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. Actually I think you’re the one getting confused… Your offering potential explanations as to why your manual therapy works, not saying that it doesn’t work. You can’t tell me that a patient walking in with acute or subacute pain of almost any sort would not get better a lot faster if a good manual therapy was applied AS A PART of your interaction. I defy any decent clinician to get someone better as quickly by “asking the patient to lie down and relax and not touch them”… I guarantee you don’t actually do that in the majority of cases in your own practice. Assessment/reassessment is not as simple as asking a patient whether they “feel better”, and if that’s all you’re doing then you’re not doing it properly. Objective measurements of range, power, et cetera are changeable within a couple of minutes of an appropriately applied manual technique… No doubt you know this. Even if you believe that all you are treating is the patient’s brain- the fact that you can achieve this through manual therapy still means that manual therapy works… You just believe it works for a particular reason. I’m sure someone of your experience is good at creating change with manual therapy… The underlying mechanism as to why this intervention produces a change might be up for debate, but the fact that it does produce a change is not – if you can prove it.

    And confusing skill with experience?? No, I’m saying that with experience your skill improves, they are 2 separate things. Can you honestly tell me that your manual therapy skills are no different now after 10 or more years of clinical experience and education than they were when you were a 15-year-old schoolkid? If they’re not, what’s going on??? We are talking about performing physical techniques, how can years of practising these techniques not result in some degree of refinement. You have mentioned a couple of times making your techniques comfortable… I agree that this is vitally important… An improvement in the comfort of the technique is an improvement in your skill at delivering it!

    Take the example of lumbar rotation mobilisation. I have tutored many employees and junior physios on getting this technique localised to the individual target level. Get an untrained person to try and copy what they see an experienced musculoskeletal physiotherapist doing with one of these techniques and most of the time all you will get is the patient feeling a quite uncomfortable sensation through their rib cage or the thoracic spine… A good manual therapist will isolate the same technique to the precise level of they are targeting. Yes this improves with experience, because experience improve the skill of doing it properly.

    If you’re so confident, then try this experiment…

    Go and grab some random punter off the street who has no training or background in manual therapy techniques. Do nothing more than quickly show him a few techniques and give him a couple of basic instructions. Dress him up to look well-qualified and professional. Now, when you’re patients come to your clinic you are only allowed to do the talking and the direction of assessment. Tell them you have an injury and that your very experienced and well-qualified colleague is going to perform the manual therapy on your behalf. Your random punter will perform the techniques that you decide should be used. Can you honestly tell me that he will get the same results you would? If your answer is yes then in my opinion you are either lying or there’s something really wrong in terms of your skill acquisition.

    • Hi again Lachlan

      There’s a lot of points to discuss here and maybe best done over a beer rather than written as I’m sure things get lost in translation and in sure we have a lot more common ground than uncommon judging by your comments but lets go…

      I can tell you that all patients get better if u mean ‘heal’ regardless of manual therapy being applied or not, manual therapy doesn’t ‘speed’ up healing or any other such like

      With regards to reduced pain again may other ways other than manual therapy that can reduce pain and I’ll use the example again, just talking to some one does reduce their pain, as the late great Louis Gifford said ‘effective reassurance is a bloody good pain killer’ then let’s look at movement reducing fear, threat of movement by showing them its ok to move or move without pain also reduces pain, two examples without even touching them!

      Next objective markers are more important for the therapist rather than the patient, I absolutely disagree that test/retest is more about asking a patient if they feel better, its the ONLY reason to test retest, I don’t care if someone can move an extra 10° I’m more interested if it feels better for them to move full stop, objective markers have a place but a back seat way way in the gods

      Next a random punter to apply manual therapy scenario well I thought I touched in this in my blog, my misses although not a random punter makes my neck feel so much better than any pro has done in 5 years, and she has no training, so it would be an intriguing experiment but I would bet if we could duplicate the patients perceptions and expectations between the pro and random the difference would be zilch, none

      Next the skill in applying a manip mob to a precise level is a common fallacy and a comment left by Jack Chew below explains that in more detail

      As I said a lengthy debate best had over a beer or four would be best but again if like to hear your thoughts, especially as this week I have no work and do have time to do this, sitting in a villa in Greece drinking a beer by the pool… Just to make u hate me even more 🙂

      Good talking

      Cheers

      Adam

  2. PS: for the record, I agree that a lot of (maybe most of) the change from manual therapy is centrally mediated- not just brain but also spinal cord, modulated reflex loops would probably also be a factor… but I think it’s silly to write off manual therapy for this reason. I also think it’s silly to say these techniques can’t be performed better or worse.

    • Haha PS I’m not writing of manual therapy completely just those that twist, bastardise and misuse it to profiteer and promote non evidenced and fear inducing fallacy around it

  3. PPS: this is also why I try to avoid twitter- I can’t resist getting sucked into a debate like this- I would never get anything done!!

    • As per usual an interesting and evidence based approach to critical thinking Adam. On this occasion very clever of you to come at it from a ‘personal account’ perspective… not that I didn’t have you down as clever…ish.

