More Manual Therapy Bickering!

There have been a few of papers and articles recently attempting to redefine and re-evaluate the role of manual therapy which I have discussed before. And, another one has been published by the Orthopaedic Division of the Canadian Physiotherapy Association here attempting to redefine the role of manual therapy in physiotherapy.

As much as it is encouraging to see these conversations taking place I’m extremely skeptical that these are anything more than talking a good game whilst carrying on business as usual, and just more attempts to divert attention away from the critical questions directed at manual therapy and reflect it back onto those who question it.

The first thing I want to highlight in this Canadian article is that it starts with an annoying strawman by stating that if you use manual therapy these days you must feel like a bad therapist due to the criticism and controversy some, like myself, create around it on social media.

This is a common tactic that many manual therapists use when their interventions are being criticised. They often complain about being personally attached or victimised when someone questions the role or efficacy of the techniques they use. I really wish more manual therapists could separate their identities from their interventions and recognise criticism of their methods is NOT criticism of them.

The other issue I have with this piece is the notion that online ‘bickering’ is harmful to our profession and driving our patients to other professions who have their ‘professional act together’. This is yet again another tactic to try and shame and quieten those who question the effectiveness of manual therapy, and this argument can just as easily be used to those who continue to use manual therapy ineffectively.

When it comes to all types of manual therapy there are four areas that I will continue to challenge, question and ‘bicker’ about. These are its elitist attitude, its notion of skill, its financial incentives, and finally its belief of effectiveness.

Elitism

Unfortunately, there is still a strong culture within physiotherapy all over the world that the more qualified and skilled in manual therapy you are, the more qualified and skilled a therapist you are. This is bull shit. Nothing winds me up more than some pompous pretentious spine pusher thinking they are a better physio than me just because they do more manual therapy than me.

Being an ‘elite’ physio has NOTHING to do with how well you can massage or manipulate patients, just like how being an elite solider has nothing to do with how well you can polish your boots.
There is an argument that many of the manual therapy courses these days do a good job at developing more skilled physiotherapists with better examination and diagnostic skills. This may be true, but having seen many of the postgraduate courses and MSc programs run by manual therapy institutions in the UK such as the MACP and SOMM I am again skeptical.

I know that these so called ‘advanced’ manual therapy courses still teach a lot of pseudoscience and bullcrap. I have seen them still teach physios to feel for stiff or loose spinal vertebral motions, thoracic rings, pelvises and ribs out of alignment. I have seen them teach physios how to assess for muscle knots, fascial adhesions, questionable postural imbalances and movement dysfunctions. And finally, I have seen some so called ‘advanced training’ include utter crap such as reflexology, energy meridians and even visceral manipulation.

What frustrates me about these courses is hearing how many therapists and tutors teaching know that most of it is bull shit, yet are just going through the motions and jumping through the hoops of assessments and exams, saying and doing things they don’t believe and would never do in practice just to get a certification. This is one of the biggest reasons why I never completed both my SOM or MACP diplomas, I just wasn’t and still am not prepared to play this bull shit game.

Skill

The culture that still continues to be promoted around manual therapy is that it is some highly skilled, highly technical thing that takes years to learn and perfect. This is again bull shit. I have been banging on for years since my first ‘there is NO skill in manual therapy‘ blog about how manual therapy is actually very simple and easy to apply.

If more manual therapy courses were open and honest about this and explained simply what it does and how it does it you could cut the time and cost of training down hugely. Whenever I see courses teaching myofascial release or spinal manipulation that go on for weeks, even months it makes me both laugh and cry a little.

Having done many of these drawn out manual therapy courses I know that the theory and safety considerations could be taught in a few hours, and the practical part could take even less time. Simply put once you know how and where to place your patients and your hands you’re good to go. And once you have practised a few times you soon get the hang of it and it doesn’t take years to perfect, rather just years to convince yourself that you have!

However, many manual therapy courses and tutors don’t like to admit or accept this as it challenges their illusion and delusion of technical skill and more importantly it doesn’t justify the cost of the training

Money

This leads nicely onto arguably the biggest barrier to moving manual therapy towards a more honest simplistic approach… money. Whether you are aware of it or not, manual therapy is big business, and not just for those that charge patients ridiculous amounts for a physio massage, or a spinal mobilisation, but it is actually far bigger business for those that teach it.

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

There is a hell of a lot of money to be made in manual therapy courses and it annual subscriptions to its societies. These generates huge profits for the companies, institutions, and universities who promote them. If they were to admit that the time and skill needed to teach manual therapy was far less they would have to charge far less and so earn far less. It is therefore in their own interests to ignore or refute those that say otherwise.

Effectiveness

Finally, my last point is one I have made many many times before and one I can’t be arsed to go into too much detail again, that is manual therapy just isn’t that effective at helping people in pain or with disability. I will admit it does do something, for some, for a short while, but usually it works on those who need our help the least, who have issues that have favourable natural histories and low complications.

When you look at the outcomes of manual therapy versus the cost and time to train and administer it, it just isn’t that effective, in fact, I’d say its less effective than a hot water bottle or an ice pack.

And before you all jump on that old counter argument that exercise isn’t that much more effective at reducing pain, I know it isn’t. But you can’t compare an active low-cost treatment like exercise which has a host of secondary positive psychological and physiological health-related benefits to a costly passive intervention such as manual therapy that doesn’t.

Simply put you don’t NEED manual therapy to do your job as a therapist, rather it’s an option if there’s time and a need for it AFTER you have done everything else. Lets imagine you couldn’t use manual therapy due to some major personal injury, or perhaps a global pandemic meaning you were unable to touch patients, you could still be a damn good therapist and continue help people just as effectively without manual therapy… I know because I do this day in, day out, and have done for years.

Final Thoughts

One last point I want to make clear yet again whenever I am discussing my views on manual therapy is just because I don’t use or advocate manual therapy this doesn’t mean I don’t touch my patients. This misrepresentation of my position is a tiresome straw-man.

Just because I don’t advocate the use of massage, manipulations, or mobilisations it doesn’t mean I don’t advocate a careful and thorough examination which involves the use of touch and palpation. I strongly advocate and teach that all physios use touch when they assess and treat patients but this is NOT skilled manual therapy, this is skilled physiotherapy.

So there you go another Meakins ‘attack’ against the elitism, skill, money, and general ineffectiveness of manual therapy in healthcare. I will sign off by saying that I do think manual therapy has some place in society for those that want it, but it’s not in healthcare being given by skilled clinicians at taxpayers or insurance companies expense.

As always thanks for reading
Adam