There’s no skill in manual therapy!

Excellent account or your personal experience.
You appear as a critical mind giving witness to the element of quackery involved in manual therapy.
Not only are the benefits of manipulation techniques superficial and ephemeral, with no real cure resulting, but, as you point out, some can be truly dangerous, especially those involving manipulations of the spine, not only cervical but also thoracic or lumbar
Touting the special therapeutic merits of manipulation, as you describe it, resembles closely the marketing spiel of charlatans and circus barkers selling mysterious remedies.
What is remarkable is that, with your training, your natural skeptical mind, it still has taken you years of practice, observation, and intense in-depth study to convince yourself that you had bought into a fraudulent “therapy”, and remove the veil of pseudo-science cloaking the commercial teaching of manipulation techniques.
Bravo anyway for your courage to speak up and be ready to be confronted by irate manipulation experts whose livelihood they (rightly) fear you are threatening.
There must be other critical minds like yours among physical therapists and kinesiologists who may remain silent because they feel themselves to be in a minority, but who may feel encouraged by your taking the lead in speaking up.

Adam,
You’ve done it again. Better get your bullet, mud and abuse proof vests out, if you ever take them off. You really must like the abuse, no wonder you ended up in sport!
I am pretty much with you on most of you post, your flowchart should be put on a t-shirt and handed out at Physio and Massage schools. However, I think the real skill in manual therapy is in the assessment, and I know you have had a good rant about palpation but I am talking about broader assessment here, everything from gait to ROM to observation. Got to admit, it is a bit tough to feel heat and swelling from three feet away, and unless you have perfect vision, it can be tough to see too.
As a manual therapist I agree, there is no great skill in general muscle ‘release’, the real skill is knowing where to apply your massage, hence the assessment. The caveat here is with lymphatic drainage massage, there is a skill to this, simple, yes, but a skill none the less. Could anyone learn it in a couple of days? Probably yes.
You referenced Soma Simple and I am sure you are a massive Barrett Dorko fanboi. Awesome, his work is great, but don’t you think there is value in contact (manual pressure) when a patient is getting in ‘touch’ with dysfunctional tissue. Isn’t one of the great values of a swedish style massage the patient’s awareness that it creates in their body to feelings of tension? Can you not use pressure to help a patient to reduce hypertonicity of muscle? Is there no value in finding the right intensity of massage to help someone focus and switch on before a sporting contest? Is there no skill in find the right speed and depth to get someone to calm their central nervous system post contest to enter a recovery zone?
I agree that the ‘giant-leap’ for manual therapy is that it is the patient’s brain that does >95% of the effect of treatment, but is there no skill in helping a patient to guide themselves to better function? Look at Dorko’s ideomotor work, no skill in guiding someone through motion? None at all?
No GREAT skill, like playing a violin, maybe, but no skill at all? Come on!
Aran

Could difficultly agree more… and also with the remarks done by Aran.
Bravo for your honesty to share doubts and the courage needed to keep the stance…

Wonderful article – thank you for your honesty and courage. There are more witches and wizards today than there were in Medieval days, and the faith they have in themselves doubles the placebo effect.

“One reason I haven’t taken a manual course is due to the explanatory models many classes are presenting. It seems as though few are approaching things with a neurological mindset, but I was pleased to hear Diane’s model. It is the best explanation I have heard yet”.
http://zaccupples.com/2014/05/21/course-notes-dermoneuromodulation/.

Adam – your diagram had me in stitches! bravo! A well written, reasoned and researched article. I am on that very expensive journey in expanding my manual therapy armory at the moment and haven’t yet paid enough to develop your cynicisim. However, I am also familiar with most of the recent research in chronic pain so understand the substance of your arguments. I think these are the debates our profession needs to be having on a much wider scale. You should share your post on the MSK section of ICSP and see the rebuttal. I shall look forward to reading more of your blogs. Nick

Interesting read Adam , In my experience good therapists would agree that the bio psycho social framework can house many elements and therefore they would agree that the interaction is key. I think in the main physios do exactly as you do and so I think in my experience you are preaching to the converted , thanks

Really helpful article and I appreciate that you reference it well. Thanks so much for putting these articles up for us to benefit from!

Love the article, I have always felt like this when attending an A.R.T. (the self touted “gold standard for soft tissue, aka pay them gold to have a title of ART practitioner) seminar. The neurological side, as you have discussed, is always a part, and is often overlooked.
The only fault/criticism is using Edzard Ernst as a source. It has been shown that his research is pretty much out to discredit professions who use spinal manipulation as a treatment approach. I have bias, we all do, but his sole purpose (IMO) is to discredit manual therapy.

Yep, simply put the skill is in being a therapist, and selecting a mode of therapy that works for the individual patient. 20 years in & I’m starting to get the hang of it. A bit.
I’m suspicious of anyone banging on about any one approach (hands on or off) being the answer.
Cheers.

