Manual therapy; a change in perception…

Regular readers will know that there is no love lost between me and manual therapy. I’ve had more debates, disagreements, arguments, and falling outs over manual therapy than anything else over the years, and to be honest I’m pretty bored of it all. I’m bored of all the time wasted squabbling over such a low value, unreliable, stupid intervention. However, yet again I find myself writing another bloody blog about it.

Now hate is a very strong word and one I don’t use a lot, but I hate manual therapy. I hate it for the way its over used, over hyped and over complicated. I hate it for being surrounded by myths, fallacy’s and complete and utter bull shit. I hate it for promising much and delivering little. I hate it for misleading and fooling me, and many others with false promises and high expectations of how it can help my patients in pain. And I really hate how so many continue to think that it is an essential intervention for physios to do/use on all their patients.

Manual therapy is just an adjunct, an extra, a luxury to be used if there is suitable time, funds, and more importantly suitable patients. Most of the time manual therapy should NOT be used because these are not suitable. Now although I hate manual therapy I will say I have seen it help some patients in some pain, so I don’t completely reject or ignore its utility or effectiveness for some, but as I said its a luxury and not an essential intervention for most patients I see.

In fact, I have now abandoned manual therapy in my practice and I don’t miss it one little bit. I don’t mobilise, massage, manip anything. I may facilitate or assist movement but this is not the rubbing, poking, pulling, or prodding peddled by the sycophants and gurus of manual therapy.

Although I dont use it anymore what still really winds me up about manual therapy is those who continue to explain its effects using out dated thinking. Things such as it creates biomechanical changes or structural differences in tissues or joints. I still hear many therapists using terms like releasing, loosening or freeing up soft tissues or joints, or rubbing out muscle knots, breaking down scar tissue. Some even still tell patients they are putting joints back into place. All these terms and explanations are simply bull shit and I have had many interesting and lively discussions with therapists about these in the past, present, and I’m sure the future. Now, some therapists try to tell me that these terms are ok to use, and its just semantics, as these explanations are simple and easy for patients to understand and contextualise.

Nonsense.

All these terms are inaccurate, misleading and deceitful, and need to be stopped being used immediatly. I also think these terms can be extremely harmful to some patients, producing nocebic effects, and/or instilling a false notion that the effects of manual therapy, such as less pain, less stiffness, and easier movement can ONLY be achieved by manual therapy doing these structural biomechanical things, so leading to a reliance and dependance on manual therapy.

We know that words we use can be misinterpreted by our patients (Barker 2009) and create nocebic effects (Richter 2010). I have seen first hand how words can be implanted onto a patients and create dependence and a reliance upon manual therapy in patients, removing their locus of control. I have also seen some unscrupulous and unethical therapists scumbags use this to their advantage to keep patients coming back regularly for expensive, ineffective ‘treatment’ top ups.

However, thats not to say all manual therapist use these terms deceitfully or with any malice in mind. Some use these terms with the genuine belief this is what is happening due to others teachings, misinformation, or simply outdated education.

Soft tissue isn’t soft?

Our soft connective tissue is strong stuff, in fact the term ‘soft tissue’ is a misnomer. Soft tissue isn’t really soft… Its bloody tough and it isn’t deformed or altered as easily or as quickly as therapists believe. Connective tissue has to be tough and resilient. It has to hold us together. It has to protect us from the external environment. It has to physically move us around and transfer large forces. It has to withstand loads, stresses, strains, shear, compression and friction forces. It cant afford to be fragile, delicate or easily changed.

Human connective tissue is made up of lots of different types, styles and compositions. Some is a bit softer than others such as the superficial fasica found just under our skin, but most connective tissue that manual therapists believe they are working on such as muscle, tendon, ligament and even the ‘general’ myofasica is not soft, delicate or deformable.

These tissues don’t simply yield, stretch, give, release or melt easily. Certainly not when rubbed, pushed or poked for a few minutes, a few times a week, such as with a therapists thumb, hand, knuckle, elbow or even some metal instrument. Think about it, if connective tissue was deformed this easily we would soon be big puddles of sloppy goo and bones on the floor very quickly.

