There have been a couple of publications recently calling for therapists to re-evaluate the role of manual therapy in healthcare (ref, ref). These opinion pieces have generated a lot of interest and discussion, and many have asked for my views on them especially as one of my blogs has been referenced.
So I gave my thoughts on social media, but when one of my colleagues Sigurd Mikkelsen, who I respect hugely expresses his frustration and accuses me of lacking nuance, I take notice. So I thought I would expand further on these calls to re-evaluate manual therapy within healthcare.
The first thing to mention is that I am pleased these discussions are taking place in and around manual therapy as opposed to the usual attitude of ‘how dare you question something we have always done’, and I am also encouraged to see that the authors of these papers are attempting to promote a more honest, rational, and evidence-based view of what manual therapy is, what it can do, and more importantly what it can not do. I also appreciate their calls for physios not to totally abandon manual therapy even if I do fundamentally disagree.
Now most of you reading this will know or may have read my previous blogs here, here, and here about my concerns I have with manual therapy as a treatment for those in pain both in the public and private sectors, and although this is not new news it is worth stating again just how much I ‘hate’ manual therapy.
Hate is a strong word
When I say I ‘hate’ manual therapy I don’t actually hate it per se or those that use it, rather I hate the industry that has arisen around it for both personal and professional reasons. I also hate the many biased, elitist, and deluded gurus and teachers who continue to mislead and misinform patients and therapist about the effects and benefits of manual therapy.
I hate the manual therapy industry for promising a lot but delivering little, for wasting time, money, and resources. I hate it for confusing and misleading therapists and patients with the beliefs that these techniques are highly skilled and take years of training and dedicated practice to perfect.
They don’t.
I hate manual therapy for the pompous air of arrogance and elitism it has, for allowing some to believe that they are superior to others because they have gone through a pseudoscientific accreditation program and have a few more letters after their name, and now think they have supernatural powers of palpation and narcissistic beliefs that they can heal people.
They don’t.
I hate manual therapy for the overcomplicated grand theatrics it uses, making therapists stand in a certain way, push in a certain way, whilst pulling their stupid little faces with their noses up in the air, eyes closed, gently nodding to themselves when they think they have found and felt some illusionary stiff, sticky, misaligned joint, or a tight, adhered, knotted piece of soft tissue.
They haven’t.
I hate manual therapy for sucking the critical thinking, the common sense, and the banter out of those who use it, turning many manual therapists into witless, humourless idiots who can’t see when someone is just questioning, critiquing or even taking the piss out of their beloved treatments.
I hate manual therapy for turning some therapists into nasty, spiteful, vindictive wankers, who will attack and try to undermine another’s personal and professional reputation if they dare question, challenge, or take the piss out of their cherished treatments.
I could go on and on… but I won’t… simply put I hate the manual therapy industry, its groups, and many of its gurus for lots of reasons, but mostly for overcomplicating the simple process of touching people.
Touch your patients!
There is no doubt or argument from me that touch is an essential part of being human and it has many physical and psychological benefits. And there is no doubt or argument from me that touching our patients during an exam is an essential and vital part of our jobs, and although I don’t use any manual therapy, I still touch ALL of my patients. I make sure I spend the time to fully examine and palpate a patient who has concerns and worries about an area that hurts, as I know this is very important and often means a great deal to them.
I can’t recall how many times I have heard a patient say “he/she didn’t even look at it” when they tell me of past experiences with healthcare professionals, and I know, patients will not truly believe me or be fully reassured when I come to say that there is nothing for them to worry about when I haven’t even examined or palpated an area that is of concern or hurts them.
Using careful, caring touch in healthcare clearly has many benefits but mostly it helps reassure patients you have taken their issue seriously, it demonstrates care and empathy, and helps develop a trusting therapeutic alliance.
So just because I don’t use manual therapy and I think we need to abandon it, this doesn’t mean I think we should stop touching our patients during our examinations. This argument is often used as a strawman against my position of abandoning manual therapy and it pisses me off immensely.
Touching and examining patients is essential, but touching patients as a treatment is not. Many disagree and tend to throw papers or articles at me like this, or this, or this that show how touch reduces pain, and how we humans need touch of others to develop and function normally, and I don’t disagree.
