There is no skill in manual therapy…?

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!

My experience

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.

Frustration

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 that stretching a tissue in a certain way, for a certain amount of time just won’t effect it’s structure in any signficant way (Solomonow 2007, Weppler 2010, Katalinic 2011 Konard 2014)

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.

Caveats

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

Adam

113 thoughts on “There is no skill in manual therapy…?

  1. Excellent account or your personal experience.

    You appear as a critical mind giving witness to the element of quackery involved in manual therapy.

    Not only are the benefits of manipulation techniques superficial and ephemeral, with no real cure resulting, but, as you point out, some can be truly dangerous, especially those involving manipulations of the spine, not only cervical but also thoracic or lumbar

    Touting the special therapeutic merits of manipulation, as you describe it, resembles closely the marketing spiel of charlatans and circus barkers selling mysterious remedies.

    What is remarkable is that, with your training, your natural skeptical mind, it still has taken you years of practice, observation, and intense in-depth study to convince yourself that you had bought into a fraudulent “therapy”, and remove the veil of pseudo-science cloaking the commercial teaching of manipulation techniques.

    Bravo anyway for your courage to speak up and be ready to be confronted by irate manipulation experts whose livelihood they (rightly) fear you are threatening.
    There must be other critical minds like yours among physical therapists and kinesiologists who may remain silent because they feel themselves to be in a minority, but who may feel encouraged by your taking the lead in speaking up.

    • Thanks Roo for your comments, you are quite right there are many others like me who speak up and out against the pseudo science and myths around manual therapy far better, more eloquently and with more knowledge and intelligence than I ever could do, many of them are on twitter and they are a source of my awaking and I suggest you get on there and follow them too!

      All the best Adam

      • As the above named Menke of 2014, I applaud your synthesis of information. I too had the scales fall from my eyes. Once they fall, there is no putting them back in. As a chiropractor for many years, my research brain was seeing too much “hit and miss” with the outcomes. And everyone was better within a few weeks. When I found myself trying to get them in before they got better, I sensed I was perpetuating a lie.

        • Hi Micheal

          Thanks for taking the time to read my blog and for your comments!

          Your paper is very good and hopefully with more like it more will start to see that although manual therapy helps some it is not as powerful or as specific as most like to think it is

          Kind regards

          Adam

  2. Adam,

    You’ve done it again. Better get your bullet, mud and abuse proof vests out, if you ever take them off. You really must like the abuse, no wonder you ended up in sport!

    I am pretty much with you on most of you post, your flowchart should be put on a t-shirt and handed out at Physio and Massage schools. However, I think the real skill in manual therapy is in the assessment, and I know you have had a good rant about palpation but I am talking about broader assessment here, everything from gait to ROM to observation. Got to admit, it is a bit tough to feel heat and swelling from three feet away, and unless you have perfect vision, it can be tough to see too.

    As a manual therapist I agree, there is no great skill in general muscle ‘release’, the real skill is knowing where to apply your massage, hence the assessment. The caveat here is with lymphatic drainage massage, there is a skill to this, simple, yes, but a skill none the less. Could anyone learn it in a couple of days? Probably yes.

    You referenced Soma Simple and I am sure you are a massive Barrett Dorko fanboi. Awesome, his work is great, but don’t you think there is value in contact (manual pressure) when a patient is getting in ‘touch’ with dysfunctional tissue. Isn’t one of the great values of a swedish style massage the patient’s awareness that it creates in their body to feelings of tension? Can you not use pressure to help a patient to reduce hypertonicity of muscle? Is there no value in finding the right intensity of massage to help someone focus and switch on before a sporting contest? Is there no skill in find the right speed and depth to get someone to calm their central nervous system post contest to enter a recovery zone?

    I agree that the ‘giant-leap’ for manual therapy is that it is the patient’s brain that does >95% of the effect of treatment, but is there no skill in helping a patient to guide themselves to better function? Look at Dorko’s ideomotor work, no skill in guiding someone through motion? None at all?

    No GREAT skill, like playing a violin, maybe, but no skill at all? Come on!

    Aran

    • Hi Aran

      Thanks for your insightful comments, first of all re the mud slinging and ad hom attacks, yes I’ve got used to them, but I certainly don’t enjoy them, just recognise it’s to be expected, strong views = strong opinions

      You make some interesting points and I think I covered them in my caveats, eg being able to check for red flags for example an infection you will need to touch a patient to feel for heat swelling etc.

