Manual Therapy Demon Strawmen

When challenged or criticised we often tend to go on the defensive. This is perfectly normal behaviour and something we all do. However, when defending ourselves from criticism one tactic often used is to strawman the criticism.

A strawman is a sneaky, snide, and devious tactic that gives the impression of refuting criticism or an opposing argument by twisting and distorting it. Using a strawman often appears to challenge an opponent’s argument when actually it attacks a version of an argument which has never been stated.

I encounter strawman arguments all the time around my criticisms of manual therapy, things such as I advocate a no-touch or hands-off approach, that I think manual therapy doesn’t work or help people, or that I think all manual therapists are malicious and malevolent. These are all strawman arguments and things I have never stated or implied anywhere, ever, at all.

Recently, two editorials blogs have been published here and here by some well-known manual therapy teachers and researchers which have yet again strawmanned my arguments and criticisms towards the manual therapy profession and these are now circulating on social media and being reposted far and wide.

International Concern?

In these blogs, some of my own blogs and opinions have been described as demonising and destructive, and that I am unfairly and inaccurately attacking manual therapy. They even go on to say how this is causing international concern and is having adverse consequences for the physio profession.

Now, I must admit that I’m flattered that the blogs I wrote many years ago are still creating such strong and emotional responses from the higher ranks of the physiotherapy manual therapy world. This tells me that I am doing something right, but it also gives me hope that if I can do this, anyone can, and if more physios were to question and challenge the complexity, overuse and general arrogance and elitism around manual therapy then hopefully it may change for the better.

As these articles are now circulating widely I feel obliged to respond to these allegations of my so-called ‘demonisation’ and ‘destruction’ of manual therapy, and will highlight their strawmen arguments and reiterate what my actual arguments against manual therapy are. I will attempt to keep this short and sweet but I make no promises, so grab a drink and settle in.

Strawman No1: Manual Therapy Has No Unique Specific Effects

The belief that manual therapy does something ‘unique’ to reduce pain is utter nonsense. Despite these blogs claims, no one knows with any certainty how manual therapy reduces pain due to the many potential mechanisms and mediators that can occur during the application of manual therapy (ref).

The so-called ‘specific’ neurophysiological pain modulatory effects of manual therapy are simply not specific or unique to manual therapy and have been seen to also occur during many things such as exercise and activity (ref, ref)

Also, many studies have demonstrated that it doesn’t matter what type of manual therapy is used, who does it, or how it’s done, we get very similar outcomes and results, highlighting how manual therapy is not that specific or skilled (ref, ref, ref, ref, ref, ref, ref).

My actual argument against manual therapy is NOT that it doesn’t or can’t reduce pain, just that it doesn’t do it better or any differently than anything else, and that no type of manual therapy needs extensive, extended, or expensive training to do it well.

My argument against the specificity of manual therapy is, and always has been, around the ridiculous extended and expensive training, with its ideology and indoctrination that it needs to be applied in a highly skilful and specific way, and that manual therapy does not help reduce pain by repositioning joints, releasing fascia, or breaking down scar tissue or adhesions (ref, ref, ref, ref)

Strawman No2: The Use Of Manual Therapy Leads to Patient Reliance, Dependency, and Low Self-Efficacy.

I know that some manual therapy given by some manual therapists causes fear and nocebo, and leads some people to become dependent on treatment and suffer reduced self-efficacy as a consequence. I will accept, as I have done before, that these are my anecdotal experiences and that I have no formal evidence to support them.

I will also admit that these issues are not unique to manual therapy treatments and can also occur with other treatments such as acupuncture, electrotherapy, taping, and so-called ‘corrective’ exercise treatments as well.

However, I see far more patients with negative beliefs and reduced self-efficacy who tell me they need their pelvis or spine pushed back into place, a muscle knot untangled, or an adhesion broken down by a manual therapist. I have seen far more patients tell me they have seen manual therapists weekly for years having totally unnecessary treatments in a misguided and misinformed belief that they are essential for a pain-free life and to prevent things from getting worse.

If this is not the definition of creating reliance, dependency, and a loss of self-efficacy then I don’t know what is. As I’ve said this is just my personal anecdotal experience, and I will say again I have no idea how often this happens, other than I see and hear it happening a lot.

The strawman here is the classic fallacy of “absence of evidence equals evidence of absence”.