      I can see why some consider the title pointlessly sensationalised but I have an insight as to why you like to provoke debate following our chat for the podcast and I think many will benefit from a listen when it’s aired in a couple of weeks.

      Your thoughts and experience with manual therapy are very much in line with my own so I haven’t, for a change, got much I fancy critiquing, BUT…
      The key thing that has piped me up on your comments section for the first time, is the above responses from Lachlan. Comments such as:

      ‘Take the example of lumbar rotation mobilisation. I have tutored many employees and junior physios on getting this technique localised to the individual target level. Get an untrained person to try and copy what they see an experienced musculoskeletal physiotherapist doing with one of these techniques and most of the time all you will get is the patient feeling a quite uncomfortable sensation through their rib cage or the thoracic spine… A good manual therapist will isolate the same technique to the precise level of they are targeting. Yes this improves with experience, because experience improve the skill of doing it properly.’

      …suggest to me that he might benefit from reading your article on Pareidolia (https://thesportsphysio.wordpress.com/2014/05/05/diagnostic-palpation-is-it-a-skill-an-art-or-an-illusion/) or this series by Diane Jacobs (http://humanantigravitysuit.blogspot.ca/2014/05/my-take-on-why-manual-therapy-works.html) prior to continuation of the debate.

      Personally, I find that safe, comfortable application of touch of any kind can be taught to a lay person and if anything can produce better results. In my practice, as explained several times on twitter, I will engage a patient with education, advice, rehab, forward planning and motivation as best possible. As part of my assessment I have inevitably touched them and may dabble with a bit of manual therapy to assess its pain relieving effects. If the patient feels that they require pain relief in a different form to counter medication and exercise, I direct them to a local beautician (an ex patient of mine) who gives a great massage. I have also taught her several manual techniques that she applies when advised by me or my team.

      Why do I do this when of course I could do it myself? She charges £20 an hour, my rates are £50 an hour. Patients appreciate our honesty, we save them money and dispel myths that they have been sold previously. It is this that often means my beautician friend gets ‘better’ ‘quicker’ results with manual therapy than I do. As my business grows I of course intend on employing therapy assistants that we can use in a similar fashion to keep it all ‘in house’. But for now, are outcomes are good and my hands pain free.

      I look forward to airing the next episode of the physio matters podcast in which we discuss all of the above in more detail. Keep up the good work.

      Jack

      • Hi Jack

        Thanks for those comments and thoughts and the links, even my own one!

        I also look forward to the podcast coming out so I can perhaps get my point across better than I do in blogs or on twitter

        As you say its not about demonising manual therapy per se, rather its about demonising those that look to bastardise and profiteer for untruths, myths and fallacy a that surround it

        I love your example of massage being just as good if not better no matter the qualifications if the care and attention is the same the results will be the same

        All the best Jack

        Cheers

        Adam

      • Jack… Thanks for your patronising advice champ! Unfortunately you have completely missed the point. Do I need to point out again that I am not arguing about WHY manual therapy can make a difference? Your 2 articles have nothing to do with the question at hand.

        I don’t even need to read the first one. The title itself shows that you’ve missed the point. I’ve never claimed to be able to diagnose through touch.

        The second one made me laugh. It’s a good article… But again you’ve missed the point. The article is mostly talking about WHY manual techniques might work. Very early on in the article it actually backs me up!! I quote: “But manual therapy sandwiched in there can be optimal, in my opinion. ”

        You haven’t actually addressed any flaws in my argument about lumbar rotation. Whether you think this technique is a good one or not doesn’t change the point that someone who’s inexperienced and therefore less skilled will have trouble targeting their force to the lumbar spine. Assuming you’re trying to treat the lumbar spine then this is just a simple example of how skill with a physical technique can make a difference to your outcome. I can’t believe need to point this out! (I wasn’t even talking about manipulation Adam).

        … And please, don’t ever again use massage as an example in a debate like this. Of course the beautician can do massage. I refer to a masseur as well, I employ one. Did I ever say that I was discussing the skill of massage? Anyone can do massage. I’m talking about the more difficult techniques we can utilise. If you don’t have any techniques in your arsenal that require practice to refine then I feel sorry for you. I do, and sometimes they’re very helpful.

        I have absolutely no doubt that the major reasons I am a far better practitioner than I was 10+ years ago are my abilities to build rapport, listen, communicate, educate, instil confidence, understand pathology, understand pain neurophysiology, diagnose and plan. Even the simple fact that I am older gives my patient more confidence and contributes to better outcomes no doubt. However where I disagree with Adam is that I believe I possess refined skills with SOME manual techniques and these can be a powerful tool for patient outcomes in addition to what I have already mentioned.

        And Adam- I can see we’re going to go round in circles if I keep arguing with you. Touche. Let’s agree to disagree. Physiological healing doesn’t need to occur for a patient to feel better or improve. Next time my patient presents with an acute neck that hurts, will only turn halfway and is referring a headache I will confidently rely on my refined manual skills to send them out the door 10 minutes later with full rotation, no pain and no headache. I’ll be impressed if you can do that with a chat, or get your wife/punter to do it for you.

