‘Does it feel tight?’
It’s a cliché to say it, but I really do get asked this a lot. I mean a lot. So what does a painful back feel like to a manual therapist? If we are critical thinkers and want to be evidence-based, we need to determine if a therapist can really 'feel' your tightness.
Well, there has only been a small amount of research in which experienced therapists were asked to find tight spots on subject's backs using only palpation (feeling). The results were not encouraging. Physicians with training in manual medicine couldn’t even tell which side of a back was painful much better than a coin-toss (study). In a similar study, experts couldn’t even agree on the location of trigger points (tight sore-spots, or knots) when given the same body to examine (study). If so many highly-skilled manual therapists regularly claim to be able to diagnose with their hands, how do we explain this?
The feeling of having a tight back is real enough; I’ve felt it too. But it doesn’t mean your muscles are actually tight. Ever feel like your shoulders are tight after a heavy bench press? Notice your arms spread just as wide as normal. Areas of muscle firmness do not correlate with sore bits (study). Even more to the point, muscle tightness doesn’t even relate to pain – the issue is not in the tissue, rather, it is probably something to do with the central nervous system.
A grand illusion?
Your brain tricks you, a lot. It sees, hears and even feels patterns where none exist – it actively looks for them all the time. You see movement in the forest, faces in the clouds and hear footsteps when nobody’s there. It’s called pareidolia (wiki) and it’s an unconscious cognition (wiki). Put your hands on a squidgy, squashy bag of meat – the human body, and it's to easy to think you can feel something that simply doesn’t exist. Especially if you believe that an ‘expert’ taught you that it was possible. As an evidence-based practitioner, I refuse to trust my silly, fallible brain. What your back feels like to me is irrelevant. Besides, how could I possibly know what’s ‘normal’ for you? What matters is how it feels to you.
Feeling things that do not exist. Palpatory pareidolia doesn’t mean good palpatory skills don’t exist, but it does show that it’s possible to be deluded while remaining oblivious to the illusion. If you’ve already told me one side of your back hurts, it would be too easy to say “ooh, yes, that feels really tight” and delude both of us into thinking I’m super-skilled. This deception is pretty much bread and butter for your working psychic – look up the Barnum effect (wiki) and cold reading (wiki). And likewise, I suspect that diagnosis by palpation would fail the James Randi million-dollar challenge. I am not saying manual therapists are lying, but are probably deluded; we are all victims of brain tricks. Bet some are lying though - it’s a tempting business model to have patients believing you have magic hands.
Here’s a trick I sometimes play when I put my hands on someone:
Moose: “You’re left-handed aren’t you?”
Client: “Yes! You can tell?”
Moose: “I watched you sign the forms”
It’s super-easy to make people think you’re skilled and smart, but it is also shockingly easy to delude yourself.
Maybe it’s me... Well, I can’t disprove that, so lets go on what we do know:
- The small amount of evidence looking at identifying problem areas using palpation shows poor results and low levels of consensus between experienced therapists.
- It is firmly established in psychology that the brain perceives patterns that do not exist.
- The influence of a perceived expert will compound this effect along with confirmation bias and wishful thinking
- Areas of muscle tension (firmness) does not correlate with painful areas
I don’t rely on palpation at all, it’s just too vague, problematic and has a very high risk of false-positives. I don’t know how you could reliably ensure palpatory pareidolia was not involved. However, questions like “does that feel sore or tender?”, are much more useful. More importantly though, if you tell a patient they have a tight back, what good does it do? None I can think of.
So I propose:
The God-Hands delusion: The belief that you can feel muscular ‘issues’, fix said muscles with your hands and subsequently feel the improvement (see also healer ego, messianic complex).
The fixing of muscles will be addressed in The God-hands delusion: Part 2.
Big Moose love,
The Massage Moose