PHYSICAL therapy meme

Exercise, manual therapy or both?


In this episode of #AskMikeReinold, we talk about the recent debate between exercise versus manual therapy. But honestly, why choose? To see more episodes, subscribe and ask questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 235: Exercise, Manual Therapy, or Both?

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Transcription

Eric King:
Okay. We have John from Philadelphia. I work at a clinic that treats many recreational weightlifters with low back pain, dead squats and lifts. My colleagues use a lot of transverse abdominal bracing and manual therapy like joint mobilizations and release of trigger points to be treated. I use more graduated exposure to exercise and movement patterns.

Eric King:
How do you all approach this population?

Mike Reinold:
Impressive. Good job, Eric. I love it. Good. Welcome to the show. Don’t we like these types of questions, such and such questions, right? Like, will there ever be something where we don’t say both?

Dave Tilley:
Yeah. Right.

Mike Reinold:
As always, is there something [crosstalk 00:03:22] I guess that’s true. Trump and Biden. Republican, Democrat, I guess we’ll never say both. We cannot come to any agreement. Okay. So yeah, we hear that all the time. It’s pretty funny watching John’s thing. So you can almost see that there is almost like a change in thought process within a clinic, right? Transverse abdomen and manual therapy, joint mobs, like it’s probably a bit more of a veteran physiotherapist, right. It was a very popular style of treatment, probably I don’t know, 90, two thousand, right?

Mike Reinold:
Start two thousand. And now John wants to use graduated exposure to exercise. What I agree with, I was just cracked up with the wording of graduated exercise exposure. I think it’s just exercise, right? We will slowly expose them to the exercise. But yeah, I mean, I think it comes down to is there a need for a paradigm shift? So John obviously feels like the current approach to graduated exposure is probably the best approach, but I think you could say that his colleagues had some pretty positive results, or they wouldn’t do it yet, no? So I don’t know, who wants to start this one other than the boat? We’ll come back to weightlifters with the backache concept of that, and what we can do, but I guess that’s more of the boat, but Pope, what do you think?

Dan Pope:
I think there’s a lot of pressure in the social media world right now, at least in the world of physical therapy and strength conditioning, that manual therapy may be unnecessary, you know? And I feel like a lot of people start to stop with all of their manual techniques, they don’t really try it and use it. I really liked the analogy that if you have a headache, if you wait a day or two, it will probably go away. But if you take ibuprofen, it gets better. I think manual therapy is a bit similar, and most people who come to us want to ease their pain and get back to their activities. So why don’t we do both? But I think a lot of research coming out on manual therapies and the long term effects people start to think, I don’t need to do this, I should stop doing this, it doesn’t help at all my patients. I’ll make them count on me.

Dan Pope:
I think all of these things are floating around in people’s heads so they feel bad about using them. But yes obviously we use both and we think both can be useful for people for various reasons.

Mike Reinold:
Dan always answers these questions so well, and so politically correct and stuff, I’m just pissed off, just like the answers too, I appreciate that, that’s so good. But I think that’s a really good approach, Dan, and a good way to put it, too. And keep in mind too, with Dan commenting on some of the research that casts doubt on some of these things, just realize that most of these studies are studies on whether manual therapy works for back pain.

Mike Reinold:
Right. And wow, there are so many limitations with this concept. We are talking about back pain. You are literally looking at subjects 25 to 85, how do you define manual therapy, how do you define back pain? It’s like a ridiculous question that we are trying to ask. But yeah, a great way to put it, Dan. I think it’s great. Dave, what do you think?

Dave Tilley:
Yeah, I mean, I think I’m a perfect example of someone who went through what Dan was talking about. Early in my career, I got out and got into the world of pain science and kind of gave up on manual therapy, and I was dealing with a lot of non-specific low back pain. So I was obviously trying to get these people moving more.

Dave Tilley:
But as I got into sports and started working with you, I realized I needed a lot of biomechanical education. Strength conditioning has a huge role to play. And so it’s hilarious because especially when I’m talking to students now and things, like 80-90%, if you look at the basics, are the same in both things in terms of, what do you do with it? manual therapy, exercise? And I think if you define it as manual therapy, as Dan said, as a way to help someone be a little more comfortable when they are exercising, why the hell isn’t it? would you not use both? And I think we see a lot of that in the clinic where someone can’t tolerate even the basic exercises, and as a new graduate you are scratching your head because there is no directional preference. , everything hurts, it’s chemical irritation.

Dave Tilley:
So okay, three to seven days is like educating yourself and trying to calm yourself down, and then we’ll walk you through the exercises more. But 90% of the time I do manual therapy and education to get someone to tolerate a directional preference of McKenzie or SFMA exercises with more comfortable pressures and say, okay, both do it hours until I see you next week. And they come back and they feel a lot better, with the education, basic manual therapy, a little warmth and just super down to earth, easy stuff. And it’s really not rocket science, I think people get caught, like Dan said, on social media.

