Should we abandon the structural/biomechanical model of low back pain?
Erik Dalton: I’ve been a long-time fan of Eyal Lederman and respect the enthusiasm, brilliance and energy he brings to the manual therapy community, not only through his CPDO workshops in England, but his extensive writings. In the recently published paper titled, “The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain,” he debunks almost every conceivable assessment and treatment modality for low back pain.
Although well-researched and eloquently presented, this is not “hot-off-the-press” news. Every day, new studies surface from elite medical journals debunking another researcher’s findings. Scientists have collected over a century’s worth of low back data and, as yet, no one’s been able to produce a single piece of impervious, irrefutable evidence to completely explain the complexities inherent in lumbopelvic pain. According to Dr Lederman, it’s time to clean house on this structural/biomechanical model. So, let’s begin by tossing out all the manual therapy trash. We’ll make it simple by immediately eliminating all hands-on modalities including muscle energy, structural integration, orthopedic massage, visceral, myofascial release, cranial, strain-counterstrain, assisted stretching, visceral, high-velocity thrust, nerve mobilization (did I miss anyone)? And let’s not forget the orthopedic tests…still no good inter-tester reliability there either. What about functional movement training/core stability…sorry…gotta go! Needless to say, there’ll be no need to keep your physical therapy rehab appointment Monday cause we’re doing away with electrical stim, ultrasound, tens, stretching, thermal therapy, lifting advice, SI joint belts, home-retraining exercises, neuromuscular, and traction too. But to be fair, we need to also clean house in the medical community.
Neuro and ortho surgeons will be delighted with the extra time on the golf course since we’re ridding the operating room of virtually all surgeries and injections for back pain including: laminectomies, discectomies, cage fusions, artificial discs, Herrington Rods, sacroplasty, vertebroplasty, steroid/facet/prolo injections and kyphoplasty. Well, wait a minute, maybe not kyphoplasty, a procedure which seeks to stabilize compression fractures, restore normal alignment and reduce symptoms. Since aberrant spinal curves do not correlate with spinal dysfunction, according to Lederman, we probably won’t be seeing many of these kyphotic surgeries. Please tell that to gravity! The radiologists can take the day off too cause we’re doing away with MRIs, myelograms, CTs, bone scintigraphy, electromyography, PET scans, plain films and the like. They just don’t seem to provide the reliability we’d hoped. But the MDs tell us that’s not fair…”granted none of these tests can be considered 100 percent reliable as a standalone diagnosis, but when viewed in conjunction with other exams, the reliability factor increases…Oh…so that’s OK???”
It seems that notable manual and movement therapy leaders like Philip Greenman, James Cyriax, Janet Travell, Warren Hammer, Fred Mitchell, Jr., Paul Chek, David Butler, Leon Chaitow, Craig Liebenson, Stuart McGill, John Upledger, Gray Cook and many others have been telling us that for decades. It’s obvious to any experienced manual or medical clinician that orthopedic tests, including visual gait screening, have better reliability when used in conjunction with other such tests. But, maybe that’s where the magic comes in that’s proved so difficult to measure in the confines of a laboratory. The ‘key’ to client satisfaction may lie with the experienced therapist who, through trial-and-error, has developed a combination of orthopedic tests and corrections to custom fit the client/patient that stands before them. Now that may be a tough study to design when dealing with the biomechanical complexities of the lumbar spine.
The bottom line seems to be that no low back pain testing strategies will ever prove successful as long as techniques/modalities/assessments are ‘clumped” into a single group and then generalized to a large population. Low back pain cannot be successfully evaluated independent from the functioning of the entire body. The researchers may have better success by breaking the studies into sub-groups, i.e., sciatica, piriformis syndrome, facet syndrome, etc.
Maintaining a healthy back is an individual thing and part of an ongoing process that requires a positive mental attitude, stress reduction, exercise, sex, diet, etc. Because we live in a society that thrives on sympathetic system overload, unnatural ergonomics, sedentary lifestyles, central nervous system malregulation, etc. we need to include ONGOING self-help therapies such as stretching, functional training, touch therapy, diet and psychological counseling to battle our self-imposed physical, spiritual, and emotional deficits. The idea of eliminating thousands of years of lifestyle enhancements via of touch and movement therapy simply because researchers have been unsuccessful in developing tools or experienced operators to measure their validity is naïve.
The problem partly lies with the difficulties inherent in screening for validity in such a personal arena as manual therapy where inter/intra operator reliability is, by nature, biased based on the clinician’s experience. And most importantly, it’s difficult to extrapolate a “second-in-time” from a person’s life, and declare that a particular intervention will never be effective. Therapy should be based on an ongoing “life-long” model of care. To throw out all postural therapeutics, functional testing, and associated treatment modalities simply because they may not perform well when randomized to a general population of low back pain sufferers may be going a bit far. It’s like saying, “my wife went on a diet, didn’t lose the weight she’d anticipated so abandoned the diet after a few months…musta’ been a bad diet.” The fact is, back pain or any neuromusculoskeletal condition must be an on-going DAILY process just like training to be an elite competitive athlete.
It’s no accident that superior performing athletes have magnificent bodies. If postural therapeutics, core stability and functional training were useless, Olympic athletes wouldn’t seek the help of manual and movement therapists. If scoliosis, slumped shoulders, valgus knees, short legs, twisted torsos, etc. have no effect on the individual as Lederman states, then why don’t we see these distorted bodies competing in professional sports such as the NBA? It’s because the postural/functional faults have already taken their toll via injuries somewhere along the kinetic chain and resigned them back to running with the “weekend-warriors.” My brother was a very good competitive wrestler and worked his butt off…and I can tell you his success wasn’t because of superior genetics. Not to say genetics doesn’t play a vital role….it certainly does.
