Speaker 1:
Dr. Jared Powell:
Hello, it's Jared. I want to talk about something that I think a lot of clinicians already know intuitively, but that we don't say out loud enough. It's this, there is no clearly best treatment for musculoskeletal pain conditions. Nothing has separated itself from the pack in any consistent or convincing way across decades of research. Now, that may sound like a depressing conclusion. Decades of trials, thousands of patients, millions of dollars in funding, and the answer is everything kind of works about the same, but I actually think it's one of the most important and liberating findings in our field, and I want to unpack why in today's episode.
Dr. Jared Powell:
I recently published a paper in the Journal of Orthopedic and Sports Physical Therapy called Many Paths to Recovery, the Case for Treatment Pluralism. And in this episode, I want to walk you through the argument, challenge some of the assumptions buried in how we talk about treatment, and hopefully reconstitute a debate that I think has been stuck for too long. So let's start with the evidence, the cold hearted evidence, meta-analysis comparing exercise-based interventions and manual therapy based interventions for broad spectrum musculoskeletal conditions, low back pain, shoulder pain, knee oa, neck pain, for example, show broadly comparable average effects for pain and function. Now, this is absolutely not a new finding. It has been replicated over and over again, and it's also not just limited to exercise and manual therapy. When we look across many different treatment comparisons, the picture is the same exercise versus surgery combined approaches versus single approaches, active versus passive treatment.
Dr. Jared Powell:
The differences at the group level are small, often trivial, and frequently not clinically meaningful. So my question to you is what do we do with that one response seems to be a very common one, and that is to say, well, exercise has fewer side effects, it's cheaper, it's more accessible, and the effect is the same. So exercise should be the default, and this is indeed my personal bias as well, but I think if we stop there, we miss the more interesting question and line of inquiry, which is why do these interventions produce similar outcomes? The answer seems to be, as best as we can tell with the courage evidence that we have, is that they probably work through overlapping or shared mechanisms. These are non-specific effects, contextual factors, you know, the therapeutic alliance expectation, reassurance, the simple act of doing something with someone who cares or at least pretends to care natural history regression to the mean, all that good stuff that is not really specific to any particular treatment.
Dr. Jared Powell:
Now, if we strip away these surface level differences between a mobilization technique from a skilled manual therapist and a loaded exercise from an expert rehab coach, and what we're left with is a lot of shared territory. Right now we don't have any strong evidence for a specific unique mechanism that makes one intervention clearly superior to another for musculoskeletal pain at the group level. Both manual therapy and exercise, for example, rely heavily on non-specific and contextual mechanisms. Many elective surgeries probably do as well. So this is not an asymmetric criticism of physical therapy treatments. I want to make that very clear. But it does get more nuanced and I also think more clinically relevant as well. Group level equivalence does not mean individual level equivalence. This is the point that gets lost constantly in these debates. A randomized control trial reports an average treatment effect. For example, what is the average pain score of group A compared to group B at various time points after their exposure to a particular treatment? So this average conceals substantial variability in individual outcomes. Again, this is not a new concept, but it needs repeating. Some people in the group A, let's say that's the exercise group, reported dramatically better outcomes, some got worse, some didn't change at all. The same is true of group three, the manual therapy group and even a surgery group or a no treatment group, whatever group there may be.
Dr. Jared Powell:
The average is a statistical summary. It's useful, but it may not be a prescription for the person sitting in front of you. This is what we call the heterogeneity of treatment effects phenomenon, and it helps explain why group level comparisons so often show equivalence because variation within groups dilutes the differences between them. So when someone says exercise and manual therapy are equivalent, what they're really saying is on average across a heterogeneous sample with a specific set of outcomes measured its specific time points. The group means we're similar. That's a very different claim from it doesn't matter what you do. Now, can we predict with precision who will respond to what treatment? Not yet. There are emerging frameworks, for example, the person centered hypothesis framework being one that aim to integrate pain phenotyping, contextual factors and clinical pattern recognition to improve treatment matching. But I want to make it very clear that precision is mostly aspirational at this point.
