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, and 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. The tests that found something abnormal, however, don’t say how important those findings are to your problem. You have more information about what’s going on in your body, but not always clear guidance for what the best treatment decision is moving forward. Weighing all this can become paralysis by analysis.
As a manual therapist, I deal with this kind of problem every day. People I typically see are working on a complex web of issues: several different chronic pains and imbalances, gut health, weakness, stress. How are they connected? How do we start treatment? These are the questions running through my mind. The first visit for many folks also involves reviewing scans and reports they’ve had done over the years, each with their own unique light to shed on the situation. 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 detail here. But with so many concurrent pains and problems, determining where to start treatment can still be 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, and where to start. Yet, the patient is still there in the treatment room in need of help, and a decision needs to be made.
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 sit on my stool and speak with this gentleman, I need to admit to myself that I do not know where we really need to start. I must let go of my hypothesis, my assumptions, and my desire to “be right”. The body knows what’s really going on, and that’s what I need to be focusing on by feeling through my hands.
TREAT WHAT WE FIND
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, and if all I did was focus on his lower lumbar region, treatment might help that day, but it wouldn’t be as long-lasting. Not everyone fits the mold, even with the best evidence out there informing us. My job is to keep an open mind, treat the movement dysfunctions that I find, and trust that this opens the door for the body to naturally self-correct from within. After all, everything in the body is connected, and everything counts.
Many practitioners will at least say that they agree with this. They find a stiff ankle, a stiff lumbar spine, weak glutes, poor posture, etc. They will say that their treatment is based off the examination findings. But even if they truly do this without preconception, and actually invest enough time doing detailed manual work in these places, there is still the issue of figuring out where to start.
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 feel we need to begin. We are trusting not only the restriction we feel with the hands, but trusting its clinical importance in the body. In essence, we are letting go again. We are letting go of our analytical side for a moment, and letting go of our need to figure out how all the pieces fit. We are 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
I’m not saying that we shouldn’t try to understand how the pieces of the puzzle fit together in the patients we see, or to stop mastering our craft as therapists. In fact, these are the things about which I am most passionate. Knowledge of anatomy and biomechanics is essential in this work. It’s important to stay grounded, and re-examine things physically to see that we are making the changes we seek in the body. Having the body guide where we work (versus ourselves) is not a cop-out. 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 manual, osteopathic techniques to help pain and movement dysfunction. His expertise is in visceral manipulation, gentle spinal manipulation, and craniosacral therapy. He is the owner of Inspire Movement Physical Therapy in Columbia, MD.
