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Modern manual therapy with Robin Kerr

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In this episode with Robin Kerr, we discuss her Research Review of a recent article which looked at the clinical effectiveness of manual therapy. We discuss how manual therapy has evolved within the Physiotherapy profession and how we can learn to use manual therapy in our clinical practice in addition to other treatments.

See Robin’s full Research Review here - https://physio.network/kerr-reviews1

Robin Kerr is an Australian trained physiotherapist with post graduate training in gait lab biomechanics and psychology. Over the last 35 years she has focused on research informed management of running injuries, pelvic floor issues, more recently the focus has shifted to persistent pain management and she continues to see elite athletes.

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Our host is Michael Rizk (@thatphysioguy).


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SPEAKER_03:

Critical thinking is where you're working on your feet with the patient. Critical thinking is when you sit. back after they've gone or after you've seen them a couple of times and you examine yourself and you ask yourself questions could i have done that a different way what was i seeing there why did i see that was i being biased have i been let up the garden path by something i've read that wasn't accurate research and i think that's the way that you become a good clinician that you're constantly morphing during a treatment and you're also constantly morphing your thoughts after the treatment so

SPEAKER_01:

A clinically reasoned approach to manual therapy is something we should all aspire to. Not sure if it's happening that often. Well, today we had Robin Kerr, an Australian trained physiotherapist. Interesting training in lab biomechanics and psychology. Really interesting double. Robin reviewed this paper, Clinical Reasoning in Manual Therapy, and kind of covered how we've gotten to where we are with manual therapy in the health professional landscape. Robin has done a research review on this paper, which you can try Welcome, Robin, and thank you for joining us. Thanks, Mike. Thanks for having

SPEAKER_03:

me.

SPEAKER_01:

You've done a research review on a paper, a clinically reasoned approach to manual therapy in sports physical therapy. And we were going to start with how we might use manual therapy as a symptom modifier, or at least what your takeaway was from the paper.

SPEAKER_03:

Yes, so it's the expert opinion piece. I really enjoy these because you're getting to see what experts do in their clinical setting. It was from a physio who works for the Denver Nuggets, a soccer physio with the New York Bulls, and also one of the academics from Regis, where some of the Bioloski workers come from. So in relation to the use of manual therapy in the paper on, he's acknowledging that there's been a lot of polarization in the hands-on, hands-off active versus passive, low key value argument are cropping up around manual therapy. And they argue for the need for a pragmatic gray area. So it's quite an interesting paper. If you can actually get into the reference list as well.

UNKNOWN:

Yep.

SPEAKER_03:

Their main argument with manual therapy is a symptom modifier for athletes. So these guys are all probably professional athletes, is that athletes already do a lot of exercise, already doing a ton of active activity. So they can be a little bit different to maybe a persistent low back pain patient that we would have as clinicians in the clinic. What you can do is use manual therapy, the short-term benefits that we know that it has, to decrease an athlete's pain, keep them exercising, keep them going to their training sessions, help them with their perception of their that they are recovering, that they'll be okay. As you all know, especially with professional athletes, there is a lot of anxiety and stress being a champ. It's hard to stay on top of things and you can kind of improve their confidence by letting them see that they are responding positively to a manual therapy technique that you perform on them or perform with them.

UNKNOWN:

Yeah.

SPEAKER_03:

In this paper, it was really interesting. I really appreciated it. And they do spend quite a lot of time unpacking the controversies about manual therapy. And they talk about active versus passive and low value care. And they support their argument for using manual therapy. I think what manual therapy has suffered from, particularly in relation to social media, and what a lot of people are exposed to on social media, is what I call the reiteration effect, or more colloquially, the loudmouth construct effect that comes on Yes. Yeah. Yeah.

SPEAKER_02:

In

SPEAKER_03:

actual fact, if you read through a lot of Chad Cook's work, manual therapy actually comes out on top in a lot of cases with the research. In relation to the argument that manual therapy results in lack of resilience, in dependency, most studies have actually shown that manual therapy results in people having reduced self-efficacy. For me, this dependency argument is null and void because for me, that becomes more of a management issue. For me, that are physios who are having to meet quotas, make a certain amount of money each week. It's not actually that the manual therapy is doing that. It's a management problem. Yeah. I found that very interesting.

SPEAKER_02:

Yeah, that is.

SPEAKER_03:

Yeah, and then it's actually a really nice study from Adam Lutz in the Spine Journal. The other paper that they backed themselves with that I really enjoyed reading last year, I think it was anyway, it was the Cochrane Review by Jill Hayden. And she was looking into systematic reviews for exercise for low back pain. So it's a bit removed from what this is all about. And that's the paper in which she found that Pilates was ahead of other forms of exercise. My background is statistics before I did physio. When you dig down into that big paper, you actually see that there's no difference in outcomes between active and passive therapy for low back pain. So really this thing about active versus passive and that manual therapy is passive and a bad thing is actually just based on personal bias, which I think is a really interesting thing because that is not the impression that you get from most people when you've got these camps of people who are pro and anti manual therapy. That I found was very interesting.

