#4 - Adam Meakins and Chad Cook debate

Season #1 March 08, 2022

The topic of manual therapy and its role in physical therapy always elicits differences of opinion. In this episode, Adam Meakins and Chad Cook tackle the hard questions and attempt to clarify what manual therapy does (and doesn't) and where it fits into contemporary physical therapy care (if anywhere!).

Want to see the conversation happen live? Check us out on YouTube.

Connect with Adam, Chad and Jared:

Adam on Twitter:@AdamMeakins

Chad on Twitter: @Chadcookpt

Jared on Instagram: @shoulder_physio

Jared on Twitter: @jaredpowell12

References

To download an infographic summarising the key points from this conversation, and the reference list, click here.

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Episode Transcript

Jared Powell:
Hello, and welcome to everybody around the world and to Adam Meakins and Chad Cook specifically, this is the much anticipated conversation or showdown between Adam Meakins and Chad Cook on the eternally polarized topic of manual therapy and its role in physical therapy. Chad, I believe it's 7:00 AM your time over in the USA. So thanks for getting early and chatting with us. My pleasure. Thanks for having me and Adam. It's a, it's a polite midday over in London. So thanks for, for going a beer at the pub, more likely the backyard thanks coronavirus And chatting about a topic that you're a notorious critic of and that's manual therapy. So thanks mate for getting involved

Adam Meakins:
Now. Thanks for the invite. I am looking forward to this should be fun.

Jared Powell:
Beautiful. So to get things underway and to give everybody a little bit of a context about this discussion, I'm going to briefly, I of both you now, this is my introduction. I've done my research. You guys, haven't given me a bio of yourselves. So I'm gonna start with Chad. Chad is a renowned academician out of duke university in North Carolina in the us, Chad has more than 300 academic publications to his name around 50 of which directly addressed manual of therapy, which is the topic of today. Chad has also altered three textbooks on manual therapy and orthopedic physical examination. Chad is an undisputed thought leader and luminary of the profession of physical therapy, not just an academic though. Chad has also spent time working as a clinician and teaches a manual therapy course internationally. Consequently, Chad is well positioned to speak on the apparent truths or mistruths of manual therapy.

Jared Powell:
All right, that was, that was that was a mouthful. Adams is even longer. So let's get into Adam Meakins. So Adam Meakins, I don't think needs any introduction if ever there was a celebrity physiotherapist it's Adam, Adam has risen to prominence over the past decade due to his direct and occasionally controversial and abrasive approach to dogmatic aspects of both the physiotherapy profession and the health and fitness sector. More broadly, Adam Garner's attention, wherever he goes on social media, both positive and negative, but this doesn't seem to do or slow him down. Adam has amassed over a hundred thousand followers on Instagram and 70,000 on Twitter and has also published papers in peer review journals. Metaphorically speaking, Adam can be likened to a hot knife slicing through butter in his Savage attacks on practices he disagrees with and often leaves others reeling in his wake. Manuel therapy has born the brunt of his ferocity over the years in several blogs and podcasts as such Adam two is well placed to speak on manual therapy. Okay, so some context for today's. I don't think I've

Adam Meakins:
Ever been called a hot knife through butter before. That's the first one. Thanks. Thanks to that

Jared Powell:
Day. so some context for today's discussion. So Adam and Chad, as you're all PO possibly aware of being engaged in some online, back and forth over the last few months about manual therapy. Now, given they're both eminent thinkers over the physiotherapy profession, I thought it would be productive for these two to sit down, bash out their differences in a formal face to face discussion for the good of the ordinary physio of which I count myself as one who may be deliberating and debating the efficacy and effectiveness of manual therapy and whether they should or shouldn't be applying it in their own clinical practice. Now, this is what the whole point of today's discussion is all about. So with any, without any further ado, let's dive into the first question. And the first question, it seems like a logical place to start. What is manual therapy? Do we have a consensus definition of manual? Where does this hands off? Hands off hands on, hands off debate, come into it. Let's explore this, Adam, I'll start with you.

Adam Meakins:
So I think the simple answer is I don't think there's a consensus of what manual the is. I think if you were to get, you know, a group of manual therapies in the room and say, what is manual therapy? I think a lot of them will say different things. I think there'll be a core element that is agreed on. And so for me, I think, you know, when I talk about manual therapy, I'm talking about the, the formalized types of treatment that are believed to be, have to be done in a specific way to create specific outcomes. So I'm talking about things, you know, specific types of soft tissue massage to release certain types of tissue that have to be done for a certain amount of duration with a certain amount of force in a certain direction. And then I would also incorporate in manual therapy again, the joint manual therapy techniques.

Adam Meakins:
So the mobilizations that again, a thought to have to be done in a specific way to create specific outcomes. So working on specific joints, specific levels of the vertebrae, pushing in a certain direction at a certain amplitude at a certain velocity, et cetera. And again, of course, you know, your high velocity manipulations, low amplitude manipulations, H VLAs would also be another type type of joint, you know, technique that I would incorporate under the umbrella of manual therapy. And then you got your sort of offshoots, you know, you could also incorporate, I think they're really under manual therapy. Things like probably dry needling and even probably taping passive treatments again that are thought to have to be done in a specific way to a patient to get some sort of, of specific outcome. But for me, my core principles, when I discuss manual therapy are all the soft tissue techniques, your massages, your, my fascial releases, et cetera, of which there are probably, you know, 300 different terms and names of that. And then you joint mobilizations and manipulations, they'll be my core things of what I class as manual therapy and to put it into manual therapy and say specific techniques done in a specific way to get a specific outcome.

Jared Powell:
Okay. A specific technique done in a specific way to get a specific outcome. Chad, would you agree with that?

Chad Cook:
I think it's suffered from a common terminology for a long time and I'm in agreement with Adam that I think there's not that I agree that if you get a, a lot of manual therapists together and you get very different answers on what this terminology is. I think if you look at the professional bodies, they've described it as skilled techniques. if you go to Wikipedia, which is at higher level of, of evidence, it will include everything in Eastern culture and essentially everything under the sun. So I I'm in agreement that it, it has a it has a terminology problem, but I think it has, which contributes to its reputation problem, because there's a lot of the odd things that fall into that list. I am aware that AOP Andon is looking at developing a more modern definition of manual therapy, which will include more of the processing, the assessment, how you go about looking at someone. And I think that's very welcomed. So I, I think it's hard to put a label on it. You know, I hope we get a chance to talk about specificity and having to do it a certain way, because I think that's really rich for discussion if we can get to that later or hour or whenever.

Jared Powell:
Okay, cool. So would you agree, Chad, that dry needling perhaps acupuncture all of these types of modalities taping even would come under the banner of manual therapy?

Chad Cook:
I would not. Dry needling acupuncture, taping, I think have similar principles to manual therapy where a lot of theories behind it, but I think technique wise and the approach is a little bit different. But nonetheless, I do think that, you know, if you get, I think there's a lot of common language spoken. It's like Canadian, French and French, French with respect to dry needling and manual therapy. So I, I think there's some overlap there, but in my mind, dry needle links, not manual therapy.

Jared Powell:
Okay. So when you are thinking manual therapy, what are you thinking?

Chad Cook:
I think of it as an approach. It it's very much, you know, I just don't think about techniques because to me it's a full package. When I assess someone, I look for whether or not pain modulation might be a valuable input to their system as I progress them toward what they need. I look at the patient in the bigger picture. I, I think more people are looking at, you know, where does the patient fit in, in that communication between the patient and the therapist and whether manual therapy needs to be part of that? So I, I look at it in a broader context. I think I'm not even sure that I could put it down on piece of paper and exactly what it is, but I'm hoping I'm on two task force. I'm hoping we get it sorted at

Jared Powell:
Adam. Do you have anything job that much?

Adam Meakins:
Yeah, I, I think could get, and you know, another definition that sometimes used is anything where a therapist places their hands onto a patient. So, you know, the, the therapy of touch is sometimes classed as manual therapy. And I think, you know, this is my position often gets misrepresented hugely when I'm a critic of specific manual therapy techniques in being misrepresented as saying that that means we shouldn't touch patients. And that's something I just want to clear up as well. I do not incorporate the role of palp patient and touch in an assessment in an examination as part of manual therapy. So I think again, that is commonly misinterpreted misrepresented used in my position. When I'm saying that manual therapy has some issues in its way, it's been taught in the way it's been taught and teached to physios in the way it's explained to patients.