Being touched is essential for all of us, but here’s the kicker, its the context of how you are being touched that is essential not just the process. Being touched by your family, friends, loved ones in situations and times of need, distress, fear, love, affection, warmth etc is essential. Being touched by a medical professional although can be reassuring and comforting often isn’t in the same context as being touched by a loved one and so will not have the same effects.
If you are using manual therapy on a patient based on these reasons then I think you are missing the point of what these papers discuss, and I’d argue that if a patient is seeking your touch as a healthcare professional for any of these reasons then you have deeper psychological and social issues with the individual that you need to address and no amount of manual therapy is going to do this.
No different than a hot pack
When you look at the science of how touch reduces pain we see a complex process of neurophysiology occur (ref), and of course, touch can and does reduce pain, I won’t argue that point. However, many people, mainly manual therapist tend to overstate and over-egg this point, after all many, many things can reduce pain, such as reassurance, distraction, even swearing (ref).
When you look at the effectiveness of manual therapy on pain you won’t find much, in fact, most of the effect sizes of manual therapy are small and comparable to placebos, shams, hot packs, or going for a walk and yes I’m well aware manual therapy is about as effective as exercise on pain (ref, ref, ref, ref)
But unlike a hot pack, walking, or exercise, manual therapy is a darn site more expensive to administer, both in cost and time. With more and more healthcare coming under more and more pressure with public services looking to save money, and private insurers also doing the same, all clinicians are finding themselves with less time with their patients. Simply put, manual therapy steals valuable time from consultations and follow up sessions which could be spent doing more important and cost-effective things.
Many physiotherapists seem to have lost sight of what their primary role is, physios are not here to simply remove or reduce patients pain, we are here to help restore function and quality of life, and this may be, and often is, whilst patients are in pain. More physios need to focus on the planning and management of achieving long-term goals of our patients, not just the short-term intermittent highly unreliable symptom modifying treatments. To do this physios need to develop better skills in communication, education, reassurance and motivation, not rubbing, poking, and pressing.
At the risk of sounding very pompous, arrogant, and snooty here, manual therapy shouldn’t be administered by university educated, highly trained diagnosticians and clinicians such as physios who are in high demand and whose skills are needed elsewhere. Instead, manual therapy belongs in the service industries like health clubs, gyms, spas, and beauty salons being administered by our other therapy colleagues who have the time to do it for longer, in more relaxing environments, and who don’t charge extortionate fees for something that is relatively simple to administer.
What a waste!
Whenever I see or hear of a skilled, experienced clinician like a physio giving their patients back massages, joint mobilisations, or manipulations, I think what a waste of time and resources for both the patient and the physio. That physio should be assessing, examining, and educating that patient instead, they should be designing, planning and overseeing a care management program that addresses their long-term goals and needs.
For example, you don’t see nor expect to see an orthopaedic surgeon use their time in their consultations taking their own Xrays or MRIs. Nor would you expect to see an orthopaedic consultant changing a wound dressing every week on their patients, charging their normal fees to do it. This is not because they couldn’t do it, this is because they are needed and reimbursed to do other things.
To ask an orthopaedic consultant to do everything that a patient needs in an episode of care is an inappropriate and gross waste of time and resources, so why do physios think differently? Why do physios think they have to do and administer everything to a patient such as manual therapy and even exercise therapy.
If there is a strong desire by a patient for some manual therapy to help them with their long-term goals, and you can not see any harm in it, then you best have made sure that the patient is fully aware and understands that it is NOT an essential intervention.
They also need to know that all manual therapy’s effects are short lasting, unreliable and not fully understood. They also must understand that it doesn’t correct joint, disc, or nerves that are out of alignment, coz that shit just doesn’t happen, and it doesn’t loosen, release, melt, lengthen, or change muscles, tendons or the god damn fascia in any way shape or form either.
If they are fully aware of all of this and they still want it (usually by now most of my patients have lost interest once it has been explained like this) then refer out to a therapist working in the service industry for them to apply it, but make sure that they are not being overcharged or over treated.
Summary
So I hope I have expanded and explained my thoughts on the role of manual therapy in physiotherapy and healthcare in general. Just to summarise once more that I do strongly advocate and promote that all health care clinicians continue to use touch and palpate their patients when examining them but with the understanding that palpation is often unreliable in its ability to diagnose, but is great at reassurance and developing therapeutic alliance.
