Episode 15: Changing the Narrative of Manual Therapy

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• Joe Gambino
• Joe LaVacca

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Summary
In this episode, Joe Gambino and Joe LaVacca discuss the myths and misconceptions surrounding manual therapy. They highlight that manual therapy is not about putting the body back into alignment or breaking up scar tissue, but rather about building trust and creating a therapeutic alliance. They emphasize the importance of test-retest strategies and individualized assessments to determine the effectiveness of manual therapy. They also discuss the benefits of foam rolling and self-myofascial release for unstable clients. Overall, they encourage clients to question the narrative around manual therapy and seek multiple opinions if necessary.

Takeaways
Manual therapy is not about putting the body back into alignment or breaking up scar tissue, but rather about building trust and creating a therapeutic alliance.

Test-retest strategies and individualized assessments are important to determine the effectiveness of manual therapy.

Foam rolling and self-myofascial release can be beneficial for unstable clients.

Clients should question the narrative around manual therapy and seek multiple opinions if necessary.

Transcript

Joe Gambino (00:00)
Welcome back into the Beyond Pain podcast. I'm your host, Joe Gambino, and I'm here with the lovely Joe Lavaca. I won't throw you off this time, Joe. You can do your wave now. You can find us on Instagram. I'm at joegambinodpt and Joe Lavaca there is at strengthinmotion underscore PT. And we also do have Instagram for the podcast at the Beyond Pain. It's just Beyond Pain podcast, isn't it? I keep saying that.

Joe LaVacca (00:09)
All right.

It is just a Beyond Pain podcast. That's it. Just Beyond Pain. Know the, know the.

Joe Gambino (00:30)
Yeah, no thought. Take the thought out. And this is also on YouTube at cupsofjoe underscore PT. If you want to watch the show live and that is our intro. And then we have an application form. If you are interested in working with this, please feel free to reach out either myself or Joe or whichever one of us you select on the form. We will get back to you. And well, we're talking about manual therapy today. Well, we'll have a new BS episode. I mean, we are going.

two episodes in a row and recording. we already, I don't know if we have anything left in us anyway, Joe, to talk about at the top of this episode. We did our coffee. We had a wonderful philosophical connection between coffee and pain. So let's just jump right into it. Where do you wanna start this combo?

Joe LaVacca (01:18)
geez. think the best way to start this convo, again, from a client perspective, and we've been talking a lot about pain being so multifactorial, complex, individual, that we can just shift that same conversation to manual therapy. And I think traditionally, when our clients come in to see us and expect manual therapy or hands -on treatment,

The view of that treatment is very myopic. It's very singular focused. Hey, you break up scar tissue, you release a muscle, but you do, or we do as clinicians, something specific to that client and to the client's tissues that only we could do to have an effect because of all of our training. And I think that the shift or

focus now with manual therapy is just the same as pain. Manual therapy and its effects are multifaceted. They are a combination of both specific and non -specific things, but they're related to your relationship with the provider, maybe where you are in your recovery process, maybe where you're getting manual therapy, and I mean where in the sense of body or environment.

And I just don't think that we have a single well -defined mechanism for what manual therapy does, is, or targets. And maybe that's where we can start the conversation. What do you think about that? And just sort of manual therapy as you kind of describe

I think you're muted, buddy.

Joe Gambino (03:09)
You got me. That's the second time I've done that. I try to keep all the background noise out and then I talk without unmuting myself. But I want to start with this question to you, Joe, and then we can talk about those points. You already kind of started talking about the old viewpoint of manual therapy. If you had to come up with things that you hear from your clients, your patients, what would you say are the three biggest myths that your patients have when it comes to

you know, what they believe manual therapy does for

Joe LaVacca (03:42)
Although I think, again, collectively, it's probably that they think manual therapy puts them back into alignment. And maybe we can put mobilization or manipulation into that category as well, because I think it does fit. I think that they think manual therapy will release some sort of scar tissue. And ultimately, probably manual therapy needs to be something that I do to them or we do to them, and that it takes a very skilled provider.

with years and years of training to have an effect. And I would probably say those are the three biggest myths, the way I see

Joe Gambino (04:18)
Mm -hmm, yeah. I agree with those. mean, I do think that there is definitely from a...

