I hate manual therapy…

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.

I have now abandoned manual therapy in my practice and I don’t miss it one little bit. I don’t mobilise, massage, or 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 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 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 toolsAnyway, 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 not a skilled or specific intervention, and how its most definitely not 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

61 thoughts on “I hate manual therapy…

  1. Are we able to comment now? I’d just like to say agree agree AGREE! With all of the above. In a lecture the other day (in my new life as a physio student), the professor asked us ‘why do people stretch?’. He said that for the first time ever, he got some answers that included the nervous system, possible psychosomatic reasons, and ideas about changes in perception and sensation, so it would seem that these ‘new’ theories which go beyond the bio-mechanical model are starting to filter down into the population. Or maybe it’s just members of the population who have done a bit of reading because they’re studying the subject…? Anyway, battling the average Joe’s understanding of massage and acupuncture (give me strength), is one of my daily battles, but I REFUSE to resort to wanky answers about blood flow, adhesions and release, because my clients deserve better. The manual therapy industry is terrified to admit the lack of mechanical evidence for what they do in case it somehow harms their business. However, continuing to teach trigger point therapy, soft tissue release, frictions and massage as ways to ‘break up scar tissue’ is negligent and lazy.

    • Hi Liz, yes you are able to comment now, I have provisionally turn comments back on and see if the abuse has settled down. Its good to hear that things are changing slowly, long may it continue, and many thanks for your comments, and all the best with your studies

      Cheers

      Adam

  2. Good post. I do enjoy a massage and do feel it is loosening me up, but I am under no illusions that it is breaking up adhesions etc. I am wondering though, if I am under no illusions, does it really matter if my therapist is?

    I mean so long as I am not being ripped off by paying extra to have the same massage done with some silly tool, I am not really bothered as long as I ignore any ‘woo woo’ explanations of what it’s doing.

    • Hi William

      Thanks for your comments, and you make some very good and rationale points.

      I think you’re are spot on, as long as your not getting ripped off, you find it helps, and not sold or given any BS fear inducing explanations as to the effects or mechanisms of massage then your right you dont need to know or care how it works

      Cheers

      Adam

  3. Well Adam, there is more powerful problem which myth -busters must face on it. It’s a huge number of the patients and clients who already believe in the changes of tissue EVEN bones and spine?! such as discus hernia! The worst I’ve heard and know is that there are thousands of so called “exotic” massage practitioners and gurus recommend massage to the patients with a cancer !!! I had a great argue, and I still have and with such idiots (excuse me but I have to call them with a real name by my opinion). when you are asking them for a science proof they become a very aggressive as you mentioned. They KILL people and because these desperate people in their fear and powerlessness, they are ready for any therapy that help them to survive. These criminals rob them consciously and speed up growth of tumors! Here needs to be running – THE LAW! Anyone who uses medically and scientifically unproven therapy should be prosecuted and treated as a premeditated killer! massage is only for those who want to relax, thougheven then should be careful, due to medical reasons. Regards and Congratulations for the article !

    • Hi Per

      You have some strong opinions on the subject, I don’t think I have ever come across any evidence that anyone has died from massage, certainly a lot of charlatans ripping people off, but murderers that’s pushing it a little far!

      Thanks

      Adam

    • …”And speed up growth of tumors! …massage is only for those who want to relax, thougheven then should be careful, due to medical reasons.

      to be fair you should call B.S. where ever it happens even in your own comments section!!!!
      http://www.cancercouncil.com.au/17958/b1000/massage-and-cancer-42/massage-and-cancer-benefits-of-touch/
      Is massage safe for people with cancer?

      Light, relaxing massage can safely be given to people at all stages of cancer. Tumour or treatment sites should not be massaged to avoid discomfort or pressure on the affected area and underlying organs. If you have any concerns, talk to your doctor or call Cancer Council 13 11 20.