      With regards to having skill in assessment I sort of agree but this is going off topic, the blog is just about manual therapy application and as I mentioned the only skill you need here is in communicating that to your patient, so I guess you could argue that a skill needed in manual therapy is communication skills and more importantly a skill that makes your patient trust you to be able to feed back honestly to you

      In my opinion the skill of manual therapy comes down to the therapists interaction with the patient not the intervention

      Finally I’m no ones ‘fanboi’, which is a horrible Americanism of a word, those days of naivety and impressionablism are long gone now, all that’s left is just a dried up, withered, bitter, cynical, skeptical and twisted husk of a manual therapist ;0)

      All the best

      Adam

      • “At the end of the day in my opinion the skill of manual therapy comes down to the therapists interaction with the patient not the intervention”

        Word.

        This is the point where is still feel there is still value in manual therapy, I don’t think the mechanisms behind 90% of manual therapy add up to much. But if you can “hit the spot” in terms of patient need, then you get great results. And by “hitting” I reckon you could use any manual technique you care to choose, it just needs to be something that the patient can relate to as therapeutic.

        my .02c

  3. Could difficultly agree more… and also with the remarks done by Aran.

    Bravo for your honesty to share doubts and the courage needed to keep the stance…

  4. Wonderful article – thank you for your honesty and courage. There are more witches and wizards today than there were in Medieval days, and the faith they have in themselves doubles the placebo effect.

    • I absolutely love Diane Jacobs approach to manual therapy and think DNM has some promising aspects to it, in fact I should put this in the caveat section as an exception

      Thanks

      Adam

      • I’m a new grad PT here, skeptic, and don’t know who or what to believe anymore in the field of PT. I feel almost completely lead astray by my schooling and other PTs who have mentored me.

        In the link provided by the above poster it says that activated Ruffini endings can alter the tone of an underlying muscle. Is that supported by research? Isn’t that exactly what Kinesiotape advocates say it does? So is Kinesiotape BS or can it actually modulate tone of a muscle? Does it ‘inhibit’ or ‘facilitate’ muscles based on the degree of stretch? My colleagues swear it does. I’m skeptical although I definitely think it provides some sort of neuromodulatory effect that can decrease pain via these skin receptors.

  5. Adam – your diagram had me in stitches! bravo! A well written, reasoned and researched article. I am on that very expensive journey in expanding my manual therapy armory at the moment and haven’t yet paid enough to develop your cynicisim. However, I am also familiar with most of the recent research in chronic pain so understand the substance of your arguments. I think these are the debates our profession needs to be having on a much wider scale. You should share your post on the MSK section of ICSP and see the rebuttal. I shall look forward to reading more of your blogs. Nick

    • Thanks for your comments Nick and I might take up your suggestion of posting this on iCSP however I recently caused some panty twisting and knicker turning as well as some gnashing of teeth as I critiqued a SIJ post on there not so long ago that called one ‘unstable’ May let the dust settle a bit first…

      Thanks again

      Adam

      PS please don’t spend to much on these courses, it will make u bitter and twisted just like me!

  6. Interesting read Adam , In my experience good therapists would agree that the bio psycho social framework can house many elements and therefore they would agree that the interaction is key. I think in the main physios do exactly as you do and so I think in my experience you are preaching to the converted , thanks

    • Hi Neil

      Your right the BSP model is being used more, things are slowly changing for the better, but in my experience and dealings many many therapists are still mislead and misinformed about manual therapy greatly! I see it daily online, in course synopsis and in discussion with therapists across all professions, so I disagree, I don’t think I’m preaching to the converted, I think only a small percentage of the whole have converted, so I think there is a need to continue to preach (and I prefer to think I’m educating/informing rather than preaching) until a few more are, which is my ultimate goal believe it or not!

      Thanks for your comments

      Adam

      • I disagree , the context of the use of manual therapy is well placed in much of our profession, i believe the profession is not as entrenched in dated mechanisms that you allude to, so I feel that the informed generation are here, and your thoughts may not be as radical as you think. Thanks for getting back to me

        • Hi Neil thanks for your comments again!

