There have been a number of papers, editorials, and blogs recently attempting to redefine and re-evaluate the role of manual therapy which I have discussed before. However, another one has just come out from the Orthopaedic Division of the Canadian Physiotherapy Association here again attempting to redefine the role of manual therapy in physio, and my colleague Greg Lehman has already given his considered views on it here. However, I want to add my own slightly more opinionated views on this and on the topic of manual therapy in healthcare again.
As much as it is encouraging to see these articles appearing and the conversations they create, call me cynical, skeptical, or even biased I have doubts that these are anything other than thinly veiled disguises of some talking a good game whilst carrying on as usual, or attempts to divert attention away from the questions around manual therapy and reflect it back onto those who question it.
The first thing to highlight in this Canadian article is that it starts with a really annoying strawman by stating that if you use manual therapy then you must feel like a bad therapist due to the criticism and controversy around it on social media.
This is utter nonsense and a common tactic that many manual therapists use when their interventions are criticised. They often complain about being victimised or attacked personally when others question manual therapy and its effectiveness. I wish more manual therapists could separate their identities from their interventions and learn to tolerate different views and opinions better.
The other issue I have with this piece is the notion that online ‘bickering’ is not helpful and may even be harmful to our profession by driving our patients to other professions who have their ‘professional act together’. This is another tactic to belittle, shame, and stifle those who question the value and effectiveness of manual therapy in physio, which in my opinion is low and may actually drive more of our patients to other professions who have their professional act together such as our PT and S&C colleagues.
When it comes to manual therapy there are four key areas that I will continue to challenge, question and ‘bicker’ about both publicly and privately. These are its elitist attitude, its notion of skill, its financial incentives and finally its belief of effectiveness
Unfortunately, there is still a strong culture within physiotherapy all over the world that the more qualified and skilled in manual therapy you are, the more qualified and skilled physiotherapist you are. This is utter bull shit. Nothing winds me up more than some pompous spine pusher thinking they are a better physio than me just because they do more manual therapy than me.
Being an ‘elite’ physio has NOTHING to do with how well you can massage or manipulate patients, and this needs to be promoted more.
There is an argument that many of the manual therapy postgraduate courses do a good job in developing more skilled physiotherapists. Well, this may be possibly true but not exclusively correct. I have seen many of the postgraduate courses and MSc programs run by the big manual therapy institutions in the UK such as the MACP and SOMM and they do cover some advanced topics such as enhanced clinical reasoning and assessment skills, blood test and radiology interpretation, and independent prescribing.
However, I also know that many of these ‘advanced’ courses and MSc programs also teach a lot of pseudoscience and crap, and have a lot of old skool biomechanical thinking wrapped up in bio-psycho-social clothing.
I have seen many of the MACP and SOMM course syllabuses and coursework that still attempts to teach qualified physios to feel for stiff or loose spinal vertebral motions, thoracic rings and ribs out of place, muscle adhesions and knots. I have seen some universities teach physios on MSc programs how to assess for questionable postural imbalances and movement dysfunctions. And finally, I have seen some advanced physio training include some real crap such as reflexology, energy meridians and even visceral manipulation.
What often frustrates me about these courses is hearing how many physios and the teachers teaching it are simply going through the motions knowing full well that it is utter bull shit but still jumping through the hoops of assessments and exams, saying and doing things they don’t believe in or would never do in practice just to get the qualification. This is one of the biggest reasons why I never completed my MSc, I just wasn’t and still am not prepared to ‘play the bull shit game’.
The other culture that still continues to be perpetuated in and around manual therapy is that it is some highly skilled, highly technical thing that takes years to learn and perfect. This is again utter bull shit.
I have been banging on for years since my first ‘there is NO skill in manual therapy‘ blog about how manual therapy is actually very simple and easy to do. If more manual therapy courses were open and honest about this and explained simply what it does and how it does it you could cut the time of training down hugely. Whenever I see courses teaching myofascial release or spinal manipulation that go on for days, weeks, months it makes me both laugh and cry a little.
Having done many of these drawn out manual therapy courses I know that the theory and safety considerations could be taught in a few hours, and the practical part could take even less time. Simply put once you know where to place your patients and your hands and you know the direction and speed of force to apply, you’re good to go. And once you have practised around 5-10 times on some people you soon get the feel of how to do it and again you’re good to go.
However, manual therapy doesn’t like to admit or accept this simplistic approach as it challenges the notion, illusion, and delusion of skill and more importantly it doesn’t justify the cost of the training
This leads nicely onto arguably the biggest barrier to moving manual therapy towards a more honest simplistic approach… money. Whether you are aware of it or not, manual therapy is big business, and not just for those that charge patients ridiculous amounts for 10-15 minutes of massage, or 2-3 minutes of spinal mobilisations under the guise of skilled health care, but it is actually far bigger business for those that teach it.
If you put aside the individual business of the sole manual therapy tutors and their courses and look at the far bigger business of manual therapy institutions, companies and universities you will see that this is something that will not change quickly or easily.
There is a lot of money to be made in the societies annual subscriptions and the course and degree fees that the manual therapy companies teach. These generate good profits for the companies and institutions that teach them, and if these companies and institutions were to accept that the time and skill needed to teach manual therapy was less they would have to charge less and so earn less. It is therefore in their own best business interests to refute or ignore those that say otherwise.
Finally, the last point is one I have made many times before and one I can’t be arsed to go into too much detail again, this is that manual therapy just isn’t that effective at helping people in pain. Ok, it does do something, for some, for a short while but when you look at the outcomes versus the cost and time to administer manual therapy it isn’t that effective, in fact, I’d say its less effective than a hot water bottle or an ice pack.
And before you all jump on that old counter argument that exercise isn’t that much more effective at reducing pain, you just can’t compare an active low-cost independent treatment like exercise which has a host of other positive health-related benefits to a costly non-independent intervention such as manual therapy that doesn’t.
Simply put you don’t NEED manual therapy to do your job as a physiotherapist to help people in pain. It’s an option to use if there’s time and a need for it after you have done everything else. But, this is not how manual therapy is taught or used. Often it is justified to help open a window of opportunity BEFORE doing other things. Often manual therapy is used as a FIRST and ONLY treatment, and if you think this doesn’t happen a lot you are deluded.
One last point I need to make clear yet again whenever I am discussing my views on manual therapy is just because I don’t use or advocate manual therapy this doesn’t mean I don’t touch my patients. The false accusation that my views mean I am advocating for complete hands-off physiotherapy is another tiresome strawman used to misrepresent my position.
Just because I don’t advocate the use of massage, manipulations, or mobilisations it doesn’t mean I don’t advocate the careful and thorough use of touch and palpation during the examination and treatment of patients. I advocate that all physios should use touch when they assess and treat patients but this is NOT manual therapy, this is just good physiotherapy.
So there you go another Meakins ‘bicker’ against the elitism, skill, money, and general ineffectiveness of manual therapy in healthcare for those in pain, and I will sign off by saying that I do think manual therapy has a place in society for those that want it, but it’s not in healthcare being given by skilled clinicians at taxpayers and/or insurance companies expense.
As always thanks for reading