I'm going to say patient alliance. mean, people listen to this and may not know, but like when you're trying to build trust with somebody, right? Having skilled hands, soft hands, knowing where you're to place your hands. think, you know, when we're talking about trying to build that trust factor with our patients and our clients, I think that's probably the biggest differential than anything. I think if someone feels like they

know if your hands are going to be in the right places and you're fumbling over things, that it's not going to be as effective as someone who feels like they know where their hands are going next. So I would give you a little bit of a pushback on that one, but I do agree. think, you know, self -myofascial release and doing all that stuff can have similar benefit if you know where to push or something like that, right? But yes, that's a break.

breakup tissue, we can't put enough force into someone's body and the same thing for alignment purposes. Maybe my question for you, Joe, on how you describe this to people is on the note of alignment. I think that's a big myth that people have that they're either out of alignment and need to be put back into alignment and that our hands can do that. How do you educate?

someone that comes to you for the first time and is like, yeah, you know, I feel like this hips higher than that. I have an anterior pelvic tilt, blah, blah, blah. And I need to do core strengthening and I need you to manipulate this and to get me back into

Joe LaVacca (05:57)
Yeah, well, I think it kind of goes into this idea that your muscles exert so much force on your body. mean, walking six, eight, 10, 12 times your body weight, right? If you're going to be doing things at the gym, jumping, plyometrics, we can maybe even count from more forces than that going through your body. So what I try to tell them is that if you are out of alignment,

And I was actually able to determine that because it's also hard to determine where bony landmarks are. We know that there's not good inter -rater reliability when you and I are assessing the same person and find agreement on what hip is higher and what hip is turned or what hip is rotated. So when I tell clients that the assessment itself is unreliable, then it can't give me reliable

actionable steps for treatment. And if we're thinking about what holds your muscles in place or keeps them in position, it's muscles, right? It's muscles resisting gravity, muscles resisting postural positions, muscles resisting forces. So we can use manual therapy to make you feel better. And I don't think that

the pushback that you gave me wasn't really all that much pushback, but I think it's, it's this idea of when we look at certain studies of loved ones giving manual therapy to their spouses, we see just as good of results in reduction of pain, if not better than when we compare that to kind of a stranger's touch. And that's kind of what we are at day one, right? We are sort of just getting to know each other. So I think

the confidence in how you handle a tissue, maybe is a better way to put it, rather than I am finding a specific crevice, nuance, landmark, tendon, nerve, and I'm influencing just that thing. Because you do bring up a good point. If I am trying to build trust and I'm trying to convince people that, manual therapy is just gonna be a part of things and

your husband, your spouse, your friend, your, your loved one that you trust. You can do this at home. Maybe you can do this with even foam rolling or, or, tennis balls, massage balls, things like that. If I'm going to do that and then I'm shaking as I'm holding their leg or their arm, or I'm fumbling with my words, cause I'm trying to speak too fast. That's not probably the way to establish good trust. And like we've said in previous episodes, come back with that idea of testing and retesting

Once you have that alliance with someone, and I had this happen this week, client came in, long standing client, comes in every other week, we train together, we've been programming, helping her build her strength and do all these different things for her when it comes to tennis and running, and she's feeling great. But she reached out because she had some shoulder pain that popped up last year, and we were able to sort of just train around it. And then she reached out again this week because...

Lo and behold, it kind of came back and she felt she was losing a little bit of range of motion. So we listened to her story, we threw her on the table, and then we just kind of palpated around. And I think, I maybe have mentioned this in other episodes, but I think manual therapy, yes, is great for rapport building or therapeutic alliance enhancement, but I also think it's just great for assessment too. Like, hey, what side of the shoulder is irritating? What side of the shoulder is not responding to force the way we'd expect?

And we did a couple of like just little like palpatians, a couple of things here and there. And then just through palpation, it wasn't anything specific. And this is normally how it goes to her range of motion got better. Her pain went down and we both sort of looked at each other like, okay, well, you know how hard you're training and how much force you're putting into your body and how light that palpation was. So we know we didn't release anything. We know we didn't break anything down. We know that your shoulder was the same as it was five, 10 minutes ago.

So what could have possibly mitigated or helped your pain? And I think that's where this whole mind body connection is really important. Did we have a nervous system response? Yeah, sure. Maybe. Did we have a psychological response? Yeah, sure. Maybe because of the trust that we have. Did somehow the touch just ease some bit of mechanical tension that I couldn't even determine and maybe reduce some sensitivity through nerves in the area? Sure. Maybe.

