others there is no change at all.

I am interested in the opinions of some of the experts here regarding:

1- what is going on here? What is the difference between "responders" and "non- responders"? Is the chance that someone benefits from manual therapy purely based off expectations or does some sort of characeristic of the condition e.g. the responders may have initially been in more pain due to having more descending excitation, which in turn was able to be downregulated with manual therapy.

2- How does the response to manual therapy alter your treatment? E.g. do you educate a "non-responder" differently to a "responder"? Will they recieve different exercises or advice?

I understand that there is alot of grey area between a "responder" and a "non responder" and its obviously an over-simplification. However your opinions would be much appreciated.

[Bas Asselbergs]

1. yes, expectation is a biggie here. If they were hoping for a snap-crackle-pop solution, the soft stuff would be enormously disappointing and thus negate any positive input from the periphery. My experience is that those in more pain are often the ones who will respond better to gentle touch - a generalisation for sure.

2. Usually, I have a decent idea of what "type" of patient I have after the education part (pain neurophysiology); those who I think are paying lip-service and just say "I understand" so they can receive what they hope for usually do not get DNM, but a strong focus on active motion. My perceptions of my patient expectations are wrong sometimes.

So, yes: they get a different follow-up to the education part. Non-responders get action followed by another attempt at education. Responders are well on the way to self-help.

[John W]

Lachlan,

I don't consider myself an expert, but that's never stopped me from offering my opinion in the past.

This is a really good question about responders and non-responders to manual therapy, and I don't think any CPR will ever answer it adequately.

1. As Bas emphasized, patient expectation with manual interventions is a major factor. Simply screening the patient by inquiring about their previous experience with manual therapy can be very helpful in deciding what type or even whether to use a manual intervention. Even then, if they've had a good experience with manipulation (high-velocity thrust), particularly by a chiro who has convinced them that they have a "subluxation", then they are well on their way aboard the mothership and any attempt to bring them back to earth is improbable. By the way, that's a very difficult situation to deal with if you've been referred the patient by a physician (I mean a real physician, not a chiro).

2. I think the purpose of manual therapy is to facilitate getting patients to move on their own by reducing the threat level of mechanical input. So, if they report less pain in the region that is affected by position or movement after manual therapy, then the next step is to introduce some type of movement. The more creative and self-generated this movement, the better.

Barrett's approach with Simple Contact is an elegant integration of manual therapy and self-generated movement. It seems to me to be the "gold-standard" based on current pain theory and neurobiology. I'm not saying that this is what should be applied on every patient (ignore patient expectation at your peril) by just any therapist (you have to actually understand the neuroscience and it's application to the patient in front of you), but it should be what we compare all our other interventions to. Furthermore, I think we should aspire towards this approach to care because it makes the most sense based on what we know, and it respects the patient's personhood the most.

[Frédéric]

What both Bas and John said and :

Definitively the specific of the condition will certainly influence whether you are a responder or not.

For instance a pain which is not mechanical in origin might not yield it self as good to manual handling as would the opposite. Perhaps the first will respond better to proper education and self management while the latter might profit better from a more hand on treatment.

Dynamic tactile allodynia might also be a sign that manual touch might not be such a good idea, or at least the type of touch will need to be chosen carefully. Skin streches might not be tolerable (or not a good idea) in some of these cases.

About your second point, this thread has abundandtly discussed the pittfalls and problems with trying to treat a patient while being faithfull to both your knowledge and the pt's own set of beliefs.

[zimney3pt]

Just a side thought to responses to manual therapy. We had a section on genetics in my tDPT program this week so that is what sparks my question. Do we think that genetics play a roll in how someone will respond to manual therapy or not? (I think most will say - "yes/maybe")

But my next question is do we think that further understanding of the genome of people will someday help predict outcomes with manual therapy as they are predicting the potential with medications?

Maybe the ultimate Clinical Prediction Rule at some point will be genome, lifestyle and environmental markers...just a thought