          Perhaps you could explain then if my thoughts are not as ‘radical’ as I think, why is there all the upset, angst, commotion and gnashing of teeth with me questioning the need for over complicated and unnecessary attention to detail in manual therapy as I do in this blog?

          Surely if it was everyday common knowledge that manual therapy works via neuro modulation and other non specific effects, and that is doesn’t change physical structure or position and it doesn’t really matter which way you push, pull or poke something then surely no one would be interested in my ‘rants’ let alone commenting and questioning it?

          I’ll offer an explanation, and it will probably sound a tad arrogant and condescending Neil and I apologise in advance if I does, but I think many views on the current state of physiotherapy and its members beliefs, understanding and acceptance of the paradigm shift towards manual therapy is not as rosy as you would like to think it is, and dare I say it, a tad naive

          For example many out dated modalities and methods are still being taught at under grad level, I know I’ve seen the syllabuses, and it’s even worse on many post grad courses.

          Many teachers, tutors, seniors, mentors and managers of the new ‘informed generation’ of physios as you put it, are still believers in the old ways, fixed by years, decades of their own biases and beliefs, so their rhetoric and dogma to the old ways still continue to influence and mislead the new ‘generation’ quashing and suppressing progress, I see and hear of it everyday!

          And again without wanting to appear confrontational or accusational, in my opinion, many of the old elitist MACP disciples, are some of the worst culprits here.

          The emphasis that a lot of the old MACP gurus place on manual therapy is very strong, due to the many years, decades of indoctrinated belief and misguided structural and mechanical thinking, and this isn’t going to disappear as soon as you think!

          For example the fact the MACP only until a few years ago stood for ‘Manipulation’ Association of Physiotherapy is an example of time frames here, and it is going to take a lot longer than a few years to reverse the decades of pseudo elitist learning beliefs and biases that many in the MACP have.

          Please understand I’m aware and glad your group is changing, and it seems many MACP members have accepted neuroscience, biopsychosocial models and the other non specific effects of manual therapy, and I commend this, but its going to take a lot more time for all of your members to accept this and there are many still out there entrenched in dated mechanisms flying a MACP flag I’m afraid

          Just my perspective and opinion from an outsider with slightly judgemental eyes, please don’t take it personally!

          Thanks

          Adam

      • Thanks Adam I used a quote as you seem to love them so much! Matt is great he was a student of mine on his bsc and msc so maybe I got something right, don’t get tired about my digs at you, they are meant in the spirit of discussion,

        • How very ‘clever’ of you to reflect a compliment meant for someone else back onto you!!!!

          I’ll think I’m going to leave this discussion here before I start my own ‘digs’… In the spirit of things of course!

          Regards
          Adam

    • Thanks for your robust reply Adam, naive is a new one, however I can see that your thoughts and feelings are perhaps as set as the therapists you comment on, the reason for the ‘gnashing of teeth’ from some is because it’s not what you say, it’s the way you say it. Your work is always worth a read but you talk of doctrines in organisations like the macp which I would actively discourage, let’s hope this forum does not inadvertently create the same,

      “Religion hinges upon faith, politics hinges who can tell the most convincing lies or maybe just shout the loudest, but science hinges upon whether it’s conclusions resembles what actually happens”

      Good luck

      Neil

      • Thanks for the feedback and I totally agree with you about the way I say and write things can be, and is often dogmatic in its style and approach, but I am trying to change, but there are decades of unlearning to do first so it will be a slow process!

        Although I have strong thoughts, feelings and opinions I don’t think they are ‘set’ as you accuse me off after only a few email and twitter exchanges just because they are different from yours, also the subtle ad hominem digs you seem to keep directing towards me in our exchanges are a little tiresome, but I’ve had worse

        And surely feedback regarding others views on your organisation positive and negative should be encouraged not discouraged, as I said it’s just my view but to keep things balanced I’ll add another one, that the MACP has some excellent clinicians and thinkers pushing this profession forward such as Matt Low and they should be commended, but there are others who do your organisation no favours as well

        As you like to end with romantic philosophical quotes heres one for you “There are none so blind as those who will not see. The most deluded people are those who choose to ignore what they already know” Heywood

        Until our paths cross again Neil

        I wish you success, I don’t believe in luck

        Regards

        Adam

  7. Really helpful article and I appreciate that you reference it well. Thanks so much for putting these articles up for us to benefit from!

