I’m guessing if you are reading this then you are probably a manual therapist, or someone who uses manual therapy in all its guises to massage, mobilise and manipulate people. And I’m guessing you are either curious or probably pissed off with the title of my blog that’s just called into question your skill, your training and your experience! But before you ‘blow a fuse‘ and head straight down to the comments section to tell me what an ignoramus I am, perhaps read on and hear me out as to why I think there is NO skill in ANY manual therapy.
So a few weeks ago, I posted the above controversial tweet and it had a mixed response, some agreeing, some disagreeing, some not caring. However, I thought I would expand on this a bit more and explain why I think that there is NO skill needed to apply ANY manual therapy.
Anyone can do manual therapy
I know anyone can ‘do’ manual therapy without any formal training, without any great experience, without any long drawn out expensive post graduate courses and exams, and get just as good, if not better results than the so called ‘experts’.
This is purely anecdotal, but I’ve had an ongoing neck issue for years that grumbles now and then and is often aggravated by spending too long on laptops blogging or tweeting. Now I’ve sought the help of many professional therapists over the years for this, but the best ‘treatment’ I have had without a shadow of a doubt are my wife’s neck massages, and she isn’t a trained manual therapist, in fact she doesn’t even work in the healthcare industry.
And I’m not alone, I hear of many others who say similar, that a partner, a friend or an ‘acquaintance’ who isn’t trained in manual therapy gives the best back rubs, head massages or even clicks something now and then that hits the spot and feels ooooh sooooo good. So it’s these stories, amongst other things that I will get on to, that got me thinking, how is this possible? How is it that my wife and other non trained ‘manual therapists’ make people feel so much better, compared to a £50+ per hour highly trained professional?
Well many trained manual therapists will argue that this example isn’t a fair comparison, that there are many other factors that a professional therapist just cannot reproduce, such as high levels of familiarity, relaxation, playfulness etc. But that is exactly my point. It is these non specific factors and NOT the skilled technical application of manual therapy that makes it more effective, and this is EXACTLY why it raises some BIG questions around the belief many therapists have about the skill needed with all manual therapy.
Human touch can be powerful
Many mistake my constant skeptical, some say savage, critique of manual therapy as me saying it doesn’t work or it doesn’t have a role. That’s just not true, and it’s a false dichomtomy and pisses me off hugely, so please stop it.
Yes in my opinion manual therapy is over hyped, over used, and surrounded by heaps of pseudoscience, marketing and gimmicks, and I don’t use it much if at all anymore. But there is no denying that human touch can be a very powerful tool. Touch is part of our evolutionary development as mammals, it helps us bond, connect, reproduce, and form social groups, it helps relieves both physical and emotional pain. Simply put touching another person in the right context can be highly rewarding, soothing, calming and relaxing (source, source).
However, what I am highly critical and skeptical about is those who try to make this process of simple, caring, soothing touch over complicated, over technical and over hyped in its application!
Let me tell you a little bit about my story with manual therapy just in case you mistake my opinions as being ill-informed or inexperienced. My training and education in manual therapy started when I first trained as a physio, and extended well over a decade after. My training is extensive, wide ranging and unfortunately for me been really, really bloody expensive. I have completed all of the well recognised post grad courses in manual therapy, and a few of the other not so well recognised ones. I have been taught by some of the worlds most influential figures in their fields. I’ve sat the exams, played the game and jumped through the hoops of observed assessments and viva’s to gain these so called qualifications, which are basically worthless pieces of paper. So due to this training some would class me as ‘skilled’ manual therapist, but as I’m arguing against this I won’t, and I don’t, but believe me when I say I can click, crack, rub, pull, press a patient in all the ways you can imagine!
What is manual therapy?
Manual therapy exists under bewildering array of names, some well-known ones like massage, manipulation and mobilisation. Sometimes they have more complex and ‘scientific’ sounding names like effleurage, petrissage, myofascial release or deep transverse frictions. Some have more exotic and glamorous titles like Tunia, Graston, Active Release Techniques, and then there are those named after their influential creator such as Rolfing, Maitland or Bowen.
Although these techniques have different methods of rubbing, pressing, pulling or poking, I simply call them all manual therapy as they all have things in common. First is they all have a course or series of courses to attend and tests to pass to show you have acquired their ‘skills’. Some of these courses last a few days, others longer, with the costs ranging from a few hundred pounds, euros, dollars, to thousands. I dread to think the total cost of my manual therapy training over the years, but I guess it’s well over £10,000.
Anyway, each technique/method is thought to achieve its effects via different mechanisms, and they all vary in their thinking and explanations how this is achieved. However, regardless of the explanations use what is the same with all of these methods, is they all base there effects around the notion of changing a patients structure, position, length or freedom to move, be it a muscle, tendon, ligament, fascia or a joint. All manual therapy techniques attribute the positive effects of their manual therapy technique to these factors.
And another similarity that all these manual therapy courses have is they all think that their method is far superior than the other methods, usually with an air of arrogance, snobbery, and self-imposed superiority, it is one of the reasons I dislike the manual therapy industry and it’s practitioners and it’s guru’s so much.