Hi Adam, my one and only comment to you before ended up with me on the end of a 4 tweet tirade implying I was lazy and uneducated but I’ll let that slide as I agree pretty much with 100% of this article. I had 5 years training and have been in practice over 20 years now as a “manual” therapist. This realisation slapped me in the face early on in my career maybe only the second year out of uni. I got a postition with a really well respected Osteopath and was excited to learn more from him. Essentially he was just very good with people, got on well with all types of patients and was practice and sensible with his hands on work. I was chatting with his receptionist one day as I didn’t have a lot of patients at this stage and enquired how she began working there. She said, “I used to be a patient here”, interested I asked further ” what were you coming for?” Expecting to here her say sore knee, back,neck etc. She paused for a moment and said, ” sometimes I was just feeling a bt down and needed a laugh, so I would come to see Mr. X”. It kind of hit me hard , thinking what did I go to uni for, all I needed was a good joke book. Anyway I have been a sceptic my whole career pretty much but yet remain very hands on in my treatment. As you say if you get the connection with the patient, they feel heard ,and you apply your manual therapy in a non threatening manner you will probably get a lot of good results. There is good evidence for ischaemic nociception so it would follow that mobilising tissues ,whichever way you want, in an area effected by this would probably help.But as you say, importantly we are also a first screening point for a lot of people, and that’s probably what they are paying for, those rare occasions when there is a red flag present or the person needs further investigation. Cheers.

Well – the clear answer is yes and no. I’ve got 30 years of massage and strengthening coaching under my belt, that’s not full time – but it still adds up to a hell of a lot.
I’ve also been treated by a fair number of therapists over that time.
In that time I’ve encountered those, trained and untrained who I wouldn’t send anyone I didn’t hate to, and others – again trained and untrained to whose ministrations I would gladly trust my loved ones.
Admittedly I’m a terrible patient, but some will put their entire weight on a small area – weight that would risk being damaging for my relaxed form but which is trifling against tensed muscle – so I tense – which is counter-productive as most manual therapy works far better on a relaxed victim – others will coax knots to loosen by a patience, indirect stimulation and a good line in patter if a patient is either obviously in pain or has just tensed several kilos of muscle.
Clearly there’s skill involved in the difference, but how much of that skill comes from “training courses” or “methods”? Probably not much – except with things like acupuncture – which are a load of bollocks anyway.
I can’t cure many things by massage – because in most instances manual therapy can’t – those who claim it can are singing in the wind – but I can make a pretty fair stab at making most clients feel as though I have – that can give a space for exercise, stretching, coaching, rest, time and proper nutrition to do so – or at least get them as fixed as they can be.
For example I’ve treated a lot of shoulders for various reasons, and I could massage the same client 100 times and make them feel better each time – but without sorting out some sporting movements and strength training techniques their underlying injury will just get worse – fix the way they use the shoulder get them to get it strong and mobile and the sum total is often a cure after a few sessions at most – and they may not involve any physical contact at all.
The role of the massage (if its needed at all) is to get them to the point where they are able and willing to effect the cure themselves – I’m not going to be there to live their lives for them or wipe their arses.
Last but not least a 30 minute massage allows 30 minutes of getting the client to tell you about all of the things that might cause their pain, establishing trust and advising them of ways to avoid or mitigate it.

Hi Adam, I am a student graduating in 3 weeks from a sports therapy degree, massage and many things you do not like is what we are being taught e.g. Electrotherapy and manual therapy. I like to use massage as it does make the patients feel good and provide pain relief. Following you on Twitter though makes me question whether I wasted my time doing sports therapy and I should have done physiotherapy, Hands on treatment was a big part of what we learnt but it seems like in the therapy world it’s laughed at, from massage to METS, PNF stretches, soft tissue release techniques, these are things I have used and they seemed to provide good results however, now I’m really questioning my knowledge and the things I have been taught. Also what physiotherapy authors\books can you recommend with good information on treating injuries.
Regards
Nile

Excellent read, excellent content. As a new graduate physio I strongly agree that research based treatment is more in the realm of psychology than physical intervention. Obvious psychological or plecebo effects are seen after manual therapy. There is some good reseach on the parasympathetic effects of manual therapy which is why when I’m getting a “sports massage” I ask for it to be as relaxing as possible and with little trigger pointing. For an athlete it would be common for sympathetic responses to exercise to interrupt sleep. Que “healing hands”

