Why manual treatment may not work

Incorrect Diagnosis

This is the most simple explanation, as per the title we need to have the right reasoning for your pain, and thus all the treatment hangs off this very fact. 

If you get arm and elbow pain, and you get diagnosed with an elbow sprain, then of course the treatment will be on the elbow. If however, the pain in your elbow for example is coming from your shoulder or neck (referral pain) then treating the elbow week by week will do nothing to help you out of the pain. 

Now, this can be a very normal process the practitioner goes through, they will have a direction for treatment based on initial findings, to then change direction when either treatment is not working or other information has arisen to change the initial diagnosis. A process of elimination, with targeting the most probable cause first. 

Remember practitioners don’t have an MRI machine in their heads, so the orthopedic tests and case history alongside palpatory findings can get very close to what’s really going on. What you want to look for is a practitioner who is flexible and driven to continually find a way to better understand your pain and how to get you fixed.

A sign things have become stale, is when the treatment you receive is the same every time, or no more rehab or progression is given. The practitioner should test and re-evaluate every time to best serve you. If you don’t get an updated explanation on how it’s going and not getting a continued explanation of the diagnosis development then you may need to look for another opinion.

When should I get referred to a specialist or further imaging?

This should be from your practitioner’s digression, dependent on the severity and type of the case. It will be hard for someone who doesn’t have a medical background to know if and when they need some scans or onwards referral. 

You may be in a lot of pain and some complaints are more debilitating than others but your case may not warrant a referral of this nature. So a high amount of pain doesn’t always mean you need an X-ray or referral.

If you are unsure, do not hesitate to ask your practitioner about onwards referral or a scan. You need to be open with your concerns and let them know you are worried. 

At our clinic, we have a 3 treatment rule, this is if there is no improvement whatsoever in 3 treatments then we must consider referral. Now, this might look like another opinion from another health care provider or a specialist. Alternatively, a scan (x-ray for example) if it’s not been considered initially. In 3 treatments we know we have tried multiple treatment types and have had time to test your body enough to have a better understanding.

Style of treatment

I will take Osteopathy as an example for this topic, but this applies to all. All Osteopaths have a very similar philosophy and principles but can treat very differently from each other. The ‘style’ of the treatments refers to the techniques used and the tempo in which they are performed.

Osteopaths train all over the world and thus have different treatments, as there are hundreds of ways you can treat the elbow for example. This could be strong articulation, to very gentle fascial unwinding (don’t worry about the terminology). 

So Osteopaths have different ways of treating, but also everyone’s body is different also, and sometimes this does not match up. It’s often not your or your practitioner’s fault, but this should be found out early on in the treatments so to best serve you and your injury.

For example, if you have someone whose tissues respond very well to a lot of pressure and deep muscle work, then seeing a Cranio-sacral Osteopathy (very gentle movements tapping into the cranial rhythm) may not give you the results you want. And this works the other way around also.

Physiotherapists, Chiropractors, and Osteopaths are quite different from one another. One might not be the best approach for your condition or presenting complaint. For example, a sports physio will have more knowledge about sports injuries to help your ankle sprain (from football) than let’s say a women’s health-focused Osteopath clinic.

So before you think one profession cant help, you might consider asking your practitioner what your options are. Remember to consider the other factors listed on this blog before you consider changing. 

Not letting it rest

It’s human nature to want to get out of pain as fast as we can, and quite right, we want you to get back to what you love doing, but can you be doing too much?

A list of common mistakes when ‘not letting it rest’ takes place.

• Overstretching – either too hard too long or too frequent. There is not doing any stretching and there is doing too much. Often we are mid-way through the stretch and think “might as well get more out of this while I’m doing it now so I don’t have to do more later”. 

You end up taking the stretch and muscle past its therapeutic range into muscle breakdown and minor damage zone. Therefore it’s very important to stick to the guidelines your practitioner has mentioned and don’t hesitate to ask for a second explanation.

• Overdoing the rehab given. We can do a lot to help speed up recovery, but there is the body’s innate ability to heal itself and this is known as ‘tissue healing time’ in which the tissues need to heal and repair on their own. And by overdoing it or straining the area before it has had a chance to heal will impact its prognosis greatly. 