      Some people worry that massage can spread cancer cells throughout the body via the lymphatic system. The lymphatic system is a network of vessels, organs and nodes through which lymphatic fluid (lymph) flows. It is part of the body’s immune system. Lymphatic circulation occurs naturally as we move.

      Cancer may spread (metastasise) into the lymphatic system via the lymph nodes, or it may start in the lymphatic system itself. However, the circulation of lymph – from massage or other movement – does not cause cancer to spread. Researchers have shown that cancer develops and spreads because of changes to a cell’s DNA (genetic mutations) and other processes in the body.

  4. Thank you Adam for another very good post and interesting comment about Liz who, as a student, seems to be getting a different message.

    Much more emphasis should be on the role of nervous system in changes seen as well as changes in perception. I use manual therapy in very specific cases and I am indeed met with incredulous stares by my patients when answering the question “what are you trying to do?” as I give a very similar answer to the one Adam presented in his post. Much work needs to be done to inform, educate and kill myths that have been present for so long in the public psyche…I do feel like Don Quichotte sometimes.

    Keep on writing Adam and thanks for re-opening the comments option.

    Pierre Bonnaud

  5. I am a physiotherapist who puts his hands on patients at times but certainly not in all cases – so i maybe the one who gets the abuse in this scenario – here goes anyway, the risk is mine i guess. I am genuinely pleased when there is discussion and i really am in the same position with regards to the claims of individuals who use misleading interpretations of their mechanistic intervention. Positional palpation has no grounding, the notion that we put anything in or out or that we increase tissue length are not ones that i hold at all, mobilising tissue does not change the extensibility, i cannot see anything that would support these suggestions and so I am very much in agreement with the comments and proposals.

    As a Physiotherapist who uses hands as part of a multi-modal treatment process (bit wordy but I feel I cannot class myself as solely a manual therapist as this term is not indicative of the scope of my practice – this would be very limiting) – i place far more emphasis on understanding, empathy, education. Simple movements, and shared decisions to (try) to ensure the patient feels they have a sense of control. Solely using hands without doubt (in my mind) really fails in that process. I believe (rightly or wrongly) that the sensation of force and touch interpreted at a number of interactive neurological processes has a part to play in altering the perception and interpretation of pain for a short period of time, force i feel also links to low level mechanoreceptors involved in the perception of position and movement – again only for a short period of time. The context in which it applies will modify these processes and so it is a way to pain modulate (DNIC) perhaps, link to proprioceptors – maybe, to possibly help in certain patients to begin the motor pattern movement alteration and help interpret their emotional perception associated with that pattern to be subsequently challenged, and then enhanced with exercise and movement –re-education. There is also a great sense of empathy associated with touch that I feel again in the right context is relevant – but this is not mechanistic at all in the true sense of the word. It is vital that the patient does understand the relevancy and importance of what they do, how the clinician is really just enhancing their own ability to recover and respond.

    Of course, there are ranges of ways to do this and I don’t believe that MT is better than others. It is a method that under a clinical reasoning methodology is chosen selectively, rationally with the patient at the heart of it rather than clinician bias (or though i do recognise we all bias our selection to things we are comfortable with) that can be used with the right patient group.

    I now am going to possibly get really shouted at – i also am involved in facilitating courses that involve using your hands as a physiotherapist (I am certainly no guru – and what an awful term that is) – i without doubt agree it is ethically unsound when given this opportunity to be in an educational environment (a privilege)to not give the context and the balance to the argument – i don’t wish to offer anything more than a reasoned physiological (logical) answer with course participants and university students that i work with, and I actively look to dispel common misconceptions that clinicians may use to make themselves sound clever and detached from the patient as if they have “healed” someone – i really feel that this is unprofessional and massively unhelpful and painfully arrogant.