Hi Adam:
Well I have to tell you, you touch a darn hot spot in my everyday thinking in the value of manual therapy. Let me tell you a bit of me, I always have been skeptic about everything!, but as an undergraduate of Physical Therapy I had a lot of teachers that built in, inevitably, a Structural Paradigm in my reasoning. So when I graduated, took a Master in Orthopedic in Manual Therapy (In fact I took the most structure-based aproach I think it´s available at the time and place: Paris method of U. Saint Augustine, USA). So I met lots of people only trying to make their therapy work for the sake of their patients, and a lot of magic in every class that make me wonder, there has to be something weird in there…
Because of that I did some research that really don´t make sense of anything I was learning, so when I started treating patients and doing the reasoning for their problems, I had this: they felt great at the time of touch, but the effect was no longer than a couple of hours. So I started to realize that the efficacy of manual therapy was only the entrance of the relation between me and my patients.
Now, I´m not as frustrated about manual therapy as you I think (but still bleeding money), because this help me to know other different aproaches, like CFT and the always great Explain Pain education aproach, and this really made my therapy go leveling up. Now I have 6 years of profession training, and have my own point of view about the topic, so I think we have the almost the same issues 🙂
Clearly, we have to look in a more sensitive way of thinking about MT, but not discarding it at all. In fact, I think we can do a lot studying the sensorial training that we are doing with each manual therapy we do, rather than looking to mechanical effects, largely described as inexistant or minimal.
I think this can really do the trick in some patients, when they tell you some sensory stuff its going on http://www.ncbi.nlm.nih.gov/pubmed/24021562
Great post as always
Cheers
Felipe

Hi Adam,
I agree with your post, well said. Do you have any opinions as to how it should be taught at undergraduate level, for instance?
Terence

Well, I agree with the intent and the content. Less so the title as there is clearly some skill in manual therapy as you mention in your caveats etc. I guess you are just trying to get the article noticed, which is fair enough.

Im thinking the emotional component plays a part but so does the skill level. Use sex as an example. You may love the individual who you have relations with but if their physical skills are not comparable to your last lover, whom do you think you will be pining for. 😉

Awesome post Adam! I couldn’t agree more with your comments. I as well think manual therapy is important and there is a role for it in rehab, but I don’t think there is much skill in the actual application. The skill is knowing the most probably explanation for why it works, including it’s impact on nervous system and the abundcance of “outside” noise playing a role.
I think commericalism like you mentioned is a huge factor in manual therapy heading in the wrong direction. When people have money (sometimes lots of money) invested in a certain technique/philosophy, it simply strengthens their biases and the chances of them straying from that way of thinking decrease dramatically. Sigh.
Mark

It seems the way of the Internet really… Apparently everything has to be black or white. Of course there IS skill in manual therapy but it’s a very grey area.
My background is very similar to your’s Adam in both qualifications and experience. But I have a different view when it comes to manual therapy. In my experience (Australian physiotherapy) the best clinicians have all the attributes you have described above AND precise, comfortable manual skills. You only have to spend some time working with new-graduates to feel the difference. When it comes to manual skills alone, having a new-grad perform something like a mobilisation on an isolated cervical facet joint and then comparing this to the same technique from an experienced clinician who specialises and educates in the same field is all the evidence you need. However I still also SORT OF agree with you. It is not primarily the subtle differences in the application of the physical technique itself which separates the best from the “every day” clinician. It is also the effect of the intangible aspects of the patient interaction that you have discussed as well as the experience and superior clinical reasoning in deciding which manual technique to use, at what time, in which circumstances.
A cornerstone of Australian physiotherapy, at postgraduate level in particular, is a very strong focus on assessments/reassessment to critically evaluate your intervention. Personally, I routinely reassess the patient multiple times within one session and can show distinct, objective improvement in things like range of movement or pain immediately following a manual intervention. You can’t tell me that refined manual skills are not at least a small part of this process.
Of course non-manual therapy is a vitally important for our patients… But let’s not throw the baby out with the bathwater! I fear the day when new graduates have all read “Explain Pain” and offer the patient in acute or sub-acute pain a series of counselling sessions and exercises as their only intervention! (N.B. I highly recommend Explain Pain and have studied under David Butler- who, by the way, has excellent manual skills.)
It’s not that there is no skill in manual therapy. There is. It’s just that the reason manual therapy works brilliantly in some instances and not so well in others can be due to a myriad of complex factors and interactions that we are only beginning to understand.
I read your sentence claiming there is no skill in ANY manual therapy, and then I read your article… I don’t think they quite say the same thing. You could very well title your article with this long-winded, poorly-edited title instead: “Manual therapy doesn’t work for the old-fashioned reasons people used to think it did, it can work very well in the right situations, we just might not fully understand why… if we use it well and critically assess its effect it can be a powerful tool.”