I totally agree with Lederman’s allegation that our bodies possess an innate ability to heal themselves. In my opinion, therapists should seek to tap into the body’s innate wisdom and act as a facilitator, a coach, and a role model to help bring the body back into sync with Mother Nature.
When client’s come to see me, I expect to treat them and their families the rest of our lives. Some may need weekly therapy and others only need monthly or bi-monthly sessions. The obvious question is, “how do I know I’m doing them any more good than if they’d received no therapy at all?” The immediate answer that comes to mind is that I wouldn’t be booking clients a year in advance with a waiting list if bodywork is all a sham! Sorry, don’t have the charisma to keep any client coming for 32 years based on personality alone and it’s insulting to believe the general public can’t tell what works for them and what doesn’t.
No doubt, research is exciting, addictive and absolutely essential, but we must refrain from “marrying” each study that comes down the pike. No need to throw the baby out with the bathwater as Dr. Lederman suggests. Science is man-made and often flawed because man is flawed. But we must forgive and move on and continue enjoying the excitement of new research discoveries that better inform our individual treatment decisions. Professional athletes, the elderly, and the general public may not be a smart as scientists, but, at some point, you gotta say…”why have people persisted on drinking at the touch therapy ‘well’ since the days of Hippocrates if it’s all a placebo?” The placebo argument only stretches so far before it breaks under the weight of public opinion.
Please pick up Lederman’s Harmonic Technique book. In his articles, he’s able to drum up dozens of references to bash manual/movement therapies. But, when boasting of his own ‘hands-on’ manual therapy technique, his diligent research is strangely absent.
Steven Hanks: Intense…..Love it…This Business is being turned upside down with all the innovators, people who aren’t afraid to move forward and have escaped the stigma that so many have chained to their ankles, holding them back.
Danny Christie: What does Eyal recommend? I have only ever seen him speak positively about the Harmonic technique.
Erik Dalton: I still enjoy many concepts from Dr. Lederman’s, “Myth of Core Stability” paper from a few years ago but I sense this new edition may be too bogged down in ulterior motives. It seems a little attack oriented with two broad of a brush stroke.
My defense of the structural/biomechanical model may also have been a little over the top and I apologize if I’ve offended anyone. This is an emotionally loaded subject for those of us who’ve dedicated our lives to care-giving only to have all you’ve come to know and love, wiped out with a broad stroke of the brush. It’s degrading to have someone who’s never experienced your work or consulted with your clients inform you that all your efforts have been proven useless.
Gil Hedley: Don’t get hooked Erik my friend! There will always be hit pieces coming out, though one which dismisses so much in such broad strokes is impressive in the transparency of its bias. I’m sure there were engineers on the Titanic mocking other vessels, clear to their last gurgle…
Erik Dalton: Therapy Nicely said Gil…post it on Leon’s page. You’re clever as always my friend.
Erik Dalton:: Please ignore the placebo comment I made in the post above. Therapists are responding specifically to that statement which is only a small piece of the controversy, and not reading Dr. Lederman’s well-written, well-documented but, in my opinion… biased paper.
Rajam Roose: Not to mention, on page 9, the paper states “There are no known studies that examine the influence of manual techniques on PSB factors in the medium- or long term, in particular at the cessation of the treatment.”
Basically, the paper can’t refute manual treatment for PSB since it hasn’t been shown NOT to have any affect. That sentence to me makes me disregard the paper as any kind of threat to my profession.
Also mentioned on pg. 5 is the sentence “These studies demonstrate lack of association between work-related posture and LBP…” Again, as I wrote on Eric Dalton’s FB I have to disagree b/c I’ve had a client who was looking at surgery for heel pain due to calcaneal tendonitis or something like that. Turns out she’d been tucking her toes under her chair every day at the office for ten years! Once we loosened the adhesions in her calves and feet and she stopped toe tucking, the pain went away and she tossed her cane and canceled surgery. Not LBP but the same instances could apply and why not?
However, because that situation (among others) is anecdotal in nature, it has no bearing on whether or not something is true in the world of research and evidence based therapy.
Bodhi Haraldsson: Why defend something that dos not need defending. why not embrace a more holistic model called biopsychosocial. Pain is not a single entity. It requires a holistic multi-faceted approach.
The biomechanical model has failed when it comes to chronic pain in the neck and low back. It can have some immediate causation in acute though.
Bodhi Haraldsson: Ps. “placebo effects are genuine psychobiological events attributable to the overall therapeutic context”
Erik Dalton: Bodhi: Thanks for the post but I’m afraid I’m not quite following you. On the one hand, you say to look at pain as multifaceted and that it should be treated holistically, and then turn around and want to throw out a big centuries-old piece of the holistic pie, i.e., thevbiomechanical/structural model. This implies that the remaining piece of the holistic model for treating low back pain has all the answers …so, problem solved.
Most of the fascial work in vogue today is based on a structural/biomechanical model… shall we throw it out too? Of course, pain is multifaceted…who would deny that. Of course there is a placebo effect. None of this is new news… neurobiosocial implications have been beaten to death in the journals for years. I dedicated two chapters to the psychosocial aspects of pain in my 2005 book. In fact, we were studying placebo when I was a psychology grad student in the ’60s.
Leon Chaitow, Stuart McGill, Gary Fryer and a few others are simply defending the obvious attack on all forms of manual and movement therapy by Lederman’s obvious partiality for his Harmonic Technique. Is Harmonic an acceptable piece of the pie in your opinion?