  8. Love the article, I have always felt like this when attending an A.R.T. (the self touted “gold standard for soft tissue, aka pay them gold to have a title of ART practitioner) seminar. The neurological side, as you have discussed, is always a part, and is often overlooked.

    The only fault/criticism is using Edzard Ernst as a source. It has been shown that his research is pretty much out to discredit professions who use spinal manipulation as a treatment approach. I have bias, we all do, but his sole purpose (IMO) is to discredit manual therapy.

    • Hi thanks for your comments, and I totally agree with ur view on ART, think they are one of the worst culprits, so much so I’m thinking of starting my own Active Release Technique course in direct competition with those jokers but I’m going to make it Functional so its going to be called FART and we will see what they make of that!!! 😂😉

      With regards to your comments about Ed Ernst, I know he is an out spoken critique of manual therapy, so am I, and as you say we all have our biases, and Ed has his more than most, but he does make rationale, logical, scientific and evidenced based arguements that do get us all thinking, which is good in my opinion

      Cheers

      Adam

  9. Yep, simply put the skill is in being a therapist, and selecting a mode of therapy that works for the individual patient. 20 years in & I’m starting to get the hang of it. A bit.
    I’m suspicious of anyone banging on about any one approach (hands on or off) being the answer.
    Cheers.

  10. Hi Adam, my one and only comment to you before ended up with me on the end of a 4 tweet tirade implying I was lazy and uneducated but I’ll let that slide as I agree pretty much with 100% of this article. I had 5 years training and have been in practice over 20 years now as a “manual” therapist. This realisation slapped me in the face early on in my career maybe only the second year out of uni. I got a postition with a really well respected Osteopath and was excited to learn more from him. Essentially he was just very good with people, got on well with all types of patients and was practice and sensible with his hands on work. I was chatting with his receptionist one day as I didn’t have a lot of patients at this stage and enquired how she began working there. She said, “I used to be a patient here”, interested I asked further ” what were you coming for?” Expecting to here her say sore knee, back,neck etc. She paused for a moment and said, ” sometimes I was just feeling a bt down and needed a laugh, so I would come to see Mr. X”. It kind of hit me hard , thinking what did I go to uni for, all I needed was a good joke book. Anyway I have been a sceptic my whole career pretty much but yet remain very hands on in my treatment. As you say if you get the connection with the patient, they feel heard ,and you apply your manual therapy in a non threatening manner you will probably get a lot of good results. There is good evidence for ischaemic nociception so it would follow that mobilising tissues ,whichever way you want, in an area effected by this would probably help.But as you say, importantly we are also a first screening point for a lot of people, and that’s probably what they are paying for, those rare occasions when there is a red flag present or the person needs further investigation. Cheers.

    • Hi Nigel

      Thanks for your comments and insights and although I cannot remember our previous encounter I don’t doubt or dispute it, as I was, and can still be a bit of a hot head, especially on Twitter, so I apologise profusely for my behaviour and comments if I did say those things!

      I’m maturing a bit now, I tend not to bite until at least three tweets into a debate nowadays!

      All the best

      Adam

  11. Well – the clear answer is yes and no. I’ve got 30 years of massage and strengthening coaching under my belt, that’s not full time – but it still adds up to a hell of a lot.

    I’ve also been treated by a fair number of therapists over that time.

    In that time I’ve encountered those, trained and untrained who I wouldn’t send anyone I didn’t hate to, and others – again trained and untrained to whose ministrations I would gladly trust my loved ones.

    Admittedly I’m a terrible patient, but some will put their entire weight on a small area – weight that would risk being damaging for my relaxed form but which is trifling against tensed muscle – so I tense – which is counter-productive as most manual therapy works far better on a relaxed victim – others will coax knots to loosen by a patience, indirect stimulation and a good line in patter if a patient is either obviously in pain or has just tensed several kilos of muscle.

    Clearly there’s skill involved in the difference, but how much of that skill comes from “training courses” or “methods”? Probably not much – except with things like acupuncture – which are a load of bollocks anyway.

    I can’t cure many things by massage – because in most instances manual therapy can’t – those who claim it can are singing in the wind – but I can make a pretty fair stab at making most clients feel as though I have – that can give a space for exercise, stretching, coaching, rest, time and proper nutrition to do so – or at least get them as fixed as they can be.