The other reason why I dislike the manual therapy profession so much, and why I am highly critical of it, is that after spending many thousands of pounds, and many years of my time, being taught and lead to believe that manual therapy is a great big powerful tool that can help ‘fix’ or ‘cure’ people in pain. I have come to realise that this just isn’t the case. Manual therapy is not as powerful or as useful as many claim, and it’s certainly not as specific or as skilful as they make out.
This annoys, frustrates, and pisses me off immensely. Firstly because I feel cheated, mislead and lied to, and secondly because I see it continuing to happen right now, all the time. In fact I see the myths and misconceptions about manual therapy growing stronger and more fanciful as time goes on, and nothing seems to be changing. I don’t want young, keen, eager physios to make the same mistakes I have. I don’t want them wasting their time, money, and hopes on manual therapy. I don’t want them going through the anger, frustration, bitterness, and disillusionment with the profession that I did due to this one shitty intervention.
I personally think that a lot of good physios are lost from the profession due to frustrations with manual therapy. I feel that many physios feel so disillusioned with manual therapy and are lead to believe that you can not be a physio without using it, that many give up and go into management or even other professions. This is such a shame and a such loss, and it needs to stop. Physiotherapy is so much more than fucking manual therapy.
A slow realisation
I’ve come to realise that manual therapy isn’t what I’ve been taught or lead to believe. I’ve learnt that the results of all these manual therapy methods are highly unreliable and variable, despite my extensive training, despite my detailed assessment and skilled application. I’ve also realised that when I didn’t do the technique exactly the way I was supposed to it didn’t matter.
I’ve realised that actually it doesn’t matter at all how I poke, prod, or rub patients. I can go AP or PA, I can go proximal or distal, I can go transverse of longitudinal, I can go clockwise or anticlockwise, It just doesn’t fucking matter. Eventually, I stopped all the ritualistic, pseudo scientific assessments that I had been taught, such as looking for, and feeling for a joints position or lack of movement. I stopped poking soft tissues feeling for knots, bands, spasms etc as it just doesn’t fucking matter.
Research and evidence!
When looking at a lot of the manual therapy research what I find is most of it is grossly flawed with methodological design issues and biases so big they dwarf my own, and so can not be realised upon or trusted. However, I’ve learnt you can’t increase blood flow, break down scar tissue, melt adhesions, ‘release’ muscle or lengthen fascia with manual therapy (Shoemaker 1995, Chaudhry 2008, Chaudhry 2007, Schleip 2003, Threlkeld 1992)
I’ve learnt you don’t need to mobilise or manipulate a joint in a specific direction, based on a pattern of pain or specific assessment of movement and joint feel (Chiradejnant 2003, Aquino 2009, Schomacher 2009, Nyberg 2013)
I’ve learnt that palpation of muscles, joints, trigger points are all unreliable and leads therapists to misdiagnose and direct treatments down wrong and ineffective pathways, full list of references here
I’ve learnt that when all the different methods and techniques of manual therapy are examined through the process of systematic reviews and meta analysis, most of the research is poor and even the good research shows that it doesn’t do much (Menke 2014, Kumar 2014, Artus 2010, Kent 2005)
This has been a revelation, an awaking. A slow and gradual opening of my eyes, but they are wide open now, so I can now confidently say…
There is NO skill in manual therapy, and it really doesn’t matter how you do it.
Now having said all that there are a some caveats that a manual therapist does needs skill in. Although the risk of causing any structural damage to connective tissues is small, there are some high velocity techniques that do potentially have a small risk of harm and potential serious consequences.
High velocity manipulations, end of range traction and even joint mobilisations to the upper neck have been documented to cause some rare but serious injury’s (source)! So it goes without saying that a full awareness and identification of those at risk as well as ensuring the application of the techniques is done safely is a must. Although I argue that if there is such a risk and minimal benefit with these methods why even do them at all (source).
Fighting against the tide!
So there you go, my rather length explanation, some will say tirade, of why I think there is NO skill in manual therapy. Even if we could assess accurately and reliably a stiff joint, a muscle knot or some other structural fault, the effects of manual therapy are not structural, so it really doesnt matter how or where you press or poke someone, it only matters to the patient and so let them tell and guide you where to go.
This is my own story of my desire and curiosity to learn about manual therapy, followed by my disillusion and disenchantment by the nonsense and rubbish surrounding it. I now find myself (unexpectedly) as a cynical, skeptical and often misunderstood critique of manual therapy for which I’m hoping this blog will provide some clarity of where I am coming from.
Let me also state that my aim is not to target those that use manual therapy, rather just the explanations and justifications for its use, nor do I negate the non specific effects of human touch. Instead my aim is to try and debunk the biased crap that surrounds manual therapy, and to be a thorn in the side for the few unscrupulous, arrogant, hot headed ‘guru’s’ out there pedalling their courses and pushing their fanciful teachings for profit rather than helping physios or patients.
Unfortunately, I seem to be doing this more and more as the greedy and at times immoral, manual therapy industry continues to grow into an ugly profit driven commercial business, motivated more by money than outcomes, feeding off patients in pain and with injury, feeding off well meaning therapists wanting to help who get sucked in to all the courses, workshops, manuals, books, DVDs, and seminars. So expect to hear me continue to wail on this subject for while longer yet.
As always thanks for reading