    So, although I use techniques that this forum would classify as MT, I do agree with the view of interpreting it and not over playing it – the key to pro-active practice (IMO) is to be reflective and I have made many errors, and will continue to do so, just try to learn from then to improve. I have a belief system that is underpinned by science and experience, this is a plastic process, and I enjoy considering this system and where it is in a learning continuum.
    Just my views of course – and of course time and others will continue to modify that – something to look forward to.

    • Hi Neil, many thanks for your thoughts and comments

      Firstly as I mention, I am also a physio who occasionally puts his hands onto patients, and although my wording is passionate at times there will be no abuse directed or tolerated towards anyone willing to discuss and debate manual therapy on this site.

      The theme of this post is about the explanations and language around manual therapy not the therapists per se.

      Many therapists use these terms and explanations due to a dogmatic belief that they can and do mechanically and structurally alter connective tissue with manual therapy (and believe me, there are many…) and I am under no illsuion that this post will not make one iota of difference in their fixed beleifs and mindsets.

      However many therapists still use these terms out of habit or perhaps from a lack of knowledge or understanding of the current evidence base and literature and are willing to learn and change practice, it is these I wish to reach out to.

      If this post makes one therapist question what they do and how they explain manual therapy to patients then it has done its job, and I am happy with that.

      Kind regards

      Adam

  6. A delightfully opinionated and honest blog as ever Adam. Thanks for sharing!
    In this case I reckon the term ‘thanks for sharing’ ‘s association to the self-help-group industry is very apt!
    ‘I have a problem with manual therapy and here’s why’.
    It reminds me of Dr Neil O’Connell’s fave line: ‘I’m a recovering manual therapist’

    I very rarely hear anyone disagree that words matter and therefore most are starting to understand the need to move away from language that suggests causative structural and mechanical faults. I agree that the move away from language that suggests structural and mechanical mechanisms of treatment is a slower burner…

    What we mustn’t demonise though are the words themselves. Terms like ‘release’ and ‘break-down’ can be attached to abstract concepts, emotions and events, not only structures or other more literal constructs.
    For example;
    I share your hate for ‘release the upper traps’, however if the patient shares that massage ‘releases tension’, the word can be explored. In this case, if you were to rub said sore traps, perhaps this would be a perfect opportunity to discuss the semantics around the word ‘release’ and highlight mechanisms that might truly be caustive? Thus making manual therapy facilitatory to actual change.

    I’ve had some great conversations recently (panic not podcast fans, some are recorded) with some brilliant clinical and academic minds regarding the language used in their fields. The terms ‘entrapment neuropathy’ and ‘trapped nerve’ came up in one of these chats and we agreed that even the ‘diagnosis’ in this case can lead therapists and their patients to attribute symptom relief to ‘untrapping’, despite predominantly physiological mechanisms.

    Loving your work. But here’s hoping your groupies don’t blame the actual words!

    Jack Chew
    @Chews_Health

    • Hi Jack

      Thanks for your comments

      Firstly… groupies… where are you!!! I seem not to be aware of your exisitance…

      Secondly… you’ve recorded conversations with ‘brilliant clinical and academic minds’… I dont remember being interviewed again!!!

      Thirdly… you make some very valid points, perhaps some words like ‘release’ ‘untrapped’ can be helpful in certain senarios with clear explanations, but I still argue there are simpler easier ways to describe what manual therapy does without the risk of misinterpretation of a mechanical structural effect.

      Cheers

      Adam

      PS: Mutal appreciation of loving the work you and the team do at The Physio Matters Podcast… group hug…

  7. Hello Adam, first time reader, some-time manual therapist. Thank you by the way for having this conversation, I will be taking it to my students and continuing it. I am struggling/not struggling with what you are saying because I feel very much the same way, though not in any way as articulately. I do not hate manual therapy though. I LOVE getting treatment, but because I also treat, I struggle daily with the question – “what is this doing?” and when I’m a patient I really don’t care what you (therapist) think it’s doing – just do it.

