Abandoning manual therapy…

Over the last few months, I have received some emails from physios who are disillusioned with the profession because of the emphasis that is still being placed on manual therapy (see below). It appears that many young physios are being told that massage, manipulation, and mobilisations are an essential part of physiotherapy and should be used on everyone they see. This is not only disappointing but also complete and utter bollocks and I want to say a few words about this.

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It appears from the emails above that many physios are being chastised, reprimanded, and even threatened with dismal by their peers and managers for not using enough manual therapy on their patients to keep them attending appointments. I find this extremely sad, worrying, and frustrating that some physios seem more focused on patient retention and profit rather than evidenced-based practice and patient outcomes.

I do understand that we all need to earn a living and be fairly reimbursed for our skills, experience, and services. But I think physiotherapy (and all healthcare) reimbursement systems are screwed up, be that in the public or private sector. All healthcare, including physiotherapy, is reimbursed for its time and what treatments are done regardless of the results achieved. It doesn’t matter if an episode of care or treatment is positive or negative, physios still get paid. This is crazy!

If we only financially incentivise physiotherapy for its time or for doing treatments rather than outcomes achieved, then physios will continue to be disinterested in patient results. However, if physios were financially incentivised for successful achievement of patient outcomes I wonder if there would be as much focus on all the taping, needling, or manual therapy?

At the moment in this current healthcare system, being a conscientious evidenced-based physio who consistently looks to develops a patients self-efficacy, encourage self-management, and strives to achieve a quick and efficient discharge once a patient’s goals have been met is an extremely tough and shitty way to earn a decent living.

There is no doubt that manual therapy can help reduce pain and improve function for some people, for a short period of time. However, manual therapy is unreliable with variable effects that are only short-lived and minimal in size. In fact, I would argue that a simple hot pack has comparable pain-relieving effects to any manual therapy but is more consistent and reliable in its effect, not to mention a damn sight cheaper, and a lot less time-consuming to apply.

In my opinion manual therapy is often used to justify the therapist’s existence giving them a feeling of purpose and responsibility, and often used to pander and pamper to patients rather than to genuinely help them.

Tools in the toolbox?

Manual therapy is often described as an essential tool in the physios tool kit, and that it opens the window of opportunity for patients. However, these are lame excuses as manual therapy is more a tool to help physios retain patients and it tends to open the window of opportunity for physios bank accounts rather than patients goals.

Over the years I’ve had numerous discussions and disagreements about the pros and cons of manual therapy with many of its advocates and gurus, and I’m sure I will continue to do so. I have discussed how manual therapy is not specific and doesn’t do any of the physiological things many claim it does here. I have talked about how manual therapy is not that skilled or difficult to learn and doesn’t require hours, days, or weeks of expensive training or courses here. I have highlighted how there is a large and profitable industry behind manual therapy with many individuals with huge vested interests in it here.

Over the years I have collected and shared a good deal of research that questions, challenges, and refutes many of the pseudo-scientific claims of manual therapy and demystifies its methods of effect, and you are all welcome to read some of this in part of my Google drive that is open access here.

I have mentioned many times how I was taught to use lots of types of manual therapy on patients, all with various degrees of success and failure. I have also mentioned many times how I NOW DON’T USE ANY MANUAL THERAPY AT ALL, EVER, AND I LOVE IT.

Dropping that half-arsed 10-15 minute massage or those 3 sets of 30 secs bouncing up and down on 3 or 4 levels of a patients spine isn’t the end of the world. All I find that manual therapy does is wastes time, distracts patients, and doesn’t really help that much in the grand scheme of things. Abandoning manual therapy now gives me more time to focus on the more important aspects of my job such as talking to my patients and getting them to move and exercise more.

However, I need to reiterate that just because I don’t use manual therapy this doesn’t mean I don’t recommend that you don’t touch your patients. I use touch to examine all my patients thoroughly although I know it often has little diagnostic use. I use touch during many of my sessions to help encourage, reassure, and assist patients to move or do things that hurt or cause them concern. I just don’t use manual therapy.