SPEAKER_01:

I've found this too, Robin, with a lot of new grads that I'm interviewing for the clinics in Sydney. I've never experienced a cohort in the last two years who are almost coming into private practice saying, I will or will not do these treatments. Yep. That's really strong. I've never noticed that before, that grads are saying, I just will not do that treatment and I won't practice this certain way. I thought that they might say that about, say, other things that have come and gone in our field, but they're saying it about manual therapy, which... is something that I'm finding challenging to reconcile.

SPEAKER_03:

Yes, because manual therapy has been a big part of physiotherapy. I started physio in the 80s, so I was right in the mix when it was becoming very powerful. And in actual fact, the whole physiotherapy course was about manual therapy. And if you wanted to do some neuro or some cardiothoracics, you were the odd person out. So I think one of the things that we have to move away from with manual therapy are the pathoanatomy and the purely biomechanical concepts. We know that that's not what it's all about. So the second theme that popped up in this was what are we looking at in understanding the mechanisms of the manual therapy? And that was coming from the work of Bialoski.

SPEAKER_02:

Yes.

SPEAKER_03:

And I think one of the authors, Youngman, was working at Regis with him. So in the paper that I put into Physio Network, we actually put a flow chart on the multifactorial neurophysiological mechanisms for manual therapy.

SPEAKER_02:

that

SPEAKER_03:

they modified from Bialoski's work. And they talk about three zones of what's going on when someone performs or has manual therapy performed upon them. And it really doesn't have anything to do with the manual therapy that I learned in the 80s.

SPEAKER_02:

Yeah.

SPEAKER_03:

There's a lot of contextual and a lot of neurophysiology that we don't understand that gives us our outcomes. Yeah. So I recommend people haven't had a look at the article that I did for Physio Network this month. Have a look at those charts and dig down into Bieloski's work. It does explain a lot of the things that can happen with the use of manual therapy in the clinic that we probably haven't thought about before.

SPEAKER_00:

This podcast is sponsored by Cliniko.

SPEAKER_01:

I love that. We'll put the link in the show notes, Robin, to not only the article, but the review you've written. So we'll have all these references. So talk to me, Robin, about the clinical reasoning component. So what did you learn and what did you review?

SPEAKER_03:

So what they did in this paper, they went through those arguments, but then they presented two clinical cases. One was a sprained ankle and one was an acute low back pain. And this is where it's really good to have opinion pieces and expert opinion because you can see what they've done in the clinic and how they went through and how they managed these athletes with some manual therapy in conjunction with other cognitive therapies and team management principles and to get them back onto the field and not let them miss training and not have them sitting on the bench for too long. So I think The important thing to remember about clinical reasoning, when you're a young physio, it's a bit different to when you've got a bit more experience. When you're a young new grad or you're fresh out, you tend to be in the, what we call the hypothetico-deductive clinical reasoning area. So you will interact with a patient and you will collect information based on your training and what you can work out. And then you will generate a hypothesis and hopefully test it. Say you're after dorsiflexion in an ankle, you'll test it and then you'll form the technique and then you'll retest again so it's a modified from the work of ron r-h-o-n they've actually put a feedback loop in the article as well where they go through and they show how they assess they clinically reason they perform a technique they reassess and that clinical success comes from being able to reassess and adapt on the spot in front of the patient to get them to the goals that you've both set for the athlete While you're doing that, to also make sure that they know how to look after themselves with some self-care, with the aim in the long run to be getting them back to doing their own self-care. So we don't want them running into the physio continued treatment if they don't need it. They need to be looking after that injury themselves. To me, I was quite surprised that this is new. I think where you've had your training really affects... whether you've learned how to clinically reason or not. I went through Cumberland College in Sydney and we were heavily trained in Maitland. And there is that clinical reasoning process when you're trained in Maitland. I know a lot of people around the world probably haven't had that type of training. So articles like this are so important and that you can start to stand back and think, oh, this is how I need to be using these techniques. But I think it would be easier for some people than others because I've always been surprised that people don't clinically reason. And I've also been quite surprised that people don't go on to do critical thinking after they've finished seeing their patients. Critical thinking is where it's the next level up from clinical reasoning. Clinical reasoning is where you're working on your feet with the patient. Critical thinking is when you sit down. back after they've gone or after you've seen them a couple of times and you examine yourself and you ask yourself questions. Could I have done that a different way? What was I seeing there? Why did I see that? Was I being biased? Have I been let up the garden path by something I've read that wasn't accurate research? And I think that's the way that you become a good clinician, that you're constantly morphing during a treatment and that you're also constantly morphing your thoughts after the treatment.

SPEAKER_01:

That's a really nice thought. And sometimes I think about a busy private practice and I have empathy because you need time. Not only do you need time, but you need space as well to do that. How do you do that? How do we do that in private practice?

SPEAKER_03:

When I first started private practice, I was in the military. I was treating 50 patients a day. It was an absolute sausage factory.

UNKNOWN:

I couldn't.

SPEAKER_03:

I thought I was a great physio, but they were young and I'm just getting better because they're going to get better anyway.