    As an osteopathic manual therapist suspension of disbelief of magical thinking is really a necessary requirement to complete the education here. To continue to sustain that disbelief one must also be heavily affected by confirmation bias – an affliction too common in this industry.

    I teach Research Literacy as well (making my students evaluate a manual therapy claim using research), and I teach con-ed courses and have recently been altering them to address those language elements I am uncomfortable with. It is proving to be a LONG ongoing project but I frequently use “I don’t know the exact mechanism, but …. insert theory based on current biomechanical/physiological/anatomical/research considerations here”. Your suggestion also welcome, because ‘unlearning’ a rote reply is quite difficult.

    My other struggle is the use of research or what is often termed “evidence”. I read A LOT of research and most of it, with relation to manual therapies, is significantly methodologically flawed (whole host of reasons) and suffers from design and reporting bias in fairly obvious ways. This, however, makes the results (quantitative) not usable in the ways they are being used. Unfortunately these same results are continually used to make a point about one thing or another related to manual therapy (as a whole) without critique of the source and without specification to the research itself i.e. way too much generalization to the industry as a whole from one or two small, methodologically questionable studies based on throwaway “conclusions” from the authors. I tell my students and basically anyone who will listen that we cannot have it both ways – either the study is good, really good, and the results are usable, or the study is questionable and so are the results. Also, more than one study, please! This does not make the research unusable (evidence is a gathering process, small piece, by small piece), but like the problematic language around the mechanisms of how manual therapy works, the language around research evidence and the ways in which we take just those pieces of the evidence that suit our argument (for and against) is just as problematic. I have two ways of speaking to this – In order to believe the evidence you have to believe the EVIDENCE (critique, critique, critique), and my fave from a recent article – The Pendulum of Science Swings Again.

    The language used around MT is problematic with or without research evidence, and an uncritical reliance on the current available evidence (access is a whole other problem) is just as challenging and can equally contribute to maintaining a dogmatic approach on both sides of the fence.

    Challenge however is what we need to continue doing. My current solution is one student at a time, but I might just get myself a blog too rather than piggy backing of yours. (Verbose is a term often used to describe me – maybe why I don’t have a blog already)

    Please keep writing and challenging.
    Monica

    • Hi Monica

      Thank you so much for your comments, and you are absolutely right lots of evidence is flawed and methodologically inept, and confirmation bias is EVERYWHERE in EVERYONE!

      This is a great blog on confirmation bias by Alan Taylor you will also enjoy reading http://alteredhaemodynamics.blogspot.co.uk/2014/10/confirmation-bias-physiotherapy-and.html

      However we must use the data and the best evidence and research wisely but as Sackett originally stated it is only one part of evidence based practice, clinical expertise and the patient values and expectations are also key

      The other point you make with regards to the patient not caring too much about the terms used with manual therapy just as long as it feels good has come up before, and I do understand this. But there is still a potential for reliance on therpay and its open to abuse by some charlatans and unscrupulous practioners.

      So I do think its worth trying to change the general perception of what manual therapy does that the general public has, but i am under no illusion this will take decades if at all.

      Kind regards

      Adam

  8. Love your post. I am a newly-hired teacher of massage therapy at a private school. A lot of the curriculum has to do with the mesoderm, the muscles, bones, joints, and how we release adhesions and what-not. I’ve been a fan of Diane Jacobs, the ectoderm, Somasimple, Paul Ingraham, etc. to name a few (this is not a argument from authority fallacy – just trying to make a point of how they were a game-changer, a meme-breaker, and so on). I believe you are spot on. I do feel like a split-personality now and then, having to teach some notions that I don’t agree with. We have yet to speak about skin, cutaneous nerves, placebo, non-specific effects… we jump to “releasing muscles” too quickly, forgetting the foremost purpose of social grooming.

    I hope my post is not too horrific in syntax. Had a lot of ideas that I wanted to throw out there. Keep up the good work.

    ps: I’m getting all too tired of the “but it worked for me post-hoc fallacy” – lot of effort wasted trying to explain this one to students/believers/etc.