It should be clear that with decades of low back pain study behind, if any one branch of medicine or research or pain management doctor had definitively demonstrated irrefutable evidence showing they can cure low back pain, we wouldn’t be having this discussion now? Everybody would be flooding their clinics for treatment.
Low back pain is, indeed, multifaceted… and even when studying holistic approach possibilities, there is no consensus for management of such a complex disorder.
If we’re throwing out the structural/biomechanical model, let’s at least be fair and rid society of the rest of the useless modalities the suffering public is paying for.
Tell me why our health care system is passing on costs to the public for non-proven modalities such as electrical stim, ultrasound, thermal, cage fusions, artificial discs, PET scans, myelograms, electromyography, Celebrex, prednisone, epidurals/facet/prolo injections and on-and-on. No one seems to like to tackle this query.
At least in my practice, people are pulling out their wallet and paying hard-earned cash (voluntarily) for my manual therapy treatment while the rest of the bloated health-care system is passing along the costs for these unproven–and often harmful–treatments to the rest of us.
My wife managed the Oklahoma Medicaid and Medicare System here in Oklahoma for several years and looking from the inside out…the focus of this debate would be better served if we focused more on why insurance companies continue to pay for ineffectual and VERY expensive medical modalities such as those listed above. Please leave us…the free market society of choice alone.
I think it is insulting and intellectually degrading to demand the public should discontinue their myofascial release, structural integration, neuromuscular, muscle energy, high-velocity thrust, craniosacral, visceral, assisted stretching, functional core training, pilates, yoga, and orthopedic massage treatments until science has been able to develop tests to prove their efficacy.
One of our greatest laws is the Law of Supply and Demand.
If you’re a crappy therapist or you just do not have the skills to help people in pain, an intelligent public simply will stop writing checks and move on. Bad therapist will not be able to make a living and they’ll be forced to tackle another occupation. Let the free-market work. This country was founded on rugged individualism. I know the general public isn’t as smart as scientists but they know what works for them.
‘ Erik Dalton: I think Lederman’s paper s something every manual therapist needs to read carefully to understand the impact of what he’s saying. Basically, that the work you’re about to do today in clinic is worthless and should be abandoned. I just added analogies to other medical professions for emphasis, i.e., the disc replacement surgery you have scheduled may be worthless, the physical therapy appointment, your radiology report, etc. although none have passed the scrutiny of science. Lederman and others are asking us to refrain from performing these modalities.
Alfred Westlake: I think that it is a real mistake to take a real hard line approach. Scientific scrutiny is good as far as it goes, but I think that the crux of the issue is that no one case is exactly like another. This has been alluded to but I think that…t the number one most important thing to understand is that one size does not fit all.
This is why experience, intuition, and connection with the client/patient are the most important things on can bring to the table. Healing is a process that the client/patient needs to be engaged in with the practitioner. This is why so many are failed by the modern medical model. Like many things healing is a science in it’s learning and an art in it’s manifesting.
So often I have observed that the clients level of confidence in a particular technique or modality is as much or more important than it’s supposed scientific efficacy. If they buy into surgery then that is what works if they buy into therapy then that is what works.
This is all within certain limits. What limits? It is different with each person and is in a constant state of flux. Science simply gives us new ideas, tools and some sense of boundaries. Even the new ideas and tools usually come out of intuitive creativity and then are tested for efficacy buy science. Often creative ideas and techniques are reduced to what can be explained through scientific methods simply in order to be able to teach the ideas to others.
Allison Lea Ishman-Blanchard Hear Hear, Erik! How eloquently and amusingly you state the real-life reality.
Erik Dalton:Leon: Appreciate your desire to debate Dr. Lederman’s assertions and, no doubt, it would be a very cleansing and healthy project for the manual therapy community.
I’m working on book and really didn’t want to take the time to respond to Lederman but I felt I had to say something…then I got carried away and started ranting…it’s such an emotional issue with me.
Some of our work may be flawed but I keep hearing the Hippocratic Oath my daughter and her medical school graduating class had to chant, “Do No Harm” and I realize there are few care-giving occupations who have more of a right to make that statement.
Time permitting; I’d be willing to join with a group to offer an opposing view to Lederman. Thx for all you do ~ ERIK
Rajam Roose: Oddly enough, I find that I both agree and disagree with the paper. I disagree in the sense of what I’ve seen in my work within the eleven years I’ve been practicing massage. Granted, it is anecdotal at best, but I’ve used structural tests …and found that by facilitating the change with bodywork and client awareness, there has been decreased to no pain for several years.
On another sense, I agree with the paper b/c I think that not all therapies work the same for everyone and I also agree that there are socioeconomic and mental health issues that relate to LBP. When I read the paper, I only had the sense that there isn’t ONE therapy for LBP. It is very important to think about the mental health. LBP may be a sign the person isn’t feeling supported in their life (according to energy workers) wouldn’t this make total sense in our society where we are not set up to have much contact and support throughout our communities. If you look at tribes where their culture is highly community based, I wonder how many cases of LBP they would report?!
Here’s an anecdotal story– I had a client for a few years and one day she came in with heel pain that progressed to where she had to use a cane and her doc was recommending surgery. Well, from speaking with her about her postural habits, I learned she’d been tucking her toes under her feet at her desk for the last ten years. Once we worked out the kinky calves and hammies, AND she stopped tucking her toes–the heel pain was gone, cane tossed and she hasn’t had an incident since. So, in that sense, I can’t agree that there aren’t ways in which we use our bodies that perpetuate pain.
So those (and many other) of what I’ve seen shows that the studies cited are flawed in some way. We don’t know what was the socioeconomic status of the participants in the studies, we don’t know how exactly the studies were conducted. We don’t know exactly what types of therapies, so they used manual therapy for 100 cases of LBP and only 2 worked? Well, there are thousands of people with LBP, so the fact something didn’t work for so few doesn’t mean much.