Dr. Jared Powell:
We're not there yet and we may be a while away and that's fine. Acknowledging this uncertainty is not akin to admitting defeat. It's actually the starting point for an honest and robust conversation about what we know. So here's where I want to bring in a slightly esoteric or eclectic idea, and it's a very old idea in fact that I think frames nicely within this debate. It comes from the philosopher and historian of ideas, Isaiah Berlin, who wrote an essay called the Hedgehog in the Fox. Now Berlin distinguished between two types of thinkers. The hedgehog knows one big thing. They interpret the world through a single organizing idea or explanatory framework. The fox on the other hand knows many things. They draw from multiple perspectives and are more comfortable with complexity. Berlin didn't say one was better than the other. There were no moral claims about a superior way of thinking.
Dr. Jared Powell:
He described them as simply different cognitive styles, each with strengths and limitations depending on the context. I think this demarcation of thinking styles maps perfectly onto our profession that of physical therapy or general musculoskeletal rehabilitation. The hedgehog clinician works through a dominant framework. Maybe they're deeply skilled in exercise prescription. Maybe they've built their entire clinical model around strength and loading, or maybe they're a manual therapist who has spent 20 years refining their hands-on skills. There's nothing inherently wrong with this. Depth of expertise has real value focused and narrow clinicians can be and often are excellent clinicians. The Fox clinician draws from multiple skills and philosophies. They flex organically between exercise, manual therapy, education, psychological strategies depending on the person in front of them. They're more comfortable holding multiple frameworks in mind simultaneously. Cognitive functional therapy is an example of this kind of integrative reasoning. Here's my major thesis.
Dr. Jared Powell:
Both of these approaches, then cognitive styles can work and also both can fail. The hedgehog fails when they become overly rigid when the single lens becomes the only lens and every patient gets forced through the same framework regardless of fit. When a primarily use exercise becomes, exercise is the only legitimate intervention and everything else is passive garbage. This type of thinking is not a demonstration of expertise, but rather a demonstration of dogma. The fox may fail when flexibility becomes incoherence, when there's no clinical reasoning holding the approach together when it's flexible thinking, when a narrow focus is needed or wanted, doing a bit of everything for everyone isn't actually pluralism. Question is whether you are transparent about your orientation, your responsiveness to the person in front of you, your willingness to update or refer on when this situation demands it. So what is treatment pluralism?
Dr. Jared Powell:
Exactly. We've been dancing around it a little bit so far in this episode. Let's clarify what I mean. It starts from a pretty simple position. There is no single intervention that has proved consistently superior for musculoskeletal pain conditions. Multiple interventions can lead to recovery. Therefore, rather than enforcing uniformity, rather than insisting that everyone should do the exact same thing, we should embrace a bounded range of safe, plausible evidence-informed options shaped by patient goals, values and preferences, clinical context and clinician expertise. That's it in a nutshell. That's the core of the argument. It should be virtually impossible to misinterpret our claim. Now let me also be very clear about what pluralism is not because I think this is where people will push back and rightly so. Pluralism is absolutely not anything goes. It's not a license to do whatever you want, call it patient centered. You can't just say, let's go and do some quantum energy healing because pluralism says it's now permissible.
Dr. Jared Powell:
Intervention still need to meet a threshold, at least modest evidence of effectiveness, biological plausibility, safety, cost effectiveness, harmful or disproven approaches don't get to survive the banner or facade of choice. The boundaries should be enforced. But within these boundaries there is room room for the clinician who primarily works through exercise room for the one who integrates manual therapy room for the one who leads with education or graded exposure or some sort of other psychological intervention provided they're transparent about what they do, why they do it, and honest what they know and what they don't know. Pluralism also foreground something we claim to value, but we often override in practice and that is patient preference. Some patients genuinely prefer hands-on treatment. Some want the autonomy of an exercise program. Some need reassurance more than any type of program at all. When these options fall within evidence-informed boundaries, the these preferences are legitimate considerations.