Actually I think you’re the one getting confused… Your offering potential explanations as to why your manual therapy works, not saying that it doesn’t work. You can’t tell me that a patient walking in with acute or subacute pain of almost any sort would not get better a lot faster if a good manual therapy was applied AS A PART of your interaction. I defy any decent clinician to get someone better as quickly by “asking the patient to lie down and relax and not touch them”… I guarantee you don’t actually do that in the majority of cases in your own practice. Assessment/reassessment is not as simple as asking a patient whether they “feel better”, and if that’s all you’re doing then you’re not doing it properly. Objective measurements of range, power, et cetera are changeable within a couple of minutes of an appropriately applied manual technique… No doubt you know this. Even if you believe that all you are treating is the patient’s brain- the fact that you can achieve this through manual therapy still means that manual therapy works… You just believe it works for a particular reason. I’m sure someone of your experience is good at creating change with manual therapy… The underlying mechanism as to why this intervention produces a change might be up for debate, but the fact that it does produce a change is not – if you can prove it.
And confusing skill with experience?? No, I’m saying that with experience your skill improves, they are 2 separate things. Can you honestly tell me that your manual therapy skills are no different now after 10 or more years of clinical experience and education than they were when you were a 15-year-old schoolkid? If they’re not, what’s going on??? We are talking about performing physical techniques, how can years of practising these techniques not result in some degree of refinement. You have mentioned a couple of times making your techniques comfortable… I agree that this is vitally important… An improvement in the comfort of the technique is an improvement in your skill at delivering it!
Take the example of lumbar rotation mobilisation. I have tutored many employees and junior physios on getting this technique localised to the individual target level. Get an untrained person to try and copy what they see an experienced musculoskeletal physiotherapist doing with one of these techniques and most of the time all you will get is the patient feeling a quite uncomfortable sensation through their rib cage or the thoracic spine… A good manual therapist will isolate the same technique to the precise level of they are targeting. Yes this improves with experience, because experience improve the skill of doing it properly.
If you’re so confident, then try this experiment…
Go and grab some random punter off the street who has no training or background in manual therapy techniques. Do nothing more than quickly show him a few techniques and give him a couple of basic instructions. Dress him up to look well-qualified and professional. Now, when you’re patients come to your clinic you are only allowed to do the talking and the direction of assessment. Tell them you have an injury and that your very experienced and well-qualified colleague is going to perform the manual therapy on your behalf. Your random punter will perform the techniques that you decide should be used. Can you honestly tell me that he will get the same results you would? If your answer is yes then in my opinion you are either lying or there’s something really wrong in terms of your skill acquisition.

PS: for the record, I agree that a lot of (maybe most of) the change from manual therapy is centrally mediated- not just brain but also spinal cord, modulated reflex loops would probably also be a factor… but I think it’s silly to write off manual therapy for this reason. I also think it’s silly to say these techniques can’t be performed better or worse.

PPS: this is also why I try to avoid twitter- I can’t resist getting sucked into a debate like this- I would never get anything done!!

I think one of the big questions to tackle in the whole manual therapy conversation are;
1. Does it work? According to Menke 2014, not so much…. But I guess that in the big picture at least a part of the jury is still not convinced.
2. Does specificity even matter? Studies done point towards specificity not mattering so much.
3. How specific (segmentally) can we even be? Can we honestly prove that when we manipulate someones facet that nothing else moves? Then to speculate even further, if it doesn’t matter how specific we are, do we even have to try to be specific in the first place?
And to add for specificity question, can we actually measure this phenomena? Can we define, validate and reliably prove that something needs to change and manual therapy changes it? We cannot reliably assess joint play, it’s nonehow measurable and quantifiable (then does it have to be) since it is something we must “feel”. We can only observe the indirect effects of this intervention.
Also one part of the controversy in my opinion is that of the methodological quality of the studies and the many times the interventions used as control. Quite often it looks like the control group has been designed to fail, which of course is not too good.
But, not to be too skeptical, I do believe manual therapy has it’s time and place in the right patient population, but it surely is no panacea.

The same could be said for carpentry. You do not need a qualification to hit a nail on it’s head and bang it into a bit of wood. I could do it,however I choose to pay someone to do it for me. You are in the unenviable place that you have a loving wife who will rub your back/neck for you. Many peole don’t. And if there is no evidence of therapists actually doing anything, (not that your like have been able to measure anyway) what IS T that your untrained therapist of a wife manages to do to get you to feel better than any trained person of whatever therapy? (Keep it clean please)

Again…a divisive title to an otherwise insightful article that again fails to get to the heart of the matter.
Neuroscience is demonstrating that most changes with regards to pain or function are a result of alterations in the nervous system. The question is what techniques are most effective in bringing about these changes. Clearly helping a patient change negative beliefs, improving self image and changing behaviour are powerful. Clearly there is an arguement that movement (less so exercise) will make stable changes to the nervous system, and clearly we can interact with the nervous system in a positive way through touch. I feel manipulation can have a powerful impact on the nervous system evidenced in my own clinic by dramatic changes in range of motion and pain following manipulation. all these modalities are of use and their efficacy will vary with the type of patient, their attitudes, beliefs and their presenting condition and comorbidities … something most research woefully fails to account for.
Does skill alter the impact of treatment. The perception that the practitioner is skilled is maybe of key importance. Could we all save ourselves some time and money and just provide some simple education on pain, rub the painful area a bit, reassure people and encourage them to keep moving and practice and progress difficult movements at a level below the threshold of pain? I think this is logically where your line of arguement may lead but I think you may be missing some of the art in the science. I think Skilled manual therapy has a very important role to play for many people as part an integrated treatment plan.

