Manual Therapy SUCKS…

After recent events and discussions around negativity, critique, and confrontation I’ve thought long and hard about if it’s worth the time, effort, and no doubt aggravation this blog will create. However, after some consideration I’ve decided to go ahead, not to just piss off some overly optimistic happy clappers who think we should not ‘decry’ our profession, but to also highlight the risks that can occur from voicing opinions that are strong, different, and unpopular, and to show how some in our profession can be malicious, vindictive, and downright nasty. So if you think this will offend, upset, or bore you… DO NOT READ ON!

As you may be aware, I launched some t-shirts a few months ago with some cheeky, some will say cheesy slogans that take the piss mickey out of physiotherapy and expresses my opinions on a few things, including one that says ‘Manual Therapy SUCKS’. However, this slogan it appears was just too much for some of our ‘leaders’ and ‘presidents’ of our profession to bear, and so the proverbial shit hit the fan!

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A few weeks after I launched the t-shirts an official complaint was sent to the Chartered Society of Physiotherapy by nine ‘senior’ physiotherapists, heads of special interest groups, and leaders of our profession claiming that these shirts along with some of my blogs and social media posts were ‘damaging the reputation of the society and the profession’. They wanted disciplinary action to be taken against me and the t-shirts removed, however, they didn’t stop there. They then went on and further accused me of sexism and bullying in an effort to discredit my personal and professional reputation.

After a couple of stressful weeks with me having to defend my opinions, views, and reputation against these vile accusations, I am pleased to say that an official CSP panel could not find any evidence to any of these accusations and none of the complaints were upheld. As relieving as this is, I can assure you it was an unpleasant experience, which I’m sure is what these so-called ‘caring professionals’ wanted. However, I have no doubt that their real goal was for me to lose my licence as a physio and to be publicly discredited so that I would stop expressing my opinions on manual therapy which conflict with their own and threaten their interests.

This nasty, spiteful, and pathetic tactic of attacking a person’s character and not their argument is often used by those who want to divert attention away from things they wish not to be discussed anymore, or who just dislike the other individual. This is a classic logical fallacy called ad hominem and has been used on me many times before, but this was, without doubt, the most vicious, vindictive, and vile episode I have ever experienced.

Name calling

I’ve been called all manner of offensive and derogatory things over the years, as well as being accused of having all sorts of ulterior motives for expressing my views and opinions. I’ve also had previous complaints, disciplinary’s, solicitors letters, even ‘open’ letters sent to me on social media. But, these have never bothered me as I know most are nothing more than pathetic expressions of angst, frustration, jealousy, or envy. I also accept that my strong views and opinions will attract strong views and opinions back, and I am also aware that I can have a direct and sometimes blunt way in conversing and discussing things, and yes, I am also aware that I swear a lot which I know offends some people!

But so fucking what!

Your offence at what I say, where I say it, and how I say it is just that, yours. Offence is more often than not taken rather than given. Simply put no one makes anyone listen to or read anything they don’t want to. We all have a choice at what annoys or upset us, take this blog for example, if it’s pissing you off… STOP READING IT. 

Being offended at someone expressing their views, or their tone, or their language is essentially demonstrating that you are incapable of controlling your own emotions and expect others to do it for you. GROW UP.

However, this is not making excuses for, or defending some clearly obnoxious twats who deliberately go looking to offend others, these are clearly indefensible. But offence is on a continuum and many need to be more tolerant of different views, opinions, expressions and even language used. Now I will admit I have made some mistakes in the past in how I have communicated online and face to face, and I have no doubt that I will continue to make more in the future. This is called being a human. But believe it or not, I learn from them and I try not to repeat them, but this doesn’t mean I will soften or change my views or opinions on topics I feel strongly about.

Harmful

Many see the public online discussions, disagreements, and arguments that myself and a few others create as being harmful to our profession. They think that calling out nonsense, bull shit, or outdated practice is harsh and unproductive. Well, I think the exact opposite. I see ALL the discussions and disagreements as useful and signs of progress, even the flame wars which although can be a little tedious and pathetic at times, usually give me something to ponder. As Gandhi famously said ‘honest disagreement is a good sign of progress’.

Personally, I think by dragging the difficult topics and taboo issues out into the light from behind the closed forums and specialist echo chambers, and laying out different views and opinions for all to see, more will become aware, and more will feel confident to add their own views, and the more chance things have of changing and moving forward. As Jack Chew said on his recent podcast with me last month, when there are disagreements and difference of opinions the answer is always more discussion, not less.

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As I am sure you know, I like to make my views and opinions clear on many things such as taping, injections, motor control exercises and often many disagree with them. This is great, and partly why I do it, and also why I occasionally take a stronger position to play devil’s advocate. I enjoy many of these debates and disagreements, however, I find I am enjoying the discussions around manual therapy less and less, mainly due to the maliciousness and nastiness of those who have vested interests in it and who just want to attack me rather than my argument.

