THE ROOT OF THE PROBLEM
Imagine this common scenario:
You’ve got a health issue. You saw your primary care, a specialist, and you’ve gotten an x-ray, MRI, perhaps bloodwork. Maybe a colonoscopy or EGD if you have some digestive issues. Possibly a nerve conduction test. Some of these tests found nothing, and some found something. You’re armed with data, but it’s hard to know how important these findings are to your problem. Despite being armed with new information, you still lack clear guidance for what the best treatment is. Weighing all this can become paralysis by analysis.
This story is familiar to folks I see for manual therapy. Many of these people, for lack of a better term, have “slipped through the cracks” in our healthcare system, and are managing a complex web of issues: several different chronic pains, issues with gut health, mental well-being, and more. Could these problems be connected? Which issue needs to be addressed first for the best outcomes? Is there something else that the tests haven’t captured? These are the questions running through my mind.
Fortunately, in the osteopathic model that I follow, we know that the symptomatic area and the root(s) of the problem are often in different places. So we don’t get too hung up on every little data point. With several concurrent pains and problems, clearly determining where to start treatment is challenging, and my attitude toward diagnosis has required some evolving over the years.
LETTING GO OF WHAT WE KNOW
I am a believer in evidence-based medicine. I think it’s the only way for practitioners to hold ourselves accountable and advance our collective knowledge. However I also know how much further we need to go in our research when it comes to manual therapy and complex health/pain conditions. Sadly, the available evidence out there is just scratching the surface of how we should be treating a given condition. Yet, the patient is still there in the treatment room in need of help, and a decision needs to be made. We need to know where to start.
If a patient comes in with pain running down his leg, I can take an educated guess that it’s a compressed nerve root in his lower lumbar spine, but I still can’t be positive that this is where I need to begin treatment. There could be another, deeper issue driving this problem. The lumbar region might be over-strained due to a restriction higher up in the spine, problems in the feet, or even tension coming from the abdominal organs in front of it. As I’m speaking with this gentleman, I need to admit to myself that I do not yet know where we really need to start our work. I must let go of my hypothesis and assumptions for a moment, and now feel with my hands. The body will show me where its tensions are, and that’s what I need to be focusing on.
THE PROBLEM WITH PROTOCOLS
I treat the restrictions I find, even if they seem unrelated to the patient’s problem. I can’t neatly categorize people as “low back pain” or “stiff shoulder” patients and follow a standardized protocol from there. This is because I am often surprised. The gentleman with the compressed nerve in the lumbar spine might have a very stiff neck that was causing the problem. If I had ignored the lines of tension I could feel pulling my hands toward his neck, and instead only focused on his low back, he might feel better for a while after that day’s treatment, but it wouldn’t be as long-lasting.
It’s important to keep an open mind and trust what we feel with our hands. And that by addressing these major areas of tension and dysfunction in the body, that this will open the door for the body to naturally self-correct from within. After all, everything in the body is connected, and everything counts.
So we have an open mind toward treating what we find in the body, and trust that this will help. But there’s still the question about where to start. How do we know what to work on first?
THE BIG LEAP: TRUST WHAT THE BODY HAS TO SAY
With our hands, we can sense in the body where the tensions are the most significant, and where treatment is needed the most. This is done with the palpation skill of “listening”, and requires a big paradigm shift: that we will get better outcomes if we prioritize hands-on treatment where the tissue tension is most pronounced, and NOT where we might think we need to begin. We are trusting not only where we feel restriction in the body, but also its clinical importance. In essence, we are letting go again. For a moment we are letting go of our analytical side and our need to see how all the pieces fit. We’re trusting what our hands feel in the body as the most important thing to address, even if it seems unrelated to our symptoms.
TRUST, BUT VERIFY
The body’s tensions can guide the practitioner to many different places that might be long forgotten (or yet to be detected) problems. Sometimes it’s hard to see in that moment how it relates to the symptoms that brought the person into the office. It’s important to stay grounded, and continually re-examine things physically to see that we are on the right track, and making changes that indicate progress toward the patient’s primary complaint. We still expect to see results. But we understand that we are better off working for the body than we are working on the body.
About the author:
Tim Newton, PT, DPT, OCS, CFMM and a board-certified Orthopedic Clinical Specialist who specializes in Osteopathic Manual Therapy techniques to help pain, stress, and digestive issues. His expertise is in Visceral Manipulation, Gentle Spine Manipulation, and Craniosacral Therapy. He is the owner of Inspire Movement Physical Therapy in Columbia, MD.