Not doing doesn’t equal easy

I am a proud and vocal advocate that as a physio you don’t need any manual therapy to do your job well. However, I will admit that this is not as simple or easy as it sounds. In fact, there are some pretty significant barriers and hurdles to overcome with abandoning manual therapy.

The first obstacle is the ridicule and rebuke you will get from other therapists, seniors, and managers who use manual therapy. I still have many therapists attempt to belittle me for not using manual therapy, mostly osteopaths, chiropractors, and even the osteopractors in the US (yes that is actually a title some physios in the US like to use, more on that stupidity here).

These weak wristed, chino wearing pillocks seem to have some misguided delusion that comparing me to a personal trainer somehow insults, offends, or upsets me. These idiots with their freakishly soft overly moisturised hands truly believe that they are more skilled and more effective than me because they think they can feel and correct subluxed ribs, stiff spinal segments, or muscle knots (they can’t, go see my google drive for the research that proves it).

However, I don’t let these elitist treatment table based therapists bother me and I suggest you don’t either. Instead, be confident in the large body of research that refutes all the pseudoscientific bull shit and take comfort that most of them couldn’t work out one end of a trap bar from the other or demonstrate a loaded squat if their life depended on it.

Patients do want it!

What will be harder to overcome will be the barriers you encounter with patients who want, insist, or demand manual therapy due to previous experiences or expectations of getting it.

Unfortunately, the physiotherapy profession has a very strong societal reputation for giving massages and rubs. If I had a pound for every time I heard someone say “I bet you give good massages” when I tell them I’m a physio I’d be a rich man. As frustrating as this reputation is, those of us who know the real benefits of physio lie in rehab, not massage just tend to grit our teeth, have a little fake laugh, and politely explain that this is NOT what physiotherapy is about.

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What is even harder to overcome is when a patient has had previous positive experience of manual therapy and wants it again. When this occurs, which it does a lot, I find the best way to manage this situation is by asking the patient what they think it does. About 99% of the time they have either been misinformed or believe that it does something which it does not.

After some rationale explanations around the more evidenced-based and simple mechanisms of manual therapy based on basic science and good evidence, I find most patients are normally a little surprised, but also not that interested in getting it anymore now the magic and mystique is removed. Some still don’t care and still want me to rub or crack them, then I try and explain that due to its unreliable and short-lived effects that they are better of using a hot pack or getting their partner to rub it rather than me.

Now I’m not going to lie to you and say this works all the time, because it doesn’t. Even after spending time and explaining this all I still have disgruntled patients who just want me to shut the hell up and crack their back or rub their quads. In the old days I used to bite my tongue and do what they asked, but these days I don’t anymore.

I have made a commitment to myself that as an evidence-based physiotherapist trying to provide the best quality care using high-value treatments that I will not lower my standards and do soft tissue massages or joint manipulations which are non-essential treatments. This does cause some disgruntled patients and a few complaints and I am well aware that some will go elsewhere to get it from someone who is willing to do it. So be it. This is their right and their choice.

When this does happen I do still see this as a failure on my part in that I haven’t been able to convince a patient that manual therapy is not needed nor essential and that they should instead be focusing on other things. However, over the years I have also learnt to recognise that you can’t connect with or help everyone you meet in this job and there will always be wins and losses. I just try to make sure you have more of the former than the latter!

A respected profession?

So to wrap this up I just want to say again that manual therapy is NOT an essential part of our profession, and if you feel pressurised to use it when you deem it’s unnecessary or not needed then I think you have a responsibility as an autonomous healthcare professional to challenge and question it.

Personally, I don’t think manual therapy should be part of our profession at all. Physiotherapy is striving to be a respected evidenced-based healthcare profession, to do this we need to recognise what is high-value cost-effective treatment and what isn’t. Manual therapy isn’t.