Adam Meakins:
But that doesn't mean we suddenly stop touching patients. Cause we all know, and the evidence tells us, you know, therapeutic touch is beneficial. It does help patients. It can Orum, you know, I don't think there's anything worse than hearing a patient saying the last guy didn't even look at it, let alone touch it. So I am a keen advocate of using palp patient and touch and differentiating that from formal specific manual therapy where I think it sometimes as say it gets a bit confusing is when, you know, touch starts to, you know, directed in that specific way to then believe to get those specific outcomes. That's the bit I challenge and question a lot about, but I don't refute the benefits of touching patients when they've got pain.

Jared Powell:
Yeah. Good. Okay. So I think the next question's gonna get to this specificity question that, that we all wanna touch on. So just to conclude that question, therapeutic touch is important, Adam, you, you will, you, you that's, that's, that's something that you certainly agree with. However, what you question is that whether it needs to be done in this specific manner, in a specific direction, et cetera, et cetera, to achieve a specific outcome.

Adam Meakins:
That's what absolutely, you know, my, my, my frustrations is, is that I find manual therapy SA is, is believed and taught to a lot of physiotherapists is still having to be done in a specific way to create these specific outcomes. And, and I know things take a while to change, but you know, this stuff has been going on in my opinion, way too long. And it's still quite prevail in a lot of the manual therapy training in universities. And in post-graduate courses, the belief that, you know, you have to stand in a certain position, you have to push something in a certain direction at a certain ample Juda, a certain force to create a so-called specific tissue effect. When actually, you know, we know that manual therapy based on the research and the clinical evidence doesn't work that way. I mean, there's numerous trials that have compared, you know, sham applied manual therapy versus specific manual therapy.

Adam Meakins:
And we don't see significant difference in the outcomes. You know, just the top of my head, the neck one was the Aquino paper from 2009 there's multiple ones done in the Lubar spine. There's been some studies looking at M WMS as well in the peripheral joints. And again, finding no real difference, whether you do a randomly selected a technique versus a so-called therapist specific selected technique. Yet I do still find that as say, a lot of these beliefs about the specificity are still rife. They're still being taught currently. And, and I find again, the other problem I have is that that amount of time that it takes to teach a physiotherapist is so-called specific techniques I think is, is a waste of time. It, it is. Not fortunately I think clogging up the curriculums in physiotherapy teaching practices. And I think what it's doing is also distracting a lot of physiotherapists away from time that could be spent on other things that they would be more useful at.

Adam Meakins:
I mean, just for example, when most physiotherapists, if you ask them, you know, from, you know, day one of the graduation could show you a grade three unilateral mobilization on a supposedly stiff L four five segment, yet they probably couldn't tell you or demonstrate to you how to communicate really well with a patient that's frustrated, that's distressed in pain because their time has been spent a lot or manual therapy training than effective communication skills. And likewise, you know, with soft tissue techniques, you ask a physiotherapist after graduation. Could you show me something that releases this piece of fasc, and they'll probably show you 33 techniques that they've been picked up on their training. Yet, if you were to ask them, could you show me 33 different types and ways of means of loading somebody who's got a painful E joint, they would struggle to do that. So again, I just think that again, my, my frustration with manual therapy is the time wasted in training the need to do it in a specific technique to get specific outcomes when there is no real need.

Jared Powell:
Yeah, well, well said, so Chad, I I'll throw it over to you. So Adam set this up really nicely. So it is unquestionable. I think that a lot of manual therapy techniques are still being taught most institutions all around the world as highly specific, highly skilled interventions. Why do you think this is the case? And is there any evidence that manual therapy must be applied specifically to achieve a specific outcome?

Chad Cook:
Yeah, there's a lot to unpack there. So I'll start with the why. And I think that's probably philosophy and guru driven. And, and I've said this in the past, I don't mean to be negative toward a lot of the pioneers in manual therapy, but they were truly building the plane as they were flying it. And they created these philosophies that matched what they felt was going on. And the rigidity of those philosophies has not been removed by a lot of modern manual therapist. They've stuck with the same philosophies, something somebody said 50 a hundred years ago, that was based on faulty biomechanical constructs. And, you know, I've written about this before and some of my first publications where I tackled frets law, what a crap law that is. And, you know, just a lot of these principles that really have not held up to modern science.

Chad Cook:
So I'm in agreement there primarily too, that the evidence is not worn out, that it needs to be a specific technique. I, I know nine smaller, but reasonably well designed studies that comparatively assesses Adam said either a randomly selected technique or a a, a placebo based mobilization versus a therapist selected technique, including one of ours, which we published in 2016 and J O S P T. We even tried to set it up so that the placebo was so bad that the, the manual therapy technique that was selected by a therapist would be better. And we did didn't see any differences in self-reported health outcomes. We did see a difference in the gro and, but the gro measures something differently and, and that's worth, that's more of a patient expectation patient experience type measure. There are two studies that have actually shown that, that the gro changes, but the self-report measure stone.

Chad Cook:
So the specificity for self report outcomes such as your legacy measures, you haven't seen a difference with that. Emily Slavin did do a meta analysis and showed that it does seem to be trending toward specificity at the neck, but it only included two studies. And that needs to be further investigation. The no way nonspecific techniques tend to have as much value as a specific technique. I, I think we know enough about that right now that we don't need to investigate that any further. And, and that's all right, as far as, you know, Adam and mentioned, there's a lot of time baked into education. I think the is probably a bell curve on that. It probably reflects the faculty in, in that particular program. I know in the United States where I'm from, we, we have a problem in that we don't incorporate enough manual therapy in our curriculum.

Chad Cook:
I know that we have approximately 15 contact hours on manual therapy, but it's an elected at duke. So you don't even have to take it. Other than that, you just get a smattering of it. So we're definitely not one of those. We teach a very nonspecific approach. We don't, I don't even think we teach grades. So it it's very much, I think university dependent, if you have someone who is a believer of a philosophy, and in my experience, it's been very much the biochemical philosophies. And there are certain regions of the, of the world. I believe those individual are steadfastly holding on to some principles that make up who they are. And, and I don't mean to be offensive, but it's, it just hasn't, like I said, born out in modern science, the more flexible approaches and I would, I am not affiliated with Mulligan, but I think the Mulligan approach is more flexible and their assessment approach. I don't think they, I think they adapt with evidence that comes about, I think other approaches do too. So I think it really depends on the approach. You've seen one, you've seen one. Mm,

Jared Powell:
Okay, cool. So I think, I think there's a fair bit of agreement within that manual therapy probably doesn't need to be in order, certainly not superior to a nonspecific type technique in terms of clinical outcomes, perhaps for rock or, or global rating of change, which is a different conversation, which, which we might get to and possibly university specific or institution specific in terms of how much time they spend or devote to teaching manual therapy, which is interesting. Adam, do you have any follow up comments there?

Adam Meakins:
No, I, I agree with what Chad said there, you know, at the end of the day is variable. It is regional. It is probably, you know, dependent on institutions like Chad says and based on who is working and affiliated with those institutions. So yeah, I do see a wide spectrum and I don't wanna tar everybody with the same brush cuz that often comes across as what I'm doing as well. I know that there are many rational evidence based manual therapies out there using manual therapy in a very reasonable, pragmatic way. I just find them in the minority. There are the majority out there, the institutions out there, particularly postgraduate institutions, you know, these things that spring up, you know, without any, you know, peer review without any sort of, you know, accreditation or affiliation or ways of checking quality. These individuals as say are very much driven by other reasons, mainly financial.

Adam Meakins:
And again, they're still going off. Well, Chad said, which is these gurus that have, you know, come up with ideas pioneers back in the day who didn't know any better. And as Chad said, you know, we don't demonize them. We, we very much, you know, respect what they knew and what they did for us, but we know more now and therefore, you know, carrying on their philosophy, you know, needs to be represe in and adapting to the new knowledge that we got. And a lot of the gurus in this day and age are not doing that.

Jared Powell:
Yep. Fair. I think that's fair. It's a, a conversation about mechanisms and how manual therapy may or may not work could be interesting, but I, I don't think, think we'll go down that, that pathway, a question that I want to go into next is, is a really interesting one to me. And I think it should be of interest to a lot of people out there, which is manual therapy and its its role or, or possible role in, in value-based care. So it quite often gets thrown out there. That manual therapy is a low value intervention. And I want to, I wanna discuss this. So where does manual therapy fit in value-based care paradigm, what evidence exists for, or against it in this concept? And then finally I want you both to answer is manual therapy, a high or low value intervention. And does it have negative long term se does it, does it result in any long term harms? Does it leave to passive dependency, reduce self-efficacy and all these things that get thrown around at manual therapy? Adam, I'll start with you.

