Manual Therapy SUCKS…

After recent 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. But, after some careful consideration I’ve decided to go ahead to highlight some of the risks that can occur from voicing your opinions that maybe different and unpopular, and I also want show how some in our profession can be malicious, vindictive, and downright nasty about this.

As you may be aware, I produced some t-shirts a few months ago with some cheeky, some will say cheesy slogans that take the piss mickey out of physiotherapy and express some of my opinions, 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 this t-shirt an official complaint was sent to the Chartered Society of Physiotherapy by nine ‘senior’ physiotherapists, heads of special interest groups, presidents and leaders of our profession claiming that these t-shirts along with some of my blogs and social media posts were ‘damaging the reputation of the society and the profession’. They insisted that disciplinary action had to be taken against me and the t-shirts removed, however, they didn’t only 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 annoying and stressful weeks with me having to defend my opinions, views, and reputation against these ridiculous and 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 to some extent. 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 own personal and professional 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. But these 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… and these attacks are signs that manual therapy in healthcare is dying and these acts are the desperate death throes of those whose reputations and livelihoods are built on this shitty intervention!

Well, good riddance!

As always thanks for reading

Adam

52 thoughts on “Manual Therapy SUCKS…

  1. Although I cannot fully agree that Manual Therapy sucks ( I am biased by MWM’s as part of movement strategies ), I will always defend your right to says the things you say and the way you say it. Cheers, mate

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  2. Well written Adam.
    Sad to read that attacks become so personal. There must be space for disagreements.
    In a profession as ours, there is no truth but assumptions.
    Keep voicing your opinions as you wish.
    If we had clear answers to all our questoins there wouldn’t be room for arguments.

  3. Hehehe … “if you don’t have to defend your opinion, than your opinion does not realy matter”
    I agree on the manual terapy topic …
    I have tried to make a blog once but I did not have self discipline to do it for longer time period …
    All I can tell you, if it matters, is keep up with the good work …

  4. I understand your need to use strong, emotive language.

    I also understand your position, and the way you have coming about reaching it.

    However, I like the view that Diane Jacobs uses when it comes to manual therapy “always optional, but sometimes optimal” (paraphrased).

    Just as manual therapy has non-specific effects, as does exercise, lifestyle interventions and education.

    That is not to say they aren’t high value interventions, because most people could stand to improve their health in some capacity, it just begs the question whether it is necessary to have 4 year undergraduate physiotherapy programs to do so? Why not put the resources into psychology (behaviour change, stress management) and exercise physiology (physical activity)?

    I think the key challenge, is recognising when it *is* optimal, utilising it accordingly, and recognising when it isn’t, and not wasting time and money “chasing pain”.

    Thanks for raising the topic.

    PS I am an osteopath, and you could swap osteo/chiro for physio in my comment.

  5. Hi Adam, sorry to hear what happened to you. This is a prime example of why our profession has always struggled to progress. It’s our own physios dragging us down. You are doing a great job of challenging the so called dinosaurs of physiotherapy. I agree with everything about people in the profession who can be vicious and vindictive. I certainly believe that the younger generation of physios are much open to discussion which is promising. Keep up your good work.

  6. I agree with your view and i ‘m trying for 7 years in my own practice changing what I learnt so far. It’s a continuing effort against so many misconception. To convince patients and healthcare Collegue take time and lot of work. We have to continue the battle and Your blog is precious for encouraging us in the same direction.
    At thus time I fill raht we are more and more physio changing our practice .I don’t do anymore technic courses. Instead I learn how to manage better communication and helping people to be more confident in they own solving problem. Bravo et bonne chance from 🇨🇭

  7. Hi Adam,
    Those senior PTs have to evolve and learn how to communicate in a dialogue instead of attacking you. Manual Therapy doesn’t work longterm. It’s a passive coping skill. The only concept that has some short term benefit might be Mulligan’s concept. Ultimately, it’s explaining and educating clients and use an exercise approach that makes them move in a healthy way again and promoting self-efficacy.
    I enjoy reading your blogs. You are a very inspiring physio to look up to. If I knew you before Peter O’Sullivan’s CFT course in London in June 2016 I would have said hi. Will attend one of your future courses when I’m back in Europe. Keep up the good work….