Well, I understand the juncture in the road that you hit. I hit it too.
If you are a thinking and engaged therapist then you realize that one method does not work all the time, but if you keep thinking then you also realize that it does work sometimes. The other road that I have taken has been to try to figure out when to use what tool and how to use it to its full advantage. There are times that general techniques work. But there are times that only specific techniques work. There are patients that only need a neurophysiological intervention to get them going in the right direction – is manipulation or dry needling with electrical stimulation better, or just a light touch? There are patients that have huge emotional components to their problem. Some need ergonomic education… Some need better nutrition. Until the research is better at the inclusion criteria for any particular intervention I am not going to throw out one of my tools. Plus, when you isolate a technique for research then you take it out of the context of a real treatment. Who only uses one tool while treating?
Perhaps your manual therapy training was just a set of cookie-cutter techniques. A lot of schools are doing that. If so, I can see why you are disappointed. Mine was focused on anatomy and clinical reasoning, differential diagnosis and safety. The training I went through taught me to think. To me OMPT = clinical reasoning. http://naiomt.me/2014/03/19/its-about-clinical-reasoning/
What I really applaud you on is creating controversy for dialog and engagement. You do it very well!!!

Again Adam is doing well. You don’t have to agree, you can choose to disagree. Because it’s hard to change what you were taught through uni (by respected professors/academics -they must know what they are talking about), or what you practiced for years, and more it affects and the less likely you are to accept views that challenge your survival (income). I work in China, and i see it all too common, old dr’s who belief they don’t need to know what the west is doing, and think what can some guy 20yr’s younger then them know that they don’t, they are threatened and rightfully (it’s their whole life for 40 or so yrs). Now if i was a explorer in ancient times who believed the world was flat & explored to the known limits for my whole life, now someone comes with a GoPro footage showing me clearly they sailed right around the non-flat world i for god sake would not accept that or listen to them. And if i truely believed their evidence was right, i would put all my effort into challenging it, or proving it was wrong with any piece of evidence i had that may suggest the earth is flat, i would probably even get some “Pirates of the Carribean” movie footage as evidence.
And so everyone has the right to criticise and challenge. And hey keep doing what they think. Chiro’s got no evidence, yet they seem to still be making money easily and very popular in USA. Simply the general population doesn’t know what evidence or research says, they just want to ‘buy-in’ to whatever you can sell them. Your the professional, and most patients will accept what you tell them.
The fact Adam’s getting criticised and hate mail, is great. It means these people who want to prove the world is still flat, are ‘threatened’ that he may be right, and what to do everything to prove him wrong so they can keep doing what they were.
Ps.I love the chart by the way. Should be given out back in undergrad school. If i had that back then i could of saved a lot of money.

PPPS: Adam, good on you for promoting the debate, damn you for sucking me in and sinking my to-do list for the past 24 hours!

A wonderful post. So now my question how can a Physical (manual) therapist influence pain. With pain science growing a paradigm shift is happening in the way we see pain, where do you think the shift is taking us.
Thanks a lot for this post.

Well stirred and great healthy comments. I think that a healthy questioning attitude has always been around, just not by many. My WTF look on being told to “bend the flys legs” got me in trouble in the 80s. Just touch was helpful I was sure, just had no evidence!!
I have been on the “Staring at Goats” course. Which was pretty effective if done with a positive attitude and a smile, but adding touch achieved another dimension of positive response. Maybe those pioneers of physio ( Society of medical Masseurs) were onto something? 🙂 Keep writing.

You’ve boiled a bit of blood again! Nice work Adam!
Most of the discussion so far is centred around the “no skill required” idea. I want to look at your piece from a bit of a different perspective.
But I will quickly chime in with regards to skill. How could I resist?
Clearly if you do a lumber rotation PIIVM, 10,000 times you are going to refine that motor pattern in your brain, you will be more “skilful” at performing it. Would it be fair to say your argument is that this doesn’t really matter? As it’s the broader context of the treatment that really seems to help?
What is it about this broader context- confidence in treatment, reassurance, relaxation etc – that causes neurophysiological events which subsequently result in a reduced conscious experience of pain (assuming neurophysiological states are the prime determinant of pain)?
In my eyes the important factor would appear to be engaging the patient and therefore their brain, or inducing salience to put it in different terms. I feel this is where the true skill lies. Using subjective questioning, active listening and experience to find a window in to the patients brain, to induce, hopefully, long lasting and positive neuroplastic change.
Thanks again for a good read.
Jack

Hi Michelle, This is the blog I told you about on the trail today. Food for thought… Do you know if that September course is going ahead? We might be here at that time. Good to see you! Mary

Hi Adam, fairly recent Physio graduate and agree with manual therapy being mainly interaction/patient expectations over intervention, was wondering if you could share how you explain to a patient in simple terms how manual therapy may/may not work.
(And I appreciate all your twitter/blog posts as well, really helpful for a new Physio)