Can manual therapy change stuff?

Many therapists believe that manual therapy can affect myofascial tissue and this is what improves movement and reduces pain and stiffness. Well I doubt it, in fact I will be bold enough to say quiet categorically that no manual therapy can affect the ‘structure’ of any human tissue significantly.

Whats that? You don’t believe me! You want proof? Well how about this paper by Vardiman 2014. It looked at the use of instrument assisted massage (IASTM) on the calf muscles. Now IASTM its the latest crappy manual therapy fad that involves scrapping ridiculously expensive metal utensils up and down patients bodies. However, to save you all some money I have recently launched my own set of IASTM tools, see below for more details…

IASTM tools

Anyway, this study found that after a session of IASTM to the calf muscles there was absolutely NO change in ANY of the physical parameters they measured. Nothing, nada, zip, diddly squat change in anything measured….including muscle biopsy tests. OK, so it could be argued that it was only after a single session of manual therapy, and maybe some changes would appear after more treatments. But it does question the belief that the immediate effects of less stiffness or pain that many feel after manual therapy is due to any structural or biomechanical or biochemical changes in tissues.

Would any structural tissue changes occur after longer periods of manual therapy?

Simply put, this is also very unlikely. If a rigorous six week, three times a day stretching regime of the calf muscles had absolutely NO effect on the physical structure of the calf connective tissue as shown by Konrad 2014 then you have to ask yourself what chance does a bit of manual therapy given at best a few times a week for 20-30 minutes have? Again i’d say none, nada, zip, diddly squat!

Now this lack of structural, physical or biomechanical change after any manual therapy or stretching isn’t new news. In fact it has been doubted and questioned for a long, long time! Papers by Threlkeld 1992, Bialosky 2009, Zusman 2011 and a host of others, have all questioned the physical effects of manual therapy and the notions of changing tissue or structure in any way, yet these crappy beliefs still exist!

So why do these inaccurate and misleading explanations still continue?

I believe this is due to many therapists being ignorant or choosing not to believe the evidence as it directly challenges their thoughts and teaching as well as their businesses and livelihoods. Its very hard to get someone to change their minds about something when their income depends on them not. Also hard ingrained beliefs are very, very hard to change, especially in the dogmatic.

Another reason why these explanations continue to thrive is they are very popular, and are often used by patients and the media and reinforced by  manual therapists, and the influential teachers and guru’s. This again makes it uncomfortable for anyone to say something different from the masses and challenge or contradict the so called experts. Believe me when I say it can be daunting and frightening to do this, as many of these manual therapy ‘experts’ get defensive, aggressive and downright nasty when their guruism, beliefs and ultimatley their incomes are questioned. This unfortunately means that the many post hoc fallacys of manaul therapy will continue to remain with us for a long, long time…

Time to speak up.

Nothing will change if we continue to roll over and bury our heads in the sand. It’s about time we started to challenge the beliefs of manual therapy, about how its a skilled or specific intervention , or how its an essential one. So this is a plea to you all reading this, let’s first start to change the language we use when we explain the effects of manual therapy to each other and to patients, and then lets start to challenge others spouting the bull shit more. I have and will continue to do so, and if you want support come find me… i’ve got your back!!!

don-t-worry-i-ve-got-your-back-t-shirts-men-s-muscle-t-shirt

What do I say?

Many ask me how do I explain to a patient what manual therapy has done or is doing? Well as I don’t use it anymore I don’t say this as often but if a patient does ask me about it, I tend to say something like this…

We are not compleltey sure, but the current evidence is showing that manual therapy changes your perceptions and feelings of stiffness/pain

This simple and honest explanation is I feel based on our current understanding but still leaves some ambiguity and openness of uncertainty. It doesn’t involve any descriptions of tissue structure being changed, and it also allows me a way to start to explain the role of the nervous system and how any effects they perceive need to be reinforced afterwards by movement.