Low-value

Now just in case anyone is still unclear on what my position is on manual therapy I will lay it out one more time. I believe, based on current evidence, and my own clinical experience that ALL manual therapy used in musculoskeletal physiotherapy for pain is a very low-value intervention due to its non-specific, unreliable, short lasting, small effects.

In a nutshell, I think ‘Manual Therapy SUCKS!’ and should be abandoned by all musculoskeletal physiotherapists as it offers little for the effort and resources it consumes.

I do accept that manual therapy can reduce pain, a bit, in some, for a short while, but so can using heat, or ice, or going for a walk, and these are far cheaper and simpler to administer. When you compare manual therapy to other interventions for pain relief in many musculoskeletal conditions it’s hardly impressive, and this is why I believe that it has NO place in a public tax-funded health care system. It wastes resources, clogs up services, detracts time and attention away from the simpler higher value interventions. Of course there are many other interventions besides manual therapy that also waste resources and are low value, but lets just stick to manual therapy for now.

Many think my ‘hands off‘ position is too black and white, and that I am too harsh in my critique of manual therapy, after all, it’s a low-risk intervention with very little adverse effects when compared to things such as medications or surgery. Although this is true it still doesn’t mean manual therapy is worth using. Low risk, doesn’t mean worth using.

I do accept that manual therapy rarely causes any serious adverse events that medications and surgery can do (ref). But what many don’t understand or recognise are the other adverse issues manual therapy can cause. The first is that all pain relief treatments be that medications, injections, or manual therapy have the potential to, and do create reliance and dependency on them. Some patients can associate the temporary pain reducing effects that these interventions create as essential and necessary to continue, and this can lead to a loss of time, money, but more importantly self-efficacy.

I also don’t think many recognise the detrimental effects these low-value interventions have on our economy and healthcare services. As a clinician in a busy, overstretched, underfunded, NHS orthopaedic department I am constantly frustrated daily when I see and hear patients who could have been managed quickly and easily with some simple advice, guidance, and reassurance. But instead, they have been passed from pillar to post and forced to wait months due to departments and services clogged up with patients being rubbed, poked, clicked, pricked, taped or zapped for things that just don’t need it.

Finally, I don’t think many understand or recognise the detrimental effects these low-value interventions have on our society as a whole. The constant desire to reduce pain when it’s not necessary I believe is making our society less tolerant to pain, and many healthcare professionals are to blame for this, and this means YOU.

More clinicians need to understand that there is nothing uncaring, unprofessional, or unethical in advising patients to endure some pain from time to time. Many healthcare professionals need to understand that for most musculoskeletal conditions they often just need to confidently, respectfully, compassionately advise patients to carry on as normal.

However, do not think this is easy to do, this is hard, very hard and requires a clinician with skill, training and experience to do it well. The clinician needs to have an in-depth understanding of pain, pathology, and psychology, and this is why many do not do it. They are either unaware, unable, or unwilling to do this as it is often far easier to give the crappy explanations, do the shitty manual therapy, strap on the buzzy machines, or stick a needle into a patient to distract them rather than explain the complexity and uncertainty of pain and to carry on regardless.

Make no mistake, the physiotherapy profession is at an important crossroad in its history. It can either continue on the way it has offering low-value treatments to anything and everything putting us alongside the complimentary ‘professions’ on the fringes of healthcare with their energy crystals and chakra realignments. Or we can choose to abandon the low-value interventions and focus on doing the simple things better. Things such as giving good advice and education more effectively, encouraging physical activity and reducing sedentary behaviour better, and helping with other physical and psychological stressors that contribute to pain and poor health.

Vested interests

It is these views along with my concerns about the motives, ethics, and vested interests of many within the training and education ‘industry’ that has built up around manual therapy that make me question and challenge it so much. All postgraduate training in manual therapy often always over complicates its application and over exaggerates the technical skill needed to apply it and the mechanisms of its effect, not to mention over promoting its use and overcharging for its courses.

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However, this does not mean, nor have I suggested that manual therapy can never be used. I know that some health care professionals use manual therapy responsibly, wisely, judiciously and to good effect, annoyingly. But these excellent clinicians are in the minority. In my experience many who use manual therapy use it inappropriately or at the expense of other more effective treatments. In my opinion manual therapy can be most useful outside of healthcare in other environments such as health spa’s, beauty salons, even in sports, although I see similar issues with its overuse and over exaggeration here as well. However, in my opinion it is in these environments where manual therapy belongs, as a luxury, an extra, some frills around the edges, some sprinkles on the top, a nicety rather than a necessity.