Mike Reinold:
Yeah. Scaduto, I want to get you involved. I feel like we haven’t heard any wisdom from you in a while, but if any of your patients are working with you and they have non-specific low back pain or something, don’t is this not? Tell us a bit about your approach, like how do you combine manual therapy with exercise and some of the benefits that come with it I guess?

Mike Scaduto:
Yeah, absolutely. I really think it boils down to evaluation like what Dave just said. If they have a directional preference, I think it can be very helpful in our processing. But overall, my general philosophy will be that of course we are going to use manual therapy to try and alleviate some of their symptoms. I’m not necessarily sure how it works physiologically or psychologically, but if it can help reduce their symptoms in the short term, I totally agree with that. And I think we have to change this program over time, this program just evolves. And then as they progress and their symptoms subside, I will increase the volume or intensity of their training program. So we’re going to gradually transition them to an exercise-based program.

Mike Scaduto:
I think it’s great to do. I think you are okay to focus on manual therapy early on in a patient’s treatment and gradually move them to a strength or movement based program. So I think it’s about how their treatment changes over time and getting them to the point where they’re ready for what they want to do and what they want to get back to.

Mike Reinold:
Right. And you know what, I also always say, yeah, we’re dealing with a more athletic population at Champion, but I think that’s a little specific to John’s question. Anywhere with recreational weightlifters these days fitness athletes even recreational fitness athletes think about what they are doing there is so much stress on their body with good manners because they add stress positive to have a positive change in their body, and those are always empowering things. It makes your muscles sore. It makes them tight, it makes them sore. They are not injured, they have no back pathology. Sometimes they just have lower back pain because it’s just too much stress from training, lifting at the gym. Manual therapy is therefore very useful for these people to help them move better and make them move again, warm the tissues and move.

Mike Reinold:
This way you can then achieve your gradual exposure to exercise. So we can still do that sort of thing with them, but manual therapy helps them. But remember, it’s not just the pain they feel, their soft tissues are probably tired and sore from the activities they do. So we know that manual therapy helps increase range of motion. This helps improve movement patterns afterwards. It helps modulate neuro pain. We’ve seen all of these things with it. I mean, if my hamstrings hurt because I just did a few sprints yesterday, which I would never do by the way, but imagine if I did the first thing I would probably do would be wanting make me soft tissue.

Mike Reinold:
Also, I don’t worry about the graduated exposure to more sprints. I’m worried about doing foam rolling, maybe vibration therapy, even soft tissue on myself, to try and make those soft tissues feel better so that I can then resume my activities. So I think we ended up in this mess because we were too reliant or too simply on manual therapy and then kick the person out of the clinic and that’s all we did. This is poor practice of physiotherapy. It hurts. This is not physical therapy, it is just bad practice. It’s not about that. So I think we got a bad rap, but what’s happened now is everyone pooping on these things. So like everything else, if you’re just doing manual therapy and not exercising, I don’t even know, I don’t even think it’s 50%.

Mike Reinold:
It’s not enough. And vice versa, if you are only exercising, you are not doing any manual therapy, you are definitely slowing down your results, and you are probably not even addressing their main source of complaints. It’s not about you and your theories, what you wanna do with this person, this person was lifting yesterday and his hamstrings are sore, his back hurts because she just put a PR on his deadlift. Rub their backs, right? You know what I mean? You are not doing our whole profession a disservice because you are doing soft tissue on their backs. They want to come back and lift again in three days, let’s help them feel better ASAP so they can come back. But of course we want to include that with exercise. So put these two together and I think that’s an important way to do it.

Mike Reinold:
It’s going to be a so-and-so question where we’re almost always going to say both, but I really think you miss the boat. If you do both I think you will have very good success. If you do one, I think you’ll only get 20% success both ways. So it’s huge to bring those two things together, and I think that’s some of our fundamental concepts that we apply at Champion, and I think we’ve seen that work in a number of different athletes in different sports over time.

Mike Reinold:
Good. Right. Okay. Diwesh liked it, I think we’re good enough, so sorry. Sorry, I didn’t mean to yell at you, but I didn’t yell at you, John. But anyway, I hope we will help make it a little different. What I’m trying to do is not feel bad about doing that sort of thing, right? If you think this is the best thing to do, do it. But like everything else, I think there is a happy medium we can do to really help our patients even more. Such a good question, John, I know this concerns a lot of people. I know a lot of people feel the same way. So keep asking yourself questions like that, we’re here to answer based on our clinical experience, all the years we’ve spent doing this we’re here to help. So keep asking, go to mikereinold.com, click on that podcast link and fill out the form to ask us questions. We’re here for you. Anything we can do to help, and we’ll see you in the next episode. Thanks again.



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