Introduction: Roland Lucas graduated from the University of Sydney, with a degree in Physiotherapy, in 1992. He completed the Manual Therapy Residency Program at Kaiser Permanente in Hayward and is a FAAOMPT. He currently runs a private clinic in Sunnyvale, Ca called Lucas Physical Therapy and Fitness. He is also the chair of COMPTSIG. Enjoy!
1. Can you tell me a bit about how you started your private practice?
a. I transitioned from working at Kaiser Permanente in the Bay Area to private practice in the early 2000s. I did very little planning and was lucky things worked out. I started out in a shared space, but transitioned to my own office a year or so later.
2. I am aware that you perform biomechanical analysis in your clinic. Can you tell me a little more about it?
a. My area of expertise has always been about direct treatment to the source of the symptoms without too much focus on movement analysis. In 2013, I took a Six Month Certificate Series in Advanced Functional Biomechanics offered by Christopher Powers PT PhD FACSM FAPTA and it really opened my eyes. However, I don’t do a full biomechanical evaluation on everyone as I believe biomechanics is only a percentage of a patient’s problem. Also, if people have significant musculoskeletal impairments (such as weakness or pain limited movement) I tend to try and resolve them, with traditional manual therapy and exercise, prior to full video analysis as I want to get a more accurate assessment of the patient’s true mechanics.
3. If I am gonna start my clinic now and incorporate this kind of technology, how much am I looking to spend?
a. The system I have is an entry level system, costing 3-5k, but the analysis is very labour intensive. If video analysis was the major focus of my practice then I would have to upgrade to a more automated system starting at around 15k.
4. What kind of impact is COMPTSIG making on our profession in California ?
a. COMPTSIG has worked with the CPTA to defend our right to practice manual therapy in California.
b. Additionally, CAREC (a pre-cursor to comptsig) helped the PT schools in California unify their approach to teaching manual therapy.
c. COMPTSIG also provides a forum for like-minded PTs to become involved in the mission of advancing manual therapy practice in California.
5. What makes someone a “manual therapist”?
a. I have a very broad definition of manual therapy. I think a person is a manual therapist if they use their hands during patient treatment, even relatively simple procedures like passive range of motion and soft tissue mobilization. However, it is important to have professional specialization in manual therapy where PTs delve into mastering the theory and depth of manual therapy practice. In some ways all PTs are manual therapists, but with varying levels of expertize and experience.
6. What are some ways to maximize the non-specific effects of manual therapy?
a. The intention of my manual techniques is to improve tissue physiology and movement quality and explaining this intention probably maximizes the neurophysiological effects of manual therapy. Some of the things that matter include: trying to understand patient’s point of view, explaining their condition, explaining the plan before doing it, giving options, considering their expectations, giving a heads up if there should be any soreness, etc. All of these things will together build confidence, rapport, understanding and maximize any non-specific effects.
7. What kind of physiological effects do you think is going on when you perform manual? A lot of evidence is showing that mostly neurophysiological effects occur after hands-on treatment. For example, it takes tons of force to deform a fascia in cadaver studies.
a. I don’t think the absence of evidence for tissue changes is the same as evidence of the absence of tissue based-effects from manual therapy. At this stage, I am not willing to relegate the effects of my manual therapy to only neurophysiological effects. I still approach my patients from a mechanical/histological point of view. I am aware of the role of manual therapy induced analgesia (MIA), but I am not willing to rule out the possibility of tissue based changes. It is a really big philosophical question that strikes at what it means to be a manual therapist. I feel that it is reasonable to believe that connective tissues have time-limited response to loads applied during manual therapy just like how they respond to mechanical loads from exercises.
8. Can you zoom in and give me an example of what you theorize is happening at a microscopic level when you are applying PA’s on L4-L5 in prone?
a. If a section of the annulus fibrosis is symptomatic due to alterations in its loading tolerance and if loads applied during PA's to L5 stress the annulus beyond its comfort zone, then it is reasonable to assume that manual therapy may result in a fibroblast-initiated attempt at remodeling the symptomatic tissue (mechanotransduction), similar to what we hope for during exercise-induced changes in tendinopathy. When looking for movement- related changes, and especially malalignment-related changes, due to manual therapy we have been disappointed, so we have started to explain the benefit of manual therapy by neurophysiological responses (MIA), but I feel this is premature. We may not need to have evidence of movement-related changes to conclude that there have been beneficial connective tissue changes. Currently, we do not have strong evidence of histological changes due to manual therapy, and if they exist they are probably small and time-limited, but I am uncomfortable saying that the primary benefit of manual therapy is a short-term analgesic response, probably in the vicinity of 20% reduction in pain.
b. I think at this stage considering the limited evidence, it is better to consider that manual therapy works due to a number of proposed explanations: 1) short-term analgesia, 2) long-term brain related changes, 3) histological adaptation and remodeling, 4) structural lengthening. At this stage I am uncomfortable ruling out #3 and #4.