    • Hi Stephane

      Thanks for your comments. I too often read Diane Jacobs and Paul Ingrams work and think they do some awesome and great stuff, I try to get onto Soma every now and then and find it a useful and enlightening source, but do find the site a little pompous and condescending in tone at times, and can be way over my head with the neuroscience and philosophy as well.

      You mention having split personalities and I can relate to this, I think a lot of therapists can, and in a way that’s not a bad thing as we still have no conclusive evidence, and probably never will that one way or mechanism is the right way, so keeping some skepticism and not placing all your egs into one metaphorical basket is essential in my opinion.

      You are also right about post-hoc fallacy’s being extremely rife in the manual therapy profession and again can and is used for lazy clinical reasoning and quackary, not cool, we should always question whi why something works or doesn’t.

      Thanks again

      Adam

  9. I am a Massage Therapist Adam and there have been great changes afoot. Perhaps we are not doing what we thought we were doing, but we do still get results. I have met Physios that speak of adhesions, muscle release, fascia, I have met physios that explain all problems as mechanical, a structuralist view that involves stretching, exercising. I believe both professions are changing radically.
    Will physio as it is today, still be around in 10 years? Maybe not, you guys also have to change your view, your understanding, you too are not necessarily taught pain science as we understand it today. I have just been on a course about the nervous system, full of physios. Their understanding seemed no better than mine. In my view Adam, you are not a perfect profession and nor are we.
    We know we need to calm the nervous system, what better way that touch, reassurance, education. Room for us all.

    • Whoa whoa Susan… please read my post again, you will see that I don’t name or point to any profession, instead I use the term manual therapist, this means physio, osteo, chiro, massage therapists, rolfers, ART, MFR etc etc doesn’t matter what you call yourself or what qualification you have or dont have, this post is directed at ALL.

      There are just as many ‘manual therapists’ in all professions that still cling to the mechanistic fallacy’s around manual therapy and I am in NO way saying phyios are any better or any worse than others, nor does it say this in my post, rather I think your own interpretation of the blog sees it as such due to your own biases and defense mechanisms being a tad high.

      And…. NO… physio will not be the same in 10 years time, just as it is not the same today than it was 10 years ago in the past, That’s normal scientific progress, but not all will follow it, it is easy for some to get comfortable and stay comfortable, when change and evidence dictates change in practice many don’t as it feels threatening.

      In my view Susan I think you may want to step down from hyper-vigilance and defense at little and see that I am saying just as you have said, that ALL manual therapy professions are as bad (and good) as each other.

      Regards

      Adam

      • Thanks Adam, yup, a bit defensive and biased I’ll agree. No doubt arising from a complete discombobulated concept of what we do and what I do in particular. Thanks for voice of reason.

  10. Adam, thanks for your raw honesty!

    Many in my [chiropractic] profession here in America insist that not only is it important to choose the one, precisely correct spinal segment to “adjust,” but they add magical, mysterious twists and torques to their hand contacts during a light thrust (often entirely absorbed by soft tissues) as they feign higher wisdom for their years of experience with their particular technique. Nauseating.

    With much of spinal manual therapy, does it really matter “where” or “to what spinal segment” our pokes and thrusts are directed? We don’t know (though many of us pretend to know.) When confronted with what many perceive to be a lack of segmental mobility (Triano’s “functional spinal lesion”) does it matter whether manual therapy is performed AT ALL? Still hard to say, and neither the Cochrane Database or prevailing meta-analyses are of much help at present.

    So what are we doing with manual therapy? Mobilizing intra-articular synovial folds, as Lynton Giles (Australia) suggests? Breaking up long-standing intra-articular adhesions? Or, in the context of myofascial tissues, are we initiating a molecular process when addressing “lumpy bits” or “fibrous adhesions” within fascia over time (purportedly shortening molecular linkages to the 5-dalton range) as Antonio Stecco (Fascial Manipulation, Italy) suggests? Are we simply creating dependence on passively-applied therapies? Is it really all just the laying-on-of-hands?