Nice blog happening here. I came across from BiM to have a looksee.
Nowadays I treat most conditions exactly the same way. The patient gets some interferential (mainly because the machine looks very impressive with the flashing lights and buzzing – read ‘placebo’) and a bit of a rub with some massage cream. Just a bit of a rub, like your good wife gives you. Absolutely no skill required… at least in the physical sense.
In any interaction – clinical or otherwise – there are unseen elements at play and we’re all familiar with them, or should be. These are the things I mentioned on BiM. Back when I was trained, I think the word ‘rapport’ was mentioned only a few times in passing, and from what I hear it’s not much better for modern day students. Instead they are taught “well there’s no evidence to suggest manipulation is any better than placebo, and there’s no evidence to support using trigger point needling and well… there’s no evidence for anything really, apart from fear reduction techniques”. All of which is absolutely true, but they don’t seem to give them much that they CAN use. 4 years of expensive training, and what do you get for that?
The person doing the ‘rubbing’ needs to be present, attentive, relaxed, congruent, open and ‘vibing’ with the patient at some level. If he can vibe nicely with the patient, he can choose whatever “technique” he likes because they are all equally ineffective. It’s the interpersonal connection that makes them effective. Going back to your example, I bet there are some days when your wife rubs your neck and you think “hmm, that didn’t really work as well as usual”. Why is that? Maybe she’s a bit tired. You will feel it in her hands and it simply… won’t…. work. This is not just about having relaxed hands – it’s MUCH more than that.
Imagine a 4 year degree course crammed into the space of a weekend. It could be done. Learning how to rub someone’s neck or knee can be learned in a weekend, but the other stuff – the real crux of it all – might take a lifetime because it has almost endless scope and depth.
Cameron
[disclosure: I’m no master therapist. However I have spent thousands of hours reflecting on and deconstructing clinical outcomes and matching this with the modern pain science and psychology research. Just like you, I was gobsmacked by what I found.]

Hey Adam,
Sure, a high midi-chlorian count helps. Heh.
I taught myself how to apply a mental technique, and when I apply it, the results are vastly superior to those times when I don’t. So I’d say it’s definitely possible to teach this. But in terms of how natural this feels, and how easily it is applied, I agree that there would be big differences between therapists.
In sport, there are those who readily pick up new skills, and there are those who work their arses off to reach a skill level which is maybe 75% of the naturals. I think it’s a similar sort of thing with Physio. The thing is, the true ‘naturals’, the ‘miracle workers’ in Physio are very few and far between. The rest of us do what we can to learn the process.
Cheers,
Cameron

An excellent piece Adam where once again you point out some of the rather hubristic assumptions endemic to the therapies. After all formal training in most is, historically, a relatively new phenomenon.
We overestimate our value and continue to underestimate the harm we can do. Time to get rid of the professional smoke and mirrors.
ANdy

I do seem rather late in responding to this now, but after reading through many comments, I do still feel compelled to do so.
Firstly, I am not going to go back through all of the tedious and frankly irrelevant debate of hand on/hands off. Evidence can be wielded around by both sides to attempt to champion people’s own beliefs. My word of caution about much of Adam’s discussion is that we need to consider the limitations of much of the research that is out there. I will give an example of one of the pieces of literature which Adam has used to support his statement of no skill needed in Manual Therapy- Chiradejnant et al., (2003). I am using this study, not because it is worse or better than any other, but just so we can consider the problem with lumping bits of evidence together to prove a point. As Adam rightly says, we need to not only look at the abstract (not because of bias always, but because it simply does not give sufficient information about the study, which allows you to consider the limitations, and therefore ability to extrapolate into your own clinical practice). Chiradejnant et al. (2003) found that there was no difference between therapists specifically treating the painful region, or randomly mobilising another lumbar level. I have picked up a few points which are worth considering about this paper. One of the outcome meausures used was active ROM using an inclinometer, but do not reveal the error meaures of the tool. This simply means that we have no idea of what differences (pre to post) we would need to be sure that this difference is due to a real effect, and not to error alone (quite important in a pre-post design). They use 2 x 1 minutes of mobilisation, which may not be sufficient to show a therapeutic effect, but there is no justification for this dose. A recent study suggested that 4 sets of 30 secs or 1 minute may be more benefical in provdiding a hypoalgesic effect (Pentelka et al., 2012), although granted this was in asymptomatic participants (the point here really is that we just don’t even know the basics of what makes an effective treatment dose- this may because as Adam says it doesn’t matter what you do with your hands, or that we just haven’t worked it out yet). We don’t know if the individuals which were chosen to particpate in the study would have been treated with PAIVMs at all in practice- it is possible that the Physiotherapist might have decided to use other management strategies. Percentage changes scores have high risk of bias when it comes to analysis (Bonate 2000), which might boost the risk of a type I error (i.e. falsely accepting the null hypothesis), so it is worth remembering that not all statistical analysis gives us the truth. There was no comment about the marked difference in duration of symptoms between the 2 groups (184.1 days for the specific level group compared to 89.3 for the random group)- and no attempt was made to adjust the analysis to take this into consideration. The lower lumbar levels provided better results than upper lumbar levels, but the authors did not give an indication of where the pain emanated from (ie, did it hurt more when the lower levels or upper levels were mobilised?).
Ok enough already- the point here is that there is no such thing as perfect research- all studies have limitations which seriously limits their extrapolation into clinical practice. Which ever side you choose to sit on, you can find evidence to support your point of view, but it must always be countered by the critique of that literature.
My concern about Adam’s post is that it is a one sided, biased account of the nature of manual therapy (very useful for stimultaing debate though!). Skill aquisition is based on multiple factors. I don’t see skill being only about where or how you put your hands on an individual, but in the whole interaction with the individual, the respect you give them, the value you place upon their own values and beliefs, whilst acknowledging your own. I appreciate Adam that you do bring these sorts of issues up when you are talking about skill, but bringing them low down on your list lessens their relevence, and suggests that clinicians who use manual therapy do not consider these as highly as the laying on of hands. That is certainly not my experience of today’s manual therapists. Is it not time that we started to accept that the biopsychosocial model is alive and well in today’s manual therapy society?