I do think the paper is important b/c there are some interesting points. I’ve had enough clients coming from failed PT sessions to know that not all PT works for LBP. I also agree that we do need to change our thinking about our bodies and the mechanisms of pain.
Erik Dalton: Yes Rajam. That is my point exactly. The mechanisms for what we see clinically will always be upgraded and disputed because of the inherent complexity involved with the ever-changing combination of evaluations and treatments we bring to the… session for each individual.
No part of the medical community (surgical, pharmacological, radiological rehabilitation, psychological, manual) can provide reliable/irrefutable evidence showing
they have a successful treatment for low back pain…and I doubt it will happen in the near future.
So are we to believe physical therapists will stop performing modalities such as electrical stim, ultrasound, thermal, exercise therapy… or will surgeons stop requesting myelograms, PET scans, MRIs, and quit performing disc replacements, cage fusions and laminectomies just because there’s no reliable proof of their efficacy? But Dr. Lederman’s asking us to do just that..why?
Janet Lawlor Cmt: Rajam, you make some excellent points and I agree with you. I’m currently working with a PT patient for LBP. After several months of 2x/week sessions with no progress, they sent her to me for 3 sessions. The first session re3.lieved 50% LBP, the second reduced her pain another 50%, and I have one session left.
Discussion from Leon Chaitow’s Facebook
Leon Chaitow via Erik Dalton Myoskeletal Therapy: Thanks for posting this Erik I’ve invited a number of manual therapy experts to debate the points Eyal Lederman makes – but so far the only response has been from one DC/scientist who agrees with his perspective! I am seeking individuals who can counter his arguments so that these can be published in the Journal of Bodywork and Movement Therapies. Do you feel you could offer counter-arguments that are supported by the literature Erik? If so you could be one of the debaters? Let me know.
Herb Levin: It is almost impossible for the Human Mind to except the concept of simply, Not Knowing.
Margie Plog: Is Lederman throwing the baby out with the bath water? How about debate this with physics…starting with “Wolff’s Law” ~ Form follows function and function follows form…also Isaac Newtons “Law of Motion”
Oliver Thomson: Does he realize that LBP is multi factorial??!!
Herb Levin: He must! All of life is Multi Factorial which is why trying to find the proverbial needle is so difficult,
Leon Chaitow: I urge those who have commented – or who are interested in countering his findings – to carefully read Lederman’s article, and find flaws. So far all I can come up with is his over reliance and possible misinterpretation of the metaanalysis he uses to justify his sweeping assertions. To counter these will take time and effort. The link to download it is on the very top of this page.
Dianna Linden: Not sure whether to call you Dr. Chaitow or use the more familiar, your first name. Are we automatically on first name basis when friended in the land of fb?
I’m still thinking about this article. There’s a lot to chew on. My view of it will …not win friends or foster popularity in the massage community, I’m gonna guess.
I came across an abstract of Dr. Lederman’s that I found interesting while cruising thru his website in search of what he does espouse. Clearly, other people’s paradigms are something he’s been busy writing papers refuting. It is the methodology of good science to do so and perhaps one of these papers earned him some additional letters after his name.
This study of his (“Co-contraction of triceps during isometric activity in biceps brachii: implications to Muscle Energy Technique”) challenged the “widespread, but unsubstantiated, belief in osteopathy that during MET the isometric contraction of agonists will reciprocally inhibit the antagonistic muscles” http://www.cpdo.net/res/osteopathy_11.html second abstract on the page. I, personally, have found several MET techniques very useful, and seemingly effective at addressing postural ‘anomalies’ and relieving pain, but now he not only has the cojones to challenge the relevance of these postural anomalies to pain syndromes but the very method employed. DRAT!!!!! HARUMPHHHH!!!! What’s a girl to do?!*^%$#
Unfortunately, since I’m an in the trenches kinda practitioner who loves the Yogi Berra quote: “In theory there’s no difference between theory and practice. In practice, there is.” and not a researcher, it isn’t that easy for me to evaluate the methodologies of any of these studies quoted or recapped to see how they came to the conclusions presented. It does seem to me, though, if you look long and hard enuf., you can almost find a study (whether well designed or not) to support or disclaim most hypotheses proposed, funding issues notwithstanding.
His adaptation of harmonic technique certainly sounds interesting, probably worth the purchase of the book,
I agree with quite a few of his observations/comments on “The Myth of Core Stability” . I also think he’s made some excellent points in his gathering of studies in “The Fall of the PSB Model” and missed some important ones, to boot. Hopefully I can find the time to articulate further, if nothing more than to clarify my own thoughts on this.
I do think there’s been a whole lot of whoey being sold as true and the basis for whole schools of bodywork by folks who have Rpt, DO, DC, MS, PhD. after their names or a book in print, self published or not, which seems to be enuf to validate their methods to the wide eyed community of well meaning and sincere manual and massage therapists. I think he makes a valid point that much of what is simply accepted as true in these belief systems that we cling to as though they are our religion might just be myths worth discarding and serve as nothing more than expensive distractions. Some of us have paid big money to be in workshops of too many students to learn what might just be mostly, partly, or slightly BS while the gurus slingin it as truth with a capital T, (or C.H.E.K.) rake in the bucks and sell their line of Emperor’s clothes as the new fashion forward trend this season to all who’ll buy in.
