For many of us touch is a large part of treatment, but only a small part of the recommendations, which is as an adjunct therapy. So how do we reconcile our hands-on practice with the evidence?

Small Vital Changes

There's no need to stop hands-on work with your patients who are experiencing back pain, but there is a need to change your clinical reasoning and explanations about why you would provide it. Honesty is probably the best policy. If a patient comes to you with back pain and expects you to fix it, then you need to explain why that's not possible and why it would be better if you provided the tools for them to change their own situation.

That doesn't mean you can do nothing for your patient, on the contrary, that means you can offer treatment that will provide them with reassurance, knowledge and a plan for the future. It is a perfect opportunity to offer knowledge and empowerment for your patient.

It's a perfect opportunity for you to provide treatment for a whole person experience.

For Acute and Sub-Acute Pain

Apart from exercise, the recommendations do not suggest manual therapy for acute and sub-acute low back pain. It may possibly be part of a multidisciplinary program, but that is not a given.

However, our medical system isn't all that up to speed with these recommendations or doctors don't really have the time or language to provide the information a patient needs. Often times patients will contact someone they see as knowledgeable in MSK care before they see their doctor. In which case, how can you help and stay within the guidelines?

• Always review what the person has done so far.
  • What did their doctor say if they went?
  • If their doctor advised a scan in the absence of red flags ask why.
  • Are there red flags that you see? Do you need to refer?
• Review and or advise self-care strategies like heat or ice, a combination of rest and tolerated movement.
• Reassure the patient that most episodes of low back pain resolve on their own and treatment is generally conservative.
• Review yellow flags (see guidelines for a list of yellow flags and recommendations).
  • Does your patient believe that if it hurts it must be causing harm?
• Address the yellow flags that are in your scope.
  • Provide reassurance, and if necessary evidence, that pain is a protective system and movement is safe.
• Give your patient reasonable timelines for feeling better and address the possibility that pain during recovery may be variable.
• Be honest about manual treatment.
  • Good effects are usually temporary, but may help relieve some symptoms.
  • Positive post-treatment effects may help calm a protective response allowing easier movement with less pain.
    • In which case, encourage mobility within tolerance levels.
    • Depending on the stage of recovery, encourage increasing activity.
  • Hands-on treatment is not a panacea, it should be one part of an overall plan.
    • Ask them about their plan.
• Provide or modify exercises for home care.
• Don't recommend more treatment when there is no reason.
  • If the patient finds hands-on work helps with compensation aches and pains then provide a plan that will be optimal for their goals.

For Chronic Pain

The recommendations for chronic low back pain consider massage therapy an adjunct treatment or additional option. Massage and hands-on work are not considered primary or first-line treatments for chronic back pain. Yet, we often see patients with chronic low back pain who are looking for help. Those patients have been to their doctor many times, they have tried different medications and seen many therapists who have provided them with problems (see above list) and supposed solutions for those problems. What is common though is that these patients have had with very little sage, evidence-informed advice and an honest recovery picture. So how can you help?

• Always review what the person has done so far.
  • What did their doctor say if they went?
  • If their doctor advised a scan in the absence of red flags ask why.
  • Are there red flags that you see? Do you need to refer?
  • What other therapies have been tried and did the patient find them helpful or not?
• Reassure the patient that most chronic low back pain does not require invasive procedures.
  • Provide evidence if needed.
• Review yellow flags (see guidelines for a list of yellow flags and recommendations).
  • Does your patient believe that if it hurts it must be causing more harm?
  • Have they stopped activities?
  • Are their ADLs being affected by pain?
• Address the yellow flags that are in your scope.
  • Provide reassurance, and if necessary evidence, that pain is a protective system and movement is safe.
• Give your patient reasonable timelines for feeling better and address the possibility that pain during recovery may be variable.
• Be honest about manual treatment.
  • Good effects are usually temporary, but may help relieve some symptoms.
  • Positive post-treatment effects may help calm a protective response allowing easier movement with less pain.
    • In which case, encourage mobility that does not increase pain, even if it doesn't resolve the pain.
    • Encourage grading and pacing activities.
    • Provide information on flare-up episodes.
      • Management strategies.
      • They are not indicative of more damage.
  • Hands-on treatment is not a panacea, it should be one part of an overall plan.
    • Ask them about their plan.
    • Provide an idea of what a plan might look like.
    • Provide activity or other treatment options that could be part of the plan (see guideline for recommendations).
• Provide or modify exercises for home care when relevant.
  • Reassure that movement is safe.
  • Help them to use pain as a guide so they can manage on their own.
• Don't recommend more treatment when there is no reason.
  • Have clear boundaries around what you can and cannot provide.
  • If the patient finds hands-on work helps with compensation aches and pains then provide a plan that will be optimal for their goals.
• Always work toward liberating your patient from "needing" hands-on therapy to manage their pain.