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.
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…
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!!!
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