-“Dock leaf, dock leaf in and out. Take the sting of the nettle out. Ok is it better now?”.
-“No. What about you maybe kiss it better Daddy??”
-“Ok. Mmmmwahhhh!!!. Well? Better now?”
I’m sure my 2 1/2 year old boy Charlie has an idea in his head of what I do as a physiotherapist. He does actually get the concept that I ‘fix’ peoples’ sore legs and backs. However I did have some clarifying to do in explaining that only he and his little brother Billy get magically kissed better. I’m also certain he enjoys availing of the fact that his Daddy, like all Daddy’s, can make most things better. However on this occasion an unfortunate sting of a nettle left me scratching my own head as well as his uncovered little ankle. He initially did what all of us do in reacting to a painful stimulus. He rubbed it. OK so the first you’d probably do is scream profanities. Fair enough. Well then the second thing you would do is rub it. I joined in and helped him. But then I recalled my own childhood and summers baling hay that would inevitably lead to numerous thistle and nettle stings and how dock leaves were my mothers ‘go-to’ treatment of choice. I have no idea about the healing properties of dock leaves when it comes to reducing the stinging effect of nettles. So as someone who deals with peoples pain on a daily basis and left with no other ideas Charlie and I went in search of the nearest dock leaf.
Rubbing sore or painful parts of the body is the most natural reaction to a painful stimulus – a kick in the leg during a soccer match, a bang on the head, a knock of the funny bone, a pulled muscle during a sprint. But now 9 years in practice I have found there is still a perception out there, much like my boys’, that physiotherapists ‘rub’ things better. Attend any club training session with a physiotherapist present and watch the queue develop as complaints of tight hamstrings take centre stage. There is no doubt that manual therapy is part of a physiotherapists tool kit and something taught at undergraduate level and it certainly has its benefits. Manual therapy can be anything from soft tissue massage or deep transverse frictions to manipulation or joint mobilisation. But how does it work? What is happening physiologically while manual therapy is being carried out? Does the patient even care so long as their pain dissipates? Or like the dock leaf, do we even know what’s happening?
The answer to this is a disappointing one in that, well, we don’t really know how manual therapy works despite some claims. What we do know is that our perception of that tight or stiff structure changes by performing manual techniques. To truly know what happens would mean an in-depth understanding of neuroscience, an area that both truly scares and interests me. The concept of pain is becoming more and more understood thanks to the great and entertaining work of people such as Lorrimer Moseley. The role the brain has to play on the outcome has for years been both misunderstood and underestimated. For example why can 2 people with the same diagnosis of a low back disc protrusion have very different perceptions of pain. One may be so debilitating they are contemplating surgery, the other may be going about his or her daily life with little complaint yet on that MRI scan both have been shown to have a large protrusion of the same disc. There is so much more to pain than something touching the skin and causing a pain at that point. Doctors, chiropractors, osteopaths, consultants, massage therapists and physiotherapists (me included) all use terminology that we probably shouldn’t. Are we really “loosening a tight muscle”, “breaking up scar tissue”, or “realigning a joint” (sometimes guilty of the first two but I DO NOT say the latter one!!). This language is used as a means of explaining what the problem is and how treatment may help but is it accurate?
In recent years manual therapy is having less and less of a role. The importance of exercise and movement has become an integral part of every rehabilitation plan following injury and surgery. Patients are (or at least should be) empowered to perform their own maintenance work with foam rollers, strengthening and self mobilising exercises. No amount of massage will strengthen a hamstring sufficiently enough to return to sprinting but strengthening exercises will. There are certainly short term gains from different forms of manual therapy but how about once addressed we go after the bigger problem. How about finding out what caused that pain in the first place? Of course sometimes there is a painful stimulus like Charlie’s nettle. But what about a muscle imbalance that has lead to chronic overload of an another structure? Or prolonged sitting positions leading to shortening of some structures and weakening of others. You need to ensure that active rehabilitation is part of your treatment and if it’s not then why not. Are you happy to take the passive, ‘fix me’ approach. It’s not the answer.
Anyway back to more pressing issues: it turns out the sting from a nettle is from foric acid within the the leaf. The alkaline properties of the dock leaf apparently help to neutralise the sting (hopefully you can at least take that from this article). But it doesn’t sound half as daft as some of the treatments currently available out there in the world of sports medicine and makes a lot more sense than some of their claims. Anyone remember Robin van Persie’s placenta massage?? A dock leaf doesn’t sound so bad after all now does it?
For more information on any of the issues addressed throughout this article please contact Rob via email at firstname.lastname@example.org, Twitter @mccabephysio, Facebook at McCabe Physiotherapy or visit http://www.mccabephysiotherapy.com
Rob McCabe MISCP
MSc (pre reg) Physiotherapy, BSc Sport Science and Health, MSc Sports Physiotherapy, PG Dip Orthopaedic Medicine
Orchard House, Moorefield Rd, Newbridge, Co. Kildare