One last fix…

I’ve been blown away by the response and feedback from my recent blog on abandoning manual therapy. In less than 24 hours I have had numerous emails and messages from many of you experiencing the same problems and pressures to use manual therapy by your colleagues, managers, and patients, not because it helps that much, but rather because it’s expected.

It’s great to hear that many of you now don’t feel as isolated or alone knowing that others are in the same position. It’s also great to hear that many of you are now prepared to challenge this culture around manual therapy, which is exactly what I hoped the blog would achieve.

However, there has been some criticism, some constructive, some not so much. This is good, it keeps me on my toes and thinking hard, and I always think it means I’m doing something right if I piss certain people off. There have also been a few fallacies thrown around such as I only critique manual therapy as I’m no good at it and that I need more experience and training in it.

Experience?

Well, there is no denying that experience and training can help you become a better therapist, but experience or training of manual therapy does not make you a better therapist. For example, some research has found that therapists experience, specialist training, and certifications do not improve patients outcomes with low back pain here. And, a systematic review here has shown that more experience may actually be a risk of lower quality of care, possibly due to overconfidence as discussed here.

However, the main point I want to talk about today is the most common justification I have heard from therapists for using manual therapy, in that is it helps patients buy into more active treatments such as exercise. I must hear this justification daily, and I will admit it was one I used to use and believe myself. I don’t anymore.

The common belief that many therapists have is if a patient with back pain, shoulder pain, knee pain, or any other pain has a bit of manual therapy first it will help them do their exercises better and more often. This is unfortunately complete and utter bull shit.

There is zero evidence, nil, nada, zilch, fuck all… that patients who get manual therapy will do their exercises any better or more often than those who don’t get manual therapy. In fact, there is evidence here that shows even using strong pain-relieving steroid injections in arthritic knees and subacromial shoulder pain here before exercise doesn’t significantly improve the effects of exercise, so why would we think a bit of massage will?

Adherence?

There is no doubt or argument from me that exercise adherence of our patients when in pain is poor. In fact, it’s terrible, as low as 20% as found in some research here. But don’t be fooled or mislead into thinking that a bit of rubbing or poking will solve, correct or even significantly change this.

What will change patients adherence with exercise when in pain is talking about their concerns and worries, identifying any possible obstacles and barriers, and coming up with simple practical solutions to overcome them as discussed here. What won’t significantly improve exercise adherence when in pain is a bit of massage or manipulation.

Exercise-needs-motivation_o_21964

Over the years dealing with many types of people in pain I have come to the conclusion that the simplest and easiest way to get patients to adhere to their exercises when in pain, is to physically supervise, encourage, motivate, and reassure them as they are doing them. I find, and most research supports this, that around 6-12 sessions of exercise therapy (possibly up to 24 sessions for some) done under supervision over 3-6 months for most MSK conditions will ALWAYS outperform 6-12 sessions of any other type of therapy.

I truly believe that if more physios used their time and sessions with patients to actually do the exercises with them, sometimes multiple times a week, rather than faffing around with manual therapy and other passive modalities we would see far better results and outcomes. Patients then wouldn’t then be tempted to seek other more invasive, expensive and risky treatments, and lets not forget that they would also get the many other positive health benefits of exercise as a pleasant side effect.

Yes ok ideally in a perfect world we would like all our patients to be motivated and dedicated to doing their exercises without us having to babysit them. But news flash people we don’t live in a perfect world, we live in a world of reducing tolerance and low motivation, not to mention poor lifestyle choices and terrible health habits.

In my opinion, physios who spend their time with patients only talking, massaging, manipulating, poking or sticking them, leaving the exercise for the last 5 minutes of the session, handing them a poorly photocopied sheet of shitty exercises to be done at home are the bane of my life and a cancer in our profession.

This lazy, bone idle, disinterested, apathetic attitude towards exercise belittles and devalues the importance and benefit of exercise therapy for many MSK conditions. If a therapist is disinterested, bored, apathetic about exercise, you can guarantee patients will be as well. Is it any surprise that so many patients ‘fail physio’ with this lacklustre approach to exercise and rehab?

Weaning?

Also, don’t think that by giving some patients a bit of manual therapy you will help move them away from wanting it, which is another common justification I hear for its use. I know there are patients who do only want a few sessions of rubbing and poking and then they will be fine, but there are also plenty of patients who ONLY want the rubbing and poking continuously.

I see a good few patients who are fixated on getting hands-on treatments and addicted to the crack, the joint crack that is. These patients only want a joint popping or a muscle rubbed and have little to no interest in the active side of their treatment.

