More manual therapy bickering…

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 Canadian colleague Greg Lehman has already given his considered views on it here. However, I want to add my own slightly more opinionated and robust views on this and on the topic of manual therapy in healthcare again.

As much as it is encouraging to see these kind of articles appearing and the conversations they create, call me cynical, skeptical, or even biased I have doubts that these are anything other than thin disguises of some talking a good game whilst carrying on as usual, or more likely just attempts to divert attention away from the questions directed at 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 I and others create 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 really do wish more manual therapists could separate their identities from their interventions and learn to tolerate different views and opinions better.

Anyway, 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 shame and stifle those who question the value and effectiveness of manual therapy, which in my opinion is low and its continued use may actually drive more of our patients to other professions who have their professional act together such as our trainer 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

Elitism

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 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.

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There is an argument that many of the manual therapy postgraduate courses do a good job in developing more skilled physiotherapists with better examination and diagnosis skills. Well, this may be true. I have seen many of the postgraduate courses and MSc programs run by manual therapy institutions in the UK such as the MACP and SOMM and they do cover some enhanced clinical reasoning and assessment skills such as blood test and radiology interpretation.

However, I also know that these so called ‘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 most of it is utter bull shit but still have to jump 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 SOM or MACP diplomas, I just wasn’t and still am not prepared to play the bull shit game.

Skill

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 apply. 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 how and 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 illusion and delusion of technical skill and more importantly it doesn’t justify the cost of the training

Money

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 physio 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 businesses of the sole manual therapy tutors and their courses and look at the far bigger businesses of manual therapy institutions, companies and universities you will see that this is something that will not change quickly or easily.

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There is a lot of money to be made in these manual therapy societies annual subscriptions and the courses and degree fees that they teach. These generate huge profits for the companies, institutions, and individuals that teach them, and if these companies, institutions, and individuals 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.

Effectiveness

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, I will admit 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 just 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, I know it isn’t. But you just can’t compare an active low-cost independent treatment like exercise which has a host of other positive psychological and physiological health-related benefits to a costly passive 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.

Summary

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. This 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

Adam

22 thoughts on “More manual therapy bickering…

  1. Great article! The elitism part of manual therapy is what has always bugged me. They always keep manual therapy on a pedestal and our calibre as a physio is judged on how well we perform it.

    • Thats a common story I hear and one I perosnally have also come across and its ​complete and utter bull shit, I good physio is much much more than a good manual therapist!

  2. So you’re saying that when I gave my wife an little extra pressure when I hugged her… I mean highly skilled MT technique and got a nice little manip out of her t-spine that it wasn’t due to my skilled hands and hours training?😜 Even before I became a physio for years I had my non-trained mother step on my back cause it felt good to get a little “crack” or “pop” out of my spine and it was free, now my non-trained wife has to do it haha. I remember reading an article about how the McGill group discussed how rolling around willy nilly on a foam roller could destabilize the spine and that spinal manipulations should only ever be done by well trained clinicians. Even as a PT student, at the time, I laughed at how ridiculous the notion was. How could a piece of condensed foam turn you in to a floppy pile of meat? Much like you Adam I’ve grown frustrated and tired of trying to clear the BS that patients come in with before we can even start to help them cause of shit people in all of the allied health services (physio, chiro, osteoporosis and massage). It is nice to see the positive change starting because of people like you,but there is still lots of shit out there. So keep it up! Your presence keeps common folk like me moving forward.

  3. Hi Adam. I’ve not commented 9n your musings before but have observed them for a nunber of years on that Twitter. How the world has changed when you’ve become the arbiter… Poacher turned gatekeeper!?! 😁
    Top stuff though!

  4. There is so much truth to what you said and I totally believe you. We need more PT like you who’ll stand up for the bullies. It was a good call.

    Cheers, Shella

  5. Hey ASSHOLE! I;m an OSTEOPATH! SO FUCK YOU!

    NAh just kidding LLOL. I’m one of the few OSteos who is an EXCERCISE guy. I do some soft tissue and manipulation/mobilisation, BUT THE TRUE KEY TO REHAB IS EXCERCISE!
    I understand this!
    ANd that’s why I’m popular with athletes. Because I give them excercises and they see improvement and it transfers, rather than cracking people and their symptoms returning because they didn’t adress a motor control problem or a muscle imbalance .

  6. Just post some videos of your real treatments . We are all very curious on how do you treat and handle your patients, because you only make too much noice for nothing and you break into open doors buddy. All those things you over emphasize are already known to all of us who are not dogmatic but we still use manual therapy approach, because you know what? Manual therapy is not one thing, is not one technique, is about knowing and choosing the best avoilable knowledge, evidence, models and have good clinical reasoning skills and of course use youor hands. So just go ahead , show us how do you treat

    • Not sure who rattled your cage pal but how I treat patients and manual therapy have got NOTHING to do with the points I make in this blog.. so you know what… how about you just go ahead and do one!

      • Well, buddy, i answered to you some time ago about the nonsense you say about manual therapy but you didn’t allow my answer to be posted, so i give it another try. Maybe you just missed my answer.
        Enjoy!

        We are living in an era in which if one of the most famous and well know physios around the world says something that may be inaccurate or even wrong, many of us will humbly bow our heads.
        Many times I am asked if manual therapy or just manual (in the daily slang) is suitable for “everything”., or if I am using Kaltenborn, Maitland, or any other approach with a name – concept.