Adam Meakins:
Well, I think that the first thing we need to do here here is define the term value more. I mean, value to who and to what, because you know, when we're talking about manual therapy, we could be talking about its value to society on its economical value. We could be talking about its value on the size of the effect at reducing pain or disability, or are we talking about its value to the clinician in terms of their training, their belief and their professional identity as a healthcare professional. Are we talking about its value to the patient in terms of their expectations or their experiences on pain and disability? Cuz they are all very different things and they all have different values. An analogy I often use here is, is McDonald's. I mean, for example, if we were to judge a McDonald's on its eco on a core value and its consumer satisfaction value, I think we would class it as an incredibly high value cheap and tasty food source.

Adam Meakins:
However, if we were to judge a McDonald's on its value of its nutritional quality and its long term health benefits, I think we'd all agree and say that it's a very low value quality food source. So the value of a McDonald's can vary based on who you're looking at and who and what you're looking at. And that's no different with manual therapy. So there is no doubt that some patients and some clinicians as well, highly value manual therapy, as it can produce some small, but significant short lasting reductions in pain and disability from time to time. In some certain instances, no disagreement from me there whatsoever. However, does that make manual therapy a high value treatment option in general? I would argue no. So this is where I come across and soft and say that manual therapy is a low value intervention because just like McDonald's can give you short-term satisfaction.

Adam Meakins:
You wouldn't consider regularly having one or recommend it to others as a good long term nutritional food supplement. So instead as a responsible healthcare professional, I'm sure most of us would advise against anybody eating a McDonald's regularly, if at all. And I feel this is no real difference from manual therapy. You just can't judge the value of a treatment on how good it makes a patient feel. Just like you wouldn't judge how good a McDonald's is on its nutritional quantity, just how good it tastes. So as I say, there is no argument for me that manual therapy can make things feel nice. But what effects does that have in the long term? Are we focusing so much on the benefit it's in the short term of making things feel nice temporarily and actually losing sight of what that could be affecting into the long term effect.

Adam Meakins:
Now I'll be quite open and honest and I'm sure Chad will probably pick up on this, that if we haven't got much data on what this is doing in the long term, we don't know is the simple answer. I have opinions I have that I can't really back up that I think that we are overtreating pain a lot and I'm not just saying manual therapy. I'm not just saying physiotherapist. I'm talking about healthcare in general, but I think we are too busy at the moment currently in our society looking to reduce pain unnecessarily, when we should be doing the opposite, we should be, you know, compassionately, calmly reassuring patience with clear, concise information that the pain is not dangerous. It's not harmful has a favorable natural history. It doesn't need to be reduced and removed. It would actually be better to be dealt with and be, you know, exposed, to become more resilient and robust to it.

Adam Meakins:
One of areas I have about the increase in chronic pain epidemic is because not because we're not finding the right treatments for pain it's cause we are constantly trying to reduce it too much. We are as a society becoming less and less tolerant to pain. Cause we look for the massage, we look for the manual therapy, we look for the Paray tomorrow or the Tylenol or whatever you wanna call them too quickly, too often. And I think, you know, as society is a human race, we are losing our resilience to things that hurt and feel uncomfortable from time to time. So my argument here, as I say, is when it comes to manual therapy, it's a low value treatment based on those factors, don't judge it just by how nice it feels and how satisfied it makes patients. Cause that's a way to judge a health healthcare intervention instead, perhaps let's look at the longer term consequences and pictures, but we haven't got any evidence to say what that's pointed to in one way or the other. As far as I know,

Jared Powell:
Adam, you're sounding like a politician that's good health policy over there. You've . I quite like it. You, the tos need a new leader over there. You should, you, you should

Adam Meakins:
Put your hand up me not Tory mate. No way. No way.

Jared Powell:
Okay. Chad, so the right of reply. So Adam, I like, I like the McDonald's analogy. So, so, so Chad, do you have any ideas on what does value mean in, in, in healthcare? Do we, do we, do you have a specific definition that, that you could apply and, and where do you see manual therapy as fitting within a low or high value treatment?

Chad Cook:
So I think it's important to recognize that value based care, the definition's evolving historically it has been the amount of outcome for the cost of treatment. It, it has been devoid of any patient input on what is value and it's purely been based on health status measures and the amount of cost that went into that. If that was the way we should measure it, then the most valuable treatment we have is natural history and just leaving the patient alone, it doesn't cost anything and they tend to get better are on their own. So most people recognize that that's too limited of a definition. Nonetheless, there are quite a few cost effectiveness research studies that do show that manual therapy is more cost effective than supervised exercise than a behavioral approach as Adam kind of mentioned near the end, but do we have enough?

Chad Cook:
No, I think obviously we need to look further into that and it primarily wins and cost effectiveness because there are fewer treatments involved with that particular patient. So value wise with respect to cost effective. Yeah, it's, it's actually valuable value wise as far as downs stream healthcare that needs to be sorted out further. What we do know is unfortunately, a supervised exercise program, a lifestyle modification, behavioral modification, any cognitive behavioral approach, the downstream adherence to that and long term benefit is actually poor and it's partially poor. But because we think by going in and modifying patient level factors, it's gonna make a big enough difference to change overall health status of patient. And in reality, it's probably more societal social public policy related elements that are gonna influence that person's ability to thrive later on. So on my end of it, you know, this, this idea that manual therapy is a low value care essentially came out of two narratives who took every passive approach and threw it in low value and every active approach and threw it in a higher value.

Chad Cook:
And again, the, there you run the risk with narratives of getting, you know, some opinion leaders to draw, how things move forward and reality. It hasn't been sorted out enough. If you ask me right now, I would be the, a true researcher and say, we need more information on this, but with respect to how I categorize manual therapy, how I use it, you know, two, maybe three visits is a pain modular segment to a more of an active approach with heavy lifestyle modification, trying to change the behaviors, the patient working on pain interference versus pain intensity. Cause I'm in full agreement with that in there that we're, we're losing the battle, trying to get rid of pain intensity. It's really about helping them live with pain and, and helping them modify their pain and their perceptions of pain. Then I would say that there is that it's a high value therapy because it's inexpensive. You can do it fairly quickly and you can add it to other elements, which on, in theory should be high value, but really haven't, hasn't really born out like a lot of people claim. They are. It's easy to say that exercise is the best intervention until you actually look at the literature and the, and it's not this silver bullet that we had hoped it to be

Adam Meakins:
Adam. Yeah, no, I, I, I totally agree when you say that comparing manual therapies effects on pain for exercise doesn't show any difference. And I, and I'll be the first to agree that I think exercise for pain has a lot of limitations and for various different reasons, one I think is because again, and this is just my bias is that we do a poor job at prescribing exercise or explaining exercise to be yes, we do as to why they yeah. As to why they need to do it. And, and we believe again that there needs to be a lot of specificity. And again, like manual therapy, there doesn't appear to be that case. You know, when we look at exercise, we can use it in a very nonspecific way and tap into a lot of beneficial effects that way. So yeah, there's no argument from me there that I'm comparing manual therapy against exercise, although I'm a huge advocate of exercises.

Adam Meakins:
I'm sure everybody here is, you know, we gotta recognize that it doesn't perform any better than anything else for people with pain and pathology. So I agree with that. I'm just interested in what Chad said about, he thinks manual therapy is relatively in expensive because I dunno where he goes to get his manual therapy from . In my experience, I, I find that most half hour sessions, 60 minute sessions with a physiotherapist doing the pokey pokey breasty breasty rub Doy stuff is not cheap compared to gonna have a hot water bottle on your back or going to have a couple paracetam or whatever. I, I don't think I would class it as inexpensive. I think it's actually quite expensive.

Chad Cook:
Yeah. I think it's when it's compared to other interventions, I'm sorry, I got a sun shooting me on the face right now, but that, I think it's when it's compared to other typical interventions and the cost effectiveness studies, it shows that it's inexpensive in comparison. Now those

Adam Meakins:
To the Sur sorry, surgery and injections, is that what you mean, Chad?