As a physio working in both public and private healthcare I now do not use ANY manual therapy. I used to, but over the years I have realised it’s just not needed to do my job well or effectively. And I don’t miss it, and neither do my patients. OK I do get some who ask me for a rub or a click now and then, but when I explain how it won’t help much in the short term and definitely won’t in the long term, and how it detracts away from what we need to be focusing on, most patients understand and continue to do an extra set of squats. But not all, some do go and get it elsewhere, and that’s ok, that’s their choice, and probably my failing for not explaining why they don’t need it better.

Now one final thing, just because I dont use manual therapy doesn’t mean I don’t touch my patients as I am often falsely accused. There is no argument from me that touch is powerful to those in pain and/or distress. Touch can and does calm, soothe, comfort, and assist both physically and psychologically, and I will occasionally use touch to guide, assist, or encourage a movement that a patient is scared, fearful, or lacking strength to do. Sometimes a few simple reassuring confident guiding touches during a painful movement is all thats needed to get a patient going forward. But this is not manual therapy per se, this is not joint cracking, pressing, or soft tissue rubbing, and there is no special technique or magic to it.

Summary

So if you’ve made it this far, well done. I will finish by saying some senior physios scumbags are nasty, spiteful, vindictive people who will attempt to sabotage a persons reputation and career if their views and opinions are challenged and especially if their vested interests are threatened.

However, if they think they will deter or stop me they are mistaken. They can keep coming for me if they wish, but I am actually more determined than ever now to continue to call out their bull shit, and nonsense, and bad outdated practice, and continue to promote a more simple, honest, pragmatic way forward for physiotherapy. I will continue to push for a monumental shift in how all healthcare professionals manage people in pain, and I will continue to argue that we need to be more open and honest about what works and what doesn’t. Finally, I will continue to argue that we need to remove and abandon low-value interventions and adjuncts from healthcare including manual therapy, which quite frankly SUCKS…

As always thanks for reading

Adam

 

 

42 thoughts on “Manual Therapy SUCKS…

  1. I treated acute and subacute ACL reconstruction patients for years in a balls to the wall public in-patient surgical ward, up to my neck in people who really had something to complain about. My most sublime function was helping them adjust and move forward in their situation. I used my hands to show them they could mobilize scarring incisions and to help them work with normalizing ROM. This is sort of a mobilization with motion (MWM), but probably not in the way Mulligan intended. Anyway, as a research scientist with strong clinical experience that closely mirrors yours, people should know that nothing you say is particularly inaccurate in the framework of the scientific method and EBM. Keep it up Adam.

  2. I agree and disagree. Manual therapy does have its place, but I think the conceptual framework behind the therapy does need to change significantly (IMO from biomechanical to neuromodulation). Only then I feel that it is validated within the ethical, practical, scientific and clinical physiotherapy practice.

  3. Refreshing piece, Adam. Well said. I’ve been a skeptical physio for many years. All that time and money wasted on electrotherapy and manual therapy …. As a physio, I’ve had most fun in my career working with the elderly, trying to stop them falling over – which involves a lot of problem solving, environmental changes, equipment prescription, education etc and absolutely no manual therapy – until I discovered lymphoedema therapy – an area wear touching someone could actually help them (and improve their mobility). So there is hope out there for some ‘manual therapy’. I’m living in the US at the moment – it was too hard to get my PT license (thank the Lord – healthcare system here is just about making money, it seems, for the most part) – so I’ve just gotten my massage license. I’ve got to say, if you like touching people and using manual therapy, then life as a massage therapist can be a whole lot sweeter than dealing with the snotty physio’s who claim that 60 seconds of joint mobilisations and a hot pack and some intereferential is going to make a difference to someone’s LBP. Don’t get me started on core exercises. Keep up the discussion and never assume that anything that is taught or dictated is effective or relevant. Bravo!

  4. Hi Adam,

    Long time reader of your blog and recent graduate in Physiotherapy. Interesting article and thought provoking in evaluating times I have used manual therapy in practice. In terms of managing pain manual therapy may have the placebo effects that provide pain relief for a pt. When I see pt. who I feel need a bit of poking as you say I refer to education on self management using foam rollers or hockey balls or whatever they find works in providing the pain relief. However I still find pt will complain about lack of manual therapy or think education on pain management and reassurance that moving through some pain is safe just isn’t enough. These pt cohort will swear they feel better after manual therapy be it massage, mwm, joint mobs etc… how do you suggest we keep these pt happy with non manual therapy based treatment ?

    • Sometimes you can’t and shouldn’t keep patients happy!!! Patient satisfaction is a terrible measure of effective management in healthcare. A lot of my patients if you asked them would say they are not happy to do what I ask… but they all understand why they have to do it!!!

  5. I feel like your final paragraph undoes everything you wrote before it.

    “Touch can and does calm, soothe, comfort, and assist both physically and psychologically, and I will occasionally use touch to guide, assist, or encourage a movement that a patient is scared, fearful, or lacking strength to do.”