SPEAKER_02:

Yeah.

SPEAKER_03:

And then nowadays I work a bit more with people who've had a lot of failed back surgeries, a lot of very chronic low back pain. And I cannot get through all this within an hour. I need an hour. And that can be a real problem in some practices.

SPEAKER_01:

Yeah. We need to see less, have longer consults, charge more, some combination of those things.

SPEAKER_03:

And the problem is, is that some people cannot afford those higher fees.

SPEAKER_01:

Especially those in persistent pain. There's a link there, right?

SPEAKER_03:

Yeah. My feeling is sports teams, especially these sports teams that these guys have come from in America, have tons of money. In actual fact, what they found in this study was that by having the physio there doing manual therapy, it's actually more efficient because they don't go on to have to pay for MRIs and they don't have to go on to have injections and more expensive care. And they also made some comments about modality because modalities like shockwave machines are very expensive and And the physio clinically reasoning and implying a bit of symptom modification with their manual therapy is actually a lot cheaper than having the modalities going as well. So it's quite an interesting paper in a lot of ways. It gets you thinking.

SPEAKER_01:

What's your response to, I just prefer to spend my time on higher value things, said with a bit of sarcasm and arrogance normally.

SPEAKER_03:

Yeah. I get students saying this to me all the time and it's like, prove to me what the higher value things are, especially in relation to back pain, which is what I see in this clinic predominantly.

SPEAKER_02:

Yeah.

SPEAKER_03:

After a lot of these metas and these Jewel Hayden's Cochrane, I don't think they should be able to say that. Everything's about the same. There's not one thing active is not better than passive. I think they've been a victim of this reiteration effect on social media. They've come to think that what they're being told is true, but in actual fact, what they're being fed is personal bias.

SPEAKER_01:

And then I want to seep into some deeper arguments around that. You did a little bit earlier, but Have there actually been any proven risks, as in are they going to become more dependent or are they going to become reliant? No. Have we ever shown that?

SPEAKER_03:

It's never been shown. Chad Cook wrote a nice paper on the demonisation of manual therapy a couple of years ago in response to some of the criticism that was coming off social media. Yeah. And he actually had a medical researcher, like a medical librarian researcher, track that question for quite a long period of time and there was nothing coming up on the fact that manual therapy causes a lack of self-efficacy. There's nothing.

SPEAKER_01:

I'm glad you mentioned that. And then there's the thought of, this is another one I hear, I use my hands. I just don't do manual therapy in how you would describe it. So I think what they're alluding to is they'll guide a patient, they'll put a hand on a shoulder and which I love, but also they're kind of saying that with a view of, but I wouldn't do mobs or I wouldn't do a hamstring rub. Any thoughts on that?

SPEAKER_03:

So my problem is before I'm doing this sort of work, I was working in very elite level sport in Premier League overseas soccer. If you've got somebody who's had recurrent ankle sprains, I'll use an example.

SPEAKER_02:

Yeah.

SPEAKER_03:

Recurrent ankle sprains have lost a bit of dorsiflexion in their ankle. You can see that they've lost dorsiflexion in their ankle when you do your test and you might put your hand on it and wiggle their foot around a bit. So what are you going to do about it? If they've had loss of dorsiflexion for two months and they've called you in as a consultant, well, you've lost dorsiflexion. What are you going to do about it? You can give them some exercises. They've probably been exercising forever to try and get rid of that. If I can apply some quick manual therapy to that, to push that around, to get the dorsiflexion back, I'm going to do it.

SPEAKER_01:

Yeah. It makes sense.

SPEAKER_03:

Yeah.

SPEAKER_01:

They've tried the other things we're assuming at this point. And then I guess I'd zoom out one more time where the other discussion point I hear is, I prefer to focus on the patient's values and shared values and shared decision-making.

SPEAKER_02:

Yep.

SPEAKER_01:

And so I kind of sometimes wonder, maybe in that example and others, you could highlight ways around that. Or I feel like, of course, we're considering the patient's values if he's a soccer player who's lost dorsiflexion.

SPEAKER_03:

Yeah. Chad Cook's quite strong on this point as well. What his research has come up with, he's found that patients who actually pay for and pursue their care If manual therapy is used, do better. They have better outcomes. And in actual fact, patients who only get active exercise intervention have poorer outcomes.

SPEAKER_01:

Wow. And how is that measured?

SPEAKER_03:

I'm not quite sure. That was in that demonization of manual therapy article.

SPEAKER_01:

Yeah.

SPEAKER_03:

Then I think you can back that with the Adam Lutz recent research.

SPEAKER_02:

Yeah.

SPEAKER_03:

where he found that the best clinicians for low back pain, there were a lot of them, that was a really detailed meta. The better clinicians use manual therapy.

SPEAKER_01:

Well, we're out of time, Robin. Oh, that went quickly. We covered the paper and some nice opinions. Things I've wanted to chat to you about personally for a while. So we'll put the papers that you've referenced and your research review in the show notes. And thank you so much for your time.

SPEAKER_03:

Oh, you're welcome, Mike. That was a pleasure. Thank you.