Don’t think you can change this by giving them a few sessions of manual therapy and then all of a sudden they will buy into what you want them to do. Giving a manual therapy ‘addict’ more manual therapy isn’t going to help them want it less. ‘One last fix’ is often used as an excuse by many addicts but it often fails as it just perpetuates and continues the vicious circle of stimulus and reward. One last fix is never one last fix!

To break a habit a clean break is needed with support, motivation, and sometimes a distraction. The best way to move someone away from manual therapy is not to give them more but instead give them something else to focus on, like exercise.

Finally to wrap this up please remember that you don’t need ANY treatment to keep patients coming back. Also, remember that focusing on getting patients to come back is actually a pretty shitty way to work. Instead, physios should be focusing on getting patients better and NOT needing to come back as quickly as possible. Also, remember that patients will return to a therapist who they trust and believe is able to help them with the issues and problems they have, and this has NOTHING to do with what type of treatments you do, or don’t use.

As always thanks for reading

Adam

 

20 thoughts on “One last fix…

  1. Great stuff as always Adam. Mainly through your teachings I’ve been doing my best to reduce the amount of manual therapy I use with my clients. It’s still very easy to succumb to the pressure though as it’s easy to get scared that they’ll just go away thinking that because didn’t do anything *to* them, I didn’t do anything *for* them. I console myself with the knowledge that at least if they’re on my table I can talk to them about the importance of exercise etc while giving them a massage, as opposed to them running off to someone else’s table and getting told they’re “a mass of knots” or whatever other bollocks they get told. I’ll get there in the end though…. keep up the good work!

  2. I use manual therapy in my private practise and I’m serious about exercise too. Ive got the luxury of 45 minutes with my patients so don’t have to skimp on time choosing and practising exercises.

    If i was to forgo manual therapy i would lose 50% of my client base to competitor professions both in the same clinic and the many dotted around the city.

    I can’t count the patients I’ve had success with who have had nhs physio (I’m nhs also) and had to go private because lack of results. I’m not saying i succeed because of manual therapy but the patient perception of needing some hands on and the immediate relief many experience just reinforces their beliefs that I’m awesome and know what I’m doing.

    So for me I see no option but to continue to use manual therapy. To be honest i think the clinic would sack me if i stopped using it.

    My point is.. it’s easier said than done to give up manual therapy. I appreciate I’m perpetuating “the problem” but i got bills to pay.

    • Hi Karl, thanks for your very honest and rational comment.

      This is one that many others have also said and as you say this approach does help get patients to feel valued and looked after, but is perpetuating the cycle of unnecessary use of manual therapy in my opinion. I guess that if you have the time and the patients have the financial means for some manual therapy and, this is the important part, they have a good understanding of how it works and that it doesnt fix or correct things, and isnt the solution, and that they are engaged and onboard with exercise and active treatments then I guess this is a happy balance to achieve for now!

      Cheers and all the best
      Adam

  3. If as you say, there is so much commentary subsequent to your blog posts, where is the discussion? A few comments hardly makes a tsunami. It’s not like many other physios before you have not seen the writing on the wall long ago. Many of us spent years, decades even, offering constructive criticisms, questioning dogma. The problem is not “manual therapy”, or “exercise therapy”, but the lack of depth in defining the theoretical underpinnings and philosophy that ties such a therapeutic approach together into a coherent, sensible paradigm. This discussion never seems to get off the ground and the adults just leave the profession. This is just immature ranting that appeals to a sycophantic audience on social media, nothing more.

    • Oh Darla, once again thank you for your comments about my immaturity and ineffectiveness, as before on my other blog that you commented on I do find your comments hugely ironic. Complaining about a blog on a blog. Fantastic!!!

      Anyway Just because you are unaware of the debates, discussions, disagreements, does this mean they do NOT exist? Seems a very assured and arrogant position to take.

      And agree or not ONE of the big problems with physiotherapy IS its relationship with manual therapy. Manual therapy has embedded itself into our profession so much that it has assumed a position of necessity, skill, and effectiveness that it just does NOT deserve. Yes this is not the ONLY issue with physio, but it is ONE issue and the ONE I am focusing on for now.

      Regards
      Adam

  4. I’d be interested to know how many nhs departments will allow you 6-12 treatment sessions or up to 24 over a 3 -6 month timeframe ???
    Or which private insurance companies will continue to keep authorising up to 24 treatment sessions ??
    Or do you just ask the patient to come in multiple times per week to sit and do their exercises with them ??

    • Most NHS departments allow at least 6 sessions per patient per problem, this can be extended if the physio deems its clinically necessary. Most insurance companies will also fund 4-6 sessions per problem and then a progress report will need to be submitted with a clinical reason to justify more. I find if I can clinically reason and justify a need for more evidenced-based therapy that clearly demonstrates a need and incorporates a plan with a likely prognosis with timeframe I dont come across many barriers.