Chad Cook:
No, it's actually supervised exercise, a cognitive behavioral approach, a graded exercise approach, a home exercise program because the, you, you have to factor in of the improvement that you see versus the comparative group for the cost. And that's actually how they analyze it. So cost effectiveness studies actually support it from what we have right now, but I'll be the first to say, yes, there are studies out there and I'm happy to share those references by the way everybody should. I'm from the United States, you should fact check me. Our politicians have a history of not telling the truth, but happy to share the, the references that I do have, it's not near enough and we need to further tease out value based care to include the patient's voice and what is actually valuable. And I think it's really important to know that patients want pain, Mo elements. They wanna know what's wrong with them. They wanna know how they can address their pain, whether it be through a clinician or themselves, typically both, and they want another prognosis. So in many cases, I think part of that package of the value, if we include the patient has to include some pain Mo component and they firmly believe that I believe it cuz most patients believe that

Jared Powell:
Adam, any, any last thoughts on, on value based care,

Adam Meakins:
Again, I'm just gonna go back to that analogy. I, I get the, I standing of needing to get patients feedback and views as to, you know, what makes good value treatment for pain. I do understand that, but, and we'll probably get onto this in the next question around, you know, patient centeredness. It are patients, experts able to actually judge what is best for them. I do understand we need their feedback, but at the end of the day, I think they also need guidance and support from healthcare professionals. So I, I have a little bit of a say of an issue here when it comes to listening to patients and just doing whatever they want or expect or say, which I'm sure is not what many do, but I just think we gotta be, we we're treading a fine line. We've gotta be very careful with, you know, patients, beliefs and expectations of what they want from their treatment because often what they want, isn't what they really need. And again, I'll go back to the McDonald's analogy. Everybody wants the McDonald's, you know, it's tasty. It's lovely. Who doesn't want one, but is it really good to have a McDonald's

Jared Powell:
So Adam, do you think exercise is a high value intervention

Adam Meakins:
For pain for pain?

Jared Powell:
No. Do we have any high value interventions for pain

Adam Meakins:
Again? I suppose it depends on the population or what type of pain we're talking about. I mean, when it comes to exercise, I think it's high a value, not because of its effects on pain because of its effects on a person. So I, I play the secondary benefits card a lot here. I, I often say, look, we've got things that work equally well for pain. You know, the issue with pain is that not that nothing works. It's that, everything works. All right. And so we've gotta look at other things that can help with pain, but also probably have more beneficial, secondary benefits around it. And, you know, the benefit, the secondary benefits of getting people to be more active and engage in exercise are gonna far outweigh any secondary benefits of having a massage or some joint mobilizations or a manipulation. So again, I, I say a everything, you know, on an equal par when it comes to helping pain looks pretty even. But what about looking beyond the effects on pain? What about the other secondary benefits?

Jared Powell:
Any thoughts?

Chad Cook:
Yeah. you know, on, on paper, secondary benefits are gonna Trump, everything in life, they don't because the adherence is not there. The carryover effects aren't there, the behavioral change isn't there, the lifestyle modification isn't there. You're not changing social factors. You're not changing just challenges that have to be addressed through public policy. And you know, again, I'm, I'm with Adam. If, if, if we could elevate something, the golden cap is exercise and lifestyle modification. And, but in reality, it just doesn't, it doesn't bore out. If we look at patient expectations, they are the strongest predictor of outcomes for a number of muscles, got elements, including surgery. So if trying to change patient expectations and I'm in a big trial right now, we've been in it for two and a half years. It's incredibly difficult to change. Someone's expectation of what they need. And you can spend a lot of time talking to them about changing, or you can be a career clinician and incorporate a little bit of what they think they need and expect, but bake in those other things that we hope have secondary benefits.

Chad Cook:
We know we're not making major strength changes in the short time that we see our patients. I think the good folks in great Britain see their patients probably even shorter than what we do in the United States. So at best, if we can lead them down a path and have them, you know, know what to do on their own and how to, to incorporate that exercise based behavior. But if you look at the long term studies, it just suggests we're not super successful with that. So what I try to do is bake all of that in, you know, I have my hope that they'll carry that forward, but I also address in a very close, connected way what the patient feels they need and what, how that blends into their expectations and my thoughts as a professional. And how can we take those two things together and make 'em work? That's patient centered care. That's a definition of patient centered

Jared Powell:
Care. So it sounds like Chad, you're saying that if there is an expectation that manual therapy is to be provided and they've had success with it in the past, then you are not, you won't object to giving a bit of manual therapy in the right context, in the right sort of narrative and using the right rhetoric and, and going about prescribing exercise, lifestyle change, perhaps behavior modification, all these sorts of things. But, but you don't see providing manual therapy. If, if, if, if somebody requests it or if somebody thinks that they need it in inverted coms, you don't think that's doing any harm

Chad Cook:
As long as there's not a risk involved in that case. As long as the patient doesn't have a maladaptive thought toward that, then no, I don't see any harm in it whatsoever. Have I ever engaged a patient where I thought there was risk involved? And I said, no, we're not gonna do this. You bet. I ever have I ever talked to a patient who had just an ill-conceived thought of what they need. I, I had, I had a lady one time come to me and she was treated for pelvic mal alignment, which I've been a very outspoken critic of. And I said, I'm sorry, I'm not the right person to work with you on that because you know, it's against my belief system. If this is something and you believe you're probably better off finding another clinician, she divorced me, went and found another clinician that was fine. It was a better match for her because that's what she wanted. And we could have sat and butted heads, or she could find whatever she wants. And hopefully that person will, you know, carry forward in introduce the secondary. And hopefully they, they latch on with her.

Jared Powell:
Adam, I imagine this must happen a bit to you perhaps, or maybe not now, but perhaps in the past, before you were so famous where people were coming to you and wanting manual therapy, look, let's face it. It is ubiquitous. Most people want it. And how do you deal with these and how do you have these, these two challenging conversations with your patients?

Adam Meakins:
Yeah, absolutely. I think Chad just described my regular day to day occurrence there with that one example he had. So, no, I, I, I definitely, and I still do come across this a lot. You know, people still seek me out online and they still want my, you know, treatment and advice and they, they use these terms, you know, I've been told, I've got this outta place, this is wrong. I need to have this push back in. I need to have this little bit released because of what they've been told by other healthcare professionals before. And just like Chad says, it's very difficult sometimes to reeducate people away from these false narratives and these beliefs and it isn't easy, but I do to the best of my ability, but am I successful all the time? Absolutely not. You know, it really is again, down to communication skills.

Adam Meakins:
And again, it's something that, that Chad says, you know, we, we, we don't see good compliance or endurance to things like exercise because I don't think we are taught good ways of communicating and convincing and sure in patients when they're in pain and distress, I don't think physios are taught to communicate well in various different settings and scenarios, particularly with distressed, anxious, worried, off frustrated people, you know, so I think again, that the effectiveness of all of our treatments could be hugely proved. If we, as clinicians just learn how to communicate better, we could start to break down some of these barriers. I hope a bit more effectively again, you know, it's, it's not easy. I'm not gonna say it's a walk in the park. Cause it isn't the amount of patients that have, you know, given me the old stink eye when I'm trying to explain things and they've like curled their lips up.

Adam Meakins:
And Chad says, they've divorced me or told me to F off, which happens quite a lot in the UK, if you disagree with somebody it, it still happens in my clinics now, but you know, I am getting better. I am seeing, you know, with my reading and education around, you know, behavioral modification, techniques, communication skills, using a couple of techniques that I've picked up from various different sources. I, I find that I am able to interact with people that are frustrated and off better, and they do start to listen and trust you better as well because of that. So again, I think if we could work and get physios to learn, to understand, you know, the intricacies of human communication better, I think we'll see better outcomes with our interventions be that exercise or manual therapy based

Jared Powell:
Chad, last words.

Chad Cook:
No, I, you know, I, I actually, I was, this is pointed in my skillset in communication and management of chronic pain and actually did a certificate program two and a half years at McGill to bump up my knowledge. So I, I I'm in full agreement. And I think the most powerful thing we have in our, in our, our, basically in our arsenal is community. And, and even if you are a lousy prescriber of exercise or a manual therapist or whatever, what I've seen is that cookie therapist, that person who has that ability to really create that therapy, the lines, the non-specific factors are incredibly powerful. And I mean, truly it, so it is an incredibly valuable skill to have. And by the way, if you look at what patients want, and there are many studies that qualitatively sit down with MSK patients on that first day and say, what do you really want out of your intervention?

Chad Cook:
They wanna be respected. They want to have a good experience. They want to be able to tell their story and, and a good clinician allows the, and to do that and actually aids that process. So again, you know, and I've told people before, cuz some people knew that we from Twitter, that Adam and I were gonna talk today and they said, oh my God, you guys aren't, aren't gonna agree in anything. I said, no, I think we'll probably agree on about 80% of the things. It's just gonna be the fringe things that, but communication. Heck yes. Mm-Hmm. So we'll, we'll throw out day to day Byers.