Finally, I want to close by saying that I never became a physio to learn how to massage muscles or manipulate joints. I didn’t become a physio to rub, poke, or prod people. I became a physio to learn how to assess, diagnose and manage pain and pathology. I became a physio to learn how to plan rehab programs to get those in pain or with disability back to function and performance. I became a physio to help people become as robust and as resilient as they can, and I am going to continue to do this. Who wants to join me?

As always thanks for reading

Adam

 

 

36 thoughts on “Abandoning manual therapy…

  1. I predict zero contact physical assessment will be added to your bag of tricks shortly.

    What’s the latest data on patient compliance with exercise prescription?

    • And I predict false dichotomies and straw man arguments from manual therapy advocates.

      And exercise compliance is around 90-100% when done under supervision and around 30-60% when not.

      Next question?

      • Adam, any physio with their head screwed on knows 70% of consumers weight masseurs, personal trainers, and physios equally. And they obviously don’t give a stuff how much education either has had, as long as they make them feel better, even if for 12 hours.

        That’s the world we live in. It’s full of ill informed apathetics, who also think the UK needs more Socialism and unskilled immigrants.
        I met a Scottish twat physio last year who is all for NHS and lots of immigration of unskilled non english speaking backgrounds.
        And here he is, trying to migrate to Australia because he doesn’t get paid enough back home.
        Truth be known, I find most physios profoundly naive and always overcompensating for wasting 4-5 years learning squat about health.

        BTW, what exercises do you recommend for Chiari malformation secondary to intracranial hypertension of unknown cause? And what are common causes of IC-HTN?

        • Hi again Bruce, you will hear no argument from me about how the public percieve physios as mass​eurs or personal trainers, but that because they tend to act like them offering nothing above and beyond, except charging more and walking around with an air of superiority thats not deserved.

          And again you will hear no disagreement from me about physios over-compensating in areas like manual therapy and exercise skill and eliteness to make up for their inadequacy issues from their poor education and not actually knowing much about much.

          I will ignore your slightly xeonphobic and racist comments as they are not helpful.

          And what has a central nervous pathology affecting the cerebellum got to do with this post or discussion?

      • Adam, that’s 5 ‘next questions’ you’ve deleted after suspending in ‘awaiting moderation’ state.
        You need to eat your veges mate, and stop modeling yourself on the weasels like Zuckerberg and Dorsey.
        It’s obvious what your caper is when I receive notices of new posts, while mine are still ‘awaiting moderation’.

        Never mind. You obviously don’t have the clinical breadth and depth to debate the issue with any degree of authority or insight.

        • Wow, Bruce, you really are an inpatient, angry, little toss pot aint ya.

          Ok, let me explain something here… I work 2 jobs during the week, I teach most weekends, and have a family and social life as well. Therefore blog comments are waaaaaaay down on my priority list of things to do, but I try to go through them once every couple of weeks.

          Some short simple comments are approved on the fly, but the long, winded, whinny, complainy or just strange ones dont, and yes sometimes they get ignored and trashed because guess what Bruce…. its a fucking blog.

          Now I suggest you do something more productive with your time other than comment on a blog. I am!

  2. Interesting article – however not sure if all the research you have cited makes the point quite as strongly as you do.
    Exercise therapy is brilliant agreed.
    Older models of diagnosis are often floored agreed.
    More research required agreed.
    Can we say that manual therapy does not work no!

    • Have I said manual therapy does not work? No! I have said many over use and over promote manual therapy. I have said that manual therapy is being used to retain patients and pander and pamper them rather than genuinely help them.

  3. I do agree manual therapy should not be used all the time but in my opinion it does have a place in certain instances. I have been helped immensely by the specific upper cervical spine work of Dean Watson here in Sydney. It is the only technique that has helped my neck/headaches.
    The emphasis is on home exercise too.