I argue and will continue to do so, that physiotherapists and all the other skilled diagnostic healthcare professionals need to move away from manual therapy as a treatment as it wastes their time and other resources. Instead, they should be referring patients who wish to have manual therapy to our colleagues working in the service industries such as gyms, spas, and salons to administer it in environments with more time and fewer costs, but only once it has been clearly and honestly explained to patients what it does and does not do.
Finally, I will continue to question, challenge, even argue with all those who claim that there is some great skill or secret, magical, mystical, art to any manual therapy. I will continue to highlight how it doesn’t deserve the time, attention, and more importantly the money we continue to waste on it.
And I will continue to challenge the many biased, financially motivated special interest groups, and their gurus, along with all the other wassocks who continue to confuse and mislead therapists and patients with their bull shit claims, expensive courses and made up pseudoscientific accreditations.
I am and will always be #TeamHandsOff
As always, thanks for reading
Adam
A very interesting article. I would imagine that it causes a divide amongst readers.
The effects of manual therapy obviously needs to be researched more. However, there is research that sees it in a positive light, for example Herzog (2010), Potter et al (2005).
I admire your stand that we should practice evidence based therapy, and that we need to be careful in what we claim. A multi faceted approach is a good place to start from.
I’m with you mate. People generally relate low value treatments as a treatment with little effect. No! It’s much more than that- it’s about high care utilisation, it’s about costs of providing the treatment versus benefit, it’s the financial burden on the health care system, loss of productivity ( time off work to attend sessions) and the economic burden to the country. So MT is IMO is all that stuff- low value treatment is a big deal let’s stop trivialising these facts.
Thanks for the post, Adam. I think our profession is definitely in need of being challenged to stay current and relevant in today’s healthcare environment. Chronic wrist issues from endlessly and mindlessly performing manual therapy eventually led to surgery for me and forced a change in how I practiced. I heard a saying…people don’t change until it hurts more to stay the same. This definitely applied in my situation. With healthcare cutbacks, etc. that you mentioned, I think the physiotherapy profession has an opportunity to be at the forefront of treating MSK conditions but we need to make our way out of the dark ages first. Unfortunately, we may not change until it hurts more to stay the same.
That’s a good saying…
Hi Adam, just wanted to say I appreciate this post. I’m not sure you always word things in the best way ( you can be more inflammatory than I think is necessary or helpful but I suspect this might be intended?!) but I am grateful for the discussion and I completely agree with you. I appreciate you bringing this topic to wider attention and making people sit up and notice – and for being inflammatory when I struggle to be!
Thanks ?
Good blog, extra marks for the use of the word “wassock”.
I’m in the same camp and most of what I do is manual therapy or massage or touch. Reality checks are needed. Keep it coming!
Very nice post Adam, and thanks for clearing up the false dichotomy that gets me so frustrated – if one dares to criticize manual therapy in any way or form thats means one has stopped touching patients. I think another big difference is also when that touch has a meaning behind it, ie fits into the clinical reasoning of what goes on and how it will help getting the person back to their valued activities makes a HUGE difference.
Thanks Kjartan, and totally agree, touch without meaning in healthcare is as bad if not worse as exercise without meaning!
Being totally dismissive is derisory. The problem is that therapists see manual therapy as the be all losing sight of the primary objective. Manual therapy as with every other adjunct such as electrotherapy are merely spokes in the wheel that assists movement. If they are not going to help don’t use them if they are even if it could be psychological then that’s a different discussion. It just doesn’t need to use up a whole 30minute appointment just enough to get the patient moving again.
I mostly agree, as hands off techniques are my most deadly weapons in daily practice. However, sometimes, when people are really sensitized, some mobilisations/manipulations may be a great and complementary tool to allow people, even in short-term, do some exercises with less pain and maybe, come back, slowly, to usual daily habits alongside a proper education about pain and exercise program under our guidance (at least in the beginning). But again, there’s a lot of factors which could explain its antalgic effect, such as placebo, neurophysiological flash etc.. and not some kind of biomechanic explanations which only make people vulnerable, kinesophobic and dependant of their therapists..
Great post!
Maciek.