    For example I’ve treated a lot of shoulders for various reasons, and I could massage the same client 100 times and make them feel better each time – but without sorting out some sporting movements and strength training techniques their underlying injury will just get worse – fix the way they use the shoulder get them to get it strong and mobile and the sum total is often a cure after a few sessions at most – and they may not involve any physical contact at all.

    The role of the massage (if its needed at all) is to get them to the point where they are able and willing to effect the cure themselves – I’m not going to be there to live their lives for them or wipe their arses.

    Last but not least a 30 minute massage allows 30 minutes of getting the client to tell you about all of the things that might cause their pain, establishing trust and advising them of ways to avoid or mitigate it.

    • Hi Ed

      Thanks for your comments and insights you make some valid points and especially the last one, ‘doing’ manual therapy may actually not be the thing that gets the effect, its the listening, discussion and education that we are ‘doing’ as we do manual therapy

      Great point

      Cheers

      Adam

  12. Hi Adam, I am a student graduating in 3 weeks from a sports therapy degree, massage and many things you do not like is what we are being taught e.g. Electrotherapy and manual therapy. I like to use massage as it does make the patients feel good and provide pain relief. Following you on Twitter though makes me question whether I wasted my time doing sports therapy and I should have done physiotherapy, Hands on treatment was a big part of what we learnt but it seems like in the therapy world it’s laughed at, from massage to METS, PNF stretches, soft tissue release techniques, these are things I have used and they seemed to provide good results however, now I’m really questioning my knowledge and the things I have been taught. Also what physiotherapy authors\books can you recommend with good information on treating injuries.

    Regards

    Nile

  13. Excellent read, excellent content. As a new graduate physio I strongly agree that research based treatment is more in the realm of psychology than physical intervention. Obvious psychological or plecebo effects are seen after manual therapy. There is some good reseach on the parasympathetic effects of manual therapy which is why when I’m getting a “sports massage” I ask for it to be as relaxing as possible and with little trigger pointing. For an athlete it would be common for sympathetic responses to exercise to interrupt sleep. Que “healing hands”

  14. Hi Adam:

    Well I have to tell you, you touch a darn hot spot in my everyday thinking in the value of manual therapy. Let me tell you a bit of me, I always have been skeptic about everything!, but as an undergraduate of Physical Therapy I had a lot of teachers that built in, inevitably, a Structural Paradigm in my reasoning. So when I graduated, took a Master in Orthopedic in Manual Therapy (In fact I took the most structure-based aproach I think it´s available at the time and place: Paris method of U. Saint Augustine, USA). So I met lots of people only trying to make their therapy work for the sake of their patients, and a lot of magic in every class that make me wonder, there has to be something weird in there…
    Because of that I did some research that really don´t make sense of anything I was learning, so when I started treating patients and doing the reasoning for their problems, I had this: they felt great at the time of touch, but the effect was no longer than a couple of hours. So I started to realize that the efficacy of manual therapy was only the entrance of the relation between me and my patients.
    Now, I´m not as frustrated about manual therapy as you I think (but still bleeding money), because this help me to know other different aproaches, like CFT and the always great Explain Pain education aproach, and this really made my therapy go leveling up. Now I have 6 years of profession training, and have my own point of view about the topic, so I think we have the almost the same issues 🙂

    Clearly, we have to look in a more sensitive way of thinking about MT, but not discarding it at all. In fact, I think we can do a lot studying the sensorial training that we are doing with each manual therapy we do, rather than looking to mechanical effects, largely described as inexistant or minimal.
    I think this can really do the trick in some patients, when they tell you some sensory stuff its going on http://www.ncbi.nlm.nih.gov/pubmed/24021562

    Great post as always

    Cheers

    Felipe

  15. Hi Adam,

    I agree with your post, well said. Do you have any opinions as to how it should be taught at undergraduate level, for instance?

    Terence

  16. Well, I agree with the intent and the content. Less so the title as there is clearly some skill in manual therapy as you mention in your caveats etc. I guess you are just trying to get the article noticed, which is fair enough.

  17. Im thinking the emotional component plays a part but so does the skill level. Use sex as an example. You may love the individual who you have relations with but if their physical skills are not comparable to your last lover, whom do you think you will be pining for. 😉

  18. Awesome post Adam! I couldn’t agree more with your comments. I as well think manual therapy is important and there is a role for it in rehab, but I don’t think there is much skill in the actual application. The skill is knowing the most probably explanation for why it works, including it’s impact on nervous system and the abundcance of “outside” noise playing a role.