• Going back to sport or activity too soon. We see this time and time again, the body gets out of pain fast but still needs time to heal. The patient feels great and charges back into what they love to do, but quickly realizes they are not 100%. Our opinion is that you are 5X more likely to reinjury yourself in the 2 weeks following getting pain-free (subject to the complaint). 

• Not taking care at work or not making the changes to reduce loading. You should be advised by your practitioner what is suitable for your occupation and lifestyle with regard to your injury. ‘Pushing through’ often sees a patient’s prognosis (time of healing) extended.

Rather take a week of work than be 50 less productive at your work for the next 2 months and at a higher risk of re-injury. 

Not doing the rehab given

This is another very simple one but is often missed and overlooked. The easy part is going to get treatment and giving the responsibility of getting you out of pain to someone else. But could you be having more treatment sessions because you didn’t help yourself more ‘outside the treatment room’?

Yes! There is a mountain of research on this topic as you would expect. You will speed up your recovery and decrease the treatment sessions needed to get you back to 100%. As mentioned above, it’s like the ‘Goldilocks paradox’. Doing too much rehab (stretching or exercises) can be damaging but on the flip side by not doing any, you will not see the results you have expected.

The exercises or stretches/rehab is not only prescribed by your practitioner just to get you out of the current pain. But they should be there to educate and give you some long-term tools to help in the future. Giving you more sustainable longevity to your area of complaint. 

Not Changing the aggravating factors

What is an aggravating factor? This is something you are doing or using during your day-to-day life that has a negative impact on your presenting complaint. It’s like swimming upstream, the water against you are the aggravating factors, and the power to swim and propel you forwards are treatment, rest, rehab (all the good stuff). 

Instead of trying to swim harder against the current, would it not be helpful to reduce the water rushing towards you. Often some of these aggravating factors are the very things that predisposed you to be in this pain in the first place.

Below is a list of common areas of our day to day life that seems to make our pain worse when not done correctly:

• Sleeping position and quality
• Sitting position
• Standing position
• Desk ergonomics 
• Particular sport and technique
• Particular hobby
• Diet – inflammatory factors, such as dairy, alcohol, gluten (dependent on the patient)
• Stress

Expectations 

Now with no medical knowledge of healing times and understanding of your condition’s particular prognosis, it is up to your practitioner to create an expectation of your complaint that is specific to you. 

If your practitioner gives you the expectation that your injury would heal in 2 weeks with treatment, and after 6 weeks you notice no improvement, then you would be wondering what was going on. 

One factor to this is the incorrect diagnosis (listed above) but also you are at the mercy of your practitioner’s experience and confidence to best judge your healing time. Most of the time the prognosis is spot on, but due to other factors, this can be delayed or pushed back. A list above with aggravating factors might show an insight into what could be prolonging your recovery.

It is important to have an open discussion with your practitioner about expectations. This should be discussed with you every treatment, so there is no misunderstanding and thus less frustration.

Rapport

Do you trust your barber not to cut your ear off? You trust your dentist not to pull out the wrong tooth. Well, you need to understand that your practitioner is doing their best to get you better. 

Now if you don’t trust your practitioner or are not confident with what direction they are taking the treatment. Then this is a waste of time for you and the practitioner, for the main reason for compliance and uptake of advice to help your pain.

So if you don’t ‘click’ or ‘gel’ with your chosen practitioner then it is likely that you might not take on board what they have to say and thus doing a disservice to your recovery. Sometimes it’s not personal. It’s just something to think about.

Summary 

There are many factors that affect your recovery from pain or an injury. It is important to be open and honest with your practitioner to get the best outcome and understanding. Remember that you are not fixed or stuck with a style of treatment or practitioner. But do review the points above before considering changing. 

The goal of any practitioner should be to get you fixed regardless of who you see and or what style of treatment you have.

If you have any further questions about these topics then please do not hesitate to reach out. 

Our Osteopathic clinic is situated on the North Shore in Auckland. A list below are the areas we serve:

• Albany
• Rosedale
• Glenfield
• Browns Bay
• Takapuna
• Milford
• Wairau Valley
• Mairangi Bay