If all you have is a hammer, everything looks like a nail.
There are many modalities in the field of manual therapy. All of them sometimes work yet many of their explanations contradict each other.
A massage therapist is trained to treat trigger points. When a client comes to them seeking relief for a pain problem, the therapist will look for trigger points, will inevitably find them, and attempt to resolve them. The client often feels some relief after the treatment. Both client and therapist conclude that the pain was a result of trigger points and that the trigger points have been resolved, at least temporarily.
Another therapist is trained in myofascial release. A client comes seeking relief from pain. The therapist will look for and inevitably find fascial restrictions. The client may feel better at the end of the session, may even find long-lasting relief. Both assume that the pain was the result of fascial restrictions that have now been properly treated and resolved.
A person with pain walks into a chiropractor's office. The chiropractor takes X-rays and finds subluxations and adjusts the patient. After a few treatments, the person feels less pain. Both the person and the chiropractor assume that the pain was the result of subluxations that have now been corrected.
Another person with pain visits an acupuncturist. The acupuncturist determines that their chi is blocked and inserts needles in certain places in order to restore its proper function. After a few treatments, the person feels less pain. The acupuncturist and the person assume that the cause of the pain must have been blocked chi which has now been restored to proper function.
What is wrong with this picture?
Is it a coincidence that every person who walks into our office just happens to have the very pathology that we have been trained to treat? What happens to the person with trigger points who visits the therapist who treats fascial restrictions? Will they get better? How would that happen if the therapist is not treating the trigger points?
What happens to the person who has subluxations who visits the acupuncturist? Does acupuncture correct subluxations? How does that happen? If a person with subluxations never sees a chiropractor, does that mean they will never get out of pain?
What of all the people whose pain comes and goes? Did their trigger points/fascial restrictions/subluxations/blocked chi resolve itself and then come back? What of people who have pain for awhile and then, without treatment, it goes away and never returns? Did their body magically correct the supposed pathology? And if it's capable of that, did they need therapy in the first place?
Is there a common denominator?
It seems unlikely that only those who have the pathology that we are trained to treat come to see us. All modalities seem to have some effect with some people and no modality works for everyone. Many modalities completely contradict other modalities which are often just as effective with some populations. Some people get better without any treatment at all. How can we explain this?
Modern pain science is changing the way we think about pain. Melzack and Wall, authors of the Gate Theory of pain, later developed the Neuromatrix Theory of pain to fill the gaps that Gate Theory left unexplained. Current pain science looks at pain as an output of the brain, rather than input from tissues. Pain is seen as an experience created by the brain in response to perceived threat rather than a direct result of tissue damage. Melzack and Wall propose that pain is not purely a result of tissue damage but has physical, psychological, and social factors involved.
Taking what we know about current pain science, how can we find a common denominator among the disparate modalities used to treat pain? I would like to suggest that the nervous system is the common denominator.
Neurocentrism as a unified field theory.
When the various modalities in manual therapy are seen as separate entities with different and competing explanations, it is hard to explain why they may all work to varying degrees, how it is that any person who visits a manual therapist happens to have the very pathology that person is trained to treat, and how it is that people often respond to whatever treatment they are given. However, when manual therapy is examined in the light of current pain science, it makes perfect sense.
The various modalities of manual therapy share certain common characteristics. First of all, the fact that they are a manual therapy means that the therapist will be handling the client's body. This direct contact with the body has an influence on the nervous system and if it is done in a manner that makes the brain feel safe, rather than threatened, that alone may allow the body to relax and begin to turn down the volume on pain. If the therapist is confident and interacts with the clientin a manner that puts them at ease, that can have a positive effect. If the therapist has an explanation that appears to make sense and holds out a possibility for correction, that sets up hope for the client and enhances the possibility for a positive outcome.
If the modality involves gentle handling of the body, this novel input into the nervous system can get the brain's attention and focus it on something outside of the persistent pain. If the brain likes the handling, it may then relax and restore a state of normalcy. Some types of handling may relieve mechanical pressure on nerves, interrupting the impulses that have been signaling the brain that something potentially dangerous is happening.
All manual therapies create some sort of novel input to the nervous system. Whether one believes they are treating trigger points, fascia, chi, or subluxations, one is touching the body in a different way, stimulating the nervous system, and the nervous system is responding both locally and centrally. All manual therapy relies on a response from the nervous system in order to work.
Does this mean we need to abandon our modalities? I think not. I think it means we need to think a little differently about them. If our particular approach to handling the body works well for us and our clients, there is no reason to stop handling them in that manner. However, if we start thinking about the role of the nervous system in how we handle the body, it might begin to modify what we do with our hands. If we have been employing approaches that cause pain, we would certainly want to modify our approach as to not cause pain. As we understand better how the brain is in control of the experience of pain or tension or ease, it may expand our thinking and open us to new possibilities. However, most existing manual therapies can continue to be used with an understanding that it is the brain making the changes, not our hands effecting a structural change on joints or tissues.
Recognizing the role of the brain and the nervous system in manual therapy enhances and deepens our understanding as a therapist and can increase our effectiveness with clients, no matter what modality we use, no matter what the goal of the treatment session. It takes us to a new level, takes us the to the next step.
The brain is the master controller of the body. It appears to be able to respond to many different types of input. If we understand that, it may not matter a lot which modality we choose but, rather, the way in which we use it.