    You rightly point out that in our discourse with patients we must hold allegiance to the nothing but the truth. Eschew wandering explanations. Reject the blather. In light of the work of Lorimer Moseley and both yours and his BJSM podcasts with Dr. Khan this year, my own conversations with patients are tightening up nicely.

    Thank you for your bold work, Adam.

    • Hi Dr Carmichael

      Many thanks for your comments and wise words. As you say there are many explanations for what is thought to happen with various manual therpay, and really simply put know one truly knows, certainly not me! Thats why I say as much to ALL I do rub or poke and simply ask that others consider doing the same

      Thanks

      Adam

  11. Another good one Adam, you seem to be going through your own personal journey with your blog, your comments are softening,but maybe the comments you are getting are more sensible now. I basically agree with all your saying but feel we have such a long way to go with the patients getting on board with all this, as it is, we are not even close with the therapists. I’m a bit torn as I feel instead of balance, we now have the manual therapists versus the “non” manual therapists. The strict manual therapists clinging to crazy alignment, tissue release,fascial release, shifting molecules etc, and the “non” manual therapists who feel like its a badge of honour to say “I don’t touch patients”. After 20 plus years in practice ,try as I may turning the tide is proving very difficult. Even the patients who “get” what I’m saying, don’t get it. After explanations of change in perception, affecting the nervous system (not de tightening muscles etc), I get a look like “so what, just do what you do”, I.e. They don’t care. 2 patients this week highlighted the medically educated and uneducated expectation of treatment. The first a real estate agent, I had not seen them for 8 months, have you been exercising I asked, answer “no”, have you done the exercises I advised last time, answer “no”, the patients response, “I just need that rib popped, I feel 10 years younger when that’s done”. I did my examination of his shoulder ,gave advice, stretched some ribs a bit, but it didn’t “pop”, he left almost crest fallen because the rib hadn’t been popped. I’m not really asking for advice but someone like this is almost unchangeable in their opinion of what is required, yet these are the tough nuts that need to be changed. The second was a highly regarded radiologist in my city who I had not seen for a couple of years and they proceeded to talk in terms of alignment , asking me if they were “out”, going on tell me they got a CT scan of their spine and there was a little bit of arthritis at one level so that’s why they had pain there. Then going on to tell me about their new imaging centre and how good it was as they were doing a lot of facet injections, PRP injections and other interventions that anyone who was up to speed would know are considered a waste of time now. I was a bit gobsmacked. Sorry for the long rant but that is just a small slice of the week that seems to go on and on! These days I generally take a long metaphorical sigh and wonder if there is any light at the end of the tunnel. Cheers.

    • Hi Nigel

      Thanks for your comments, you are not the first to say i am softening! I cant see it, I still think I am a cantankerous, stubborn git, maybe I am a little more tolerant, maybe I have learnt a few things over the year or so I have been blogging, maybe it is as you said just not having as many ad hom attacks.

      I think there has always been a hands on v hands off war in physio for as long as I can remember I just think its more public nowadays, but I think this is good, having the two sides will help keep the balance, there will always be outliers with extreme views the rebels, mavericks and agitators, but its these that ask the difficult questions, push the status quo and promote progress in my opinion.

      Thanks for sharing your story or rant as you call it, I can relate totally, all I can say is, your are not alone, take the rough with the smooth, the good days with the bad and in general all tends to find balance.

      Cheers

      Adam

  12. Thanks for this healthy discussion topic. I don’t want to discuss the need for a deep critical revision in the way manual therapists comment on what they actually do.