        Well, life has circles, but some people probably get dizzy when circling through life. But does manual therapy really suck? Are we all who teach manual therapy a group of physiomafia? Are we selling bullshit to our students? If yes, there must be something rotten in the kingdom of Denmark (don’t worry, I am not getting too Shakespearian).

        So allow me please to say, that manual therapy DOESN’T suck at all !!!
        This is because manual therapy is NOT :
        about putting discs back in place
        rotating vertebrae clockwise or counterclockwise
        getting an ACL operated athlete back in the field in one month post-operation
        cracking bones
        Straightening skoliosis with my bare hands (although I would love to be able to do)
        lengthening short legs
        pissing on electrotherapy
        “I have long time experience and this is my opinion”

        Manual therapy is mostly about:
        Training physios to use the available scientific knowledge in their daily practice
        Combining clinical experience that is obtained through this scientific knowledge and not through theories that only exist in the head of their founders
        Making physios use their brain in an open minded process and try to find their limits of knowledge too. It is not an indefinite idea !!!

        Telling that manual therapy sucks, is something like telling that physiotherapy is only ultrasound, or like medicine is only cortisone injections. So in my opinion is someone uses quotes like this, it either because he wants to draw attention to himself or has no idea what he is talking about whatsoever.
        So if manual therapy really sucks, I would like to know how one can mobilize a stiff joint like a knee, foot etc . Maybe there is an “open sesame” or “close sesame” technique that I am not aware of.
        Maybe we should ask ourselves: are we changing from “bone movers” to “bone whisperers”? are we shifted from hands on for everything to hands off for everything?

        I hope not. I think that there is a danger of losing common sense. We do have to learn how to palpate, we do have to touch our patients and use our hands, but at the same time we do have to be humble and careful on how do we explain the mechanisms of our techniques. We are all using the same techniques as always, but the explanations are dramatically changed and we have to deal with it .

        So we need to find the correct procedures to pick the appropriate approach for each patient because of course not all patients are suitable for hands on treatment, not all patients are suitable manips, of course we have to bring education for patients to everybody’s level of understanding and culture. Sometimes we may have to use ultrabullshit because our patients just likes it and this will help him trust us giving us the possibility to move to a more scientific treatment later on.

        We may also have to massage our patients as human touch has a very positive effect. It is not about what we use, but it is about why we use it. But in the end of the day our main goal as physios is to bring our patients as soon as possible to active training and therefore restoring function and improving quality of life.
        So manual therapy doesn’t suck at all dudes. As long as it don’t narrow our minds, as long as it don’t make us committed to systems and concepts, as long as we are ready to doubt ourselves and finally as long as we the physios use reflexion and metacognition together with the available scientific knowledge and clinical skills, manual therapy will be the answer for all musculoskeletal dysfunctions.
        It is also the best tool to identify our limits when we are facing a pathology that is not suitable to be treated with physiotherapy, like cancer or other serious diseases . it is the tool to chose the type of patients that need to be treated by a multidisciplinary team of health providers.
        Long live manual therapy

        • You talk waaaay too much and totally misrepresent my views on why manual therapy sucks. As I have said many times, its not that it doesnt do anything, or reduce pain or help people from time to time. Its the cost and resources it consumes to get some small transient unreliable effects in some patients (but I guess you will tell me like most manual therapists it works all the time for you). Manual therapy just not worth the time, cost, or effort… use a hot pack its cheaper, simpler, and better!

          • No my biased and narrow minded friend, I will not tell you that, because you probably did not read thoroughly my post. But please don’t tell me that you go around teaching about hot packs and get paid for that. Come on, I would expect better arguments from you. Modern manual therapy is evolving, you probably have a limited and biased opinion because either you failed, or you just want to draw attention to your profile and sell your product. You really have no idea about manual therapy. Anyway every one can make his conclusions from what you write. Take care buddy

            • First we are not friends! Second whats my product? Third I have many certifications in all forms of manual therapy, and many years experience using it. Fourth, manual therapy is evolving, but really slowly and it still doesn’t change the fact its affects are not worth the cost and resources to achieve! Finally you still sound like a judgemental bell end who knows fuck all about me! Maybe we will meet one day and either agree to disagree over a beer or continue to think each other is a fucktard!

              • That would be fun. Looking forward to that honestly. Because I agree with many of your comments I have questioned strongly the dinosaurs, the Structuralists, the concepts with their biases, I was also a black sheep of the concept I was educated in, but I still believe that manual therapy rocks. I am a huge fun of Zusman and consider him as my most important mentor.
                So if we meet, the first beer is on me.
                Cheers

  7. Kostas, it’s hard to understand you perhaps because of a language barrier. But, it doesn’t appear to me that you are using science at all, but a perversion of it to support your beliefs. This is exactly the dogma of manual therapy and why the PT profession has such a difficult time moving forward.

  8. Must be the first article where your views start to be clear. Great read!
    I do not feel the same about some of the topics you address, but hey, it is your blog😂.
    A physio doesn’t need manual therapy to have succesful outcomes, but I feel that sometimes(!) that is something you need to enable the exercise part.
    In Finland most occupational health physiotherapy contracts include only active physiotherapy(no manual therapy are allowed), many of the clients think that there nothing I can do and they are wondering why are they refered to me if I only assess and give advices😂😂 yep, there is nothing I can do if I can no Apply my manual therapy skills..except the core of physiotherapy, that is everything else.

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