      Unfortunately in the past physios have abused their positions with insurance companies and the NHS with over treating patients using passive modalities to address the symptoms rather than the problems, not to mention the asinine excuses of maintenance treatments, meaning that most insurance compaines dont trust physios to sensibly and ethically treat patients without close supervision. Physios have made the problems with funding themselves, by not being responsible and more importantly not demonstrating worth or results of their treatments.

  5. Is that the best you can offer by way of a response? These blog posts cease being about a pursuit for truth when you arbitrarily assign a value based on your own biases and don’t explore the issue. When have you ever demonstrated the superiority of your approach sans manual therapy, compared to any other approach? The point is that there is no robust evidence of the efficacy of exercise over manual therapy–both are comparably low in lastly effectiveness.

    Finger-pointing at others is just your way of trying to avoid the reality that you are part of a profession that continues to avoid having to deal with psychology and sociology. Maybe it’s time that physiotherapy dragged its backside into the 21st century and evolved into a modern therapy best of information derived from a variety of epistemological approaches.

    I think I will pass on the immature ad hominem’s, thanks though.

  6. I love your blogs ….. you are just suggesting that physio’s get rid of the ‘fluff’, and so they should.
    My daughter is an ‘Exercise Physiologist’. I am wondering what you think of this profession, and how it stacks up against Physiotherapy?

  7. I have patients who are able to do their mobility en strengthening with way less pain with the manual work. I know the manual work doesn’t provide anything in the long-term, but it just makes the exercise/therapist-adherence way better. I also tell them the manual work does nothing in the long-term. In the end of the rehab i really make sure i don’t use any manual therapy. I just think the education about manual therapy to the patient just needs to be more adequate. Still think the combination is in a lot of cases the best way to go in the begin. Still great thoughts and this makes me even more careful to not use it too much. Just don’t thinks it’s this much black-white. Prove me wrong Adam!

    Toon Clement

  8. Hello Adam,
    I really enjoyed reading your blog and I definitely agree with you on how efficient exercise and that it is proven that manual therapy does not get rid of the pain and improve your condition. But I was wondering, since pain comes from the nervous system, would anything that could calm down the nervous system be a good trick? I explain myself: For example, at the moment, I am treating a 83 years old lady who is suffering from VERY bad frozen shoulder for years. I feel like this is an injury she just never bothered to sort out but I could feel she has loads of other worries that do not motivate her to feel better…Basically, I feel she is carrying the world on her shoulders! She feels lonely and in fact, cried after 10 mns on our first consultation. She does all her exercises seriously and is improving week after week and I can see how happy she is to see me each time. I offer consultation at her home. BUT I do some manual therapy, not because she expects me to do so, but I feel it helps her relax and she feels someone is taking care of her. I might be stupid with my comment here but I’d love to hear your thoughts on that.

    • Hi Syl, thanks for your comments and trust me I get a lot of stupid comments but this is not one.

      However, I would argue that NO 83 year old has a frozen shoulder. Frozen shoulder appears to be a pathology that affects the 40-60 years old. If the shoulder is stiff and painful over 65+ I would argue its most likely to be shoulder arthritis. Get an XRay to check.

      Clearly, this lady you are seeing has psychological factors due to the emotional response she had with you and these will need to be taken into account and addressed as able. I would also keep exercising and doing what you can for this lady but if the arthritis is severe then she may need some further interventions either analgesia or orthopaedic referral.

      Hope that helps

      Adam

  9. I just came across your November 2015 post on frozen shoulder, have started doing the exercise you wrote about, and find it is helping me tremendously with the referred and local pain I’ve been having. It seems to be helping with ROM as well, but it’s only been a few days so it’s hard to say. Even without any ROM increase, to get some control over the pain has been priceless. So a belated thank you for your post.

  10. Hi Adam and thanks for this great blog – and all the others.

    I’m experiencing an exhausting situation as a physio where I feel the need to answer a lot of “I’ve seen it work” reasoning with credible research but I don’t really have the time to look everything up for myself. I noticed that you posted somewhere the other day a collection of research on a google drive, or similar, that could serve as a bank of “comebacks” for someone in a similar situation as me. I just can’t seem to find it now. Would you still be willing to share?

    Best regards – Björn

  11. Hello Adam,

    In response to the previous commenter and the level of emotional/psychosomatic triggers, I was wondering what your take is on Dr. Sarno (RIP) and the postulated Tensio myositis syndrome

    “It is important to know what sort of person has a disease than to know what sort of disease a person has.”

Leave a Reply to Rowan Wood Cancel reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s