        • Anyone who reports that they can “fix” a patient in 10-minutes has to be a bull-shitter. Relying on one’s own hubris in the context of treating patients is another example of how some therapists bring our profession into the gutter….are you a chiropractor??

  4. I think one of the big questions to tackle in the whole manual therapy conversation are;
    1. Does it work? According to Menke 2014, not so much…. But I guess that in the big picture at least a part of the jury is still not convinced.
    2. Does specificity even matter? Studies done point towards specificity not mattering so much.
    3. How specific (segmentally) can we even be? Can we honestly prove that when we manipulate someones facet that nothing else moves? Then to speculate even further, if it doesn’t matter how specific we are, do we even have to try to be specific in the first place?
    And to add for specificity question, can we actually measure this phenomena? Can we define, validate and reliably prove that something needs to change and manual therapy changes it? We cannot reliably assess joint play, it’s nonehow measurable and quantifiable (then does it have to be) since it is something we must “feel”. We can only observe the indirect effects of this intervention.

    Also one part of the controversy in my opinion is that of the methodological quality of the studies and the many times the interventions used as control. Quite often it looks like the control group has been designed to fail, which of course is not too good.

    But, not to be too skeptical, I do believe manual therapy has it’s time and place in the right patient population, but it surely is no panacea.

    • Hi Jukka,

      Some great points you make and I agree, manual therapy does have a role to play for some and the effects are not that big nor what a lot of others make it out to be ie a change in structure position etc but rather neuro modulation and other aspects of neuro physiology

      Cheer

      Adam

  5. The same could be said for carpentry. You do not need a qualification to hit a nail on it’s head and bang it into a bit of wood. I could do it,however I choose to pay someone to do it for me. You are in the unenviable place that you have a loving wife who will rub your back/neck for you. Many peole don’t. And if there is no evidence of therapists actually doing anything, (not that your like have been able to measure anyway) what IS T that your untrained therapist of a wife manages to do to get you to feel better than any trained person of whatever therapy? (Keep it clean please)

    • Hi Beauty from within, good name by the way

      As I mentioned in my blog the evidence on the effects of manual therapy is shown its due to reduced sensations of stiffness, pain etc via neuro modulation which is also effected by other things such as mood, beliefs, attention etc etc, so the best manual therapists are able to tap into these other non specific effects, just as my wife does, and so its has greater effect when combined with the rubbing and massage, it’s not the act of the manual therapy that helps its the other stuff around it as you do massage that’s far more important, hence no skill in manual therapy per se!

      Thanks

      Adam

  6. Again…a divisive title to an otherwise insightful article that again fails to get to the heart of the matter.

    Neuroscience is demonstrating that most changes with regards to pain or function are a result of alterations in the nervous system. The question is what techniques are most effective in bringing about these changes. Clearly helping a patient change negative beliefs, improving self image and changing behaviour are powerful. Clearly there is an arguement that movement (less so exercise) will make stable changes to the nervous system, and clearly we can interact with the nervous system in a positive way through touch. I feel manipulation can have a powerful impact on the nervous system evidenced in my own clinic by dramatic changes in range of motion and pain following manipulation. all these modalities are of use and their efficacy will vary with the type of patient, their attitudes, beliefs and their presenting condition and comorbidities … something most research woefully fails to account for.

    Does skill alter the impact of treatment. The perception that the practitioner is skilled is maybe of key importance. Could we all save ourselves some time and money and just provide some simple education on pain, rub the painful area a bit, reassure people and encourage them to keep moving and practice and progress difficult movements at a level below the threshold of pain? I think this is logically where your line of arguement may lead but I think you may be missing some of the art in the science. I think Skilled manual therapy has a very important role to play for many people as part an integrated treatment plan.

    • Hi James

      Thanks for your comments, firstly I’m sorry you thought I didn’t get to the heart of the matter, will try harder in my response here!

      To discuss a few of the points you raised!

      First to manipulations creating dramatic changes in ROM or pain, do you believe then that there is a mechanical reason for this change? If not, do you think these dramatic changes in ROM or pain could then be achieved via other mechanisms and ways?

      I do, I see just as dramatic changes in my clinic and I don’t do manips hardly at all, yes I do do them occasionally, but I often see dramatic changes when I do other things, like simply clearing up a patients understanding of a condition or pain, reassuring them they won’t do further damage and showing them how to move without pain!

      Most ‘losses’ in ROM are not mechanical but due to pain, fear and avoidance, both conscious and subconscious, remove this, and see dramatic changes, your manips do the same thing they tell the nervous system its ok to move, as well as the other effects such as patient beliefs and expectation of coming to see an osteopath (you are an osteo aren’t you James apologies if not) so they expect to get a crack and expect to feel better, a kind if self fulfilling prophecy

      And there’s nothing wrong with that, if careful, comfortable and safe, crack away, but is there skill in it, well I guess a bit with regards to safety as I mention in my caveat section but not ‘technical’ skill

      Next pain education isn’t just ‘simple’ as you kinda of flippantly threw in here, its bloody hard work, many many therapists see the advice and education as the bit to do at the end the simple couple of minutes chat, its NOT, having a clearer deeper understanding of pain and all the biopsycho issues around it is an immense topic and one that needs far more skill in applying than a back rub or manipulation in my opinion

      Lastly the ‘art in the science’ debate, that I’ve had plenty of times before, I’ll use the same reply here, the art is in your patient interaction the science is in the intervention, never is there an art to back rubs or manips that’s just Derren Brown showmanship nonsense I’m afraid that wind me up hence the blog!

