Manip U Later

Once in a couple of years, the country's best manipulators descend on Rotorua to discuss the state of the art in manipulating.

No, its not the New Zealand chapter of Villain-Con. Thanks to our language's nuances, manipulator can mean something other than this definition:
"exercise of undue influence through mental distortion and emotional exploitation, with the intention to seize power, control, benefits, and privileges at the victim's expense".

Manipulative Therapy (MT) or manual therapy is the use of manual skills to improve the function of the musculoskeletal system. Yes we do use exercise, but we don't exercise undue influence - well okay, we do that but only with consent and in the hope of benevolent intentions.

So, setting the scene, we ironically spend a lot of the time doing something most physiotherapists decry: sitting. This year, the chairs at the particular venue were bottom friendly and the leg room was generous, but I digress, as this is not a web based rating of a multinational hotel chains bottom support policy. If sitting is the new smoking we have just sat in the collective smoke of 150 odd people, sitting the equivalent of a pack a day. Luckily there is lunchtime where we can get up to sit down to a healthy carb infested smorgasbord!

A keynote speaker gets 40 minutes. An honours student has a mere 10 minutes, and your homegrown local academic might squeeze another five minutes over that allowance.
This year two eminent Australians shared the keynote ticket, and by miraculous timing, had to find excuses on Sunday morning for their abysmal Wallabies. The best excuse was, "I'm Victorian, and we don't care about rugby."

Professor Gwen Jull, recent recipient of the order of Australia, head of Physiotherapy at Queensland University and immortalised as the founder of the Cranio Cervical Flexion Test - I am sure you wondered who came up with that - was to deliver several pearls on headache, whiplash and cervical dizziness.
Her talk on headaches was a retrospective on where we were as opposed to now, across her illustrious career. Her work has placed the headache from the neck (cervicogenic headache) as a separate entity, and a large player in the whole spectrum of head-related pain. Previously the powers that be in head pain attributed it mostly to head and migraine, however studies are now showing the neck to be a major contributor, not just a minor party. She also took time out to disassociate our profession from tension type headache (TTH) which appears to be mostly from the neck. This sat nicely with me as I have seen a high percentage of headache and migraine sufferers that have been successfully treated by ministering to the upper neck joints.

Professor Kim Bennell, the Victorian, has an interest in conservative non drug management of osteoarthritis, with a particular emphasis on exercise as preventative and therapeutic as opposed to medications and surgery. This was a fascinating collection of research findings which is what I hope for attending these sorts of conferences - something useful for next Monday.
The findings were specific for groups with knee and hip osteoarthritis, which represent a large slice of the health financial pie.
The guidelines they recommend form a broad selection of approaches. At the core of treatment approach, education, strengthening and weight loss are the most effective.
Education should be verbal and written and should aim to counter misinformation, for example the knee image put out by Arthritis NZ with glass inside the joint. We are now finding that many can have arthritic joints and yet be unaware. My colleague regularly frames OA to his clients as like wrinkles in the joint. You get older, you get wrinkles. Wrinkles don't have to hurt.

The old way of framing OA in words contributes to the pain.
"Bone on bone, cartilage worn out, wear and tear, inevitable progression" are all misconceptions and loaded statements creating fear, avoidance and exacerbating pain.
Bennell asserts that clinical imaging (X-ray, MRI) is overused in OA, as they have shown it can be diagnosed on the clinical features of stiffness and activity-based pain. There is movement away from treating the images as advances in resolution of scans are finding pathology in normal individuals, or else normal functioning people can have tendon tears, degeneration and bursitis without trace of symptoms.

Exercises are as effective as drugs. They are safe and there isn't evidence that they negatively affect structure. A combination of strengthening and aerobic exercise is best, and even better when combined with manual therapy. There appears to be no difference between high and low intensity exercise, which is good for those who aren't inclined to hard work. The best effect came with supervision, frequency and accountability, and research showed 12 sessions over several months with a physio was best.
Weight loss was best achieved with diet change and exercise. A decrease in inflammation and compressive loads occurred with a 10 per cent or more weight loss.
Studies show again and again that a low carbohydrate approach was superior and is anti inflammatory.

Interestingly Bennell's team found that shoes increased the loads knees experience unless they were very flat and flexible. Obviously heels didn't fare well in these studies.
Walking sticks worked best on the opposite side with a 10 per cent reduction in knee load and coming in early at heel strike was the best way to use one.
Braces were maybe as good as a placebo, as was acupuncture.

Other small gems that emerged from the conference were the positive role of exercise in depression, and giving physiotherapists the tools to identify a depressed client.
Being able to diagnose a hip joint labral tear on the basis of statistical probability, where four or more relevant signs and symptoms occurring give an 83 per cent likelihood of a tear got my maths geek all a flutter. And yet this is something I can actually use tomorrow! Ahh to find meaning and inspiration at a biennial conference is strangely satisfying. It helps me to love what I do even more.

So it appears my efforts to sit still for sessions of two hours or more have borne a small yield of fruits that I can pass on to you for your potential good. Hopefully in reading this you may find improvement in your body.

Greg Bell is a physiotherapist practising at Bell Physiotherapy. www.bellphysio.co.nz