This quote is often used and abused by quacks to claim all sorts of stupid and ridiculous shit, but that doesn’t mean the statement is invalid. Just because something hasn’t been studied, investigated, or researched doesn’t mean it doesn’t happen or exist.

If anyone doesn’t think that there is an issue here, then all I ask them to do is go on social media and search the hashtags #Physiotherapy #PhysicalTherapy #Chiropractic for about 5-10 minutes to see some of the utter bullshit that surrounds all manual therapy treatments.

Strawman No3: Manual Therapy Provides Short-Term Changes Which Do Not Equate to Long-Term Changes

The claims that manual therapy produces short-term changes which in turn leads to better long-term outcomes is just not well supported (ref). However, there is no denying that those who do get quicker improvements in their pain with ANY physiotherapy treatment usually do go on to do well in the long term.

However, what these quicker responders most likely highlight is not an effective treatment, but rather an individual with fewer complications and confounding factors that could delay or adversely affect their natural history (ref).

Individuals with fewer physiological and psycho-social confounders or complications are more likely to have more favourable natural outcomes with time regardless of the type of treatment they receive. Often the treatments that these individuals receive are unfairly given credit for improvements when it’s essentially natural history, placebo, and contextual effects helping people feel better.

There has never been an argument from me that some manual therapy cannot quickly reduce symptoms in some people. My argument is that this is not unique to manual therapy and often affects those with favourable backgrounds and natural histories.

The other far more important question which often gets ignored here is whether we should be judging our success in how quickly we can reduce or remove pain, or should we be more reassuring those we see who have pain that it’s safe and okay, and supporting and encouraging them to tolerate and build robustness and resilience to it instead?

Strawman No4: Manual Therapy Techniques Are Based On Outdated, Inappropriate Philosophies That Were Derived To Support Guru’s Theories

The ego, elitism, and arrogance of many of the gurus who promote, practise, and teach manual therapy has always been one of my biggest criticisms against it, yet it is often ignored or considered unprofessional.

The number of therapists who are made to feel inferior, unskilled and worthless because they can’t palpate some fictitious dysfunction or pseudo-structural abnormality made up by some half-witted deluded manual therapy egomaniac is both frustrating and annoying. I am regularly contacted by new and young physios who feel disillusioned and despondent and are thinking of leaving the profession because they cant feel things or do things they are told they should be able to do, and it breaks my heart.

If more manual therapy teachers and researchers were less elitist and more open and honest then I would not have as much of an issue with it as I do. I also find it hugely hypocritical that these blogs accuse me of being demonising and unprofessional yet seem to agree with my argument and position here.

Strawman No5: Manual Therapists Lack Skills In Communication, Reassurance, And Empathy

I don’t think manual therapists can’t communicate, reassure, or emphasise well with their patients at all. In fact, I think just the opposite. Many manual therapists often communicate extremely well, it’s just WHAT they communicate and HOW they reassure their patients that’s the issue.

Manual therapists often display lots of empathy and confidence which adds huge amounts of credibility to their outdated and inaccurate explanations and narratives, and can give patients the impression that they are in the hands of a skilled ‘expert’ who knows exactly what’s wrong and exactly how to fix it… usually in 8-12 treatments, with regular monthly maintenance sessions after to ensure it doesn’t come back.

Many patients are told that their spine is out of alignment, their pelvis is unstable, or their muscles are unbalanced by some smooth-talking, overly confident, manual therapist who has been taught to believe these things by an outdated elitist gurus and egomaniacs already mentioned above.

Strawman No6: Manual Therapy Does Not Fit Within Value-Based Healthcare

You can argue about whether manual therapy is a high or low-value treatment as much as you like, but this won’t change the fact that most public Health Services are at breaking point. Public Health Services simply cannot afford the resources to give patients with mild MSK issues that have favourable natural histories passive treatments to temporarily modulate pain when self-administered hot water bottles or over-the-counter analgesia can do the same thing.

Decades of underfunding, chronic mismanagement, and a rapidly growing population riddled with obesity and low activity levels means all healthcare services are struggling to keep up. Some difficult and tough decisions are needed to be made in terms of prioritising what treatments are considered effective and efficient and it is my belief that manual therapy is just not one of them.