    I think commericalism like you mentioned is a huge factor in manual therapy heading in the wrong direction. When people have money (sometimes lots of money) invested in a certain technique/philosophy, it simply strengthens their biases and the chances of them straying from that way of thinking decrease dramatically. Sigh.

    Mark

  19. It seems the way of the Internet really… Apparently everything has to be black or white. Of course there IS skill in manual therapy but it’s a very grey area.

    My background is very similar to your’s Adam in both qualifications and experience. But I have a different view when it comes to manual therapy. In my experience (Australian physiotherapy) the best clinicians have all the attributes you have described above AND precise, comfortable manual skills. You only have to spend some time working with new-graduates to feel the difference. When it comes to manual skills alone, having a new-grad perform something like a mobilisation on an isolated cervical facet joint and then comparing this to the same technique from an experienced clinician who specialises and educates in the same field is all the evidence you need. However I still also SORT OF agree with you. It is not primarily the subtle differences in the application of the physical technique itself which separates the best from the “every day” clinician. It is also the effect of the intangible aspects of the patient interaction that you have discussed as well as the experience and superior clinical reasoning in deciding which manual technique to use, at what time, in which circumstances.

    A cornerstone of Australian physiotherapy, at postgraduate level in particular, is a very strong focus on assessments/reassessment to critically evaluate your intervention. Personally, I routinely reassess the patient multiple times within one session and can show distinct, objective improvement in things like range of movement or pain immediately following a manual intervention. You can’t tell me that refined manual skills are not at least a small part of this process.

    Of course non-manual therapy is a vitally important for our patients… But let’s not throw the baby out with the bathwater! I fear the day when new graduates have all read “Explain Pain” and offer the patient in acute or sub-acute pain a series of counselling sessions and exercises as their only intervention! (N.B. I highly recommend Explain Pain and have studied under David Butler- who, by the way, has excellent manual skills.)

    It’s not that there is no skill in manual therapy. There is. It’s just that the reason manual therapy works brilliantly in some instances and not so well in others can be due to a myriad of complex factors and interactions that we are only beginning to understand.

    I read your sentence claiming there is no skill in ANY manual therapy, and then I read your article… I don’t think they quite say the same thing. You could very well title your article with this long-winded, poorly-edited title instead: “Manual therapy doesn’t work for the old-fashioned reasons people used to think it did, it can work very well in the right situations, we just might not fully understand why… if we use it well and critically assess its effect it can be a powerful tool.”

    • Hi Lachlan

      Thanks for your reasoned, insightful comments, I understand what you are saying with students verses a physio qualified for a few years, however I’d argue (because I like to) that your confusing skill with experience!

      Having the experience to know what feels comfortable and uncomfortable through trial and error and patient feedback is something we all ‘learn’ but there’s no technical skill in this it’s something developed over time!

      Also the test and retest method is one I adhere to and a lot of other physio as well, but to say that the manual therapy plays a role in this hmmmm again I’m going to argue that very little change in a patients feelings after manual therapy are due to manual therapy per se .

      The pseudo scientific game of, I’m a professional clinician and your the patient and I’m going to make you feel better’ I feel does more for a patients sensations of improvement via their increased attention, expectations and of course the good old placebo effect all via neuromodulation, actual physical change from the manual therapy no! What if I get the same effects by get a patient to move and do some exercises, what if I get the same effects by asking the patient to lie down and relax and not touch them, what if it’s the discussion and education I’m having with the patient as I’m doing the manual therapy, etc etc

      Now don’t misunderstand me I don’t think we can ever say it’s one over the other, but I don’t place the actual manual therapy technique high on the ‘it matters list’ as much as I do say choosing my wording, or explanations with care, giving the correct advice and education, or ensuring they do some exercises / movement

      So yes test and re test to ensure that the patient is aware they are feeling better, but I attribute all of that to ‘treating the brain’ with manual therapy not the body, and that’s what I tell my patients, some get it, some don’t, some think I’m a quack but hey, at least I know I’m being honest and as evidenced based as I can be, for the moment, until the next paradigm shift and leap in our knowledge and understanding

      What do you think?

      All the best

      Adam

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