      Thanks again for your comments hope I wasn’t too ranty or too high up on my horse

      Let me know what you think

      Cheers

      Adam

      • Hi Adam, appreciate the reply. Think my own combative tone is just in response to your title but I do appreciate the thought behind your work so I hope you don’t take offence.

        I am an osteopath and do manipulate as well as rubbing tissues a bit… but I also integrate movement and exercise into all my treatment plans and believe that positive patient interaction and education regarding pain and movement is key to lasting positive outcomes. But patients do not need to know in depth neurophysiology…..simple education (pain does not reflect damage) and reassurance (movement will help) from a trusted professional is enough. Is there skill in patient interaction… Probably about as much skill as in manual therapy… I think none of us (including myself…no offence intended) are as clever as we would like to think.

        If managing patient beliefs and subconscious perceptions is key …. maybe we all have a lot to learn from Derren Brown.

        • Hi James

          Thanks for your reply and I don’t think your tone is combative at all, I’m very much enjoying the discussion

          Firstly I agree that patients don’t need full detailed scientific education about pain, but they usually want more info than they currently get, this read by Adriaan Louw springs to mind http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education#footnotes_86 highlights this! And the effort to educate patients about pain I still think is under recognised by most, I’m amazed that when I ask patients to tell me what they understand after I’ve given my best explanations as to what they perceive it as some times

          Next I totally agree re none of us being as clever as we think, me more than most, I class myself as an ignoramus stumbling around in the dark, occasionally bumping into things and going ah ha!

          I also know my thoughts and opinions on manual therapy are one sided and heavily biased by my own woeful and disappointing training and education in it over the years which is different from many others experiences

          Lastly regarding learning things from Derren Brown… Yes to psychology, sub conscious beliefs and perceptions… No to smoke and mirrors, showmanship and dodgy fascial hair!!!

          Cheers again

          Adam

  7. Well, I understand the juncture in the road that you hit. I hit it too.

    If you are a thinking and engaged therapist then you realize that one method does not work all the time, but if you keep thinking then you also realize that it does work sometimes. The other road that I have taken has been to try to figure out when to use what tool and how to use it to its full advantage. There are times that general techniques work. But there are times that only specific techniques work. There are patients that only need a neurophysiological intervention to get them going in the right direction – is manipulation or dry needling with electrical stimulation better, or just a light touch? There are patients that have huge emotional components to their problem. Some need ergonomic education… Some need better nutrition. Until the research is better at the inclusion criteria for any particular intervention I am not going to throw out one of my tools. Plus, when you isolate a technique for research then you take it out of the context of a real treatment. Who only uses one tool while treating?

    Perhaps your manual therapy training was just a set of cookie-cutter techniques. A lot of schools are doing that. If so, I can see why you are disappointed. Mine was focused on anatomy and clinical reasoning, differential diagnosis and safety. The training I went through taught me to think. To me OMPT = clinical reasoning. http://naiomt.me/2014/03/19/its-about-clinical-reasoning/

    What I really applaud you on is creating controversy for dialog and engagement. You do it very well!!!

    • Hi Rebecca

      Thanks for your comments

      First I’m not advocating to stop using manual therapy, as I’ve said it can be a powerful tool and touch does help a lot, but what I am advocating is removing all the smoke and mirror technicality and pseudo science that surrounds it

      No matter where you go or who teaches manual therapy there is the notion a skill is needed to be learnt and that this way is the right way and its just not the case

      The clinical reasoning of who will benefit from manual therapy I get, the inclusion criteria for the same I sort of get (although not convinced this will ever come to fruition due to some many variables confounding) but what I don’t get is the notion of skill and technicality in manual therapy when it doesn’t really matter what you do when you pull, poke, rub etc the end results are more or less the same!

      Thanks

      Adam

  8. Again Adam is doing well. You don’t have to agree, you can choose to disagree. Because it’s hard to change what you were taught through uni (by respected professors/academics -they must know what they are talking about), or what you practiced for years, and more it affects and the less likely you are to accept views that challenge your survival (income). I work in China, and i see it all too common, old dr’s who belief they don’t need to know what the west is doing, and think what can some guy 20yr’s younger then them know that they don’t, they are threatened and rightfully (it’s their whole life for 40 or so yrs). Now if i was a explorer in ancient times who believed the world was flat & explored to the known limits for my whole life, now someone comes with a GoPro footage showing me clearly they sailed right around the non-flat world i for god sake would not accept that or listen to them. And if i truely believed their evidence was right, i would put all my effort into challenging it, or proving it was wrong with any piece of evidence i had that may suggest the earth is flat, i would probably even get some “Pirates of the Carribean” movie footage as evidence.