The newest craze in our field that I see is the idea of the existence of myofascial meridians. Books are being translated and sold in several languages, folks are orienting their work to a belief in their intrinsic existence, creating dance and pilates corrective classes to address bringing back the balance in these flows (which might have been better left a simple study guide for structural integration) and Tom Myers, great writer and probably nice guy that he is, is raking in the dinero. Soon he’ll be able to afford not only the schooner (or ketch) of his dreams if he’s not already sailin in it, but his own private island with windward dock at which to park it.
I think Dr. Lederman’s work and voice is important. Even though it ruffles feathers by refuting cherished beliefs. He might not be any more right than the beliefs he’s pooh poohing, and his stance is not one that makes you popular in the droves of acolytes, sycophants and true believers, but his courage to put it out there is admirable, IMO, and his scholarship in so doing seems well grounded. His effort is an important scientifically based check to the propagation of rampant snipe hunts among us.
Leon Chaitow: Thanks for your input Diana – and by all means call me Leon. I will try to respond to your comments – in no particular order.
a/ MET: Our understanding of how MET has its effects has changed over the past few years – and one change has been r…ealisation (through research described thoroughly by Gary Fryer PhD DO in chapter 4 the 3rd edition of my Muscle Energy Techniques book) that postisometric and reciprocal inhibition effects do not account for the changes noted.
The increased tolerance to stretch that results from MET are now considered (Fryer 2006) to be due to a combination of nociceptive inhibition of the dorsal horn of the spinal cord (i.e. gating via mechanoreceptor stimulation during MET) AND/OR localized activation of the periaqueductal grey, producing descending pain modulation AND/OR upregulation of analgesic endocannabinoids (Fryer & Fossum 2009) AND/OR altered fluid content of connective tissue due to sponge-like behaviour during contractions (and compression) associated with MET-isometric contractions (Klingler et al 2004) AND/OR viscoelastic changes (Lederman 1997)…. Or other influences.
But please remember that NONE of these hypothesized mechanisms change how MET is sued or its effectiveness b/ Myers’ fascial meridians: These are more a reality than a fantasy. Research (dissection and clinical practice) in many centres – such as University of Padua, by the Stecco group (2009), has shown that there are indeed patterns to fascial structural and functional behaviour. Langevin has also shown that there is evidence that these can act as a communication network. c/ I agree that playing Devil’s advocate is a useful role – and Lederman does this well. His core stability paper has been welcomed by many who espouse Pilates, for moving the discussion on from this focus (the “core”) by a number of experts – see for example McNeill’s editorial in JBMT(14)1) Core stability is a subset of motor control – in which he acknowledges Lederman’s points “Is the term ‘core stability’ limiting? I believe it is. Lederman’s article shows how some ideas around core stability have become part of the problem and not part of the solution, and it is definitely time to move on from there.”
My hope is that his over-reliance on meta-analyses in his current paper will be dealt with similarly. Lederman has agreed to participate in the debate JBMT will run on this (www.elsevier.com/jbmt) – and I am gathering experts to refute some (at least) of his conclusions in – hopefully – our April 2011 issue.
What Lederman’s paper does is to refocus our attention on our clinical work. I don’t feel it in any way takes away the importance of appropriate clinical focus on those features that we can identify and treat, that impact on patient’s function and pain. Until and unless research shows particular methods to be useless or harmful, we should continue doing what we do. His paper does not show that – it just suggests that our understanding of the mechanisms involved may need revision
References
Fryer G 2006 MET- Efficacy and Research.(Chapter 4) IN: Chaitow L (Ed) Muscle Energy Techniques 3rd edition Churchill Livingstone
Fryer G Fossum C 2009 Therapeutic Mechanisms Underlying Muscle Energy Approaches. In: Physical Therapy for tension type and cervicogenic headache: physical examination, muscle and joint management Fernández de las Peñas C Arendt-Nielsen L Gerwin R (eds): Jones & Bartlett, Boston.
Klingler W Schleip R Zorn A 2004 European Fascia Research Project Report. 5th World Congress Low Back and Pelvic Pain, Melbourne, November 2004
Lederman E. Fundamentals of manual therapy. London: Churchill Livingstone; 1997
Stecco A et al 2009 The pectoral fascia: Anatomical and histological study
Journal of Bodywork and Movement Therapies 13(3):255-261
Jason Erickson: The reason I enjoyed Lederman’s paper so much… is that there is strong reason to suspect that most bodywork benefits are essentially (if not exclusively) the result of placebo effects. In other words, the client lays there all comfy while… we massage them, and it’s such a nice nurturing experience that they believe it provided real benefits… and in so believing, their brains favorably change how incoming sensorimotor, nociceptive, and other data are interpreted. This can result in positive physical and emotional sensations, even improved (or normalized) motor function.
All of the different forms of massage and bodywork are different methods by which we establish therapeutic relationships and behavior patterns with our clients. Some clients respond more favorably to some methods/therapists than others, but why this is so is unclear. However, the client’s perception of an MT (or other therapist) very likely has a direct impact upon the relative perceived effectiveness of a session.
Rather than take the joy out of my work, the above thoughts imply that we have the potential to go far beyond the “normal” perceived limits of what we do. Studying the underlying sciences of neurophysiology, psychology, anatomy, physiology, kinesiology, etc. provide inspiration for insights into how I might better help a client, while figuring out how to apply those insights imbues my craft with a certain artistic, intuitive quality.
Thank you for initiating this discussion!
Leon Chaitow: Jason, I believe that what you say contains an aspect of the truth. It does not however explain (at least to me) the changes visible on (for example) real-time ultrasound images) in soft tissues before and after (again, for example) use of …MET or StrainCounterstrain or Myofascial release. Current research by Standley and others using modelled cell cultures that are repetitively ‘strained’ for 8 hours or more, displaying a fragmented/moth-eaten look – where cell layout and behaviour modifies within 60 seconds of modelled myofascial release or counterstrain.
