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Exercise, Manual Therapy, or Both?

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

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

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Transcript

Eric King:
All right. We got John from Philadelphia. I work in a clinic that treats a lot of recreational lifters with low back pain, from squats and dead lifts. My coworkers use a lot of transverse abdominis bracing and manual therapy, like joint mobilizations and trigger point release to treat. I use more graded exposure to exercise and movement patterns.

Eric King:
How do you all approach this population?

Mike Reinold:
Awesome. Good job, Eric. I like it. Good. Welcome to the show. Don’t we love these types of questions, the this or that questions, right? Like, is there ever going to be something where we don’t say both?

Dave Tilley:
Yeah. Right.

Mike Reinold:
Like ever, is there anything [crosstalk 00:03:22] I guess that’s true. Trump and Biden. Republican, Democrat, I guess we’ll never say both. We can’t come to any agreement. All right. So yeah, we hear this all the time. That’s kind of funny, just looking at John’s thing. So you can almost see that there’s almost like a shift in thought process within one clinic, right? Transverse abdominis and manual therapy, joint mobes, like is probably a little bit more of a veteran physical therapist, right. That was a very popular treatment style, probably I don’t know, nineties, two thousands, right?

Mike Reinold:
Early two thousands. And now John wants to use graded exposure to exercise. Which I agree with, I was just cracked up with the phrasing of the graded exposure to exercise. I think that’s just exercise, right? We’re going to slowly expose them to exercise. But yeah, I mean I think what it comes down to is like, is there a need for a paradigm shift? So John obviously feels like the current approach of a graded exposure is probably the best approach, but I think you could argue that his coworkers have had some pretty successful outcomes or they wouldn’t be doing it still, right? So I don’t know, who wants to start this one off, other than the boat? We’ll get back to the lifters with back pain concept of that, and what we can do, but I guess it’s more of the boat thing, but Pope, what do you think?

Dan Pope:
I think there’s a lot of pressure out there right now in the social media world, at least in the physical therapy and strength conditioning world, that manual therapy can be useless, you know? And I feel like a lot of folks are starting to just stop with all their manual techniques, they’re not really trying it and utilizing it. I really liked the analogy that if you have a headache, if you wait a day or two, it’ll probably go away. But if you take some ibuprofen, it feels better. I think manual therapy is kind of similar, and most folks that are coming to see us, they want to get some pain relief as well as get back to their activities. So why wouldn’t we do both? But I think a lot of the research that’s coming out about manual therapies and the long-term effects, people are starting to think, I don’t need to do these, I should stop doing these, it’s not helpful for my patients at all. I’m going to make them rely on me.

Dan Pope:
I think all those things are floating around in people’s heads, so they feel poorly about using them. But yeah, obviously we use both and we think that both can be helpful for folks for a variety of reasons.

Mike Reinold:
Dan always answers these questions so well, and so politically correct and stuff, I just get irritated, just like answered as well, I appreciate that, that’s so good. But I think that’s a really good approach, Dan, and a good way of saying it too. And keep in mind too, with Dan’s comment on some of the research casting some doubt on some of these things, just realize most of these are studies on if manual therapy works for back pain.

Mike Reinold:
Right. And wow, there’s so many limitations with that concept. We’re talking about back pain. You literally look at the subjects from age 25 to 85, how do you define manual therapy, how do you define back pain? It’s like a ridiculous kind of question we’re trying to do. But yeah, a great way of saying it there, Dan. I think that’s awesome. 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 on in my career, I kind of came out and got very kind of into the pain science world and I kind of went away from manual therapy, and I was treating a lot of non-specific low back pain. So I was obviously trying to get these people moving more.

Dave Tilley:
But then as I got into more sports and started working with you guys, I realized that I needed a lot of biomechanical education. There’s a huge role for proper strength conditioning. And so it’s hilarious because especially when I talk to the students now and stuff, like 80 to 90%, if you look at the base principles, are the same in both things in terms of like, what are you doing with manual therapy, what is exercise doing? And I think if you frame it as manual therapy, like Dan said, as a way to help somebody be a little bit more comfortable when they exercise, why in the world would you not use both? And I think we see a lot of that in the clinic where someone can’t tolerate even basic exercises, and as a new grad you’re scratching your head because there’s no directional preference, it all hurts, it’s chemical irritation.

Dave Tilley:
So okay, three to seven days, it’s like educate you and try to calm you down however, and then we’ll get you more on the exercise stuff. But 90% of the time I’m doing manual therapy and education to get someone to tolerate a directional preference of McKenzie or SFMA exercises with more comfortable press-ups and say, okay do this every couple of hours until I see you next week. And they come back and they feel significantly better, with education, basic manual therapy, a little bit of heat and just like super down to earth, easy stuff. And it’s really not rocket science, I think people get caught up, like Dan said, in 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 you got one of your patients is working with you and they have non-specific low back pain or something like that, right? Tell us about your approach a little bit, like how do you combine manual therapy in exercise and some of the benefits that are combined in it, I guess?