    • Thanks for your comment and as I say in the blog there is no doubt that manual therapy can help some in some circumstances. However, the point of the blog is to highlight those who are overusing it as a way to keep patients coming back, also lets not forget that all these useful manual therapy techniques can be self taught and administered. You wouldnt expect to go to a doctor everytime you had to take your medication for a condition, its no different for a physio and their treatments for conditions. If your physio is asking you to come back repeatedly, find another physio.

  4. This entire discussion simply demonstrates the utter lack of effectiveness overall of what physios do, the lack of leadership, identity and direction. Regardless of whether the therapists uses predominantly manual or exercise, or a combination, physio is doing little to develop a progressive model of care that combines biology with psychology and sociology. The present argument is nothing more than petty tribalism and does little to address the fundamental issues. Offering these blog articles seems much more geared towards stirring up the waters without much else.

    • Hi Darla, thank you for your opinion, however, I find the irony of your comment simply delicious. Complaining about a blog by complaining on a blog, and then stating my blog is a petty, futile and ineffective way to help or progress the profession, coming from someone who leaves a petty futile ineffective comment on said blog… as I said is just beautifully ironic.

      Anyway just FYI, this petty, futile, ineffective blog has had in less than 48 hours over 45,000 reads, it has over 3.2 million impressions across all of social media. I have had 100s of comments, emails, and messages sent via all social media platforms from physios of all levels in all areas expressing their frustrations, angst, relief and thanks for the post. I have had invitations of further discussions with university heads, healthcare managers, policy makers to discuss this further.

      Just out of interest apart from complaining about the ineffectiveness of my blog, what are you doing to “develop a positive model of care that combines biology with psychology and sociology” that is both cost effective and gets good results and outcomes for patients?

      Regards
      Adam

  5. Hi Adam,
    Great article !

    I wish most universities think this way, but since I just finished 2015, everything was based on manual therapy. When I was going through my placements I got pretty banged up by my clinical advisors, telling me that I should do more manual therapy, which I replied, I can get better results from exercise and education. Mind you, I got some shitty marks. Oh well. Came back to canada same shit.

    Thanks

    • Thanks Geoff and unfortunately this is a common story I am hearing and it was my experience 19 years ago and doesnt seem to have changed much. I really do think we need to do a Wiki Leaks Edward Norton style name and shame of these universities and other companies who are teaching or promoting outdated and unevidenced methods. I truly think this is the only way it will create public backlash and uproar to force change?

  6. Well stated and valid discussion as always Adam appreciate your blogs to use to support my on going battle against overused techniques and dare I say still used certain electro therapy machines. Great work mate keep it coming👏🏻👏🏻👍🏻😎

  7. Hi Adam! I find this post very interesting and I’m agree with your thoughts. But everytime I read you I wonder how the fvck you do your job hahaha. I’m a young physio from Spain (sorry for my english) and I work in a private clinic and everytime a patient comes in due to unspecific low back or cervical pain I think about you and I wonder how you would face that case. Patients just wanna lie down and receive a massage in the lumbar region or crack their necks. It would be interesting to read some post about real patients and your treatments. Thank you for making us doubt about our profession, that’s the way to improve!

    • The answer is simple, I assess, diagnosis and then educate the patients about what their issues are. I give them a plan of how to manage this and some simple strategies of how to self manage and then give them some exercise dependant on their pain levels and irritability. Cheers Adam

  8. Hi Adam,

    Always makes me laugh when I read your blogs and all the negative comments are directed at you and ‘the way you go about your opinions’ of the BS treatment within physio. Rarely do I see anyone challenging it with evidence, just offence from your ‘tone’ which appears to be taken so personally by many. As Ricky Gervais says, ‘just because you’re offended doesn’t mean you’re right!’

    I agree we can add so much more value and skill than poking and prodding painful structures.