Jared Powell:
Where, where are you North Carolina? Get me over there. I need some sun looks good over there. So we'll throw out exercise prescription. We're gonna throw manual therapy. We're gonna throw out cognitive behavioral therapy. We'll become master communicators and that's gonna solve it all. I think

Adam Meakins:
Potentially. Yeah. So I don't, I don't think we have to. I don't think we, again, I don't think we have to throw things out. I have, or I I've abandoned certain techniques and I've written a couple of blogs about that, but I don't, I don't go round when I teach and talk to physios screaming at 'em saying stop pressing people, stop doing mobilizations cuz that's not what my position is at all. It's a personal choice. Like Chad says, you know, you have your own as a clinician, you have your own beliefs, you have your own morals, you have your own things that you wanna do. I have realized, or I've come to the decision slowly, gradually over a process of time that I don't want to use any of these manual therapy treatment techniques anymore because I think the time would be better spent doing other things.

Adam Meakins:
Now it's not an easy decision to make. There have been lots of areas and problems along the way of doing that as a clinician. But it's a choice. It's a personal choice. So I don't think, you know, if you don't have to stop doing things to be an evidence based clinician, to be up to date, you often just have to change the narrative around them. You know, you just have to start using them all rationally. You have to blame them more clear and conciser, and again, non specifically and you start to see that that can be just as beneficial.

Jared Powell:
Okay. I like it. So let's, let's move on to the next question. And this is a, this is a doozy and Adam, this is something that grinds your gears often. I think so. So manual therapy has been accused of being MI in an elitist and egotistical culture with the manual therapist often placing themselves in a position of power as a fixer healer rather than a facilitator guide, I guess. Do you agree with this? And I'm gonna throw this to you, Chad, do you agree with this and why is this the case? And could it in fact be harmful where manual therapy is fixing and healing and are we taking away their own pain self-efficacy in regards to this?

Chad Cook:
Yeah, there's a lot to that. So, you know, Adam's probably experienced the elitist and, and I'm gonna, I'm not gonna lie. I, I think it was worse than the eighties and 90 these when I trade because I experienced it too. And again, we, we, we touched on this before. I think certain philosophies are a little bit more dogmatic and condemning of any variant of their approach. Very much the bio mechanical philosophies, which are, that's a house of cards right there, cuz they're hanging on to things that just don't really exist. So I've experienced that as well. It, it's very similar to a trial list. If you, in research in the research world, a trial list is the elitist. There's nothing but randomized trials. There are no other studies that lend value to anything. So yeah, I've, I've experienced that too. The second piece that is, can it be detrimental to the patient?

Chad Cook:
I think the story that is told to the patient can be detrimental and I, I have no problems with my chiropractic colleagues, but, and, and by the way, good on them for releasing the recent papers that basically suggest that it does not, that manipulation does not change cancer and all these other elements and their thought leaders came forward and said, it's time to stop. But traditional historic chiropractic philosophy and my brother was a chiropractor. So I know this really told a lot of stories to patients, which I think led to some potentially negative recidivism patients constantly seeking out caregivers for an adjustment. Those that sort of language needs to stop. I think the modern manual therapists to is primarily using at least the ones I'm affiliated with using any manual therapy approach as a pain modulator and as a segue to moving forward with that patient.

Chad Cook:
I think that is not a negative way to go because they're using it in a patient centered care format. It, but it really is how it staged in how it's used. And again, that's gonna be a bell curve depending on the interactions that one has with certain types of manual therapists. Historically I think it was pretty bad. I manual therapy shopped until I found a philosophy that I actually felt was less abrasive, less dog, less full of. And then targeted that approach because I was looking for something because pain management pain modulation is a powerful thing for many patients. And without going to a SAR sidebar, there is evidence that that between should change makes a difference. We, we published a paper in 20 17, 6 month outcomes. It had anywhere from odds from four to six times more likely to improve. Is it because of manual therapy? I think it's probably more because of the patient and it could be another approach, but that is very powerful to a patient to show that you can be, make a difference in their pain and then teach 'em how to make a difference. So I think it's how it's framed and I think there's a horse historical overlap that is slowly going away. But we need to continue to stay on it to make sure that those theories are gone out of

Adam Meakins:
Yeah. Again, lot to discuss there. So like Chad says, I was also exposed to a lot of elitist and, you know, guru us with my manual therapy training. I was very much wanting to, you know, learn all its intricacies and its technical skills and become the Jedi master of all. And yeah, I just found it horrendously offput in and that's pretty much what started my kickback against it. I became very frustrated at all these individuals walking around with this air of superiority and arrogance because they believed they could do these things that I didn't think they could or the evidence didn't prove they could. And I started to kick back against it. I still do kick it, get back against it. Cause I do see it still quite prevail in this day and age as well. But to get back to, you know, the other point about, you know, manual therapy being, you know, helping people that may have a better outcome because you can reduce their pain, you can demonstrate to them, you know, that there are improvements being made in between sessions.

Adam Meakins:
I agree with that. I think, you know, there is a role there for, you know, demonstrating to somebody that their pain is changeable. And then as we know, somebody that does have changeable pain is more likely to have a favorable natural history. So I think there is role here for us to use techniques, to demonstrate to people that they can work around pain, their pain can be changed and that can sometimes be very, very powerful, but that doesn't have to be with manual therapy. So you can use lots of different techniques and tips and, and things to do to modulate somebody's pain. You don't have to touch them. You can just ask them to move in a different way. You can change the context of the movement. You can just reassure them and give them good again, education, if you've got those communication skills and the patient trusts and believes what you say, you can make them feel better just by walking out one of my, for many, many years ago, God rest his soul.

Adam Meakins:
Louis Gifford famously said it, you know, effective reassurance is a bloody good painkiller. So I, I am a believer of what Chad said there. Yep. Great. Try to get pain to change in the patients you see. Absolutely. It's powerful if you can do that, but then look at the other side of the flip point more about the ones that don't are we writing those off? Are we saying, you know, oh, well, you know, they're, they're not gonna be having such a favorable natural history. Do we set them up for failure? And I think sometimes we're guilty of that as well. So again, I just want us to be a little bit careful when we look for, you know, short term, quick changes in pain that yes, it's powerful, but we don't write those off that don't get those effects, Chad.

Chad Cook:
Yeah. I, you know, I tend to look at those individuals that don't seem to be paying adaptive as two ways. One, they probably need a different approach. One that is gonna most likely be a little bit longer, one that is going to take more cognitive behavioral elements. I think one that may be best assisted by medical intervention too, cuz those populations tend to do better with the medicated approach as well. And also it's prognostic. I, I know that it's gonna be a longer outcome and since patients want prognosis, you know, one of the things you can say is, you know, there are some things that we've identified here. This may not be a recovery in one week, two weeks that we commonly see. So we're gonna have to do some things that are different and then we'll spend some time going into those, be behavioral elements, those mock vacation components, the cognitive elements like that.

Chad Cook:
I know this is a discussion about manual therapy, but I'm just very surprised that there isn't a similar discussion about psychologically informed interventions and, and how quickly everybody accepted these despite nominal research and support, especially research among physios. I have a lot of colleagues that are psychologists and I said, you have a wonderful opportunity because you can both use psychological interventions, which have a very small effect and physical interventions, which also have a small effect and maybe get a combined element from that. So I, I think manual therapy is sometimes targeted with respect to a lot of good reasons. But as an intervention it's outcome is quite similar to exercise. It's quite similar to cognitive behavioral therapy. It's not really superior or inferior to any other intervention and they're all better than nothing. And that's essentially what the literature tells us.

Adam Meakins:
Adam. Yeah. I, I can understand why Chad thinks manual therapy is probably unfairly targeted because of the , you know, bubbles, we all tend to circulate in and the sort of echo chambers we listen to. And you know, if you start engaging on social media, you start to follow certain individuals and they all start to retweet and hash things around. But I actually don't see manual therapy being targeted, critiqued lambasted enough, compared to other things in my experience. So I, I, I will still say that I see a lot of applauds advocates, you know, people pushing manual therapy up onto pedestals where it doesn't deserve to be. I, I, I find very few strong staunch critics of manual therapy. Questioners are manual therapy because it's bloody hard to do so from my own personal experience again, because of the elitism and arrogance and egos. So it can be very daunting to start to challenge the so-called manual therapy beliefs.