    I would like to say two things :

    1. Radiologists, rheumatologists and GPs may benefit from engaging in the same critical revision. There’s quite a gap between those who conduct and publish RCTs and other research, and those who treat and explain things to patients. My opinion is that the problem you describe in Manual Therapy is not, alas!, limited to Manual Therapy

    2. Your point is focused on “what’s happening when a patient is treated through manual therapy”. I would be interested to read your opinion on “what happened when pain/stiffness/distress suddenly occurred”. I’ve got my idea, based on the same danger signals, complex nervous system interactions, etc. but I would sincerely be happy to read yours.

    • Hi Marco

      Thanks for your comments. That is an excellent point that many other healthcare professions are far worse in the terms and explanations they use. I wrote a little about this in my previous blog on how long things take.

      With regards what happened or happens when pain stiffness occur I agree fully with your view that its the threat sensed by the neural system of potential tissue injury or overload that creates a lot of it, however lets not fully forget the structure and nociception which also has a role in pain stiffness perception

      Kind regards

      Adam

  13. Thank you very much for your blog that I follow with a great attention.
    Your post is very true, I work as an osteopath, and I use the neuromatrix model (neuroscience education and motor graded imagery) with my patients. I agree with you about the dogma of the biomechanical model in manual therapy. Unfortunately, most of the patients believe in that model wich is very Cartesian and easy to understand. It’s difficult to find the good pedagogical way to change their beliefs. If you want to shift their paradigm about pain, you need to be smooth, and maybe the way you wrote your last post is a little bit too agressive for manual therapist who received their training course based on the biomechanical model. Belief is hard to change. Regards. Laurent

    • Hi Laurent

      Thanks for the feedback, and I agree, you are not the first and wont be the last to criticise my rather forth right abrupt style when it comes to these things.

      I take your points on board, and will try as I can to stop being a bull in a china shop at times

      Thanks for a rather gentle voice of reason

      Kindest regards

      Adam

  14. Hi Adam,

    I am relatively new to this game, and though I love doing ‘manual therapy’ I am aware of the limitations of this and always tell patients this is for short term relief and will require some commitment from them to change their posture/ do their exercises etc. I am not familiar with the level of intensity with which you argue your point(s) (surely discussion can be engaging without being vehement?) and tend to agree with a couple of the gentler comments above that touch, reassurance and confidence in the therapist are all effective ways of improving a patient’s perception of their pain or their overall problem.
    I tell my patients that massage and acupuncture stimulate an increase in circulation to the area, and that the body, via the blood, then gets going with its nutrient supply / healing mechanisms, with a bit of endorphin release from the brain. That seems to cover all bases, informs the patient and reassures me that I am giving some benefit to them, but now I am not sure if this is ‘right’…?
    I’d be very interested to be pointed in the direction of any research that refutes the existence / relevance of trigger point therapy etc because I have used this and experienced this and it has worked well, again within the context of not letting the problem build up again (e.g. postural problems).
    Thanks for the post, though it makes me very uncomfortable I guess that’s the point..?! I’ll keep reading, in a take-your-medicine kind of way… 😉

  15. Adam

    Out of curiosity, what interventions to you use for the treatment of your patients and do you know the respective evidence for those interventions (i.e. exercise, modalities, etc). Thanks!

  16. Adam,

    Nice to see the comments opened up again. I just graduated and over he course of my internships and own critical thinking I have changed my perception on manual therapy. I have worked and interned at about a dozen places at this point and looking back they all did everything differently, mostly everyone got better, and the people that get better the quickest are those that do some sort of HEP and or are in decent shape. I now feel vindicated for getting the SIJ tests, FRSR, upslips/downslips, nutations, trigger points, MET, and alignment wrong when asked by my clinical instructor what was wrong after she “assessed” the patient. I felt like I was a complete idiot for a few months because I thought I just couldn’t get it.