    And so everyone has the right to criticise and challenge. And hey keep doing what they think. Chiro’s got no evidence, yet they seem to still be making money easily and very popular in USA. Simply the general population doesn’t know what evidence or research says, they just want to ‘buy-in’ to whatever you can sell them. Your the professional, and most patients will accept what you tell them.

    The fact Adam’s getting criticised and hate mail, is great. It means these people who want to prove the world is still flat, are ‘threatened’ that he may be right, and what to do everything to prove him wrong so they can keep doing what they were.

    Ps.I love the chart by the way. Should be given out back in undergrad school. If i had that back then i could of saved a lot of money.

  9. PPPS: Adam, good on you for promoting the debate, damn you for sucking me in and sinking my to-do list for the past 24 hours!

    • Apologies that you were patronised… champ. If I have missed your points then I either assumed you’d be able to ‘join the dots’ so to speak, or your points are so philosophically deep that I’m not grasping them. It wouldn’t be the first time for the latter, if that’s the case.

      What I was getting at:
      How are you identifying a target level for a lumbar rotation mobilisation and what makes you think that it matters? This is why I referred to the first article.
      The second article is a great series which explores the fact that of course MT has a place but it doesn’t matter how or on occasion where we go pressing. I assumed it relevant in a discussion about ‘skill’.

      Massage is manual therapy. It was a broad and basic example. I have also taught said beautician to do lumbar rotation mobilisations and C-spine SNAGS, which are what she does when I have deemed it appropriate. Please apply same story in light of her extended menu.

      Our ability to influence change in patients of course improves with experience. The skill, in my opinion, is the way in which we interact to instil patient confidence. This process can of course involve MT, taping and a variety of other passive modalities, however when our results improve I think it is easy to attribute it to technique ‘upskilling’ rather than context, reputation, interaction and explanation. All of which are shown to play a larger part in patient experience, and therefore symptoms, than the specifics of techniques used.

      Its extremely difficult to do and I know because I’ve been there myself (apologies if this again patronises) but the brave modern clinician interferes less and reflects on the lack of dissimilar outcomes.

      Your own acute neck and headache patient is a good example. What might have happened to her if she hadn’t have come to you or another clinician? You have essentially administered pain relief, no doubt reassured and advised her then sent her away reassured. The key variables as to why she mightn’t self resolve without you are her thoughts and beliefs as to why it hurts which will affect what she then does with her body as it recovers. Your pain relieving intervention could have been many other things.
      Was it therefore skilful?

      Hope this makes sense enough that you get my points whether you agree with them or not. If they don’t then I’m out!

      I wouldn’t word my opinion quite as strongly as Adam has in terms of ‘NO skill’, but I think that said upskilling tops out at about 6 months of experience.

      Cheers for your thoughts, and I agree with you re:to do list.
      Ridiculous digression from what I should be doing but healthy all the same I reckon.

      Jack

  10. A wonderful post. So now my question how can a Physical (manual) therapist influence pain. With pain science growing a paradigm shift is happening in the way we see pain, where do you think the shift is taking us.
    Thanks a lot for this post.

    • Hi Krishna

      A good question that has many answers, simply I think we are looking towards the neurophysiology of pain and the role immune endocrine systems play here and of course the psychology behind the other factors that affect the output we all perceive as pain!

      Regards

      Adam

  11. Well stirred and great healthy comments. I think that a healthy questioning attitude has always been around, just not by many. My WTF look on being told to “bend the flys legs” got me in trouble in the 80s. Just touch was helpful I was sure, just had no evidence!!
    I have been on the “Staring at Goats” course. Which was pretty effective if done with a positive attitude and a smile, but adding touch achieved another dimension of positive response. Maybe those pioneers of physio ( Society of medical Masseurs) were onto something? 🙂 Keep writing.

  12. You’ve boiled a bit of blood again! Nice work Adam!

    Most of the discussion so far is centred around the “no skill required” idea. I want to look at your piece from a bit of a different perspective.

    But I will quickly chime in with regards to skill. How could I resist?

    Clearly if you do a lumber rotation PIIVM, 10,000 times you are going to refine that motor pattern in your brain, you will be more “skilful” at performing it. Would it be fair to say your argument is that this doesn’t really matter? As it’s the broader context of the treatment that really seems to help?

    What is it about this broader context- confidence in treatment, reassurance, relaxation etc – that causes neurophysiological events which subsequently result in a reduced conscious experience of pain (assuming neurophysiological states are the prime determinant of pain)?

    In my eyes the important factor would appear to be engaging the patient and therefore their brain, or inducing salience to put it in different terms. I feel this is where the true skill lies. Using subjective questioning, active listening and experience to find a window in to the patients brain, to induce, hopefully, long lasting and positive neuroplastic change.

    Thanks again for a good read.

    Jack

  13. Hi Michelle, This is the blog I told you about on the trail today. Food for thought… Do you know if that September course is going ahead? We might be here at that time. Good to see you! Mary

  14. Hi Adam, fairly recent Physio graduate and agree with manual therapy being mainly interaction/patient expectations over intervention, was wondering if you could share how you explain to a patient in simple terms how manual therapy may/may not work.