    Now I know you follow this up, by qualifying that this touch isn’t manual therapy, but it’s still the basis on which effective manual therapy is used. If you could perform a relatively quick technique that helps to reduce pain in your patients (albeit, temporary reduction) and allows them to perform more exercise, why wouldn’t you?

    So long as they’re clearly educated on what manual therapy does and how exercise is the best thing for them in the long run, why wouldn’t you do it?

    I think you have a lot of good points, and a lot of good other content on this blog, but it loses its oomph for me when it’s spoken in such absolutism… but I suppose that generates good conversation.

    • I disagree… caring reassuring touch is NOT manual therapy. Shaking someones hand, placing a hand on a scared patients shoulder to guide them to move is NOT manual therapy. Cheers Adam

  6. Hi Adam,

    I find myself largely in agreement. I consider myself generally a somewhat hands-off Physiotherapist and I certainly consider providing patients with the right education absolutely fundamental.
    That said, I would be interested to hear why you suggest Manual Therapy should be completely abandoned:

    “There is no argument from me that touch is powerful to those in pain and/or distress. Touch can and does calm, soothe, comfort, and assist both physically and psychologically, and I will occasionally use touch to guide, assist, or encourage a movement that a patient is scared, fearful, or lacking strength to do ”

    As you have acknowledged here touch can help reduce distress, etc. Therefore if Manual Therapy is provided with the right/honest education, it can also be used to reduce distress and encourage movement. I feel that many patients would simply be more ‘on board’ with Physiotherapy if we could help to reduce their symptoms whilst advising them that any improvements are purely short-term. I’m sure we have all heard patients that have seen other Physiotherapists that have said ‘they only gave me a sheet of exercises’.
    I also remember you hearing one of your that with some Shoulder Assessments you would conduct a ‘comprehensive assessment’ that parts of the assessment would purely be included just to make the patient feel more at ease. Just to note I do completely agree with this – but I also tend to see Manual Therapy in a similar light.
    Not attacking any views – just interested to hear what you would have to say about Manual Therapy being a supplement to the more important components of Physiotherapy. For many patients I feel that could be the best of both worlds.

    Thanks,

    Ken

    • Hi Kane, thanks for your comments. In my opinion there is a huge difference in a caring reassuring guiding touch and what is often labelled as manual therapy. For me manual therapy covers the 3 Ms… massage, joint mobilisations, and manipulations. Cheers Adam

  7. It has been a very needed breath of fresh air to read this article and see the support for the views expressed. My own professional journey over the last few years has been to arrive at similar conclusions regarding the evidence-base of much that the profession endorses, leaving me feeling isolated and disillusioned with the profession. So much of what I learned at University over twenty years ago has ben shown to be ineffective or is currently under question. My own professional body, the Australian Physiotherapy Association’s has only deepened that disillusionment with recent examples such as the endorsement of a lecture on Visceral manipulation as Professional Development and the the prominence of dry needling on the program of the upcoming national conference. Added to that is the reinstating of dry needling as a practice in my own Health Service District, after a review of the evidence by, surprise, surprise, practitioners who use dry needling.

    Physiotherapy has maintained a privileged position, being considered an evidenced-based profession by the medical fraternity and the general public but I see this position being eroded and could eventually be lost if the majority continue to cling to practices that, although very profitable to many, can no longer be justified by high quality evidence.

    • Hi Karl, thanks for your comments and I completely agree with all you say, its embarrassing the rubbish that is labelled as physiotherapy and makes me at time ashamed to call myself one. All the best Adam

  8. Hi Adam, as soon as I became an NHS outpatient physio (after those godawful ITU rotations) I remember saying to an ESP: “Surely if the patient likes you they will do what you need them to do?”. He smiled and said “yea. Pretty much”. WTF?? What about all those electrotherapy settings I learned by heart? (Actually,not true) or the Maitland grades and the thingy you pumped up and shoved under trans ab to detect if their contraction was just so? Was it all nonsense? So, due to my growing disillusionment with manual therapy, I ended up in the wildly unsexy world of chronic pain (well the older, dress-wearing physios pitied my retrograde step). My most satisfying customers to date were the ones attending the physio-led pain management programme we nicked from Guys and Tommy’s. All just sensible advice really. A bit of psychology, a lot of exercises, loads and loads of explanation and reassurance. Hard work but great, measurable results in the ones that got better. Now I’m in the private sector and feel under pressure to “do something” but I know it is mainly futile. Taping falls off and my thumbs hurt from all that mobilising. What am I doing?… Really good objective assessments are vital so there’s my manual therapy right there. The rest is rapport and explanation, maybe? So glad you wrote about this CSP shenanigans and just feel so sorry you had to go through all that nastiness. But, here’s the thing: you have steeled my resolve to do the simple stuff well.Thanks so much Adam. See you on the November shoulder course!

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