Mike Scaduto:
Yeah, absolutely. I definitely think it comes down to the assessment like what Dave was just saying. If they do have a directional preference, I think that can be very helpful in our treatment. But overall my general philosophy is going to be that, of course, we’re going to use manual therapy to try to alleviate some of their symptoms. Don’t necessarily know how that works from a physiological or psychological standpoint, but if it can help decrease their symptoms in the short term, I’m all on board with that. And I think we do need to change that program over time, that program just evolves. And then as we go and as they’re continuing to make progress and their symptoms have decreased, then I’m going to up the volume or up the intensity of their workout program. So we’re going to kind of slowly transition them to more of an exercise-based program.

Mike Scaduto:
I think that’s totally fine to do. I think you’re allowed to have an emphasis on manual therapy early on in a treatment of a patient and slowly transition them into the emphasis is being more of a strength-based or movement-based program. So I think it’s all about the evolution of their treatment over time and eventually progressing them to the point that prepares them for what they want to do and what they want to return to.

Mike Reinold:
Right. And you know what, I always say too, yeah we’re dealing with more of an athletic population at Champion, but I think that’s kind of specific to John’s question. Anywhere with recreational lifters, the fitness athletes nowadays, even just recreational fitness athletes, think about what they’re doing, there’s so much stress on their body in good ways, because they’re adding positive stress to have positive change to their bodies, and they’re always stimulating things. That makes your muscles sore. That makes them tight, that makes them sore. They’re not injured, they don’t have a back pathology. Sometimes they just have low back pain because it’s just some excessive stress from training, from lifting in the gym. So manual therapy is super helpful for those people to help them move better and get them moving again, warm up the tissue and move.

Mike Reinold:
So that way, then you can perform your graded exposure to exercise. So we can still do that sort of thing with them, but the manual therapy kind of helps them. But remember, it’s not just pain that they’re in, their soft tissue is probably tired and sore from their activities that they’re doing. So we know manual therapy helps increase range of motion. It helps improve movement patterns afterwards. It helps neuro modulate pain. We’ve seen all these things with that. I mean, if my hamstring hurt because I just did some sprints yesterday, which I would never do by the way, but imagine if I did, the first thing I would do is probably want to do some soft tissue on myself.

Mike Reinold:
And then, I’m not worried about graded exposure to more sprints. I’m worried about doing some foam rolling, maybe some vibration therapy, even some soft tissue on myself, to try to make that soft tissue feel better so that way I can then resume back into my activities. So I think we got into this mess because we had too much reliance or over-reliance on just manual therapy and then kick the person out of the clinic and that’s all we did. That’s a bad physical therapy practice. That’s doing it wrong. That’s not physical therapy, that’s just a bad practice. It’s not about that. So I think we got a bit of a bad rap, but what’s happened now is everybody’s poo-pooed on these things. So just like everything else, if you’re just doing manual therapy and you’re not doing exercise, I don’t even know, I don’t even think that’s 50% of it.

Mike Reinold:
It’s not enough. And vice versa, if you’re only doing exercise, you’re not doing any manual therapy, you’re definitely slowing down your outcomes and probably not even treating their biggest source of their complaints. It’s not about you and your theories, what you want to get done with that person, that person was lifting yesterday and their hamstrings are sore, their back’s sore because they just set a PR on their deadlift. Rub their back, right? You know what I mean? You’re not doing a disservice to our entire profession because you’re doing soft tissue on their back. They want to get back and deadlift again in three days, let’s help them feel better as soon as we can so they can get back. But of course, we want to include that with exercise. So put those two together and I think that’s an important way of doing it.

Mike Reinold:
It’s going to be a this or that question where we’re almost always going to say both, but I really think that you’re missing the boat. If you do both, I think you’re going to get really good success. If you do one, I think you’re only going to get like 20% success in both directions. So it’s enormous with putting those two together, and I think that’s some of our fundamental concepts that we do at Champion, and I think we’ve seen that work across several different athletes in different sports over time.

Mike Reinold:
Good. Right. All right. Diwesh liked it, I think we’re good enough so sorry. Sorry, I didn’t mean to yell at you, but I wasn’t yelling at you, John. But anyway, hopefully we help make it a little bit different. What I’m trying to get at is don’t feel bad about doing that sort of thing, right? If you feel that that’s the most appropriate thing, to do it. But just like everything else, I think there’s a happy medium that we can do to really help our patients even more. So good question, John, I know that’s on a lot of people’s mind. I know a lot of people are feeling the same way. So keep questions like that coming, we’re here to answer based on our clinical experience, all the years of doing this that we’re doing, we’re here to help. So keep asking away, head 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 will see you on the next episode. Thanks again.

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