    (And I appreciate all your twitter/blog posts as well, really helpful for a new Physio)

    • Hi Luke

      Thanks for your question and simply put I tell the few people I do rub and poke the same thing….

      I’m not treating the tissue or the joint, I’m treating your brain, I explain about the millions of mechanoreceptors and nocioceptors in the skin that constantly fire off signals to the brain and that by rubbing, pressing or poking them it reduces or alters the rate and amount they fire, so gives the SENSATION of less stiffness, tightness or pain, not done anything to the tissue or joint at all!

      Hope that helps, I do occasionally go into more detail about the central nervous system and brain areas that also are affected if they ask, but that’s not often

      Cheers

      Adam

  15. Nice blog happening here. I came across from BiM to have a looksee.

    Nowadays I treat most conditions exactly the same way. The patient gets some interferential (mainly because the machine looks very impressive with the flashing lights and buzzing – read ‘placebo’) and a bit of a rub with some massage cream. Just a bit of a rub, like your good wife gives you. Absolutely no skill required… at least in the physical sense.

    In any interaction – clinical or otherwise – there are unseen elements at play and we’re all familiar with them, or should be. These are the things I mentioned on BiM. Back when I was trained, I think the word ‘rapport’ was mentioned only a few times in passing, and from what I hear it’s not much better for modern day students. Instead they are taught “well there’s no evidence to suggest manipulation is any better than placebo, and there’s no evidence to support using trigger point needling and well… there’s no evidence for anything really, apart from fear reduction techniques”. All of which is absolutely true, but they don’t seem to give them much that they CAN use. 4 years of expensive training, and what do you get for that?

    The person doing the ‘rubbing’ needs to be present, attentive, relaxed, congruent, open and ‘vibing’ with the patient at some level. If he can vibe nicely with the patient, he can choose whatever “technique” he likes because they are all equally ineffective. It’s the interpersonal connection that makes them effective. Going back to your example, I bet there are some days when your wife rubs your neck and you think “hmm, that didn’t really work as well as usual”. Why is that? Maybe she’s a bit tired. You will feel it in her hands and it simply… won’t…. work. This is not just about having relaxed hands – it’s MUCH more than that.

    Imagine a 4 year degree course crammed into the space of a weekend. It could be done. Learning how to rub someone’s neck or knee can be learned in a weekend, but the other stuff – the real crux of it all – might take a lifetime because it has almost endless scope and depth.

    Cameron

    [disclosure: I’m no master therapist. However I have spent thousands of hours reflecting on and deconstructing clinical outcomes and matching this with the modern pain science and psychology research. Just like you, I was gobsmacked by what I found.]

    • Hi Cameron

      Thanks for your comments and visiting from the awesome BiM (love that site) Lorimer is about the only charismatic Aussie I actually pay attention to what he is saying 😉

      I totally agree with your views, the technicality of manual therapy can be done and dusted in a few hours, the ‘skill’ of interaction, connection, attention, compassion, plausible empathy and rapport is something that takes a lifetime to learn

      But I don’t think it can be really taught, you either have what it takes or you don’t, if you do, you learn and get better over a lifetime, if you don’t you don’t and find another walk in life

      Just my thoughts on what a therapists is, it’s not just a job, it’s not a skill, it’s a personality

      Cheers

      Adam

  16. Hey Adam,

    Sure, a high midi-chlorian count helps. Heh.

    I taught myself how to apply a mental technique, and when I apply it, the results are vastly superior to those times when I don’t. So I’d say it’s definitely possible to teach this. But in terms of how natural this feels, and how easily it is applied, I agree that there would be big differences between therapists.

    In sport, there are those who readily pick up new skills, and there are those who work their arses off to reach a skill level which is maybe 75% of the naturals. I think it’s a similar sort of thing with Physio. The thing is, the true ‘naturals’, the ‘miracle workers’ in Physio are very few and far between. The rest of us do what we can to learn the process.

    Cheers,

    Cameron

  17. An excellent piece Adam where once again you point out some of the rather hubristic assumptions endemic to the therapies. After all formal training in most is, historically, a relatively new phenomenon.

    We overestimate our value and continue to underestimate the harm we can do. Time to get rid of the professional smoke and mirrors.

