Hands Off!

When involved a debate or an argument it’s very easy for the main points to get lost or twisted amongst the claims, counterclaims, or the general shit flinging that tends to occur. This happens a lot in many discussions, but it occurs the most whenever I’m involved in a debate about manual therapy and its role within the physiotherapy profession.

It’s no secret that I have had my fair share of disagreements over the years with many of the leaders, gurus, and celebrities of all the manual therapy treatments such as joint manipulations, mobilisations with movements, soft tissue massage, and myofascial release. I have made public and voiced my frustrations, dislikes, and even hatred of all these interventions many times on social media and in my blogs for years, and I will continue to do so.

Strong Views

It’s also fair to say that I have some strong polarising opinions about ALL manual therapy, but believe it or not, I welcome the disagreements they create. Despite many of the physiotherapy top brass and elite claiming that these arguments are harmful and detrimental for the profession, I think the opposite.

As George Patton famously said, “if everyone is agreeing, then someone isn’t thinking”. In my opinion, open, honest, passionate, heated disagreement is a sign of a profession and the individuals within it trying to sort out what’s good from bad, better from worse, less wrong and more likely right. It’s disagreements that often drive change and progress.

However, as much as I welcome the disagreements and debates around my views on manual therapy what annoys and frustrates me the most is when people twist, contort or misrepresent them. This usually occurs due to others ignorance, stupidity, or simply because they dislike me.

So when I read a spectacular misrepresentation of my arguments around manual therapy by someone I consider neither ignorant or stupid and who I like and respect, I was a little surprised and taken aback. These were my feelings when I read Roger Kerry’s recent piece titled ‘Hands on, hands off: is that even a thing?

In this article, Roger references a few of my blogs and appears to have highlighted me as the reprehensible social media pariah of physiotherapy! Underneath his extensive vocabulary, fancy words, and charming rhetoric, Roger attempts to paint me and others who question and challenge manual therapy on social media as ‘non-differentiating, tired, and vacuous’ and more annoyingly that we advocate a ‘hands-off’ approach.

This is a breathtakingly inaccurate and frustrating straw man argument that I hear often from manual therapy supporters in an attempt to undermine and distract attention away from my real arguments against manual therapy as a healthcare treatment.

False Dichotomy

I find it ironic that at the start of this article Roger states the hands-on, hands-off debate is a false dichotomy when actually none of my arguments against manual therapy are about hands on or hands off. Rogers choice of words in using ‘hands-on, hands-off’ rather than ‘manual therapy, or no manual therapy’ is a deliberate ploy to misrepresent my position and in doing so he has essentially created his own false dichotomy, which is kind of strange for a professor of philosophy.

My arguments for reducing, removing, and even abandoning manual therapy by the physiotherapy profession is not, nor ever has been about suggesting that physiotherapists stop touching their patients. This is an absurd but clever distraction away from my true positions against manual therapy as a healthcare intervention.

So I will reiterate once again why I think manual therapy ‘sucks’ and why I think it should be abandoned by most physiotherapists. My first reason is due to the constant and continued misinformation about what manual therapy does, and how it does it. Despite it being 2019 and a large evidence base many physios still stubbornly and dogmatically teach and explain that manual therapy corrects and adjusts faulty joint positions or mobility issues, that it lengthens and releases muscles, fascia and other soft tissues when it simply can not, and does not (ref).

Another reason I think manual therapy should be ‘abandoned’ is due to it being over-complicated, over-hyped, over-used, and over-priced for what it achieves (ref). Most manual therapy at best gives some people, some small, short-lasting transient effects on their pain which may or may not affect their function (ref). If manual therapy were a drug it would never be prescribed as its effects are so low and cost so high when compared to other simpler cheaper alternatives (ref).

My other argument for ‘leaving’ manual therapy behind is that its a huge distraction for therapists and patients, stealing their time and attention away from active rehabilitation interventions that have bigger and better health benefits (ref). In the UK most MSK physios have very limited time with patients, anywhere from 2 to 8 sessions that last between 20-45 minutes on average (ref). In this time they have to gain a history, do a physical exam, consider any imaging and investigations, develop a working diagnosis, formulate a treatment plan, give advice and education, and practice and rehearse rehabilitation strategies.

If all of the above is being done thoroughly and to the best ability there simply can not be enough time for the application of manual therapy. When manual therapy is used what often tends to get compromised is the active rehabilitation. I know many physios disagree with me here and they say they can do both manual therapy and active rehabilitation well, but I call bullshit on that.

When I used to use manual therapy in my practice it always reduced the time I had with patients to explore, experiment, and rehearse movements and exercises, and tinker with loading parameters. I know this is anecdotal so can’t be trusted but I hear many patients telling me about physiotherapy sessions in which they had manual therapy and how either no rehab was given at all, or if it was, it was at the end of the session given as an after-thought, usually, by the physio handing them a sheet of photocopied exercises to do at home with no explanation or practice to ensure they could do them, or that they were even beneficial for them.