  8. How lazy people are?!!!. Never read. Never think. Just want to maintain status quo and run behind fancy techniques. When we stop seeing patients as golden goose and have real concern for a patient, when really we want to remove their suffering, when we get self confidence on ourselves and our mental faculty … May be we might improve as a profession.

  9. It makes me think a lot about what I am doing everyday. I think active movement is always the best way for proactive patients but getting some relief with manual therapy helps too even for a short time.

  10. Well said. Disappointing, though not surprising you have been attacked personally. Not everybody can let go of their beliefs quite so easily and will defend them until the cows come home, turning nasty if they feel their beliefs and therefore their sense of self is being threatened. Don’t forget, cracking necks is not just something they/we do, it is who they are and they rely on it to put bread on the table. I have not given up manual therapy all together…. yet. I have however given up holding on to my opinions and beliefs as if they were the truth that needs to be defended with aggression and anger.

    • Thanks for your comments and insights. I know I can come across harsh on manual therapists but it is the intervention not the individuals I challenge. And we should all be able to separate our emotions from our treatments. Interventions are not identities… if and when people critique exercise I don’t personally find it upsetting, rather intriguing… All the best, Adam

  11. Same as Jonny, I am from the US as well. I have had similar thoughts from way back in PT school when they introduced spinal mobilization and manipulation. “So why are we doing this professor?” “Well, we are not really sure but it might help reduce pain… But make sure it is done this exact way”. Flash forward a few years and I start hearing and reading about “we don’t have to be as exact with the technique as we thought …”. I do some work in insurance auth for PT and I see the scenarios you have EVERY day

  12. Some Physiotherapists may not support your views, however I’m fairly sure every Scientist would agree with you based on current evidence. Shame really.

  13. Great post Adam, and considering your experiences so far actually pretty brave too as I am sure you could do without a lot of the stress and hassle that often follows these type of posts.
    However it is really important what you are doing and to be vindicated by the CSP panel is a significant victory over the manual therapy advocates. Like you I work in public and private practice and over the 10yrs I have been doing it I have found myself becoming more disillusioned with the requests from patients for manual therapy. As you said it’s really hard work constantly explaining why exercise is the better option. In fact unlike you I am soon to be quitting the world of MSK physio as quite simply I don’t feel effective enough in the grand scheme of things. There’s too many other therapists willing to rub and poke that I feel it simply makes the conversations with patients too repetitive and frustrating. Instead I’m moving into NHS leadership roles. So massive respect to you for continuing to fight the good fight. And I will certainly continue to read your posts as they are always entertaining! So thank you.

    • Hi Chris, thanks for the comments, and its a shame to hear the profession is loosing your experience, but im sure you can still do ‘good’ in management. I hear this happening a lot, good therapists being ground down by the system and bull shit and so leave the profession completely or head into HR/management. Such a shame! All the best for the future pal

  14. Enjoyed the post Adam. I am proof that you can teach an old dog new tricks. I have been working in private orthopaedic practice for just over 20 years. I taught in the Canadian manual therapy system for 10 years. The change in my treatment paradigm was a slow one. I read David Butler’s “The Sensitive Nervous System” in 2007 which led to me questioning some ideas/concepts I was taught in university and throughout the manual therapy system. Frustration with inconsistent treatment results and an ailing wrist issue due to years of manual therapy also encouraged a re-thinking of my approach. Through lots of reading and introspection, my way of treating patients slowly started to change. While I was off work for 3 months following wrist surgery, I read Louis Gifford’s 3 books and was encouraged that patients could be successfully treated with good quality education and exercise. I still use some manual work with a select few patients but am very open regarding the short-term effects and that the best way for long-term improvement is through exercise and lifestyle changes.
    It’s unfortunate that some people over-react to another’s opinion. I agree that the challenging of old school ideas is necessary for the betterment of our profession. Keep stirring the pot. Cheers.

    Aaron

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