Adam Meakins:
So I don't see a lot of people having the gumption to do it and I don't blame them because it can be quite nasty and toxic to do so. And again, I know a lot of people, you know, well, that's probably based on how you do it and how you interact with it, but I've tried over the years to critique things, you know, bluntly directly to the point, not skirting around the issues. I've also tried to do it politely and respectfully. And it, I always seem to get the same kickback response, no matter how I do it. And, and I also don't and when just, I don't, I don't agree with what Chad says is that we don't critique exercise enough. I am seeing more and more critics of exercise now. And I think it's a good thing. But I am seeing again, there is now a lot of people challenging, you know, the motor control paradigm, the corrective exercise paradigm, the belief you have to do it in a specific way to help specific things with certain types of pathologies. So I, I, I disagree that we don't critique things equally enough. I, I see it from a different angle. I think manual therapy still gets away with a lot compared to other things. Chad, last words.

Chad Cook:
No, I mean, this that's Adam's experience. So I can't debate that. You know, he is got a good point about exercise. My concern was a lot of the cognitive psychologically informed approaches, which, I mean, if we look at the literature on that, there is no one dominant, successful approach through shared mechanism. They all have a similar outcome, regardless of what angle they go in. And as a profession worldwide, we absolutely with open arms just said, tell us what we need to do without questioning any of the evidence behind this. I, I went on a podcast one time and I think the person thought I was going to just seeing the praises of cognitive a therapy. And I said, well, let's talk about limitations. And there are a lot and in many cases, it, the, especially those provided by physios and occupational therapists, the outcomes aren't any different than a comparative intervention, whether that would be exercise or, or manual therapy.

Chad Cook:
And, and again, that's because of shared mechanisms. It it's just that there are many different ways to get to London, right? A lot of streets go to London and they all have a, a very similar outcome, but they don't, but no, I can't debate what Adam has experienced. Hey, I, I do wanna mention the, the earliest publications in my career were affiliated with questioning a lot of the typical manual therapy. Dogmen we attacked coupling. We looked at it in theoric cervical and lumbar. I mean, we looked at roll, spin and slide the, how the, these manual therapists came to these biomechanical theories. They were using wooden blocks to try to mimic movements of the body or very unsophisticated non-scientific methods. And, and to me, that was just unacceptable. So I ran into a lot of the same pushback where people were just close minded.

Chad Cook:
They would not even listen. And I was quoting science. I was like, no. So we've got these RSA studies that actually show that, you know, sick act joint does not flop around like a piece of paper. And they're like, oh, that those studies are flawed because it's like, no, they're not. It's, it's pretty remarkable. So I understand where he is coming from. And a lot of the concern that what, from what I'm hearing, they're valid concerns. I, my area is, I think my world of manual therapy is more of a gray, moderate world. I, I don't I'm not an extremist with respect to what I think it does. I think I've called it the ibuprofen of the physical therapy world. I think it does a nice job of pain modulation and it gets you, it gives you the ability to move on to something different. Okay. That's

Jared Powell:
Good. I, I pretty much agree with both of you there, there is. I think there is an elitist culture associated with manual therapy still. I still think there are dodgy, pseudo scientific explanations for what manual therapy does out there. And it's far more commonplace than we think I experienced it weekly in my clinic will practice and it's, it is still pervasive. So that's something that we must change. And I think you both are important in dispelling some of these myths. So, so thank you for the work that you do there, but in terms of in terms of the, the, the, the clinical outcomes in terms of approaches to modulate pain, that's an interesting discussion. And I, again, I find myself agreeing with both of you manual therapy can be used. Movement can be used. Interaction can be used. I think there's many different ways to skin cap there.

Jared Powell:
So I don't think there's any point arguing that one death let's move on to the next question, which is patient-centered care or shared decision making. So can we incorporate manual therapy into this model of shared decision making or patient centered care, or does this simply imply that therapists are just surrendering and, and simply giving people what they want and not what they need coming back to Adam's McDonald's analogy. So is there are any evidence for this affecting clinical outcomes by, by not giving people what they need perhaps, or giving people what they need. So Adam, I'll throw this one over to you, mate. Do you have any thoughts on this?

Adam Meakins:
Yeah, well, I think it's about, you know, giving patients what they want, not what they need. So are, are we just, you know, you know, putting the patient in the center say asking them, you know, these are all the possible treatments you could have, which one would you like? You pick it's, it's a, it's a menu, you know, take your list. You want two of those and three of those and one of those, and then we'll put it all together. Is that what we mean by patient centerness? I don't think so. I think, you know, that can be recipe for the disaster, particularly, you know, if you wouldn't see it in any other aspect of healthcare, you would not see a cancer specialist going and explaining you got cancer to a patient. Here's all the treatment options that we could do, and then throwing in there.

Adam Meakins:
Well, you could go for a bit of Reiki. You could take your homeopathy as well, because that's, you know, been claimed by the homeopaths to help , you know, with your cancer treatment, you would not see a rational evidence based cancer specialist doing that. And I think, you know, I know the risks are different obviously with muscu skeletal health, but we shouldn't just be, you know, putting out everything onto the table and saying to the patient that these are all the options, there's a Smoger board of choice, you know, you just pick and choose what we want, patients need options for sure. And they need to have some guidance and some assistance in making those options correctly. So I, I don't really like the term patient centered care. I know it's all a bit of a buzzword at the moment. But I I'll actually prefer the term patient focused care.

Adam Meakins:
You know, I think it just changes the narrative of saying, look, we, we are focusing on you, the other person that this matters to, but when we're not really, and again, I know this analogy is probably used differently for different people. We're not putting you in the driving seat. We are here to help you, okay. Make the right decisions and the choices for this particular situation that you're in. So again, and for me, I think it's just finding that balance of, you know, presenting as unbiasedly as you can, all the treatment options to the patient, explaining through the benefits, the risks, the alternatives, you know, what happens if you don't do, do you need this treatment? Is it necessary? Is it essential? All of these things I think are needed to be done to truly use or say that you are fully informing the patient, you're giving them fully informed consent of the treatment and letting them make a focused choice, an evidence based guided focused choice as to which so suits their particular desires, expectations, beliefs better, Chad.

Chad Cook:
Yeah, I mean, we had something called Obamacare here in the early 2000 teens and basically it mandated, shared decision making and patient and centered care. And I was like, okay, what is this? And so Janique two signal, the Flamini actually did a systematic review of all of the muscu skeletal studies in 2017 that used patient-centered care, shared decision making principles. And there were zero, there was a systematic review of zero. We adopted an approach that had never been tested and that, and its effectiveness, there's a guy named Martin Underwood and they published their work in, I think, 2019. And they actually showed that shared decision making. When you put it all on the table to the patient, say it's all the same as Adam described can actually lead to worse outcomes in the shared decision making group versus the opposite operator. And at that time, at that point, I'm like, what is this nonsense?

Chad Cook:
But we've incorporated shared decision making principles into another trial and we've modified it. And I think that near the end of Adam's discussion and what, the way we modify it is is that here, you know, these are the things that you prefer that you've shown interest in. And you have to tease that out of a patient, cuz in many cases they don't know what they really need or want. And then you as a clinician come to them and you say, this is what I think you need. There's based on my expertise, based on what the litera says, let's from into common ground and let's decide what works best for you. That's shared decision making. The, the mistake is made is if you just say, you know, it all, it's all the same thing. Just like we said today, they all have similar effects and they do.

Chad Cook:
But part of it is really ramping up what the patient feels they need in, in, in embedding that to what you think the patient needs and then targeting those interventions. So can manual therapy fit that? I think so. You know, if you look at studies and what patients want, they want pain, modulatory elements. They want to relieve their pain, but they also want what we do very poorly and that they want something they can do at home for pain modulation among the pain modulatory laboratory group that have NIH and a recent review of the literature on what are the skills that patients are given self modulated pain, it's all bit absent. And so whether that, technically that's not manual therapy, cuz you're not putting hands on some, but that's a method of helping the patient self modulate. So all of those things I think can be baked into patient centered care manual therapy can fit if that patient is very interested in, but it can't be the only thing. And, and I think most of the modern manual therapists are not just using manual therapy and saying, this is what's going to fix you. It is gonna be a segue to something else. And then there's the hopes that that will carry on in result in a lifestyle change for those patients.

Jared Powell:
Adam, any last words on that one?

