Was it the HVLAT? A Reflective Case Discussion

There is quite the debate these days about how manual therapy works and particularly what types are best or get different/better results or is it all just placebo. Here is a case,  n=1.

I’m evaluating a patient with upper back pain, medial to the scapular border and lateral to the spine, around T5-ish.  We all know where this spot is, right? The complaints are approximately 8 months in duration, 5/10 pain secondary to increased breast tissue (20 lbs) during pregnancy and post-partum time periods, per the patient.

So, after a thorough evaluation including subjective statements from the patient like “it feels like it needs to pop” I throw down a super-boss  pre-technique education session and set up a nice high-dog, mid-dog and low-dog supine thoracic HVLAT.  Clickity poppity.  0/10 pain.  High fives.  For real, she threw up a high five.

This patient was seen 5 more times, not on my schedule (I’m an intern, not in control of my schedule!)  She came in about 5/10 pain (so no real long lasting effects from HVLAT, she reported an 8 hr relief after the above encounter) and would perform specific exercises and get soft tissue mobilization and scapular mobs and spinal mobs and leave in 5/10 pain.  No one at the clinic where I intern was trained in the HVLAT technique.  I saw her again on 6th treatment visit; was able to get some good cavitations, and got 0/10 pain again.  High Fives.

The point of the case is not that I’m magical, or that HVLAT is magical… but that it was magical for this patient.  Adam Meakins wrote a very interesting and thought provoking post here titled “There is no skill in Manual Therapy..?” I agree that across the board manual therapy is interactive and engaging and involves touch and therapeutic context and a lot of things cannot be parsed apart from one technique to the next. The ectodermists certainly have my attention as far as interacting with the brain through the skin, love that idea.  In this case (n=1), however, other attention giving touching techniques were provided with no benefit to the patient.  That gets me to thinking that there was something about the HVLAT… or about the provider or the context.

The other providers at the clinic I intern in are caring and interact just fine with patients and there was therapeutic touching going on.  But perhaps the ol’ concepts of ‘expectation’ and anchoring and priming are at play here.  She came in wanting “the thing that makes my pain better” and was not able to get it.  Using this idea, if she had gotten grade 3 spinal mobs at evaluation and got relief, then other techniques, such as soft-tissue or HVLAT, would not have been successful.

Was it just attention? Many will say that manual therapy is simply placebo, or no better than placebo.  Perhaps they are right, I suppose research nerds are working on it now.  Placebo is one of the most powerful forces in medicine and should not be under estimated.  Erik Meira has a great post here at PT Podcast titled “Why I’m not a manual therapist” that makes some very nice points about all of this uncertainty.

Now, I don’t get caught up in the “It seems to make the patient better, so why not just do it?” mindset. I like to have evidence to support my clinical reasoning; the three pillars and all.  (If you will note above the patient preference pillar was kept in high regard in her treatment approach. Mix that with what I’ve seen clinically and some evidence for immediate effects from HVLAT, and there we go).

That being said, I am OK with some unknown placebo influenced outcomes.  I’m mean, heck, I’m not sure I can control for all that anyway.  I may look like a guy who played a doctor on a TV show that a patient saw when they were a kid and now they are more likely to get better, etc,etc.  We don’t live in a bubble, non-specific effects surround us, no doubt.

Now , as mentioned above, I’m not going to provide craniosacral treatment or rub peanut butter on it because it “just seems to work.” I chose Physical Therapy… I will use the placebo treatments within my scope!  (don’t fall into the sar-chasm)  In all honesty, that’s kind of true.  I’m not a physician providing pills that may have a stronger placebo effect that their specific biological agents.  I’m not a chiro who is providing life-saving vertebral re-placement adjustments, which work off placebo.  I’m going to be a practicing PT, who will maximize the science and the placebo behind the treatment approaches we employ.  (Note: I don’t find placebo a bad word; it is simply providing a positive environment wherein actions take place.  I do not support deception or fraud in any manner.)

Now all this above writing is an exercise in reflection, a chance to try to work out how and what happened with my patient. I hope it spawned reflection with you as well.

Why did one thing work and not another?  What was the causal agent? Was it the technique, the education, the provider?  If another patient presents like this again, what will I maximize?  Will I consider HVLAT?  Will I consider maintaining the continuum of care within one provider?

To the untrained brain the HVLAT looks like the major change in treatment for this patient.  But perhaps, as mentioned above, there are many factors which changed from provider to provider, day to day. In all I am happy to have been a part of some relief for this patient… now to figure out how all that happened…

Matt D

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5 thoughts on “Was it the HVLAT? A Reflective Case Discussion

  1. Hey Matt,

    Nice post. This is an interesting topic and one I think about quite a bit. I was speaking about it with Kyle Ridgeway and had a few rough questions about the window of relief that a manipulation (or another intervention that a patient can expect a benefit from) that I would be interested to hear your perspective on– The manipulation provides a nice window of opportunity/relief, but why? Because she felt like it needed to pop? What gave her this idea in the first place? The manip was utilized, but then her pain came right back. Do we keep doing the manip for the short term window of relief until she’s all better (for any combination of reasons including regression to the mean, natural history, etc etc)? Where do we draw the line in harnessing this sort of expectation to get a transient bit of relief?

    Thanks for sharing. Keep up the good work.

    Like

    • Thanks for the feedback Kenny,
      I have those similar questions. I’m not sure what made her think about the need for it to pop, perhaps she equated a stiffness with that solution? I know that if she had offered up negative feelings about a clickity-poppy-type technique during Hx, I would have avoided it.
      She did report 8 hr of relief. Now, how did that happen? Well I know I did not “put something back into place” but I did give input to the nervous system, etc. Neurophysiological results and such.
      I wonder if the HVLAT could have been employed consecutively if she would have gotten 10 hrs relief, then 15, then a day, then 2, etc… I don’t know. Not too much research on that either, that I can tell.
      I told her that the relief from the HVLAT would allow her to move through the therex better, thereby improving her condition. To me I thought of it like taking an aspirin. Not really full treatment, but part of treatment that would allow for recovery to occur.

      I do like that she kind of served as her own control in a way. A-B-A study design, right?! Although this was just clinical observation, not research.
      Do you employ any of these techniques, Kenny? What is your clinical opinion about it all? I feel I have more questions than answer, perhaps that’s healthy though…

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  2. It is also possible that as the novelty of the HVLAT wore off with consecutive applications the effect would diminish. Who knows? I’m working my way through Todd Hargrove’s book and he discusses the “parking lot effect” (coined by Dr. Eric Cobb) where a novel passive stimulus (HVLAT, massage, foam rolling etc) piques the curiosity of the patient’s brain and they leave the clinic feeling great. But, by the time they reach the “parking lot” they are already beginning to lose the analgesic effect.

    Now, does that mean we should use these passive interventions as a means of providing a novel stimulus that subsequently allows a window for more active approaches that may “stick” better? Maybe! Like you mention, I always find myself with more questions than answers.

    There is an interesting discussion/boatload of resources over here that you might find useful — http://www.somasimple.com/forums/showthread.php?t=14981

    There are some really good things to think about in here. Thanks again for sharing the case.

    Like

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