Some patients get it, others I need to explain a bit further. For these few I try to expand a bit further and use a metaphor of how there are lots of small sensors distributed throughout every millimetre of our skin, muscle, fascia, joint capsule etc, and how these are constantly monitoring and sending information to the brain to inform it of its current position and physical state, which you are normally blissfully unaware of.

However, when a tissue is over loaded, fatigued or injured these sensors send more signals to the brain telling it that its tight, stiff or painful. By rubbing or poking things, these sensors change the amount or type of information being sent to the brain, so it perceives a change in stiffness, tightness or pain. This tends to do the trick for most and I haven’t had many issues or barriers when I use it.

However I do recognise that these non structural explanations may conflict with some patients own preconceived perceptions and beliefs about manual therapy due to other past experiences or misinformation, and by giving an alternative explanation there is a risk of causing conflict and even mistrust. But, just because it can be challenging or difficult, it is still no excuse not to try to fully inform patients to the best of your ability.

So in summary I hope I have shown you why some of the langauge used with manual therapy is incorrect, inaccurate and potentially harmful. My plea again is to ask all therapists to change their explanations and descriptions, and to stop telling people who are stiff or in pain that we are releasing, freeing up or loosing things when we rub or poke them. Instead lets tell patients we we are simply creating a temporary change in their perception. And believe it or not manual therapy is NOT the only way to so this. In fact I dont even think its the BEST way to do this, and it certainly isn’t essential.

As always, thanks for reading

Adam

60 thoughts on “Manual therapy; a change in perception…

  1. Well – here we are again – neither of us have been prosecuted for tearing a client limb from limb so I think we’re still safe in the assumption that fascia is way tougher than massage.

    My two penn’th is based on my experience of what massage/manual therapy seems to do when I do it and what it does when done on my (right and wrong).

    It mobilised tissue – hey – we’re physically moving it
    It puts heat into tissue – can’t move it without
    As we’re moving tissue we’re also stimulation passive fluid flows in the body
    When done right it promotes relaxation and trust (both in their body and the therapist) – the whole touch/comfort thing – (conversely do it wrong and you get an increase in muscle tension and elevated pain levels)

    This “seems to” make active exercise easier for the client in the bast majority of cases.
    Clients report a reduction in pain levels after a manual therapy session
    It “appears to” boost confidence in the client’s ability to move and exercise – and do do so without excessive pain.

    My inference is that when manual therapy is used right it provides the combined benefits of a warm up and stretching session with a bit of feel good factor and confidence, this could be considered a smoke and mirrors thing – warm it up, move it around and hey its warm and been moved “TADA – CHING”, but at times active stretching or exercise causes pain and undesired muscular reactions in a way that MT doesn’t – the knock on appears to the following.

    1) They’re better able to start/resume physical activity safely
    2) They’re more likely to listen to keep up exercise regime/modified behaviour suggestions you give them

    p.s. – yes there’s the occasional something went clunk and the pain went away either during or shortly after a session, but poking people till they go clunk without a very clear set of symptoms is asking for trouble in my view
    p.p.s. a lot of these stupid tools strike me as likely to reduce the beneficial effects of touch as well as cutting the amount of heat that is likely to be put into the client, they also make it harder for me to sense whether the punter is responding well to what I’m doing or whether I’m hurting them unnecessarily.

  2. Thank you for posting this information. I have a “severe shoulder tendinitis” with a small tear, diagnosed by an mri, so I don’t need surgery. I am on my fourth month of PT and have had manual therapy that caused me to have severe pain for weeks. I was told that it works for most people. Thinking I was just the odd duck out there all by myself, I waited for my pain to subside. PT went easier on me also. I feel a bit more empowered now thanks to your post. Never having had any problems with my shoulder, how would I know what to expect? I was fearful that not letting the therapist do manual therapy on me would set me up for future problems with my shoulder freezing up or not being able to move correctly. Logical thinking doesn’t always enter into the picture when you are in pain and afraid.

  3. I always find your articles interesting and it makes so much sense but I am a massage therapist (Sports Therapist) and most of the time people feel better after seeing me and this includes physical parameters such as ROM as well as perceptions of pain. I also feel better after manual treatments such as manipulation and massage. I’m not sure why but it does happen and I want to know why!