Adam Meakins:
I, I agree with everything that Chad said they're more or less and I'll be quite interesting to see you know, the results of what you find when you you finished that review Chad. So yeah. Great points that you made that it's interest

Jared Powell:
I'll just, just say something quickly. So Chad, you you said there's a paper that shared decision making could lead to worse outcomes. Yes. It's fascinating that wasn't, wasn't there a line paper in 2019 that says these are the 11 things that you must do for musculoskeletal care. And like number one was, was patient centered care. I'm a bit confused by that. Where, where such a strong recommendation like that come from

Chad Cook:
Narratives. It's the, there are the, the challenge with narratives in publishing. There's a green leaf paper too, that basically says that most of the patient centered elements are flawed and that you can actually lead to all kinds. It's, it's not that easy to actually do patient centered care. It has a number of ways that it can be derailed, but you know, just a sidebar for a second, most journals have recognized that narratives or viewpoints or other elements, which don't have to be necessarily grounded into a comparative investigation in the literature. They are cited very well in they're very popular. They have high tric scores and, and they really drive discussion. So unfortunately value based care. It's built on two narratives of that. Passive all, all passive therapies are, are low value. Why? I mean, what, what are you basing that on other than your opinion? And, and we've got all kinds of challenges associated with some of the narratives that have come out

Jared Powell:
Fascinating, Adam, sorry mate. I, I cut you off before.

Adam Meakins:
No, no. I was just about to say that, you know, again, and is that balance between, you know, patient expectations trying to, you know, find that way in with a patient and you know, including them in the decision making process. But I also find, you know, like Chad said, there are some barriers, there is that a lot of patients really don't know what is the best option to take. And so they in, you know, pretty much at the whim of the clinicians biases as to which way to go, cuz the clinician then will make the decision and the choice for them. So again, if you've got a biased exercise clinician, they're gonna probably recommend exercise based strategies. You've got a manual therapist, clinician they're gonna recommend manual the therapy based strategies. And again, as long as the patient is, you know, tied into that and has got trust and belief in the clinician, then they're probably gonna get a good outcome with either approach.

Jared Powell:
So, so patient centered care is not simply relenting or surrendering to the patients wants desire is and needs it's it's, it's the expert, the clinician coming to the party as well and suggesting perhaps what they think might be effective. And then there's a meeting in the middle. There's a collaboration, there's a conversation around that. So I think that's an important point that this patient centered care or shared decision making is not simply just doing what they want all the time, which it's a nice thought, but it doesn't take away any of our expertise and knowledge that we work so hard to get over the years. Okay. So I think, I think we'll move on to the next question. We we're going taking a long time. This is gonna happen. So, so why is manual therapy still so often seen and believe to be an essential part of physiotherapy care by patients and clinicians alike? And we're touching on societal expectations here. This is the culture of hands on care that's associated with with physiotherapy. Does this need to change for the good of our profession? Do we need to move beyond this, this, this thought process, that manual therapy is a core component of physiotherapy. Chad.

Chad Cook:
So I'm not surprised that manual therapy is sought out by patients. I mean, we've got 1.5 billion people with chronic pain in the world, 40%. And my continent have chronic pain. 42% in south America it's even higher in Europe. So I, I'm not surprised that patients are looking for something. I'm not surprised that we have an opioid epidemic because the pain is I read yesterday that that 28% of the suicides in my continent are related to chronic pain issues. So I, I think I, I'm not surprised at all by the clinicians. I mean, by the patients with respect to the clinicians, I think clinicians are looking for something they're looking for an edge. They're looking to actually do good work and meaningful work. And it, and I mentioned earlier, it's very powerful for a patient to see change in their pain and change in their movement.

Chad Cook:
In, during given sessions, I think it's powerful for the clinician too, and then meaningful for the clinician. I think some clinicians get into it because may therapy can be viewed as being quite sexy as an intervention. But I think others such as myself honestly believe that it can be a valuable contributor and they've seen the literature in, you know, the 40 plus randomized trials that have shown a clinical effect. And I, I think so I'm not surprised the clinician side too, that manual therapy has been elevated. I don't think it has the mystique and the mystery and the the thoughts that it used to. You know, I have the, the gift of being around since the eighties, nineties, and two thousands as a clinician. And I think we've gotten a little bit it more pragmatic in how we view it. It's not, we're not completely there yet, but you know, we used to elevate these clinicians on these pedestals.

Chad Cook:
It's a master clinician. You know, if you really, if you've got a, you need to go to that person because they're going to fix you. And I don't think we do that as much anymore. Is it harmful for the profession him, this is probably gonna be, and I predicting where Adam and I differ. I, I do not think it's harmful for the profession. I think it's a way to improve the therapeutic Alliance with the patient. I think it's something that we do. I mean, as a profession, we, I think we do a good job of building that relationship with our patient pain module, moving the patient, talking lifestyle like the psychologist says, I, I think we have the ability to touch on the psychology and the physical aspect at the same time. And I think there's value there. So I don't think that's harmful for the profession, Adam.

Adam Meakins:
Yeah. I have a different view than what Chad has, which is probably why we're having this podcast. I, I find and I believe that yes, manual therapy can help patients with pain. I just don't think the physio profession is best placed to actually provide it. I think we are diagnosticians. We are clinicians who have our skill set, probably better placed elsewhere. I, again, and then down to, you know, limitations in time as well is a huge factor. I think, I think the best effects with manual therapy come from when there is an hour session where everything is calm and relaxed, where the clinician is, you know, suitably, you know, filled out as well. The, the, the patient can come into a, a clinic environment, warm fluffy towels. There's a little candle flickering in the corner bit of whale music going in the background as well.

Adam Meakins:
Nice Laven dissented area, you know, and that hour is spent dedicated to the therapist applying the time and the consideration of doing all their hands on treatments to that patient. I bet that patient comes out feeling fantastic manual therapy in a physiotherapy environment though, is normally done in a cold sterile clinical, normally ruble with a little flimsy curtain maybe in a hospital setting as well. You know, they've got a cold plinth, the therapist is stressed out cause they've got 24 patients still to see, and they're 10 minutes running over at the moment and they haven't done any documentation for the rest of the day. They are doing their manual therapy probably in a 30 minute session. You gonna do it probably for about 10, maybe 15 minutes of that session. So it's all gonna be a bit quick rush Pokemon Pressy and prody.

Adam Meakins:
And therefore I think, you know, the effects are probably not going to be as good as somebody going to get it in that nice other environment with the way music, et cetera. So I truly do think that I say, I think we need to look and say, okay, many therapy can help, but who's the best people to actually apply it. And again, you know, who, what is the right cost for that? Because I find obviously physiotherapists normally charge a premium compared to other manual therapists. Is that fair to patients because, you know, do we see physiotherapists applying them manual therapy techniques any better than Sharon works in a spa? You know, or, you know, somebody else who's done a weekend soft tissue massage course, do you know, they can charge probably less for probably just as effective outcomes. So my argument is, is that physiotherapy and manual therapy really need to think about separating. In my opinion, I think we need to be look more towards other things where we are, you know, probably more, our time is better spent rather than doing the 15, 10 minutes succession of that pokey process stuff in a clinical environment.

Jared Powell:
Chad, what do you think about that?

Chad Cook:
Well, I mean, that's Adam's opinion. I can't say anything about that. You know, I could counter with, we have certified personal trainers here. You don't even have to have a degree for that. You take a weekend course and you're able to take people through an exercise regimen long term. I mean, that's a correlate to what Adam is describing. Should we then discard all over the exercise that we do physical therapists because these certified personal trainers wouldn't have the debt that we incur from our education. You wouldn't have to mess around with the high costs associated with that. We could just give 'em to a personal trainer. I, I don't agree with that. I, I think that, you know, I respect Adam's opinion, that's his opinion, and there is nothing that I'm gonna say that's gonna change his mind and there's nothing that's gonna say, that's gonna change my mind.

Chad Cook:
Those ships have sailed. But my, my feeling is this I think it's when used wisely and appropriately, I think it can be an additional option for a physical therapist just as psychological components exercise and, and in some rare cases, nothing, sometimes the best thing to do with the patient is nothing. So I think all of those things are, are going to be contributions that we can provide is the profess I think when somebody falls into one only, or, you know, this is the only thing I do is X. I, I think that is somewhat limiting. But that's my opinion.

Jared Powell:
So, so Adam, if, if manual therapy should be left to the spa and, and the, the wild music cloud places then should exercise be given to the, the weekend warrior PTs.

Adam Meakins:
Well, it may surprise you when I say yes, I do think that is also an option as well. I, I, I truly think that physiotherapy should be acting more like a, a spoke not spoke a hub in a wheel. And they've got lots of other professions that they can sort of out to. And they've got these spokes that they can send patients to. I think that's where physiotherapy skillset is. It's triaging, it's recognizing who is best suited for certain types of approaches, exercise based. Yeah, you need this TW you just need to get moving for another 12 weeks a bit more. That's gonna sort you out. I know this mate down here, or I've got this colleague here who can do that for you, keep you supervised, keep you motivated. Then there's another patient that comes in. I think you'd approach, you'd be better off with the rub Dubby pokey stuff.

