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Hands on, hands off? The swings in musculoskeletal physiotherapy practice

      There are swings and roundabouts in every sphere of life which are often driven by prevailing socioeconomic factors, societal needs and desires as well as an increase in knowledge or evidence base. This includes healthcare. Of interest in this instance is the conservative management of neck and back pain where in simple terms, the extremes are solely passive or solely active treatment approaches. In this context, we question whether it is time to steady the swing in musculoskeletal physiotherapy practice and offer ‘coffee time’ observations and comments.
      Reflecting on historical trends, there has been a considerable swing in the model for the diagnosis and management of back and neck pain disorders. In earlier times the model had almost a uniquely biological base and debates often related to disc versus facet joints as the origin of pain to direct medical interventions. The failure of many early surgical interventions amongst many other factors pointed to the obvious limitations of the biological model for the diagnosis and management of neck and back pain. The seminal paper by
      • Waddell G.
      1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain.
      led to worldwide change in ethos to consider and manage patients with spinal pain disorders within a biopsychosocial context, rather than a biological one alone. The last 25 years has seen a surge in research into neurosciences and behavioural sciences. This is providing a deeper understanding of pain and the presence and possible modifying/mediating roles of psychosocial features. However has the pendulum swung too far?
      • Hancock M.J.
      • Maher C.G.
      • Laslett M.
      • Hay E.
      • Koes B.
      Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?.
      have recently expressed concern that consideration of a pathoanatomical diagnosis for low back pain seems to have almost disappeared, which is the antithesis of the medical approach to most other conditions/diseases. They note that clinical practice guidelines appear content to use the label ‘nonspecific back pain’ for 90% of low back pain patients. The result is that guidelines direct general symptomatic treatments for the majority of back pain patients which at best are having small effects. They argue for the need for continuing research to better understand the biological component of low back pain, that is, a return to a balanced biopsychosocial model for future research into low back pain.
      Are we seeing the same unreasonable swings in musculoskeletal physiotherapy practice? Let us consider the two ends of the spectrum, passive management approaches and active management approaches. Shifts and advances in practices are expected and indeed needed. Certainly we would not like to remain in earlier times of predominantly passive approaches. Then there was a dominance of prescribed passive treatments such as bed rest, collars and corsets, traction and electrophysical agents. Such modalities were supplemented with some general strengthening exercises in one direction or another, depending the practitioner's preference for the flexion or extension concepts of the times. We welcomed the massive growth and development of the practice of manipulative/manual therapy. The framework within which manipulative/manual therapy practice was developed (i.e. a clinical reasoning framework), revolutionised the way patients with back and neck disorders, and indeed all other disorders, were assessed and managed conservatively by physiotherapists. However manipulative/manual therapy from the patient management perspective was essentially a passive approach.
      As is now well known, the evidence from clinical trials indicated that passive treatments such as prolonged use of collars or bed rest and electrophysical agents were not effective and the transition to an active approach began in earnest. However this was not the case for manipulative/manual therapy. Indeed contemporary evidence for the management of both neck and back pain in principle supports a multimodal approach inclusive of advising the patient to stay active, exercise and manipulative/manual therapy. Yet from the field, there seems to be a swing to predominantly exercise for spinal pain disorders often with overt or covert inferences that inclusion of passive treatments such as manipulative/manual therapy verges on an almost sinful approach.
      Back to the title lead, ‘Hands on, hands off?’ There is ample evidence of changes in motor control in association with neck and back pain. Thus there is no argument that exercise and activity are important components of any rehabilitation program to address these deficits. There is also ample evidence that zygapophysial joints and discs are common sources of pain. Manipulative/manual therapy is directed towards the painful joint dysfunction and there is a considerable body of research into the mechanisms of effect and effectiveness of manipulative therapy. Manipulative/manual therapy has proven pain relieving effects. However like
      • Hancock M.J.
      • Maher C.G.
      • Laslett M.
      • Hay E.
      • Koes B.
      Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?.
      call not to forget pathoanatomical lesions, and despite social pressure, the evidence suggests that the use of manipulative/manual therapy should not be forgotten. Painful joint dysfunction is present in the vast majority of neck and low back pain patients.
      The biopsychosocial model and the WHO International Classification of Functioning, Disability and Health (ICF) model are both valuable models and depict the potential multifaceted nature of spinal pain disorders. Within the biological dimension at its most basic, patients' functional disturbances are associated with varying degrees of pain, joint and muscle impairment. It is not surprising that multimodal approaches to management have proven to be superior to one-dimensional approaches in any of the biopsychosocial domains. Hence we advocate steadying the swing in musculoskeletal physiotherapy practice. The major challenge is to improve patient outcomes and the focus should be on further developing, balancing and optimising the components of a multimodal approach for the management of patients with spinal pain disorders.

      References

        • Hancock M.J.
        • Maher C.G.
        • Laslett M.
        • Hay E.
        • Koes B.
        Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain?.
        Eur Spine J. 2011; 20: 2105-2110
        • Waddell G.
        1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain.
        Spine. 1987; 1987: 632-644

      Linked Article

      • Response to Jones
        Manual TherapyVol. 17Issue 5
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          We thank Mr Jones for his considered reply to our editorial (Jull and Moore, 2012) where we highlighted and questioned the apparent swings in musculoskeletal practice.
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      • Hands on, hands off?
        Manual TherapyVol. 17Issue 5
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          The need to avoid shortcuts in clinical reasoning should be a basic premise of person-centred care. So I welcome Jull and Moore's (2012) editorial that challenges the perceived mutual exclusivity of ‘hands on’ and ‘hands off’ interventions.
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