There is a physiotherapist out of the UK named Adam Meakins who posts regularly about various physical therapy topics including issues with the profession, our techniques, and our shortcomings. He goes by "The Sports Physio" and has a very respectable social media following: 54.4K twitter followers and 76,000 followers on his blog... compared to my 270 twitter followers and 9 blog followers (plus my mom). I present these numbers for the sole purpose of demonstrating that he's a well-known PT. I have followed him and read his materials for about a year and have come to find that he challenges my thought processes, which is essential for my growth, though sometimes is hard to swallow.
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This post is not meant to be an attack on Adam. He works hard to improve healthcare and physical therapy practices - noble efforts with messages I often agree with. He expresses his perspectives confidently in an unapologetic abrasive manner that has a certain appeal for getting his message across. (AKA - there's no bullshit. He tells it like he sees it. I love this about him.) He's a physio and he's trying to help people live healthier lives doing the things they love to do... so I respect him. I have never met him in person (yet), but I do pay attention to what he's posting because I think his perspective is really valuable, even if mine differs, like it does right now. I wonder what it would be like to shadow him treating patients for a day.
The blog (and video) he posted discuss the use of palpation (evaluative touch) and how we present our findings to patients.
Adam listed multiple studies as his references, many of which I have now read, which report that either more research is needed or that palpation techniques are not reliable. To my knowledge, there are not many papers that say the opposite, and my skills of critically appraising research are certainly inferior to Adam's, but this paper contradicts the research presented in Adam's blog post. I had to search to find that one. I searched because I have found multiple occasions where someone has told me to do something with patients because they read an article about it - and I was able to find multiple publications that stated the opposite information. So when I read his post and immediately felt like it didn't sit right with me, I had to do some searching. Maybe I don't understand his message properly. Maybe I'm too biased to see through my own thought processes. Regardless, I am conflicted.
Adam points out that physical therapists are not good at palpating things like "knots" or "trigger points" or "tight bands" or "joint play at the spine" and that we are not consistent between providers or even consistent with our own practices. In non-medical terms - if you smell pizza in the morning and identify that it is, in fact, pizza - but in the afternoon smell the same exact thing and identify it as a cheeseburger, you're not being consistent with your own findings. And to tell someone that you have a cheeseburger when it's actually a pizza could be confusing or problematic. Scientific research says that physical therapists touch patients to evaluate them but report different findings. The research also says that we cannot identify if parts of the spine moves abnormally or identify which level of the spine we're touching with consistent results.
Maybe it's more about the way the care is interpreted and explained to the patient than the actual identification of specific structures and the interventions that are applied that Adam has a problem with. I agree with him that we really need to STOP TELLING PEOPLE their L5 is rotated or their back is out. What does it mean for you to throw your back out? That is not medical terminology. Can your back ever be in?
But... when I palpate, particularly at the spine, I do feel "something." Of course I'm biased on my opinion of my own patient care...it would be wrong of me to use interventions that I did not believe were helpful and, since I also manipulate the spine on occasion, I feel it is essential for me to use palpation to identify hypomobile segments of the spine. I feel hypomobility in some regions compared to other regions in the same person. While I don't generally compare spinal mobility person to person because I don't find that useful, I do correlate certain patient responses with what I'm feeling in soft tissues in my hands and compare that to what I've felt with others. If a person laying on the table in front of me presents with a neck that is tender to palpation and their cervical and thoracic spine feel stiff compared to their lumbar spine, I want to treat this issue. Maybe with manual therapy. Maybe with exercise. Maybe with both.
I used to do things very differently. I no longer say to my patients, "Wow your neck is really stiff," or "Your 1st rib is stuck"- though I do sometimes feel a stiff neck and a hypomobile first rib... which I treat. I don't say these things any more because it freaked out the patients. They'd worry about their rib being a problem.
I used to look at the pelvis and tell patients that they had one leg longer than the other. All the time. Guilty. I didn't know better, then! I used long axis distraction of a leg to distract the hip while simultaneously re-aligning the SI Joint. That's what I truly believed. I'm telling you that I used to regularly yank on people's legs. Maybe as often as daily. Wanna know why I did it so much? Because sometimes IT ACTUALLY WORKED. And they felt better. And that's a bit of what Adam Meakins is saying... that we can be convinced that the care we're providing is beneficial, even when it is not supported by research. I eventually learned that it didn't work as much as I thought it did. It didn't help enough people. It could have been harmful to the patients and I constantly felt like I was doing something to patients to try to fix them rather than guiding them towards ways to fix themselves.