Adam Meakins:
So go and see a colleague down that spoke and see how you go with that. So, you know, I, I, I think, again, it's, it's acting more like as say as a triage service, physiotherapies you go and see the physio, you get your assessment, you get, you start the process of, you know, education reassurance, et cetera. But when it actually comes to doing the things, spoke it out, dish it out to other areas because you know, the system is overloaded at the moment it's clogged up. I mean, in the NHS at the moment, our waiting list and thanks to COVID or even even huge, we cannot expect, you know, patients to be subtle waiting lists before they actually even get anybody to be seen, to assess them, to triage them. Because, you know, we are doing 12 weeks of rub, Dubby pokey stuff or exercises, you know, so I just think we've got to look at working a bit smarter. And I think, you know, when to mucus conditions, there are, like Chad said, billions of people out there who need our assistance and help. And if we're to keep them all for, you know, 12 weeks to 24 weeks or wherever, we're never gonna get anywhere, it's only gonna get worse. So I, I do think we need to refer out more.

Jared Powell:
So, so physio is to become the new GPS of musculoskeletal pain. They come in, they see us for a 15 minute 30 minute appointment, and then we refer 'em to the appropriate party.

Adam Meakins:
And then we touch base with 'em on a regular basis. So we use this sort of model of care where there is no such thing as a discharge. You know, we are, we are keeping an eye on people with long term chronic conditions, and we are, you know, we're just touching base with 'em, we're touching up, we're having a review bit like an orthopedic consultant would do. So I think there is a role there for physiotherapists to act more in that role and say, when it actually comes to doing the treatments, use other profess who have got more time, less constraints, less costs, et cetera, to the patient to use that more wisely and it'll help our healthcare systems. I'm sure. Massively. Yeah.

Jared Powell:
So, so given given that we know how much the therapeutic encounter and contextual effects and all of these sorts of things can influence could outcomes. Do you think somebody going to aspire for back pain to have a massage? There has the same contextual clinical interaction is going to an expert who's had five years training.

Adam Meakins:
Absolutely not, but if they, so how we gonna get, if they go and see the expert first and they're, and they're told to go and see the spa after they've been given the reassurance, then I think it may do.

Jared Powell:
Yep. So, so entirely changing the do job description of a physiotherapist

Adam Meakins:
Sort of not, not, not entirely .

Jared Powell:
Chad, do you have any thoughts on that?

Chad Cook:
You're starting to see, first of I recognize that different systems around the world have they're, they're much, much different roles that the physios play in those systems. And, you know, I most mostly know north America and we don't have a waiting list. And, but there are some organizations that are elevating the physical therapist to function at the top of their license. So they are functioning more as triage. And they're referring to a PT assistant, which tends to have an associate degree. So a two year educational degree specific to physical therapy. So it's not a completely outlandish model, I think, in a system such as an, a HS or some other socialized elements where there is a pretty significant wait list. And that's kind of a misconception by the way, not all social systems have this huge wait list. I, I know NHS does, but you know, Taiwan E system does not Singapore system does not, but I think in those systems, it may make more sense to modify a role of, of the physical therapist and, and then to refer out. But so I don't, I don't object to it. In my environment, I know there are a lot of clinicians who spend seven years, seven to nine years in education that probably want to have that experience with the patient, that it's why they got into the profession. It's rewarding. So, you know, I, I think at some environments that's happening in some environments, it probably won't won't happen.

Jared Powell:
Okay. Let's, let's move on to the final question. And this is, this is a doozy to finish off with. So health outcomes we know are complicated. Multidimensional, how much do we think focusing on a specific form of care, for example, manual therapy actually influences overall health outcomes. So Adam, I'll throw this one to you.

Adam Meakins:
Well, I'll answer very succinctly clearly and short, which is unusual for me. I'll say it doesn't, you know, focusing on one aspect in isolation is useless.

Jared Powell:
Good, Chad.

Chad Cook:
Yeah, I appreciate the brevity. I, I also think that if you're looking at influencing health outcome and there are some bigger fish to tackle on that social environments, public health issues, general comorbidities of the patient, all of those, if you really wanna make a, a big difference, you hit those. And I'm with Adam, that one, one intervention is not going to change the health status outcomes measures that patients the way that we use. I mean, I've spent a lot of time on this because it's maddening right? To, to see this shared mechanisms across the board, no matter what a person's given that their outcomes tend to be the same. And I think it has a lot to do with the outcomes more than a dozen interventions and those outcomes are, are broad health status measures. So every little thing is gonna be factored into that self-report measure that that patient actually communicates on. And I don't expect there to be a major change with any of the interventions. And you're starting to see the same thing, even with surgery that it's not influencing health status measures anymore than a conservative approach. And if there's no more powerful placebo than surgery, then we know we've got something going on with those outcomes measures. They're very porous, they're very all encompassing and they're not, probably not precise enough to, to, to tackle the specific effects that we use with any of our interventions.

Jared Powell:
That's interesting. So have we been looking, have we been using the wrong outcomes to measure the effects of everything we do? And, and so the whole picture becomes blurry. What is reality that if, if, if the actual measure is that we've been using, aren't reflecting the, the actual effects that we're trying to achieve.

Chad Cook:
So I'm afraid to say something because it's bla to say anything about outcomes, I'll get a visit from the Pope or something like that. But, but I mean, I've been open and saying that no, there's a place for health status outcomes measures, but let's look closely at what they actually measure and what influences them. And, you know, early work was done in the 1990s that showed that there are other fact that influence those health status measures much more than our treatments. Our treatments are probably 10% of what makes a difference and, and that's okay, as long as we accept that, that's fine. But if we, you know, we, we just need to be open and recognize that other factors in once that quite bit,

Jared Powell:
I'll get you to clarify Chad, what's just for everyone. What's the health status measure that you're referring to

Chad Cook:
O west street spotty COO any of the legacy measures that are more health status related, they're more influenced by health status than they are actually by it an an action. It would be the same that if you targeted self-report measures versus physical performance measures, you'll get two very different findings with those because the physical performance measures are more accurate measures of what the person does. A self-report measure is more accurate of a measure of what a person thinks they can do. So they're two very different things. There's nothing wrong with it. They're they are valid, but we just need to recognize that they're heavily influenced by other factors. Our recent study, when we looked at Lamar surgery, people received the same interventions. We looked at social factors, social factors actually predicted 20 to 25% of the total outcome of that, just social factors. Whereas the treatment was just marginal in comparison. So as long as we know that, that's fine, you know, we're, we're combining our hair with a rake. It, it's just not capturing the nuances of the little things that we might see in the clinic,

Jared Powell:
Adam,

Adam Meakins:
You, yeah, no, I totally agree. I have my top tips for, you know, making sure people have good health and low pain. And number one is don't be poor. Number two is don't be homeless. Number three is don't live in a deprived area. Number four is don't be disabled. Don't have a, a dependent child. Don't be a alone parent. Don't have a poor job that pays you amounts of money. That is quite stressful. Don't have an of a boss. You know, don't be a victim of neglect or social unfairness, et cetera. Those are all my top tips for, you know, having a nice, healthy lifestyle and being, you know, able and not having disability or pain.

Jared Powell:
But what about getting too much manual therapy?

Adam Meakins:
Not here, not much on manual therapy, not funny enough, not that much on exercise in there either.

Jared Powell:
All right. Beautiful. I think, I think I like that as a, as a culminating thought. I'll, I'll wrap it up. So I just wanna say thank you both so much for your time and bravery, really for committing to a difficult, and let's face it vulnerable conversation like this. So thank you. I, I thoroughly appreciate and respect you both. I just wanna leave a bit of a closing comment. If something, for us to make, feel a little bit better about ourselves. So if Nobel prize winning physicists still disagree amongst each other today, passionately about the Funment fundamental nature of reality, then we shouldn't be too harsh on our profession or each other when disagreements emerge. In fact, isn't this a sign of a mature profession that we can have these difficult convers. So disagreements arise in physiotherapy, I think because human biology, pain behavior and the subsequent interactions are wildly complex and doesn't lend itself to simple binary solutions. So let's endeavor to keep that in mind. So on that note thank you, Chad, and thank you, Adam. Thank you, Jared. Thanks guys. Thank you, Adam cheer.

#4 - Adam Meakins and Chad Cook debate

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