CAN WE OVER-TREAT? FIRST DO NO HARM

A few months ago, a question was asked during an Instagram live discussion with Matt Nichol and Dr. Mike Prebeg whether treatment can, at times, be detrimental to an athlete’s performance? The answer was ‘it depends’- which is of course true. It depends on the context of timing-right before performance or following, during recovery and also if it is performance care verses injury management. Another component of ‘it depends’ that was briefly mentioned was the skill of the practitioner. For instance, using deep tissue massage, Graston or ART, therapists may apply their skills very differently. For me what is most important regarding this question is that the practitioner a) understands the physiology of what they are trying to accomplish and b) is constantly assessing how the patients’ tissues are responding and adjust their treatment intervention accordingly. Most importantly, first do no harm! I was reminded of this recently in a discussion with Dr. Alejandro Elorriaga Claraco during the McMaster Contemporary Acupuncture Advanced programme, where he shared incredible results working with a professional athlete for extended hours. He was able to make significant, lasting improvement in long standing edema and enhance performance in an already elite athlete. This took time, patience and the application of fundamental knowledge of anatomy and physiology with a skill level few practitioners can match. This should be the gold standard of what is possible.

Although research is often studied with a set protocol, treatment should not be a standard recipe applied with exactly the same point of contact, pressure, time, dose etc. In fact, not only does it differ between patients, it may change from day to day for the same patient. This is the Art of the Science.

Let me share an experience with you from early in my career. I was working with an Ironman Triathlete doing deep tissue/myofascial release. We worked together weekly for several months. The treatment was approaching the border line of his pain threshold, never beyond or bruising. After every treatment, he experienced significantly greater mobility, which was our goal for him. However, after a few months, I had an epiphany-although he was ‘better’ immediately following treatment, he had no permanent changes and may have actually been more restricted then when we started! So even though both the patient and the therapist perceived the treatment to be effective in the short term, the reality was somewhat different.

I stopped treating in this manner but it took me a few years to understand what was happening at the physiological level. I am certain my understanding is not complete but here are two insights I have gained. First, if we think about tissue injury and the process of inflammation, there is an immediate response at the cellular level resulting in increased blood flow, nerve stimulation and chemical mediators being released. This acute phase lasts up to 48 hours and may be why, in the short term, there was improved mobility. The long-term healing of inflammation results in resolution-damaged cells repaired, regeneration of new cells to the area but also fibrosis. If we add to this more recent understanding of fascial dynamics, bio-tensegrity and mechanotransduction, it is possible that the repeated micro-inflammation was leading to a contractile response in the fascia? Of course, this is just one case and looking back I have no idea if he was overtraining/under recovering (most likely) but since that time, I have been mindful to approach the tissue barrier in a much slower and respectful way, allowing the tissue to yield, much like using compression to melt an ice cube, rather than applying over-force. This requires time and patience for both the practitioner and the athlete.

Coming back to the original question-CAN we over-treat-in my opinion it’s a resounding yes-many do BUT what is more important regarding over-treatment is not the frequency, duration, timing, condition or even modalities of treatment but rather the skills and applied knowledge of an individual practitioner. In fact, I would argue that the more skilled a practitioner is, the longer they may able to treat (think hours), refining layer by layer, without overwhelming the body’s systems. Treatment goals include improved function, decreased inflammation, edema, and pain. If you haven’t achieved at least some of these, treatment is ineffective at best and at worst detrimental. Notice that the length of treatment is not a goal and in fact, you will likely need to spend more time treating to achieve the desired outcome.

So, what are the take aways?

If you are an athlete:

1) the best time to get performance care is before you think you need it!

2) be present when you are being treated, check in with how you feel during, immediately after and in 48 hours- if you are hurting or bruised after treatment- probably time to try someone else.

3) quality treatment can take time, skill and knowledge-invest in yourself and seek out the best care

If you are a practitioner and you want to ensure you are not over-treating, my advice is this:

1) slow down, spend MORE time with your patients, seek understanding

2) treat holistically/functionally, not just locally/symptomatically

3) never use a standardized recipe or ‘indiscriminate pummelling’

4) be present-check in with your palpation/assessment and your patients’ feedback

5) let anatomy and physiology be your guides-be a lifelong learner

Yours in Health!