It also fails to explain how – for example – functional positional release can alter a dysfunctional/traumatized horse’s stride length, within minutes of treatment (see chapter by Antony Pusey DO, on animal SCS, in the 3rd edition of my book Positional Release Techniques (Elsevier 2009). Pusey and colleagues also showed (1994) definitive blood-flow changes in the limbs and necks of horses and dogs following brief positional release applications using thermographic imaging – these changes were accompanied by functional changes in movement.
I could bring other examples, but these should be sufficient to suggest that there’s more to it than placebo and the mind…there is actual biomechanical modification…visible on a cellular level, and demonstrated by means of real-case animal studies
References:
Colles C Holah G Pusey A 1994 Thermal Imaging as an aid to the diagnosis of back pain in the horse. 6th European Congress of Thermography, Bath UK.
_Dodd J et al… 2006 In Vitro Biophysical Strain Model for Understanding Mechanisms of Osteopathic Manipulative Treatment. J. American Osteopathic Association (106)3:157-166
Standley P Meltzer K 2008 In Vitro Modeling of Repetitive Motion Strain and Manual Medicine Treatments: Potential Roles for Pro- and Anti-Inflammatory Cytokines. Jnl.Bodywork and Movement Therapies 12(3):201-203
Pusey A Brookes J 2009 Positional Release in animals IN: Chaitow L (Ed) Positional Release Techniques (3rd edition) Elsevier Edinburgh
Erik Dalton:The mechanisms for what we see clinically will always be upgraded and disputed because of the inherent complexity involved with the ever-changing combination of evaluations and treatments we bring to the… session for each individual.
No part of the medical community (surgical, pharmacological, radiological rehabilitation, psychological, manual) can provide reliable/irrefutable evidence showing they have a successful treatment for low back pain…and I doubt it will happen in the near future.
So are we to believe physical therapists will stop performing modalities such as electrical stim, ultrasound, thermal, exercise therapy… or will surgeons stop requesting myelograms, PET scans, MRIs, and refrain from performing disc replacements, cage fusions and laminectomies just because there’s no reliable proof of their efficacy? But Dr. Lederman’s asking us to do just that…why?
Leon Chaitow: Thanks for your thoughts Erik
Dianna Linden @ Jason Erickson: I don’t think “there is strong reason to suspect that most bodywork benefits are essentially (if not exclusively) the result of placebo effects”. I’ve seen that suggestion articulated by Steve Barrett over on quackwatch.org, but if that were the case it would account for only a 30% (or less) success rate addressing those issues that bodywork is effectively addressing at far better rates than that, in my studio, and many others as well. Yes, anecdotal info doesn’t count in science, but it sure does help expand a referral line and keep clients coming in when they need a tune up.
Why would you be happy to consider yourself no better than a sugar pill? Your services are far more expensive. That just doesn’t make sense to me. There are a lot of subtle states being experienced by folks receiving bodywork that might be able to be characterized by biofeedback equipment as dropping into alpha, or deeper, and therefore folks are highly receptive to suggestions of change. That isn’t placebo; it’s a variant on NLP if done well. I’d buy that as an explanation for some of the possible effectiveness of massage before I’d be willing to write the benefits off to just placebo.
There’s a lot we don’t know about how or why our work is effective, but I think it’s pretty clear that it ain’t all due to the charisma of the practitioner or the art of intuition. Leon made some excellent points regarding the actual changes discerned in tissues. Horses aren’t gonna be influenced by placebo or charisma are they?
I once taught foster parents of an infant born a month premature, addicted to cocaine, how to give the little girl infant massage. She was a month old at the time I met her, so therefore, age 0. She had been crying almost nonstop since the foster parents got her. She didn’t sleep, hardly ate and was clearly crawling outa her skin in discomfort, still detoxing from her mother’s horrible drug habit. She smiled for the first time, laughed and actually relaxed during the massage.
They called me the next day after her first massage. She ate well after that and slept thru the night for the first time. From then on they massaged her daily and her discomfort abated fully quite soon after that. Tiffany Field has done some great research and developed wonderful techniques for infant massage on premies.
I just don’t think that the long term weight gains etc these babies demonstrate can be due to placebo effect. We might not know what particular pathways are being most benefited. but we can surely see the benefits, and they continue beyond just getting out of the hospital sooner with less expense.
That brings us to Erik’s position, which is that manual therapeutic methods are definitely less harmful than the “side effects” (or primary effects, for that matter) of some of the allopathic methods currently being employed to ‘cure’ disease.
Therefore they don’t, (other than Lederman’s own methods, which weren’t refuted in his paper) deserve to be discounted to the degree that Lederman’s article took it. He didn’t pooh pooh the value of MRIs or PET scans, etc. A point worth making.
This is a very interesting inquiry, Leon, Erik, thanks for bringing it into our awareness.
I’m gonna go read the article again.
Erik Dalton
Leon: Really appreciate your effort in putting this together and Prof McGill’s commitment. I should know by Friday if I can meet that deadline.
Would rather design and conduct a study using manual therapists whose experience and expertise I trust rather than relying on a non-manual therapy researcher’s choice of practitioners. I realize that’s future project so, meanwhile, I’d like to take part in your peer-reviewed project if possible. Much thx…
Erik Dalton: I’ve been following Lederman since 1998 and really appreciate his convictions and persistence although I don’t always agree with his writing finesse, black-and-white viewpoint, and sometimes his my-way-or-the-highway attitude. My response t…o his paper was not meant to be a technical rebuttal, but a “knee-jerk” response to a direct assault on many valid manual medicine principles. I was disappointed because of the attack nature of the paper….don’t think that portrays him in the light he deserves.
