My wife’s birthday is this weekend and my mom made her a cake. A chocolate cake. If you know anything about my mom it’s that she is basically the greatest chief of all time. You name it, she crushes it. Well, she absolutely crushed this chocolate cake. I just finished eating it, and I promise you it was the best chocolate cake on planet earth.

Maybe it was the chocolate cake being so good maybe it was just my ADD brain, but this experience of eating this cake got me thinking. How the heck is this chocolate cake so much better than a normal or even above average chocolate cake. There is something different. So I asked the chief herself. “Why is this so good?” This started a 10-minute breakdown of all the intricacies involved with every step of making the most dynamite chocolate cake in the history. It was jaw dropping. So many steps and each one had slight nuances and variables that needed to be perfect.

I have made chocolate cake before. It was out of a nice red box, I put some eggs in with some powder, I believe, haphazardly mixed it and then put it in a not fully pre-heated oven. Ultimately the same physical things went into that cake as my mom’s (that’s actually not true at all but run with it…sorry mom), but my cake was super dry and gross, and my mom’s made me want to eat until I required a wheelbarrow to exit the house.

The ingredients were the same but the technique was very different.

Upon reflecting on the greatest of the cake I came to the conclusion that technique matters. The little things add up. In cake making, they make a huge difference and I think the same is true for almost anything, including physical therapy.

There is a shift happening in the field of physical therapy both in the research and in certain circles away from highly technical manual therapy “tricks and techniques,” some would say that all those fancy techniques are nothing but a placebo. I think that’s a little bit of a stretch, but I do find myself leaning towards the “fancy techniques probably don’t matter so much team”….for now.

But

Technique matters a heck of a lot when making a cake and I think that the pendulum may be swinging a little too far in some circles of physical therapy. I think there is a difference (one that is very hard to detect in clinical research) between highly skilled (very technically saavy) PT and very basic PT. Like my cake vs. my mom’s. Some papers will say manual therapy works for this that or the other, some say it doesn’t but I think classifying an entire treatment method without taking the craftsmanship of the person delivering that treatment into account is missing something.

Manual therapy is just one explain. Teaching patients is another example, or exercise prescription…the list goes on and on. It is very difficult to truly measure and compare treatments because technique and nuance are very hard to account for.

In the world of conservative musculoskeletal medicine where lots of tiny effects make up big effects the nuances matter just like in making cake. Lots of little techniques at each step end up making a massive difference in the end product. 

Technique matters.