    You must use and get positive effects from manual treatments? If it can’t be done by altering the tissue I guess it must be circulatory or neural effects?

    • Hi Ben

      Why do people feel better after massage or soft tissue work, wow, thats a whole blog in that question right there.

      Lots of reasons, most is due to neurological modulation through afferent information from the skin mechanoreceptors to the central nervous system creating sensations of less pain, stiffness etc allowing greater freedom of movement, then also there are the psychological and placebo effects not to over look or to be sniffed at either.

      Please don’t misunderstand me in my critique and strong wording against manual therapy, I am not saying there is NO role for it, as you say people like it, all I am against is the nonsense and ridiculous claims that surround it, the mis information and mis selling of what it does and the over use of it that some therapists do, causing patients to become reliant and spending lots of money on it based on false beliefs with no long term benefit

      All the best

      Adam

  4. The problem with most Manual Therapy is that it requires a therapist, making it prohibitively expensive and time consuming. Self-care is usually not offered because there is no money in it for the therapist. The best a patient may get is, ‘use a tennis ball..’ or the much improved ‘place two tennis balls in a sock and use it as your trigger point tool’… We are working to change this, and hopefully someday we will be able to afford a prohibitively expensive study to convince you.

    Seriously, why not have some quality tools laying around for your clients to use and see if they say it helps them? Certainly you agree that there is a % of patients who appreciate trigger point therapy and perceive a significant benefit.

    Being the Sports Physio you are in the unique position educate clients on the larger structural issues they face, and advise against manual therapy if it clearly will be of no benefit. There is tremendous value in teaching patients about their condition and offering the more traditional stretching and strengthening that will help them in the long run.

    I think your position was best said with: “what chance does a bit of manual therapy given at best a few times a week have? None I’d say!” — well at least you were honest enough to include your bias and presumption.

    Curious if you have seen any studies on multi-year self-directed therapy at the moments immediately following a strain and for weeks there after?

    As you know, there are plenty of professional athletes and their trainers who wholeheartedly disagree with you.

    Great write up, thanks for allowing this post!

    • Hi Tom

      I’m afraid i have only just seen your message as it was sent to my spam folder due to the website you linked, and I have removed it as don’t really want my site used for advertising products.

      I agree that self management techniques for soft tissue are probably more beneficial than therapist applied techniques as they can be done more often, more regularly, and cheaper

      However just because it can be done more often doesn’t mean the mechanical effects are any greater, tissue doesn’t change by pressing, rubbing, pulling it, christ 6 weeks of strong regular full body weight stretching didn’t, rolling on a cricket ball wont either

      Cheers

      Adam

      • And I’m well aware many, many don’t agree with me, and many still believe in the mechanical structural changing effects of manual therapy, but that just means I have a lot of work still to do to educate and highlight the current recent research and evidence that disproves it

        • Adam,
          You won’t have much work to do to disprove that connective tissue does not change with manual therapy for me. I already knew this before reading your rant from all the current literature that supports this. I feel that you are quite an intelligent man, and my 1st impression of you (this blog post) is not a very accurate snapshot of who you really are. Please take what I have to say as constructive criticism. I suggest that you spend some time looking for articles to improve your style of mass communication to support your cause. It’s possible that you may be stuck in a rut of dispersing the script you created “We are not fully sure, but the current evidence is showing that I’ve just changed your perception of stiffness/pain” because of the way you delivered it. Even though I love that statement and plan to use it from now on, I struggled through all the insults to get to that quote. I trudged on to continue reading your rant with an open mind and imagined increasing cortisol levels running through my veins with each word. Shaming and insulting people that may not yet have this knowledge may cause you to do more work than you have to. Persuasion sciences show that being likeable may make it easier for you to change the way manual therapists like me educate our clients/patients and students. I think being less insulting could potentially allow someone like me to listen more intently to what you have to say with an open mind rather than a defensive mind. Though I do plan on supporting your cause one colleague, student, and patient at a time. However, I am embarrassed to share this particular link. If you decide to ever consolidate all the links to the literature you have here in a new “G” raged post, please email that to me and I would be happy to share it with all my professional contacts.