Hi Adam
You state: ‘to talk and listen to my patients more and find out their personal beliefs, experiences and more importantly what their expectations and preferences where towards manual therapy! I found asking patients these questions allowed me to gage IF manual therapy was suitable for a patient based on their preferences’
Absolutely! In my opinion this is the most important aspect of therapeutic interaction with patients, one that I would strongly advocate on the University of Brighton MSc Neuromusculoskeletal Physiotherapy course (MACP accredited), of which I am course leader. I am not informed enough about the finer content of all MSK courses but the incorporation of motivational interviewing and some of the principles of CBT, ACT and solution focused therapy are a fundamental part of the course.
I absolutely agree that manual therapy isn’t for everyone and when examining physiotherapist (on a route to MACP membership) treating patients in a clinical setting, I am as likely to be taken through to the gym as behind cubicle curtains.
It is great to hear in your comments to this blog that you recognise the changes in MACP members views (similar to the changing views of non MACP members). As you say MSK physiotherapy is changing and some individuals will be resistant to change (MACP and non MACP members alike)
It would be great to see you at this years’ MACP conference ‘Exercise Rehabilitation and Patient Engagement’ (not a ‘manual therapy’ session in sight). Alternatively Joel Bialosky (who you mention in your post) will be presenting in IFOMPT 2016 in Glasgow. Might see you there?
Best wishes
Clair Hebron (MACP Chair)

Adam,
I saw your diagram float through twitter a few weeks back and retweeted it and your blog post. Finally, I’ve had the time to sit down and read it. MAGNIFICENT! BRAVO! I can’t even come up with enough adjectives to describe my support for you hitting the nail on the head. Well done. Thank you for bringing to light what feels like so few of us know is true, but so many of us need to hear (and hear again and again). I reblogged you on my own blog http://www.youthsportspt.com. Keep up the great work!
Julie
Atlanta, GA

Nice read. My apologies, VERY, VERY NICE READ. Thank you God for your critical, excellent mind.
Interaction more than intervention! ??
Nathan
Manila, Philippines

Couldn’t agree more. I’ve been at the game for 40 years. Taken courses from many practitioners and angles dating back to “Fat Jack” Cyriax himself. I have come to view manual therapy as more of an art than a skill. I had the great honor to have the late Dick Erhard as a mentor and friend. Privately he could be quite cynical about manual therapy, but there was no denying the man’s genius for evaluating the patient and determining what it would take to improve that patient’s situation, and it often came down to a couple of simple exercises. His gift was knowing the patient, something you can’t teach in a post-grad manipulation course. The same can be said for the family doc I knew as a kid whose familiar voice, concern and assurance were more effective treatments than anything he carried in that little black bag.
I will continue to seek to develop any skill that I think may help my patient. That pursuit can, at least, sharpen my thought processes. At the same time I will remember that my most gratifying results come from developing a relationship with my patient and letting him dictate the treatment. As you said….interaction, not intervention.

I believe the problem lies in having the right perspective or medical model that increases the accuracy of choosing the right intervention for the patient’s specific problem. When all you own is a hammer… everything looks like a nail. I can train a non-professional in how to provide some of the interventions I use. I can even have them perform the intervention on a patient and results are generally positive (with pre-test and post-test findings). But, I am not ready to conclude that some interventions do not require high level of skill to execute properly.
My question for you, whoever-thinks-they-are-a-manual-therapist, is: Do your interventions have immediate effects of markedly increased ROM, increased force-generation capacity, improved fluidity of movement, and increased speed, along with long-term pain relief in the focused area where you applied the manual therapy intervention?
If your manual therapy interventions do not fix the underlying problem, then it either means you are doing something wrong (poor selection of intervention and/or poor execution) or that manual therapy is not the correct treatment of choice. You may not be getting to the problem in a way that can correct it. It is just as possible that another intervention that was properly targeted and executed would correct the problem immediately.
Think about the example of nurse-maids elbow. The elbow is dislocated and then 2-minutes after the proper manual therapy intervention the child is happy again, ROM is restored, etc. Shall we do a study of the effectiveness of relocating a nurse-maids elbow? Do we need to? Or shall we just continue our clinical practice of manual therapy, where it absolutely takes skill to interpret the findings, select the intervention, and execute?