Again, it kind of comes back to that idea of pain where how do I know which one was which? I probably don't. And I'm just going to take advantage of all those factors put together, at least when I'm able to work with people in the clinic. Do you typically have people palpate or maybe do some touch things on themselves and then maybe guide them

foam rolling, doing what you're doing, and then come back to some test, retest strategies. I'd be interested to see how you incorporate assessments with your clients.

Joe Gambino (11:24)
Sure. So a couple of things before I answer that question. You did say, I'm like 99 % sure you said muscles hold, muscles in place. And I'm pretty sure you meant muscles hold bones in place. And just on that note, what I wanted to say about it is I think that one way I explain people being out of alignment is like, there's almost like a holding pattern in a sense. Make sure people can have like bony discrepancies. And I completely agree with you with like.

for us to accurately and confidently say that someone has one hip higher than the other is, I don't think the data is there. Because again, even if I was to do the test a couple of times in different days, I might find different things. So the reliability of me doing it multiple times, or you and me, we might find different things when we assess someone. So I'm with you on that. To answer your question specifically, when I have somebody and I feel like,

Manual therapy is something that's needed in and at this time. I do exactly that. Like, okay, well, you know, this area has given you a hard time. Why don't we foam roll these areas and just see how you feel afterwards? And I think anytime we're doing manual therapy, whether it's myself doing it, whether you're doing it to yourself, you have a loved one doing it, it's always the

pre -test, post -test reaction that I care about the most, right? I don't really care specifically what structures we're pressing on. You know, I can guide you and say, hey, you know, well, your knee hurts. So let's try the quad, let's try the IT band area. Let's try, I don't know, your glutes, right? Your calves. And let's see how you feel afterwards. Do one, stand up. Do you feel better, same or worse? Do the next area, stand up. Do you feel better, same or worse? Each one helps you feel gradually better. Then we'll let them all in. If one of them gives you this huge change,

It's the only area we need to start to focus on, right? Because now we're starting to, no one has time to foam roll for 20 minutes to do all these corrective exercises, then be active the way that they want. And then if they have kids and whatever, job and all these other things, right? Like how do you manage all that stuff? And it's really just being as specific as possible and taking the things that have the biggest impact and then moving on from there. So if I can have someone roll their claws and their knee's like, wow, my knee feels so much better.

It's that window of opportunity that I care about the most. And now I want to take you and load that specific tissue or those ranges that you were struggling with. Now, how can we get these two things to come together? Both of them are forces in different ways. everything we do really interacts with the nervous system in the beginning until tissue adaptations happen over time, right? Within that four to eight week window. So how can we capitalize on these things, create this better range of movement, see

Hopefully, know, what I tell people is like, sure, you're going to foam roll now, you're to do these exercises, you're going to probably feel better for an hour after our session, say. What you want to see is after a week or two weeks, that's lasting for six hours, say. And then that's going for a day. And now all of sudden you have days where you don't feel anything, right? That's a sign that your body is starting to adapt and make changes along the way. We're not clear yet, but we're definitely on the right track. And those are probably the bigger themes and things I look at when I'm testing anything.

from a manual perspective, it's always, know, if someone does all those areas and they're like, I feel no different, it's not, it's most likely not worth their time to continue doing it at that point. It's not gonna just magically make a difference, you know, about three weeks from then.

Joe LaVacca (14:54)
Yeah, yeah, no, that's great. I think that from a standpoint of just like having that, again, test, retest, that's always popped up for us. And I think it's really important for clients to remember that. How do you get more data? How do you know you're moving in the right direction? Have that patient specific test keep coming back to it? I might say that the caveat on manual therapy foam rolling where I really try to push people to maybe think about doing it is if you are unstable, right? If you have a...

unstable shoulder. I don't really want you stretching because the body is going to take the path of least resistance. So before you're able to probably get a stretch through your pack, because everybody unstable loves to stretch and pull, you're probably getting a lot more translational forces into your joints. So if you're one of those people who, know, their, their thumbs bend all the way back to their wrists, your knees bend back, your elbows bend back. you know, someone pulls on your shoulder and you see like a three, three inch gap between

the top part of your shoulder bone and then your arm. Those are cool party tricks, but we probably don't need to be stretching those people even though that's what they kind of crave. So if you are unstable, I'm gonna push you for manual therapy. I'm gonna push you for foam rolling as your tissue prep. And then there'll be different adjuncts for training that we should consider. But that would be where I think manual therapy is probably.

most beneficial if we're kind of running out of those test retest ideas, like almost kind of thinking about a person who would specifically benefit from them. And for me, it's usually those unstable clients.