Plus if you don’t touch them you can see at least 8 pts and hour right? Seems to me that is the new goal since reimbursement continues to go down. Who is the elitist I couldn’t quite tell from reading the article. Also seems to me weather you agree or disagree with the article that was a childish way to go about it. I guess I better agree or go away seems to be to point. You can do better. Just wondering how old are you?
HI Scott, I’m 44 years old, thanks for asking, but I’m not sure why you are getting your panties in a bunch here?
I can’t see how I was/am childish in this blog, and I am more than happy to discuss with those in agreement or disagreement with my views.
You state that if I dont touch my patients it means you can book more in. I disagree completely, just because I dont use manual therapy I still see my patients 1-2-1 for anything between 30-60mins each. The session are used to talk, educate, and go through movements and exercises that they find hard, difficult, and painful, these sessions are spent reassuring, motivating, and encouraging them… and this can be done without me being present.
Regards
Adam
Hi Adam. I’m a long time fan of your blog and I do agree with a lot of the points you’ve made with regards to manual therapy. Admittedly I am still continuing through the manual therapy post-graduate level system in Canada. Despite all that you have mentioned I do find that it has helped me with understanding and identifying potential sources of pain including those that are non mechanical (psychological/emotional, visceral etc…) and as helped guide my decision making when it comes to active treatment. I can’t comment on the quality of training in other countries but I have found that the program in Canada despite all it’s flaws places a strong emphasis on clinical reasoning, critical thinking, and thorough medical screening. I’m not here to defend manual therapy however I’m curious on what your thoughts are with perhaps not scrapping manual therapy all together but using manual therapy assessment techniques to guide more effective exercise prescription or provide better advice to our clients/patients regarding activity modification/ergonomics etc…
Hi Brian, thanks for your comments, and I am sure there are many manual therapy courses and training out there that are keeping up to date with the research and evidence, and I have no doubt that they can help improve the assessment and examination of a person in pain, but it still doesnt change my argument that the application of the manual therapy techniques are relatively simple and straightforward and dont need years and years of practice to administer at huge costs. Thanks again Adam
I do enjoy reading your comments Adam even though I may not necessarily agree with all of them. I agree, essentially that we should be moving away from manual therapy but to say that we are doing so because it is ineffective is not entirely correct in my opinion. It is how we are viewing and using these tools that is ineffective. For example; you stated that you can not manipulate a joint with manual therapy, you are dismissing the entire profession of Chiropractors out of the bag. Now while I realise that they are not NHS recognized I do not dismiss their experiences nor the experiences of patients who have experienced Chiropracty. Where many chiropractors fail, like Physiotherapists do, is that they hold manual therapy as their greatest tool leading to dependency on treatment; rather than focussing on exercises to correct posture that the patients do themselves. A trip to the chiropractors to treat back pain may provide some temporary relief if you are lucky post manipulation but the effects are short lived as the ’cause’ has not been addressed. There is another significant point here and that is the ongoing debate and lack of recognition that I have found amongst therapists who fail to recognize the significance of posture and that posture can indeed be effected by self management exercises once the patient has awareness of what it is he is correcting. Our view of health care is indeed evolving and we are beginning to recognize the co-dependency of it all but there is still some way until people will be able to listen to what their bodies are telling them.
Hi Louise, I am not dismissing the chiropractic profession as spinal manipulation isn’t owned by chiropractors nor is it the sole treatment many evidenced based chiropractors have. Many poorly educated chiros who still taut the subluxation theory and do only use manip I do dismiss, but that is the same for any ill informed clinician regardless of their profession.
This is the best blog about MT I have read. Ever.
#TeamHandsOff
“Wassocks!” hahahahahhaa.
Cheers for the blog. Good and thought provoking read as always. Keep up the good work.
I don’t see any art in the nuances of manual therapy, but I do respect a skilled and educated clinician who can communicate and engage with a patient on their level and nuture the possibility of that patient reconceptualizing deep rooted (and incorrect) beliefs. The nuances of communication is a skill that should be respected. The ability to put complicated paradigms into a simple and digestible format is a true skill. I am not against manual therapy as a form of non verbal communication, but it has to be removed early otherwise it robs someone of their self efficacy
Brilliant article, and I tend to agree but…
Purely in my first hand and anecdotal experience a little manual therapy and hands on work goes a long, long way in getting the patient to take an active role in their rehab.