    ANdy

  18. I do seem rather late in responding to this now, but after reading through many comments, I do still feel compelled to do so.
    Firstly, I am not going to go back through all of the tedious and frankly irrelevant debate of hand on/hands off. Evidence can be wielded around by both sides to attempt to champion people’s own beliefs. My word of caution about much of Adam’s discussion is that we need to consider the limitations of much of the research that is out there. I will give an example of one of the pieces of literature which Adam has used to support his statement of no skill needed in Manual Therapy- Chiradejnant et al., (2003). I am using this study, not because it is worse or better than any other, but just so we can consider the problem with lumping bits of evidence together to prove a point. As Adam rightly says, we need to not only look at the abstract (not because of bias always, but because it simply does not give sufficient information about the study, which allows you to consider the limitations, and therefore ability to extrapolate into your own clinical practice). Chiradejnant et al. (2003) found that there was no difference between therapists specifically treating the painful region, or randomly mobilising another lumbar level. I have picked up a few points which are worth considering about this paper. One of the outcome meausures used was active ROM using an inclinometer, but do not reveal the error meaures of the tool. This simply means that we have no idea of what differences (pre to post) we would need to be sure that this difference is due to a real effect, and not to error alone (quite important in a pre-post design). They use 2 x 1 minutes of mobilisation, which may not be sufficient to show a therapeutic effect, but there is no justification for this dose. A recent study suggested that 4 sets of 30 secs or 1 minute may be more benefical in provdiding a hypoalgesic effect (Pentelka et al., 2012), although granted this was in asymptomatic participants (the point here really is that we just don’t even know the basics of what makes an effective treatment dose- this may because as Adam says it doesn’t matter what you do with your hands, or that we just haven’t worked it out yet). We don’t know if the individuals which were chosen to particpate in the study would have been treated with PAIVMs at all in practice- it is possible that the Physiotherapist might have decided to use other management strategies. Percentage changes scores have high risk of bias when it comes to analysis (Bonate 2000), which might boost the risk of a type I error (i.e. falsely accepting the null hypothesis), so it is worth remembering that not all statistical analysis gives us the truth. There was no comment about the marked difference in duration of symptoms between the 2 groups (184.1 days for the specific level group compared to 89.3 for the random group)- and no attempt was made to adjust the analysis to take this into consideration. The lower lumbar levels provided better results than upper lumbar levels, but the authors did not give an indication of where the pain emanated from (ie, did it hurt more when the lower levels or upper levels were mobilised?).
    Ok enough already- the point here is that there is no such thing as perfect research- all studies have limitations which seriously limits their extrapolation into clinical practice. Which ever side you choose to sit on, you can find evidence to support your point of view, but it must always be countered by the critique of that literature.
    My concern about Adam’s post is that it is a one sided, biased account of the nature of manual therapy (very useful for stimultaing debate though!). Skill aquisition is based on multiple factors. I don’t see skill being only about where or how you put your hands on an individual, but in the whole interaction with the individual, the respect you give them, the value you place upon their own values and beliefs, whilst acknowledging your own. I appreciate Adam that you do bring these sorts of issues up when you are talking about skill, but bringing them low down on your list lessens their relevence, and suggests that clinicians who use manual therapy do not consider these as highly as the laying on of hands. That is certainly not my experience of today’s manual therapists. Is it not time that we started to accept that the biopsychosocial model is alive and well in today’s manual therapy society?

    • Hi Collette

      Thank you for your detailed lengthy and eloquent response to my little blog.

      You bring up a lot of points for which I won’t respond to all but there are some I feel obliged to reply to.

      Firstly my bias… Absolute agree, we all have out biases, even you Colette, and I am the first to admit and own up to my bias against the notion of skilled expert manual therapy due to my horrible, woeful, inept, mechanalislistic teaching and tutoring I had with it, which I clearly mention in my blog and make it clear to all to see my biases, no hidden agenda here!

      Next, your experiences of therapists views on the effects manual therapy are vastly different from mine, in my experience the structural mechanical and medical model of manual therapy is alive and flourishing in many many areas and by many many therapists, the BSP model is growing and neuroscience is beginning to influence more and more, but there is a long way to go yet, hence my blog and my continued effort to promote it.

      Of course evidence and research needs to be critiqued and I’m glad you have done this for us, but I’m intrigued that you discuss the need for the BSP model and the effects of interaction but then critique and discuss the specific effects of manual therapy with regards to needing to apply 4 sets of 30sec not 2 sets of 1 min for PPIVM’s as per Chiradejnants paper

      This debate of minimum or specific dosage of manual therapy intrigues me, if I was to say do 30 sec less or 30 secs more would the effects be that noticeable for the patient when there are so many other non specific variable that contribute to manual therapy effects, I doubt it

      And it’s this exact specific application and ‘skill’ in the use of manual therapy that I am arguing AGAINST, manual therapy isn’t a hard science, that needs exact application or position or direction, it’s much more than that and it doesn’t involve any technical application skill, instead it involves a therapist to use a caring, soft, reassuring, confident yet comfortable touch much much more than remembering to to poke a vertebrae for 4 sets of 30 secs at 2Hz, and these ‘skills’ are learnt with experience, hands on trial and error not taught in the class room or from reading a book or research paper!

      I could go on but I will leave it there with this final thought that therapists need to stop thinking themselves as skilled technical healers, applicators or operators of manual therapy and rather consider themselves as interactors or human primate social groomers as per Dunbar 2009