Just as a public health system wouldn’t fund an orthopaedic surgeon to conduct rehab sessions, or a dentist to do a hygienists job, so it shouldn’t ask physiotherapists trained in MSK assessment and diagnostics to do low-skilled treatments such as massage or even rehab which can be done by rehab and therapy assistants and technicians.

The argument in private healthcare settings is completely different and it may be argued that if an individual has the finances, time, and resources to have manual therapy then there is little issue with who does it and how much it costs. But my argument on the value of manual therapy has always been about public healthcare services.

Strawman No7: Manual Therapy Causes As Much Harm As Help

There is no argument from me that severe adverse events from manual therapy such as cervical artery dissections from neck manipulations are very rare, and the less serious transient adverse reactions are also not that common (ref).

However, what these blogs do not take into account are my arguments about the possible and potential nocebic and psychological harms and damage that could be occurring due to the outdated and inaccurate explanations around how manual therapy treatments work and the burden these may take on some individuals.

As I’ve already mentioned there is no formal research or evidence on this, but there is a lot of direct proof that many manual therapists say stupid, ridiculous, non-sensical, outdated, inaccurate things on their social media posts and feeds, and that many people are negatively affected by this based on their responses and comments left in these posts. To deny or ignore this is deluded ignorance by those desperate to bury their head in the sand and avoid any criticism of their cherished interventions.

And yes before you say it, this can also be said of exercise and rehab with many therapists saying stupid, ridiculous, non-sensical, outdated, inaccurate things on their social media posts and feeds about it as well. But this does not excuse manual therapy from these criticisms.

Strawman No8: We Can’t Identify Candidates For Manual Therapy Which Means Techniques Are Unnecessary.

I’m not sure what this last point is really arguing here. Maybe its Clinical Prediction Rules can help therapists identify which patients are going to respond better to certain types of manual therapy treatment even though they have not been seen to stand the test of time well (ref). Or maybe it’s just that the way to see if manual therapy works on someone is to guess, press, and reassess.

As mentioned before those who do get good responses from manual therapy treatments, most likely would get good responses from any other placebo-rich treatments, or with just time alone due to favourable personal circumstances and natural histories.

Again my argument here goes back to the misguided belief that manual therapy needs to be administered to patients by therapists who have undergone extensive and expensive post-graduate training, who have developed the illusion and delusion of specialised, skilled, and specific assessments looking for pseudo dysfunctions and made-up abnormalities to be fixed and treated.

Conclusions

So there you go, there are my criticisms against manual therapy in physiotherapy laid out yet again. I find these blogs from Chad Cook and others disappointing that my real and valid criticisms of manual therapy have been twisted, contorted, and perversely also demonised.

Although I disagree a lot with these blogs I do recognise that this was written before Chad and I had a face-to-face debate in which we were able to express our positions a lot better away from the limitations of social media, and I would urge you all to watch that to get more of a nuanced view of both sides of the debate here.

I also want to state that when I use the term manual therapists here, I will always precede this with some, most, or many… never all. I know there are some excellent exceptional evidence-based manual therapists out there, and I am even fortunate enough to call some of them my friends and colleagues.

I also think most manual therapists who fall foul of many of the things discussed here don’t do it knowingly or maliciously, rather they are only following the teaching and guidance of others they trusted and respect.

I’m also aware that outdated misinformed beliefs, ideas, and methods are not unique to just manual therapy, with corrective exercise, electrotherapy, dry needling, strength and conditioning, surgery and medicine all having their fair share of the above.

I also want to stress that believing in these outdated ideas about manual therapy is not automatically a sign of stupidity or ignorance. I, myself during my post-graduate manual therapy training believed many of these outdated, non-sensical, pseudo-scientific things mentioned here.

However, the only way to reduce and untimely remove these outdated ideas is with continued debate, discussion and dare I say a bit of disagreement. This should be welcomed by all but especially by those in positions of respect and authority, and not labelled as demonising, destructive, harmful or unprofessional.

Robust, passionate debate and disagreement should be seen as a sign of a progressive, open-minded, profession, keen to progress and advance. And yes it may not suit everyone and it can be a little frustrating and annoying at times but we all need to recognise that it’s not destructive.

So my plea to all who may be invested and involved in this profession is to please keep questioning, challenging, debating and disagreeing on all kinds of things, and don’t let those in positions of authority put you off by claiming you are being destructive or demonising. Because if they succeed in shutting down and stopping debate and criticism then we are lost as a profession.

As always thanks for reading

Adam