    However, I do perform about 8 minutes of manual therapy each session for a few reasons. 1 patients seem to enjoy it and I feel without it I would question their compliance with attending therapy. 2 It appears that I am assessing them and doing a good a thorough examination. 3 Whatever I am doing seems to work at times. 4 I feel it’s somewhat expected by the patient. Without manual therapy I feel the patient would just say I can do these exercises at home and then not do them resulting in a failed intervention.

    Thanks again for your blog, of all the PT pod casts and blogs I read this is the one I look to the most.

    -Levin

  17. Not really of benefit to the discussion but having spent the last 12 months studying MT & discovering this blog and alternative thinking early on (probably to the detriment of my scores as most of my papers included a massive chunk of uncomfortable reading for the markers) I both love & hate you Adam .. but you get people thinking and debating.

    My scores were average but my eyes are open. And I enjoyed using STSSOAUO when discussing ‘trigger points’ …

    • Yeah i get that a lot, love / hate thing… More the hate but hey, haters gonna hate!!!

      I absolutely love the thought that someone used my acronym of STSSOAUO in a viva or osce 😂😂😂 great work

      Thanks and keep thinking and debating…. 👍

  18. Hello Adam, given my position (Chair of the SMA and Chair of GCMT) you might be surprised to hear that I agree with the premise of your article–and I suspect many of my colleagues will also agree. It is absolutely right to challenge ‘conventional wisdom’ and to ensure that any claims made are backed by evidence based research. I think most of the people I work with are pretty comfortable with the “I’m not sure why this works” response–although I’m not sure every client would understand the “I’ve just changed your perception of pain” explanation, even if it is backed up by the latest research. I’ve only just picked up on your post so missed the abusive responses–a little disappointing if I’m honest as there is no need for us to be defensive–manual therapy works on some level, why this might be we are not yet entirely sure, but any profession should be constantly challenging the status quo if it is to develop. By the way I don’t hate Physiotherapy (or Osteopathy, or Chiropractic) Physiotherapists were largely responsible for creating and sustaining the SMA and we continue to work with you in multidiscipline teams across a variety of sports and in private practice.

    Paul

    • Hi Paul

      Thank you for your message.

      I think you may have misinterpreted my meaning of the strong word hate here, I don’t hate manual therapists, i hate the bull shit around manual therapy

      I’m glad to hear that your colleagues may share my views but beleive me when I say that the majority of manual therapists dont, the ‘i’ve changed tissues, stretched fascia, broken adhesions, increased blood flow, removed waste products, etc etc’ are what most think and explain what they are doing, I see it day in day out…. A lot!!!!

      And believe it or not many if not all my patients do understand the altered perception explination, try it, i think many therapists under estimate what patients can understand, its a simple concept and doesn’t involve any technical jargon and paints a much simpler realistic picture of what we are doing when we rub and poke them, as I said give it a go, i’d be interest to hear what you experience

      Cheers

      Adam

  19. I’m really enjoying all of your posts that I’ve read so far, clear cut and honest opinions no matter what the subject is.

    Throughout the first year of my degree I sat through manual therapy lectures being told it was magical, only to spend the next few years actually researching and learning what the evidence-based reality was. If only you’d written this article a few years back!

    You said you do use MT, albeit rarely…are there any specific cases where MT is your go to treatment? If so, why?

    Thanks for the great work you’re putting out, this blog is a favourite of mine.

    Karl

    • Hi Karl

      Thanks for your comments

      There isnt any really go to ‘conditions’ that I use manual therapy on, its more there are go to patients that I use manual therapy, they are the ones with high expectations of it, those that have had good positive experiences with it in the past, and they are well informed about what it does and how it does it and don’t rely on it for pain relief or rehab and use it as a small part of an active rehab program, they are the go to patients I will use manual therapy on.

      Thanks

      Adam

  20. I have learned more from your blog and twitter debates than in my schooling thus far. It is reassuring that some of my disbelief in what we are taught is justifiable.

    Please keep it up!

    Adam

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