          Wishing you the very best,
          Ken T

          • Dear Ken

            Thank you for your comments. I do take some of what you say on board, you’re not the first and won’t be the last to try and get me to become ‘softer’ in my approach.

            However, I can assure you I won’t change, I am too long in the tooth and too stubborn, my style is, and always will be direct, often blunt and not always the most politically correct. In my opinion this is needed in this day an age of pussy footing around, if it looks like bull shit, sounds like bull shit, smells like bull shit, then call it bull shit.

            Out of interest what articles do you suggest I read to improve my style of ‘mass communication’? Not that I have any great desire for mass communication or improve my style. This is just blog, one of millions out there, its a hobby of mine that I do in my spare time, that has got a little bit popular, but is nothing in the grand scheme of things and will never be.

            Also please point out to me all the insults you mention you had to struggle and trudge through? There are some harsh words, bull shit for example, but if you can not read that without becoming offended then I politley suggest to you that you go read some articles on how to not take things personally and toughen up a little.

            I don’t force you or anyone to read anything I write, if you didnt like it, you wouldn’t have read on, but you did.

            Regards

            Adam

            • Adam,
              “Regular readers to this blog will know that there is no love lost between me and manual therapy. We have had our disagreements, we have had our arguments, and we have had our falling outs. We don’t like each other, and to be honest, we are best kept apart.”
              This statement was my first impression of you and felt like a judgment toward what I enjoy practicing. I went back and re-read your post two more times and felt that biomechanical minded manual therapists might find their intelligence being insulted. Not because of what you are saying, but rather how you are saying it. I realized that I missed out on a lot of great information that this post has to offer because the word “bullshit” attracted my lizard brain away from points you were trying to make. I am a retired Marine and have found that attractive writing draws more interest than repulsive writing when getting my point across to civilians (and most female physiotherapists in my life).

              “Hate is a very strong word, but simply put, I hate manual therapy. I hate it for the way it is over used, over hyped and over complicated. I hate it for being surrounded by myths, fallacy’s and complete and utter bull shit. I hate it for promising much and delivering little. I hate it for cheating me and millions of others with false beliefs, expectations and explanations.”
              Multiple splattering of the word “hate” within this paragraph (along with use of harsh words) may make it difficult for a reader like me to listen more openly. I do believe that harsh words have their place. A good example of this is when I try motivating a squad of Marines deploying into battle. I really didn’t have any plans of having you change your writing style to something softer. I mostly wanted to offer some tips that may allow your good advice to influence professionals in my field of work to become less biomechanical rather than irate.

              “if you cannot read that without becoming offended then I politely suggest to you that you go read some articles on how to not take things personally and toughen up a little.”
              When I left the military nearly 20 years ago, I actually had to deprogram myself to become less offensive and more sensitive- maybe I’ve overdone it- haha! Most of the way I speak and present myself now is from learning customer service tactics. I’ve found that it has allowed me to connect and communicate better with any audience I try to present an idea out to (from family and friends to a larger group of 200 people that I may lecture to). These are some books I’ve read that have improved both my professional and personal communication experiences. There are also a lot of YouTube videos out there that tap into the neuroscience of how to make a more powerful impact to what you have to say. Because I also believe that the medical profession in general has to change to a more biopsychosocial model when explaining to our customer/patient what it is that we do to them when they ask us questions.
              Talk Like TED: The 9 Public-Speaking… by Carmine Gallo
              Delivering Knock Your Socks Off Service (Knock Your Socks Off Series) by Performance Research Associates and John Bush
              How to Win Friends and Influence Peop… by Dale Carnegie

              “I don’t force you or anyone to read anything I write, if you didnt like it, you wouldn’t have read on, but you did.”
              Then again, maybe your writing is perfect the way it is, since I did end up reading this post 3 times.