    I don’t buy all the ‘clinical reasoning’ for MT as it tends to be nothing more than using buzz words/phrases such as ‘patient expectation’, ‘get that buy in’ to justify its use….Just because a patient expects ‘you will’ do MT doesn’t mean they expect ‘you to do it!’….Or as you’ve stated ‘that’s what the patient is paying for’. Bollocks, they’re only paying for that because that’s whats being ‘sold’ as that will make the most money for personal incentives. That’s ‘business centred care’ not ‘patient centred care’. If they were sold a collabarative action plan to help reduce pain and achieve ‘functional’ goals their ‘expectations’ would be completely different. But this will always be a problem in private practice when the focus is earning money.

    My experience of what ‘manual therapists’ do is poke and prod and talk about ‘general chat’ like what they’re doing at the weekend. This is boring and disengaging as a physio. I find maybe 5% of my interaction with a patient is ‘general chat’ and the other 95% is listening and Problem solving with them. Ive found when you listen to a patient and help break down the barriers as to why they have a problem this is what gets true ‘buy in’. Who builds a meaningful rapport with someone when they’re face down head buried in a plinth!?!

    I’m sure you’ll continue to offend many but you’ll definitely inspire just as many to have the confidence to challenge and question!

    Keep up the good work!

    Rick

  9. Your post sums up perfectly what I have experienced in my clinic.

    I’m glad to hear you’re not staying manual therapy is worthless!

    The way I see, clients DO come to us for manual therapy because that is what they have been told they need, and/or what has helped them in the past to relieve their symptoms and possibly improve their function.

    AND, it is our job to hear them.

    IF we choose to accept them into our practice, when appropriate we share with them the current approach of movement and education — possibly in addition to manual therapy.

    I see it as a 3-legged stool. All components are needed (for clinical outcome, adherence, and customer retention) and if one leg is broken, it won’t hold up.

    Ive found much higher levels of function by incorporating active myofascial therapy for the last 30- years, over just manual therapy alone.

    • Thanks for your comments Irene. The three legged stool idea is an interesting idea, I just wonder if they are as equally as important, that is are all the legs on the stool the same thickness. I see adherence being much thicker and fatter than retention and so I think outcomes can do without in many cases. Cheers Adam

  10. F*€# you Adam. I think you’re right. It’s just that changing my ways is scary as hell and you’re making it really uncomfortable to stay in my lane. Guess that was your intention though. I’ll try to make it to one of your courses soon.

    • Haha… having long-held beliefs and understanding questioned and challenged is annoying, frustrating and uncomfortable my friend and it when it happens to me, it also makes me go F**K YOU also…. All the best. Adam

  11. I’m in my last year of physio school in Alberta, and my professor decided to change our Advanced Musculoskeletal course (axial skeleton) to match the research for the first time this year. Although we still have to learn manual therapy techniques, the focus is on patient based response and exercise. So refreshing! Thankfully my degree overall has a had a focus on exercise rather than manual therapy and has been great for having us question current practices like modalities, but this course is a huge game changer.

    Thanks for the great post!

  12. Interesting point of view. I have a view thoughts. If someting is not scientifically proven, it is probably not tested. And if tested is it correctly tested(propper design, calculations et cetera)? And if a test is is significant, it doesn’t mean it is clinical relevant. The gold standard in the medical field is quantitative research, meaning good qualitative and fundamental reseach is automaticly lower in ranking in evidence. In physiotherapy there are more variables involved so this is a challenge in research. There are still a lot of questions on molecular level about the sliding filament model from Huxely and Noedergerke 50 years back. Some is proven some not. Like the serie elastic component of Schenau (in muscle). But a lot of people in the world use it despite of hard evidence.
    My motto is how more you know, how more you know nothing.

    • And that is a good motto to live by Alexander, it helps prevent the Dunning Kruger effect form making you look like an idiot to everyone else. Keep critical and keep uncertain, my friend!

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