Joe Gambino (16:33)
Yeah, I like that. And I think what Joe's referring to when he says unstable is people who fall very, very far on the hypermobility spectrum, which honestly, I see a good amount of it. And most people don't even realize they fall on that spectrum. They just know that they like to stretch. They typically do yoga, like things that stretch, right? Like people like to tend to move in a direction that fits within things that are most comfortable for them. And I like that I never really thought about using manual more.

Joe LaVacca (16:47)
Bye. Sure.

Joe Gambino (17:00)
for that to make people feel better as opposed to, I mean, I wouldn't have them go stretch, but I definitely am one to start to use isometrics in different positions to start to try to bring things down. And I don't want this conversation to seem like, it seems like it's, I mean, I think our conversation is pretty neutral as manual therapy goes, but I do think that.

It can definitely help. If I have somebody and I can't put my hands on them, I think it's beneficial. Go find a massage therapist that you like in your area. A lot of people already do that. They see someone on a monthly or quarterly basis. Let's double down on that. If it makes you feel good and it's going to compliment what we're doing, I mean, I'm all for it, right? And I don't want people to think that we're anti -manual therapy. think Mike Stella, when we had him on, said it really great. know, people do feel good with it. It helps build trust with the provider.

and we can use that to our advantage. even, and I think we're starting to learn what manual therapy from, what kind of impact it has on the body. It's just not what we used to think it was. and that's, think really that why the field went so far in one direction is like, well, there's research is showing that we can't make changes. And that's what we once believed. So now it's no longer relevant, which is not really the case because people still feel better and still get benefit from it. And I think it was the same thing, right? Even exercise.

If we really want to break it down because now it was all this active, you have to strengthen stuff. Those first couple of weeks, whenever you give someone something new, you have not made changes to somebody. It doesn't take two weeks to make those changes. Adaptations take again back to that 48 week window. Right. So everything we do initially is a neurological change. Right. Like you take a novice lifter, you put them in the gym for the first time and all of sudden their strength, the first three weeks, they're so much stronger than when they started.

But there has not really been any like physical adaptations that have happened for bigger muscle or anything like that that shows strength changes have happened, right? It takes a little bit longer for that to occur. So I think that's really the big takeaway for people is understanding that we're not making change. We can't put them back into alignment. Those like myths that sit there and people believe. So this way they just less rely on those things. They can use it to their benefit as they need to. They can be very specific and you know, I don't...

I hate when people tell me that they foam all for 20, 30 minutes at a time. you don't really, you don't need more than like two, three minutes in an area and just move on to the next one. not like, you're not going to get more benefit by doing more than that at any point. So we can save you time. So you can do other things that are more impactful and still feel good and feel like you're getting it if you find it to be a large benefit. Any, any final points for you Joe?

Joe LaVacca (19:16)
Right, that's it.

I think that was a great summary. I think we both kind of share a lot of the same views on manual therapy. So if you are a client that's receiving a lot of manual therapy, it's not that we're trying to tell you to go run out and stop. But I would say it is your right as a patient to be asking questions about the narrative that you've been given about it. And if we kind of jump back to those, you know, maybe like three things or four things that we're talking about, you know, are we really breaking up scar tissue?

Probably not. Are we putting you back into alignment? Probably not. Does there need to be a specific way to apply manual therapy to people? Again, in my opinion, other than maybe being confident and delivering that treatment with intent, I'd probably say probably not. So if it is something that's holding you back, and I think that's the big key for clients, if it's holding you back rather than pushing you forward, that should maybe be worthwhile questioning either your treatment plan,

or maybe seeking out a couple of opinions from other providers.

Joe Gambino (20:39)
Love it. Love it. That's a great little wrap up there. To send us home, Joy Boy, I love you. Listeners, love you guys. And if you made it to this episode, extra love for you guys.

Joe LaVacca (20:47)
I love you too.