              Wishing you the very best,
              Ken

              • P.S.
                I forgot to mention that if people like me and you are trying to change the mindset of physiotherapists and other medical professionals away from biomedical models, then a softer writing style should not be ignored.

                • Hi again Ken

                  I agree a softer approach would probably be the best, it just wont be coming from me. I also have an ex military background in the UK but without the detraining… I blame our government, may explain my ‘style’

                  Maybe you should start a blog Ken, maybe you can convert them

                  Thanks for your comments again

                  All the best

                  Adam

  5. Much of your argument fits with why I got into the Feldenkrais Method. We do “manual therapy”, in that we’re moving the client around with our hands, but we aren’t raking or scraping fascia or knots or anything. (And the party line is that we don’t do therapy, we help people learn, and that can have therapeutic effects!) Most of our manipulation involves moving the bones within the client’s range of comfort and ease, thereby clarifying cortical maps and interrelations. Sometimes we’ll squeeze/support a muscle that they seem to be holding tight to take over its work, but even then, any change is due to the nervous system deciding tension is no longer necessary, or more generally that particular motor organizations can safely be changed (at least for the moment). Ideally the client learns new motor patterns and can move on, but I have heard from some pracittioners that they have people who come by for years upon years….

    We also have movement lessons that students can do on their own, although often led in groups by an instructor giving verbal direction. Many practitioners sell recordings too. This is much less expensive for clients/students than 1 on 1 manual sessions, but both have their place. I know I was getting little benefit from group lessons until I got some personal attention for some specific blind spots I had in my own self image.

    Have you had an experience with the Feldenkrais Method? If so, how do you think it compares with typical manual therapy?

    (By the way, regarding some comments above, Moshe Feldenkrais had similar problems interacting with the medical establishment in his day, and many of his followers still do. 🙂

    • Hi Nik

      Thanks for the comments, I will admit to being naive with Frldsnkrais, I have seen some videos and spoken with some practitioners and clients but that’s it.

      My initial impressions are good, it seems realistic and not full of BS, and as you say encourages people to explore movement in a safe and controlled way and environment which is just what people in pain need, not more pain, more fear and BS explanations of this out or that knotted

      I may have to go and get my ass down to a group and have a go myself

      Cheers

      Adam

  6. I’d like to hear you thoughts on Stecco’s concept. Personally I found this as a very interesting http://www.sciencedirect.com/science/article/pii/S1360859213002027

    Its my last semester with physio degree. Ive found your blog very interesting and as a newbie my thoughts about manual therapy and physiotherapy has changed because of your texts.And because of that i feel more comfident as I will start my carwer as a physio in a few next months.

    So thank you.

    • Having read some of the Steccos work on fasica I find it interesting but do I think or agree with them in saying we can affect it significantly with manual therapy… Nope

      Effects of 20-30mins of manual therapy will have very very little effect to any tissue.

  7. You apparently do not understand the physiology of manual therapies. Vardiman’s study was performed on HEALTHY tissue, not pathologic, and he looked at the IMMEDIATE effects of IASTM. The remodeling phase takes days / weeks / months. Regarding the effect of controlled microtrauma: Damage to fasciae always causes an inflammatory reaction that promotes the healing process. The fibrous layers of the fascia can be perfectly restored; indeed, they are formed by collagen type I, the key molecule involved in the process of scar formation. When deep fascia is disrupted, three sequential, yet overlapping, phases of the reparative wound healing process occur: inflammation, proliferation and remodeling. During the inflammation phase, cell debris is phagocytosed and removed from the wound by white blood cells. Blood factors are released into the wound that cause the migration and division of cells during the proliferative phase. The proliferation phase is characterized by angiogenesis, collagen deposition and wound contraction. Fibroblasts grow and form a new, provisional ECM by excreting collagen type III and then type I collagen and fibronectin. In this phase, the collagen forms an irregular connective tissue that has the main function of closing the wound gap. But for the correct healing of the deep fascia to occur, it is fundamental that collagen be remodeled and realigned along the correct lines representing components of local tensile stress. (Stecco)

Please leave your comments here...

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s