Dr. Jared Powell:
They're not simply teachable moments where we, the expert clinicians get to tell patients why their preference is no good. So this is a point worth reflecting on and pausing on for a moment because there remains a tendency in our profession to treat patient preference as something to be managed rather than respected. They want manual therapy, but I need to educate them about why exercise is better really based on what Now, of course, if someone has been getting manual therapy three times a week for years and their pain is no better and they're stuck looking across from you desperate and insignificant pain and experiencing significant disability, it is absolutely okay and indeed, good practice for you to suggest other options. Pluralism doesn't steer us away from having uncomfortable and challenging conversations with patients. It just ultimately respects that the treatment that they choose is the patient's decision.
Dr. Jared Powell:
So I now want to go into a more philosophical part of this episode and ask a more philosophical question. Why has this debate been so persistent and so adversarial? The hands-on versus hands-on debate that is, why is it so hostile? Maybe it's 'cause we've been asking the wrong question. The question may never have been which treatment is best. We've had an answer to that question for a long time now. Nothing is clearly the best. The more interesting question is why do we keep arguing as if the answer is out there or just around the corner? I think part of it is clinical identity. Clinicians build professional identities around their preferred approach. If you've spent a decade becoming an expert in exercise prescription, it's hard and indeed threatening to hear that manual therapy produces similar outcomes. And if you've built your career around manual therapy, it's anxiety provoking to hear that exercise is just as good.
Dr. Jared Powell:
Equivalence is unsettling when your identity and reputation is tethered to superiority, particularly if it's your trademark system or approach such as functional patterns. Part of it is also tribalism. Online discourse, rewards, certainty, loudness, arrogance and punishes nuance and uncertainty. The loudest voices in these debates aren't usually the most thoughtful ones. They're the ones most committed to a position, an extreme position. This creates a distortion, a professional culture where confidence is mistaken for competence and where changing your mind is seen as weakness rather than growth. Part of it is also that we haven't had the right framework or haven't made the framework explicit enough, and this is where pluralism comes in. We've been trying to resolve a question that doesn't have a single answer, and we're getting frustrated when the data doesn't cooperate. Pluralism dissolves this debate. It doesn't provide a solution as such, but renders the debate nonsense.
Dr. Jared Powell:
So where does this leave us in practice? First, I think we can stop apologizing for clinical diversity. Different clinicians will practice differently. That's fine. In fact, it's probably a feature and not a bug. A profession where everyone does exactly the same thing will be fragile and more akin to a factory assembly line rather than a complex and dynamic healthcare provider dealing with very complex problems. Of course, some standardization is needed, but diversity of approach within evidence-informed boundaries is healthy. Second, we need to get better at transparency. If you primarily work through exercise, say so. If you integrate manual therapy, say so, let the patient know what your orientation is so they can make an informed choice. This sounds so simple, but it is actually rare. Most clinicians present their approach as the approach as if it emerged naturally from the evidence rather than being one of several reasonable options.
Dr. Jared Powell:
Third, we need to hold our positions more lightly. Holding a position lightly means being willing to revise it. It means treating your clinical framework as a working or provisional hypothesis rather than a settled truth. Nothing we do in physical therapy or MSK. Rehabilitation is a universal law of physics. It's quite the opposite. And finally, we need to redirect the energy we spend arguing about which treatment is best toward other more meaningful questions. How do we match the right treatment to the right individual at the right time? What are the mechanisms that are shared across interventions and how do we optimize them? Are there unique mediators of recovery that are unique to specific treatments? How do we communicate uncertainty honestly without undermining a patient's confidence in your ability to help them? These are harder questions, but they don't produce clean social media posts, but they are the ones worth asking.
Dr. Jared Powell:
The search for a single best treatment is illusory. After decades of research. We know that several interventions can help that they work about as well as each other on average, and that they probably do so through overlapping or shared mechanisms. Treatment pluralism takes this evidence seriously, all of it, and offers a way forward that is honest, pragmatic, and centered on the person in the room. Thanks for listening. I'm Dr. Jared Powell, and this has been another episode of the Shoulder Physio Podcast. Thank you for listening to this episode of the Shoulder Physio Podcast. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