Is it possible that there is a better way than what we “know” now as a whole group? Is it possible that skill is required to execute the specific intervention that is needed for the individual? I really believe that manual therapy will either immediately correct the problem that is specifically addressed or the problem cannot be fixed by manual therapy. I see immediate solutions every day. It does take a high level of skill and a knowledge base that is not widely known. And the reality is that the solutions are as simple as understanding anatomy and neuroscience and how both can be corrected when in a dysfunctional state. Fascia can be immediately corrected and faulty muscle spindles that restrict normal ROM can be reset. But, it takes a paradigm shift that many are not willing to make. Again, I disagree with your hypothesis.

I have one LARGE issue with this blog. A sneaky snide comment thrown in which sets manual therapists back to the dark ages. It’s comments like “if you pay a little extra” that hurt the profession. And arrogant guys like you seem to be the worst for it. I stopped reading after that comment. Sad.

Nothing light hearted about posting a comment about the stigma of manual therapy that manual therapists have been trying to overcome for decades. Seriously, get a grip.

Hey Adam,
Very, very, very interesting blog post. I am one of those guys who has spent quite a lot of money in courses and I am still waiting for an explanation that convince me about the way some techniques are supposed to work.
I would have liked to be the one writing about this topic, although it sounds much better in proper English. I am Spanish and my English sounds awkward sometimes!!
Many thanks for the post

My sentiments exactly. I’m in the first year of my career and I see and read so much bullshit that I actually became quite depressed for a while. Then I thought…well everyone feels good when they get off my table. They feel relaxed and a bit more limber for a while and that is enough for me. There aren’t many things these days except alcohol, drugs and sex that make you feel a bit more cheery and relaxed. I charge half of what others charge because I think massage rates are FAR too high and i don’t want people to think of it as a luxury for wealthier people. I read a lot, watch technique videos and talk to more experienced therapists.
Thank you for your simple, no bullshit or jumbo jumbo views!

Hi Adam,
I am (partly) glad I came accross this article, it certainly insights a lot of thought and discussion as is represented throughout the comments!!
I could go into details on my views however much of these have been discussed previously and I found myself agreeing in parts with both sides of the discussion/argument while reading through the comments, like most people I guess.
The point I will make however is that justifying parts of this discussion by evidence seems a tad worthless due to the fact that for every paper claiming manual therapy ‘doesn’t do much’ there is another representing its benefit in treating numerous musculo-skeletal conditions http://www.sciencedirect.com/science/article/pii/S1356689X15001745. Admittedly I wasn’t keen on spending $35.95 to view the whole paper to then find the likely numerous floors in the evidence but this is no different to most other studies such as Shoemaker 1995 who concluded no impact on tissue bloodflow following a study on just 10 persons.
I use manual therapy with every patient I can (those without contraindications to it) and get the right results (most of the time). I do also use re-assurance, activity modification and exercise, arguably it may be those things which impact on a patients symptoms, although I am far from convinced, but more importantly in my view I do doubt my patients would be half as happy if they left their appointment following a chat and an exercise sheet.
I understand you are not rubbishing manual therapy completely, however some of your points are less agreeable than others.
Great effort in getting such a discussion going, it’s been a good read and a good opportunity to look into the research a bit more.

Great post….I have been practicing “manual therapies” for 21 years now, my training is primarily Craniosacral Therapy to advanced level, whatever that means, biodynamic cranial, visceral manipulation and some traditional osteopathy. I also have a allopathic medical background.
What I learned from all that training was anatomy, distinctions and frames of reference, but where I learned the most was in practice. At this point, my hands are extremely sensitive, and I can feel systemic, inter-related patterns contributing to a person’s symptoms, fascially, neurologically, vascularly and lymphatically.
I’ve witnessed some seeming miracles with clients, even having several who were able to cancel surgeries after one session. Assessing and treating this stuff does take SOME skill-knowledge of anatomy, the ability to get quiet mentally to focus on and perceive extremely subtle tissue interrelational dynamics, mechanics and releases, a caring heart and true love for the patient to be able to be present with them, create a safe space and listen to them, like you said, and truly wish to serve their highest good.
Did I need to pay for any of this knowledge? Looking back, I would say no because where I learned the most was in hundreds of hours of client sessions as well as studying anatomy and neurophysiological dynamics on my own. Truly. Gotta love “google university.”
So I really have to agree with you. Just like healers of old had a “gift” and a caring heart, with a little motivation and perseverance, anyone who truly wants to can become an excellent manual therapist. My two cents! God bless.

Nice post.

Interesting

Brilliant. Great thought-provoking read.