Humans can't be symmetrical if we have hand dominance and we move to get in and out of a car in the same way all the time but less frequently on the other side of the car. Our heart is not centered in our chest cavity. There is only one spleen and one liver and they're not in the middle perfectly symmetrical.... So while Adam Meakins is practically pleading with physical therapists (and hopefully chiropractors and physicians) to STOP telling our patients that they have anatomical problems that are probably not actually problems, and I agree with that message... I still feel "something" when I palpate the spine.
If patients ask, I now use an explanation about the nervous system having a reason to try to protect that particular region of the body and that by using load management strategies, it may calm down. I explain that "hurt does not equal harm"... that the tissues of the body may hurt even though damage is not occurring. The body uses pain to protect itself. And then I give a home exercise program to guide them on restoring motion, strength, or function based on what I determine the patient needs... which I did by using palpation.
I remember sitting in PT school and being taught how to palpate the multifius and the transverse abdominus musculature to assess if they're contracting. I could never feel the multifidi. Never. And then the PTs at my first job out of PT school encouraged me to focus on assessing the multifidi in various positions and using abdominal bracing and using electric stimulation in conjunction with abdominal bracing on my patients. I tried to use that. But I could not feel it. This is what Adam seems to be describing but relevant to palpating the spine. Is it possible that we have different skills with regard to palpation? Is it possible that while I cannot feel the multifidi, I could feel hypomobility at the spine? Is it possible that the issue is not about what we identify, but more in how we express it to our patients? We are definitely impacting the beliefs of the patients we see.
The podcast interview goes a bit more into the discussion of the narratives that physical therapists (and healthcare providers) present to their patients and how this can negatively impact them. I like that Adam states in the podcast that removal of pain is the wrong way for PT to be going as a profession. We need to be empowering patients, give them realistic expectations, and help them operate within the constraints that their individual bodies allow. The goal should be developing resilience and tolerance - not elimination of pain. I agree with Adam on all these points.
I also agree that we are over-treating patients. Too many visits. Too many referrals from person to person rather than really understanding what's going on.
I also agree that the medical system doesn't operate in an ideal fashion. Insurance companies limiting treatment influence the care that patients get. This is wrong.
I also agree that sometimes the best treatment for a patient is NO TREATMENT. I recently was working with a patient who was seeing so many different providers that I just sat her down and told her - I think you're trying to find too many solutions to a small number of problems and can't follow a single path to your recovery. I recommended that she sit down and write a list of all the people she had been seeking answers from, and pick the one that she wanted to commit to. Who do you believe is helping you? Follow that person. Get rid of the rest of us. Everyone telling you different things is confusing and ineffective. I don't actually care if physical therapy is her solution. The best solution for every patient is the one they buy into and helps them find a way to get back to their function. Period.
Even as I write this, I'm feeling my thought processes shift about what I say, but I"m not ready to throw away palpation yet. I like that I'm trained to provide spine manipulations and have had some really great results using it. I use it selectively and in conjunction with movement. And so, I'm unwilling to throw away a tool from my toolbox that I sometimes find essential. At least for now.
Take Home Message: There are lots of really good physical therapists out there, many of which are creating content that is easily accessible and easy to apply. The messages differ between them. But patient populations differ and you have to believe in what you're selling to your patients. I believe in a little Mike Reinold and a little Lenny Macrina and a little Lorimer Moseley and a little Adam Meakins and then I add some strength and conditioning with Eric Cressey and a little breathing from yoga practices and a little mental health... and I'm my own unique clinical provider because of all those influences... which is why I keep writing about all of them! So use a variety of backgrounds and consider opposing opinions, try out different techniques, challenge your own beliefs and welcome growth along with failure. Feel free to tell me if I'm wrong... I may not like that, but I'd like to think I'll be respectful and consider the alternatives.
Above all else - Do No Harm.
I just tried to post my reply and I had too many characters :-p
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