      Regards
      Adam

      • Thanks for your lengthy reply Adam. I worry that the term biopsychosocial seems to have been shortened often to only cover psychosocial. To ignore the bio is just as ridiculous as to ignore the psychosocial. My main point really is that evidence is not really the correct word to use when we look at the literature because it will only ever tell us a very simplified aspect of the whole story, but we might use small aspect of it, e.g. treatment dose if we have an idea about what might be more likely to have a beneficial effect and apply it to our patients where and when appropriate. If after a thorough and “skillful” assessment and examination (meaning careful, competent questionning, following the patient’s lead, ensuring that the patient is really heard, and careful, competent handling to name but a few aspects), it becomes apparent that manual therapy would be useful for this individual, then we want to try to apply the technique in a way that might have the best effects (now of course as you know this is absolutely not just about changing the biomechanical properties of the tissue, but a complex interaction of descending inhibitory pathways, possible reduction of excitatory facilitatory pathways (see Bialosky et al., 2009), alteration of the perception of the body region etc etc). The point here is that in a way it doesn’t matter why it works (I know some people might not like the idea that we don’t know why, but I wonder if we will ever really know), but it is important that we aren’t doing our patients a disservice by not attempting to incorporate both manual therapy (done as well as we possibly can) and many other approaches to the patient.
        I see the difference that careful, skillful handling makes to the patient’s perception of the therapy, as well as helping the therapist to see if the treatment (be it manual therapy, exercise, advice or any kind of intervention) has been effective. Going back to the original point you made in this blog-the skill is in every aspect of care for the patient including what you do with your hands.
        By the way of course I am biased- it is part of human nature- another thing which takes skill to deal with during any interaction with a patient!
        Cheers,
        Colette

        • Hi again Colette

          I think evidence is the correct word to use, and should be used by all, but not to confirm what is happening but rather what is NOT happening, there is a lot stronger more robust evidence that rules out the mechanical notions of manual therapy, than it rules in, there is less biased evidence to refute any tissue change in structure with manual therapy than those that do!

          Evidence should be used to show what isn’t happening or occurring more than it attempts to show what is supposedly happening, but unfortunately due to massive publication bias most ‘negative’ research never makes the cut

          I agree with you that to fully understand and evidence all of the effects of our hands on methods will probably never be achieved, well not in my lifetime I guess, but we do know what it doesn’t do and what it doesn’t need and that’s specific application in terms of a set direction, position, amount, rate etc, and so I still argue that the technical skill of manual therapy is over rated

          Kind regards
          Adam

      • Please excuse the interruption, but which publication are you referring to specifically with Dunbar 2009?

        Aran

  19. Hi Adam

    You state: ‘to talk and listen to my patients more and find out their personal beliefs, experiences and more importantly what their expectations and preferences where towards manual therapy! I found asking patients these questions allowed me to gage IF manual therapy was suitable for a patient based on their preferences’

    Absolutely! In my opinion this is the most important aspect of therapeutic interaction with patients, one that I would strongly advocate on the University of Brighton MSc Neuromusculoskeletal Physiotherapy course (MACP accredited), of which I am course leader. I am not informed enough about the finer content of all MSK courses but the incorporation of motivational interviewing and some of the principles of CBT, ACT and solution focused therapy are a fundamental part of the course.

    I absolutely agree that manual therapy isn’t for everyone and when examining physiotherapist (on a route to MACP membership) treating patients in a clinical setting, I am as likely to be taken through to the gym as behind cubicle curtains.

    It is great to hear in your comments to this blog that you recognise the changes in MACP members views (similar to the changing views of non MACP members). As you say MSK physiotherapy is changing and some individuals will be resistant to change (MACP and non MACP members alike)

    It would be great to see you at this years’ MACP conference ‘Exercise Rehabilitation and Patient Engagement’ (not a ‘manual therapy’ session in sight). Alternatively Joel Bialosky (who you mention in your post) will be presenting in IFOMPT 2016 in Glasgow. Might see you there?

    Best wishes
    Clair Hebron (MACP Chair)

    • Hi Clair

      Thank you for your comments, I am very very interested in hearing Joel speak so I may well see you in Glasgow 2016

      As I have said before I am aware and delighted that the MACP are embracing and moving with current evidence and best practice with regards to manual therapy, especially after my own unfortunate terrible experience with ‘old’ MACP training many years ago

      I also work with and know many excellent MACP physios, just as I know and work with many excellent non MACP physios, however… there is always a however… I do think that due to the likes of the MACP (and other organisations) there is a legacy of a lot of manual therapists out there who were trained 5-10+ years ago on what we now know to be a flawed structural, mechanical and overly technical model who are still teaching and preaching poor practice and continuing the biomedical structural nonsense, and they have lost contact with current evidence, and I don’t think it’s all due to resistance to change, i think it’s also just naive misinformation or misinterpretation

      It’s these therapists I’m hoping to reach when I write things like this! I am however well aware most who read my blogs are very well informed therapists so I will be mostly preaching to the converted, but maybe, hopefully one or two who aren’t might stumble across my rantings and it may just instigate a change!

      That’s also what I’m hoping to achieve when I enter the lions den at the Therapy Expo in Manchester this September when I give my talk about the ‘Myths of Manual Therapy’ wish me luck…

      Warm regards

      Adam

  20. Adam,

    I saw your diagram float through twitter a few weeks back and retweeted it and your blog post. Finally, I’ve had the time to sit down and read it. MAGNIFICENT! BRAVO! I can’t even come up with enough adjectives to describe my support for you hitting the nail on the head. Well done. Thank you for bringing to light what feels like so few of us know is true, but so many of us need to hear (and hear again and again). I reblogged you on my own blog http://www.youthsportspt.com. Keep up the great work!

    Julie
    Atlanta, GA

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