I find a lot of the time that trying to educate patients only tends to irritate them and the biggest complaint I receive regarding previous experiences with physios is that “they never even touched me and all they did was tell me to do some exercises and lectured me”
Of course, evidence isn’t very strong at all for the use of manual therapy and I only use it as an add on making sure to explain that it’s not a panacea.
I do however find it the perfect time to educate patients on the importance of self efficacy, general activity, a healthy lifestyle and how and why their exercises and treatment recommendations are so vital.
I’ve found this gets the patient on my side and they tend to be a lot more receptive and compliant to my advice and treatment plan in comparison to when I take a hands off approach.
Hi Adam,
Your courage is admirable. I’m with you all the way. This needs to be changed at the institutional level – I bloody well hope that new-gen physios will role this out as we take the reigns in years to come – hopefully we have sense and confidence enough to challenge the ridiculous ‘knowledge’ fed to us.
I noticed your language is less aggressive these days, I think this is really helpful for reducing the risk of sensitive readers dropping out before finishing the read.
Here here to seeking and speaking the truth (or the closest to it that we can get)
Well. Having read your article and some of the responses. It’s all a point of reference. Anyone who thinks that the are going to a physio for “manual therapy” is deluded. The average degree program for physios has about 3 hours of hands on skills teaching. As for accu, taping, exercise prescription etc. These are not manual therapies.
Physios want to prescribe a regime of exercise and life adjustment that anyone can pick up on youtube in 5 mins. Manual therapy is massage, manipulation of joints and soft tissue. Sports physio is the prescription of directed, phased exersice rehab. NHS physio treatment is just cudlling along…
Very good post. In the future, I will probably fall back on your orthopedists analogy.
I advocate for more use of assistants and techs in our practice. Therapists seem to believe that they need to be involved in every aspect of care. We don’t. We should evaluate and pass on to other therapy professionals. We don’t need to stand over every patient and make sure they are perfectly executing every exercise.
In fact, we don’t need to see every patient each appointment. Assistants know when to consult PTs, and we should trust their knowledge and judgement in those situations.
Anecdotally, I have known assistants who are better at exercise prescription than their PT. And their patients trusted the assistant more than the PT when it came to exercise interventions.
Great (y) Good to hear to about this.
Clearly this blog will appeal to those who fall into one camp and annoy others in the other camp. And Adam no doubt is seen as a leader of the nohands camp, something he seems to enjoy. I don’t see how that is different from those ‘pompous’ advocates of manual therapy Adam criticises. As a manual therapist in private practice (leech?) I benefit from the abandonment of hands on treatment by physios in the NHS. Patients are constantly complaining that they are given unconvincing reassurance and a sheet of exercises.
If you are going to be a manual therapist, I say do it as best you can and take pride in your work, just as anyone should take pride in their work. Of course don’t be arrogant and assume you know all the answers. But observe differences in function in people, use your hands to discover as much as you can, pay close attention to what you are doing. You might become a good effective manual therapist – like Adam’s wife apparently!
Many of the conditions we treat are difficult. We still don’t know what causes most back pain. We need to be precise and careful in refuting one theory or advocating another theory, not blowing trumpets. Think about the dimensionality of manual therapy – the number of variables needed to describe a simple manual procedure – force, time course, angle, applicator etc. There is no way we know from clinical trials if one approach is better than another and all manual therapy is equally ineffective.
I’ll take the middle ground on this one and say for me, it depends. I totally agree that if people want some soft tissue mobilization it because it feels good, fuck that. There’s Massage Envy up the street and that person can go there. However, if I am utilizing a manual therapy technique to make my therapeutic exercise more effective, then I’m all for it. Truthfully, a good manual therapy technique shouldn’t take long to perform to be beneficial (Mulligan MWM’s for example).
It really depends on what the injury is though. Does a person with a hamstring strain need a massage? Nah! They need targeted exercises as do a lot of injuries. Could a person with a stiff neck benefit from some mobilization? Maybe, but that mobe better feed right into a relevant functional therapeutic exercise to capitalize on the new ROM that was achieved.
At the end of the day though, it should always come back to functional exercise. We are movement specialists and a person passively laying on a table like a blob isn’t movement.