Dr. Lederman implied that when selecting the article’s content, he randomly chose low back pain as a model to demonstrate the innate inadequacies of manual therapy. I doubt that. Those who subscribe to the wonderful publication “The Back Letter”, have witnessed the same illustrious researchers referenced in his paper fighting it out in respected journals. However in this low back publication, the audience (primarily neurosurgeons, orthopedists, spinal researchers, etc.), are bashing all things “medical”, i.e., surgery, rehab, pharmacology, and radiology.
After a few years of reading some of my favorite researchers bickering (my study is better than your study), one comes to realize none of them have definitive answers for effectively managing and treating low back pain. They can’t even agree on something as simple as proper lifting exercises for low back pain.
The longer you’re in this business, the more one comes to recognize the enormous complexity of lumbopelvic mechanics and the absurdity of believing any group has an all-inclusive answer for this far-reaching condition. So, my frustration and ranting was really just an emotional reaction in defence of the manual therapy world I’ve come to love and respect. If Lederman could have found a way to stop bashing for a minute and offer even one universally tried and true alternative to curing low back pain, it wouldn’t have hurt so much.
But Dr. Lederman’s a manipulative osteopath and I believe he decided to focus only on what he thinks he knows best…manual therapy. I just hope it turns out his mission isn’t to debunk all other types of manual medicine just to elevate/promote his Harmonic Technique. I’ve read his book and it may prove to be a helpful piece of the back pain puzzle…time-will-tell. But it certainly doesn’t appear as a substitute for 100+ years of teaching by osteopathic notables such as AT Still, Sutherland, Mitchell, Chaitow, Greenman, Styles, Bourdillon, Ward, Jones, Magoon, Korr, Stoddard, Kirkaldy-Willis and on-and-on. I’ll be curious to hear more from Professor McGill (Low Back Disorder) and hope many manual and movement therapists will step up to the plate and express their personal beliefs, experiences and research findings.
Michelle Doyle: Very well said, Erik. I’m hoping to give my thoughts on Lederman’s article after I give it a more thorough and focused reading…
Leon Chaitow: Excellent Erik
I also have agreement from Gary Fryer DO, leading osteopathic researcher from Australia, to participate in the debate. Leon
Rajam Roose: Oddly enough, I find that I both agree and disagree with the paper. I disagree in the sense of what I’ve seen in my work within the eleven years I’ve been practicing massage. Granted, it is anecdotal at best, but I’ve used structural tests ……and found that by facilitating the change with bodywork and client awareness there has been decreased to no pain for several years.
On another sense, I agree with the paper b/c I think that not all therapies work the same for everyone and I also agree that there are socioeconomic and mental health issues that relate to LBP. When I read the paper, I only had the sense that there isn’t ONE therapy for LBP. It is very important to think about the mental health. LBP may be a sign the person isn’t feeling supported in their life (according to energy workers) wouldn’t this make total sense in our society where we are not set up to have much contact and support throughout our communities. If you look at tribes where their culture is highly community based, I wonder how many cases of LBP they would report?!
I’ve also read Dorko’s paper about the placebo effect in massage and am a reader of his forum. Although many of those folks think of therapists as nothing more than “primate social groomers”, Mr. Dorko himself can’t give any research as to why his Simple Touch works and it sounds very similar to other forms of bodywork. Which brings me back to my point, which is there isn’t a lot of research for us manual therapists and what there is, is buried and we depend on people like Eric Dalton and others to dig it out for us.
The idea that massage is a placebo doesn’t seem to fit what I’ve seen in my work either. I’ve had clients come in who didn’t believe massage could help them, they came in to make their spouse happy or to try “just one last thing” before surgery. I’ve had several clients looking at surgery for carpal tunnel and the massage helped them avoid that surgery. One of those clients in particular didn’t believe the massage would help. I’ve had another client with sciatica who lightly mentioned she had it while on the table but didn’t say anything during the intake b/c she didn’t think massage would have any effect. Wouldn’t you know after the first session, she never experienced it again?
I can work on someone and then watch the effects immediately upon the body– I’ll work the serratus, lats, inf. trap, deltoid, and triceps on the right side and then see the shoulder has dropped lower than the other by at least an inch sometimes and I hadn’t even touched the sup trap or neck yet! That’s not a placebo. It’s not a placebo when I use passive stretch w/compression to the tendon of the hamstring (while client is prone) for a few minutes and when I put the leg down, the hip on that side has noticeably dropped lower than the other side!
On the other side of that coin, what about the clients who have come to me really believing massage would help and the massage hasn’t helped? I’ve only had this happen a few times in my career but someone will come in truly believing the massage is what they need, but the work doesn’t give them the relief they seek. Why can’t they have the placebo effect?
Although I will re-read the paper more carefully what I have noticed is that the studies he is quoting may be flawed themselves. We don’t know what was the socioeconomic status of the participants in the studies, we don’t know how exactly the studies were conducted. We don’t know exactly what types of therapies, so they used manual therapy for 100 cases of LBP and only 2 worked? Well, there are 10000’s of people with LBP, so the fact something didn’t work for so few doesn’t mean much. When people do research using massage techniques, exactly what techniques are they using? Did they just rub on the person’s back prone, or did the therapist in the study work the psoas first, followed by the spinae and then sidelying to get into the QL’s (for example). Who are the therapists participating in these studies? Are they students, are they experienced therapists?
Til Luchau: Fantastically provocative! (Thanks to alerting us to the discussion, Erik.)
