Manual Therapy vs Exercise - which is better?

Hi everyone, it's Chris from Patient Centered Training. Today's video, I suspect is going to turn into a little bit of a rant. Actually, this is something I've been thinking and talking to some colleagues about for a while. It's probably going to ruffle a few feathers. I would ask that you stick with me. It's not going to be very, very long. I might lose a few subscribers over this one, basically because it's a topic that I, I know people feel very, very strongly about on either side of the debate. And it just, it's come up again recently and I felt, I just wanted to put my two cents out there. I like to think this is a somewhat different approach to the way most people handle this topic, the way most people approach it. But I'm aware that, you know, not everyone's going to agree with me here. Like I said, hopefully kind of stick with me because it's going to go in a direction you might not expect. I like to think I'm taking a different approach on. And that's dependency and creating dependency through our care. Dependency on us. As a practitioner, one of the things I want to start by saying is that patient centered care, obviously dependency is anathema to that. You can't put the patient first whilst also creating dependency on you. Dependency by its own definition is. It's Dr. Centered. You're making it about yourself. And this is something that there's been a big debate going on more in physiotherapy and other frames, but it's come into chiropractic, it's coming to osteopathy, it's coming to all forms of manual care now. And this is the idea of creating dependency through manual therapy. And that if you, all you do is manual therapy, ultimately patients becoming dependent on you, on your magic hands to cure them. And we should be limited in how we do it. Some would say we shouldn't apply at all the extreme end. Others go, well, we should, but it should only be a small part of what we do. We should wean patients off it. And there's stage speakers, there's big names in the professions, more so in physiotherapy. But there's people who I otherwise respect and I've been to see them talk and I've been to their seminars and lectures, but they've developed quite a brand and quite a following through shouting out this idea of that, you know, you're just creating dependency with manual therapy. And quite understandably there's been quite a backlash for that amongst A lot of manual therapists who then dismiss that and go, no, that's rubbish. They don't understand it at all. They probably were just bad at manual therapy and couldn't get results there. So you have this kind of manual therapy versus exercise. I'm simplifying things there, but this kind of divide and like a lot of things in our culture right now, it's become very polarized, it's become very, very fractionated. And what happens is just the two sides yell @ each other. Now, trained as a manual therapist, as a chiropractor, obviously I have a lot of sympathy with the manual therapy side. That's what I do. That's kind of my bread and butter every day. But fortunately, I was trained in a way to also apply the exercise side of things as well. And to be honest, most of the clinicians I know fit somewhere in that spectrum. There's not many who end up just one end or the other. But the debates being like most things, controlled by the two extremes. There something that I hadn't really come across this idea until recently was mentioned by Rob Pate, who I mentioned the last video, who we're running this mentorship program with now actually is he pointed out that you can create dependency without manual therapy. You can create dependency through exercise as well. And I hadn't really come across that idea before, but actually a lot of us have probably seen some of these cases before where somebody just spent their life and they often call it rehab purgatory now, that they kept going back to see the physio, or they kept going back to see the chiro, or they kept going to see the sports therapist, personal trainer, whoever it was. And they weren't really making progress with the condition, but they just kept going and going because they were hoping that one day they get their core strong enough or they'd stabilize that shoulder or whatever it is. And it's possible to foster that as a clinician as well. And that's obviously a bad thing. Just like creating dependency on manual therapy. Oh, just whenever it hurts, come in and see me and my magic hands will fix it. You can create dependency on exercises, or if something doesn't work, come back and see me and my magic brain will give you a new magic exercise. And they actually is a condition in. They're well aware of this in psychotherapy and in mental health now of exercise dependence. And I've seen these people before. I'm sure you have too. We maybe don't spot it so easily, but these are basically people addicted to exercise. Now, that might be they want to go to spin classes seven days a week and then a hiit training in the afternoon. You know, they're sort of really ramped up. You only see them in sports gear. They always seem like they've just come from something really intense and they're getting their breath back. But it can be they're addicted to rehab. It can be that they've been doing these exercises to rehabilitate an injury for so long, and although it's not gone away, or maybe it has, but they don't trust the spine anymore. They don't trust the issue. They're still having to do all this stuff, and they're still really worried that if they don't, it's going to get worse. Even if the pain is not there, it's still in their mind controlling them. And that's something that we need to be aware of as clinicians. And we need to be aware that it is possible to create and foster exercise dependence as well as dependence on manual therapy. And often we might see these people who've already got this in place. I know I've seen people who've come in very dependent on manual therapy, and their last practitioner