9. Are there effects that you have seen anecdotally where research has yet to support in regards to manual therapy?
a. Treating thoracic spine for thoracic spine pain certainly works but we don’t have much evidence. Most of the research on thoracic manual therapy has focussed on the role of treating the thoracic spine in patients suffering from neck or shoulder pain.
10. According to 80/20 Pareto’s principle, 20% of what you do get 80% of your results. What is an 80/20 of mastering the manual techniques?
a. I agree with the 80/20 principle in manual therapy. Out of all the techniques I know, I use 20% of them for 80% of my patients. Also, I feel that using the appropriate amount of force, and hitting the right structure, is more important than manual therapy technique complexity or mastery. The main problem a new grad may have in hitting the symptomatic area is due to potential clinical reasoning errors during the evaluation process, so they should make sure they have strong system of unbiased evaluation that focuses on identifying both contributing factors and the source of the symptoms. Additionally, PTs need to make sure they have a range of techniques of varying intensity to impact all of the possible symptomatic regions in the body. Physical Therapists should make sure they have articular techniques for as many degrees of freedom that each joint has, and they should also have a range of soft tissue techniques that they can apply throughout the body.
11. What advice would you give yourself if you can go back in time 15 years ago?
a. I would say 2 things: Go to more conferences to broaden my horizons and challenge my biases. I focussed primarily on continuing education courses that interested me, which is very valuable, but may lead to narrow-mindedness. Adding conferences into the mix of weekend and long-term courses helps expose therapists to ideas they may not have sought out directly.
b. Become involved with the APTA or other professional organizations. An easy place to start is the local district meetings or special interest groups, but there are opportunities to volunteer at the state and national level as well.
12. Name 2-3 PTs who had a huge influence on you.
a. All of the staff and students on the 1996 Kaiser Hayward residency program. The residency program gave me the necessary technical and theoretical foundation, but unfortunately I was not able put it together in a clinical package while I was there (I actually failed one of my final exams). Fortunately, after the residence I worked with Larry Brown and Dennis Dempsey and they really helped me iron out my clinical reasoning. After their mentoring, I went back to Hayward to retake the exam with much higher confidence and passed.
13. Can you give me an example of specific feedback they gave you?
a. It has been a while, but I think one thing that resonates with me is that after working with them I de-emphasized pattern recognition/diagnostic labeling and focused more on deductive reasoning. Prior to working with Larry and Dennis I seemed to focus more finding the “clinical diagnosis” and how that impacts treatment selection, versus developing treatment selection through the patient’s specific clinical presentation.
14. Give me a specific patient example you saw last week regarding this thought process.
a. I think the key thing here is that we often have hypotheses regarding the source of the symptoms but we must develop hypotheses regarding the potential impact of available manual techniques. Consider, a patient I had with radiating left arm pain last week. After I ruled out the presence of significant neurological changes, which would significantly alter the course of management, I direct my evaluation to locate the most relevant findings that could potentially be related to the complaint. I become less concerned if the source of the symptoms is muscular, discogenic or facet joint in nature. I am more interested in locating physical exam findings in the region that is most symptomatic and most different from normal. Then it becomes simple trial and error to test the impact of these possible techniques (in her case Unilateral Anteroposterior Pressures at C6 and C7) on her symptomatic movements.
15. What do you recommend that PTs start doing or doing more to advance our profession?
a. Don’t be sheep. Think critically about patients and research. You are the person responsible for translating research into clinical effectiveness and you will have to decide how relevant the evidence is in comparison to your experience and the patient’s expectations.
b. Make sure you develop a range of therapeutic skills. And some of these skills will not be evidence based, such as a certain manual techniques or exercises that have not been examined yet. For example, we keep having this debate about the relative benefit of thrust versus non-thrust manual therapy. It’s irrelevant; you need to learn both. Science is going to change and patient expectations vary. Having a greater clinical repertoire will give you more options to be clinically effective.
1. If a kid walked up to asking for your advice about life and you only had a minute what advice would you give?
Develop a skill and learn how to do it well. Be great at it!
2. What 2 books would you recommend that are not written by PTs?
Wrong: Why experts keep failing us. by David Freedman: I very much like this book because it describes the limitations of knowledge transfer and how new information often contains significant bias. It discusses how people are mistakenly mislead by guru’s and how the scientific research we read has the potential to present a skewed point of view of the truth.
The Art of Thinking Clearly by Rolf Dobelli : In the vein of Thinking, Fast and Slow by Kahneman this book has 99 chapters each focussing on a known critical thinking error. Nearly every reasoning error presented is applicable to musculoskeletal rehabilitation, either in the therapist or the patient.
3. Who comes to mind when you think about the most successful person?
Many people are successful in one avenue of their life, eg career, but sacrifice other aspects of their life to do so. A friend of mine from Physiotherapy School, John Riley, has attained professional success without sacrificing relationships and the pursuit of his non-monetary interests. His career was a means to living a fulfilling life, raising his family and giving back to the community. His career was not the purpose of his life. This kind of success is difficult because it is individually defined and often contradicts society’s expectations for success in life.
How can people learn more about you?
My clinic website
My education website