I found Lederman’s article very useful in its questioning our usual structural assumptions. In turn, I of course question its assumptions. I don’t know if this help…s you in your request for specific analysis, Leon, but my interest gets piqued by the whole notion of efficacy being that which can be measured against “sham” treatments and placebos. Bear with me while I follow that tangent, if you will:
Statistically, the placebo effect is getting significantly stronger over the past couple of decades. On an average, it rose by 20% just between 2001 and 2006. As a result, it is now much harder for new drugs to beat placebo odds in trials. Half of all promising new drugs can’t beat sugar pills.
Placebo is thought to be simply a troublesome, irrational quirk in humans that messes with research results. Even the color of pills, and the way they’re delivered influences research outcomes. Maybe placebo isn’t just a sham, but a valuable lesson about the value of expectations. Relevance: expectations color results.
Interesting quotes from that article:
“Over half of all doctors admit prescribing medications or dosing at levels they knew were ineffective for a patient’s condition in order to provoke a placebo response.”
“In a study last year, Harvard Medical School researcher Ted Kaptchuk devised a clever strategy for testing his volunteers’ response to varying levels of therapeutic ritual. The study focused on irritable bowel syndrome, a painful disorder that costs more than $40 billion a year worldwide to treat. First the volunteers were placed randomly in one of three groups. One group was simply put on a waiting list; researchers know that some patients get better just because they sign up for a trial. Another group received placebo treatment from a clinician who declined to engage in small talk. Volunteers in the third group got the same sham treatment from a clinician who asked them questions about symptoms, outlined the causes of IBS, and displayed optimism about their condition.
“Not surprisingly, the health of those in the third group improved most. In fact, just by participating in the trial, volunteers in this high-interaction group got as much relief as did people taking the two leading prescription drugs for IBS. And the benefits of their bogus treatment persisted for weeks afterward, contrary to the belief—widespread in the pharmaceutical industry—that the placebo response is short-lived.”
Call me sappy, overly psychological, or what you will, but this has far more impact and relevance on how I practice than any of the clinical trials I’ve read recently (and I still enjoy reading them, as much for the mental hygiene as anything else. Beats sudoko!)
Rajam Roose: Not to mention, on page 9, the paper states “There are no known studies that examine the influence of manual techniques on PSB factors in the medium- or long term, in particular at the cessation of the treatment.”
Basically, the paper can’t …refute manual treatment for PSB since it hasn’t been shown NOT to have any affect. That sentence to me makes me disregard the paper as any kind of threat to my profession.
Also mentioned on pg5 is the sentence “These studies demonstrate lack of association between work-related posture and LBP…” Again, as I wrote on Eric Dalton’s FB I have to disagree b/c I’ve had a client who was looking at surgery for heel pain due to calcaneal tendonitis or something like that. Turns out she’d been tucking her toes under her chair every day at the office for ten years! Once we loosened the adhesions in her calves and feet and she stopped toe tucking, the pain went away and she tossed her cane and canceled surgery. Not LBP but the same instances could apply and why not?
However, because that situation (among others) is anecdotal in nature, it has no bearing on whether or not something is true in the world of research and evidence based therapy.
Bryce Taylor: I wrote this on Erik’s page but here it is again.
Well…I read his newest of the debunking series. I wasn’t impressed with “The Myth of Core Stability” and actually used some of his criticism in a recent lecture to explain the complexity in reaching a universal agreement on core stabilization/strengthening/evaluation. I too was very disappointed that he does not offer any helpful techniques, but rather continues to play the devil’s advocate for the entire paper.
I had a few issues with the “Fall of the PSB Model” paper. There were many contradictory statements made while attempting to make strong assertions. He was quick to say “No association has been found” when it met his agenda but when he was attempting to debunk an issue he would use statements such as “inconclusive evidence for an association”. I found this writing style intriguing.
It was apparent to me that he doesn’t even respect the Australian’s studies on local stabilizers (whether or not the research holds water) and instead of citing Hodges, et al, he chose to cite his own “Discussion”.
Whenever research appears to favor the PSB model, he criticizes the methodology and suggests that it could have been done better. However, when the study is used to debunk the PSB model, he has no problem accepting their methodology–even if it involves unreliable data acquisition.
Probably the biggest problem I had with his arguments was around the contradictory statements “magnitude does not correlate…” Let’s look at leg length disparity as an example: If the magnitude of disparity does not matter, then why does he accept 20mm disparity as an acceptable magnitude to suggest a correlation for LBP? How does that argument challenge the PSB model?
Leon Chaitow Responses to Til, Rajam & Bryce:
The placebo effect is undeniable. However a counter argument highlights the responses of animals to manual treatment. Dogs, cats and above all horses show marked and rapid alterations in function following myofascial release, positional release and trigger point deactivation – and I doubt there is much placebo effect going on there.
Rajam: Mountains of anecdotal data must add up to something of value – whether it involves our personal experiences or that of our patients. Even if our explanations as to just what helped what are not always accurate in the purest scientific sense – the fact that structural changes are demonstrable using – for example – real-time ultrasound or MRI scans , following particular manual methods, and that in many instances this correlates with symptomatic improvement – suggests that it is not all in the mind!
Bryce: Hopefully the debate that I will run in the Journal of Bodywork and Movement therapies, with Erik Dalton, Stuart McGill and Gary Fryer (among others) analyzing Eyal Lederman’s hypotheses and findings, will expose flaws, exaggerations, glossing over, and over-reliance on meta-analyses of research data. Eyal Lederman will of course have a right to reply, and out of all of this some clarity should emerge …..?
Rajam Roose: Thanks Dr. Chaitow. I’m glad to have a subscription to the JBMT as I’m looking forward to reading the debate among some of the great minds of our profession!