would put it back into place for them, and they just need me to put it back in place again and they'll be okay. And that's always difficult to see because I know that part of the reason why this person's problem is so chronic and is worse than it could have been is because they saw a practitioner who created that manual therapy dependence. And they often didn't do it intentionally. They often did it with the best of intentions. Very few of us are out there deliberately trying to create dependency consciously. But the end result is that this is somebody who now, because of their beliefs, is going to find it very hard to ever have some of that independence. And some of that. The stuff we were talking about the last video about that self improvement, that self dependence. But also this happens with exercise. They come in and they're totally hooked on exercise. They go, what should I do? What about this? Should I do that more? Should I do that less? And they've seen people who've created that same dependency on the exercise side of things. And it's at the state where much like we have to manage the manual therapy dependence with some skills of communication and potentially looking at some psychological strategies as well, some cognitive strategies. The same applies to the exercise dependence folks. Some of them might benefit from a burst of CBT or something like that. Often, like most addictions, the exercise dependence comes on in a period of high stress, and they maybe use the exercise as a crutch for burning off that stress. Or like somebody else might resort to just drinking a bit more in the evenings or seeking comfort food, they're seeking the endorphins. They get the adrenaline rush from intense exercise, and it's maybe now becoming problematic for them. So make sure you're aware of these folks as well. If it's a little bit of dependence, maybe over time you can just challenge it gently. You can get an understanding for some. For some of them, though, you might need to rope in a rope in. Refer to a mental health professional as well. And you want to be careful how you have that conversation. Often the approach I'll use is rather than head on and say, I'm going to get you some CBT for your exercise dependence because your addiction to exercise is a problem. If they don't see it that way, and often they don't at the start, then they're probably going to reject me instead of the exercise. Very few people will choose me over the addiction if they can't admit that it's a problem. But I might say, you know, if we can explore it a little bit, maybe over a few sessions, it takes some time to build this kind of trust. I might find out that, you know, one of the reasons why they're already into this exercise is because they've been very stressed out and because they've been having a really hard time with things. And maybe I might ask, oh, it sounds like the exercises, it's maybe a way for you to cope with that stress as well. And especially if I can get them to see that maybe all this exercise maybe makes the problem worse sometimes, or maybe they're. They're missing out on other social activities because of this exercise, or they're putting other things to the side, then they might see, okay, yeah, maybe I need to change something. If I can then make a referral to somebody to help you with the stress, that's. That's made me feel like you need this exercise. That often is a bit easier for them to accept as well. Not with everybody, unfortunately. You know, whenever you deal with these sorts of things, not everyone's going to see eye to eye. But I would be aware of that. If this debate ever, if you ever come across this debate, there's two people arguing, no, manual therapy is fine. It doesn't create dependency. And other people going, no, it's evil. You should never use it. I'd ask you just to keep in mind that it probably depends. Stu McGill's made that phrase kind of famous now, but the answer is likely. It depends. Does this patient need manual therapy? Do they need exercise? It depends on often they need both. Maybe they need a 70, 30 blend one way or the other way. But I mean, hopefully that's kind of made a bit more sense of this. It's a very hot button issue. If I've upset you with this video, I am sorry. I'm not saying this to try and challenge people in a way to seem like I've got the answers or like I'm trying to create an easy narrative and go, all those people are wrong and all the people in my tribe agree with me and boost up a brand through that. I'm just hoping I can make a bit more sense of this because it's not. It's a difficult conversation and I think that nuance is something that's often needed here. And if that can just help you guys make a bit more sense of it and hopefully means that you don't feel you have to choose one side or the other with this, then I'd be very happy with the result of that. So have a think about this. If you've got any questions on it or if there's anything, maybe you want to come back and challenge me a different way. I'm all up for a healthy debate on this. People screaming at each other on Facebook. I've tried that. I've tried screaming back. I'm not the zealot whisperer. I can't get through to people through Facebook very easily. I don't think any of us can. So I'm not going to get engaged in screaming matches on that as best I can anymore. But, you know, healthy debates are always a good thing and that's how we all learn. And I'm sure my position on this will evolve over time as well. But I just wanted to put this out there because I see it coming up again and again. And I just thought if I can throw my two cents out there, it might helpfully make sense for the majority of us who are in the middle, who feel like we're getting caught between two rather extreme but fairly small camps there. I'll be back for another video soon. Probably not one that's going to ruffle so many feathers, hopefully, or stir the pot so much. But, yeah, hopefully you found that helpful and we'll catch up soon. Take care, guys.