Finally and by no means least, I simply hate ALL manual therapy for the pompous arrogant elitism and showmanship that surrounds ALL of it and most of those that use and teach it. No matter how well presented and explained manual therapy instils a belief of skill, specialism, and superiority that it simply doesn’t deserve.

Manual therapy also instils a notion and belief that physios ‘fix’ patients rather than help them. Manual therapy takes our profession away from our rehabilitation and exercise foundations and closer to the loons and quacks in the complementary and alternative medicine fields with their crystals and chakras.

I personally believe that most physios use manual therapy more for their own benefit than that of their patients. Manual therapy is often there to pander and pamper patients rather than genuinely help them. Manual therapy makes the therapist feel special and needed, and hides their inability to prescribe good quality robust rehab or address the harder, tougher more difficult factors around a patients pain and disability.

I know many think I am unprofessional and harmful to our profession for saying this! I don’t care, because I actually think physios fannying around with manual therapy distracting patients from things they need to do and adversely affecting their outcomes is far more unprofessional and far more harmful to our profession.

NO manual therapy doesn’t mean NO touching

However, as much as I dislike/hate/loathe manual therapy for all the reasons above, I will state again that I have never suggested or implied that physiotherapists should stop touching their patients and go ‘hands-off’. In fact I recently wrote a blog saying just the opposite here.

Touch and palpation is a basic, fundamental, and vitally important part of any good thorough evidenced-based physical assessment. Although its use diagnostically is poor I cannot emphasise enough the importance of all physiotherapists taking the time care and attention to palpate their patients.

Not only does palpation stop you missing important and vital signs of pathology such as swelling, heat and deformity, it also gives patients the reassurance that you as a healthcare professional have taken their issues and concerns seriously and have examined them thoroughly. One of my ‘many’ pet peeves is listening to patients tell me that some bone idle, lazy, and incompetent healthcare professional didn’t even observe or palpate an area of concern of theirs.

However, as frustrating as it is listening to that, listening to patients who tell me that some other therapist has palpated them and found a bone out of place, or something misaligned, or a muscle knot, or fascial adhesion is far more frustrating, far more common, and a damn sight harder to deal with. The biggest reason these ridiculous, fear-inducing explanations are given to patients is due to therapists being taught and lead to believe that they can feel and diagnose things with palpation that the evidence and simple common sense tells us they cannot (ref).

Physiotherapists often develop these beliefs during their manual therapy training and why I think most of it is best avoided as it continues to be surrounded by so much outdated, non-evidenced nonsense. Roger talks in his article about the reputation of our profession being at risk if we were to go ‘hands-off’ and I agree. But I also think the reputation of our profession is in danger of being adversely affected by the woo and pseudo-science that manual therapy is riddled with.

Until manual therapy is taught in a more simple, rationale, and evidenced-based way I think most healthcare professionals are better off without it. More therapists and patients need to recognise that there is no magic, skill, or specificity in any manual therapy that costs thousands of pounds, euros, or dollars to learn, or that takes years of dedicated practice to master and perfect.

This leads to another of my arguments for physiotherapists to abandon manual therapy, that is they are not the best professionals to be providing it. Physiotherapists are autonomous diagnostic healthcare professionals who studied for 3-5 years to assess, diagnose, and manage those in pain and with disability. They are not best utilised cracking necks, giving back rubs, or applying hot packs.

For any manual therapy to be effective I believe it needs to be given by therapists who are solely focused on it, who work in calm relaxing environments, who can take the time and attention to work on the patient’s body slowly, methodically, and holistically. This is just not how physiotherapists use manual therapy, instead it’s usually rushed and done in a few minutes or less, in environments that are far from relaxing, and often they are focused on other things around the patient’s care.

Physios training, skills and time are simply better used for other things. This is not meant to sound arrogant, condescending, or conceited just honest, rationale, and pragmatic. I see a physio giving a patient a massage the same way as I see a cardio-thoracic surgeon emptying a patients bed pan. Its not that they couldn’t or shouldn’t do it, its that they are better trained and skilled for other things!

Tired?

Although it frustrates the hell out of me that the manual therapy debate is often contorted and bastardised into a hands-on, hands-off false dichotomy, I am happy that the debate is still here be had. Despite what Roger tries to present in his article, the well-rehearsed manual therapy debate is far from tired or vacuous, it is an important discussion to be had, and it’s not just a construct of today’s modern social media.

The debate about the pros and cons of manual therapy within physiotherapy has been raging for decades long before I got involved, and long before social media was around. The likes of the late great Robin McKenzie, Louis Gifford, Max Zusman, Jules Rothstein were all known for questioning and challenging the over-use, over-complication, and utter bollocks that surrounds manual therapy long before Insta-Google-Face-Tweetbook was ever invented.

Social media isn’t to blame for these debates and disagreements as they have been always been around. All social media has done is make these discussions, debates and arguments more known and accessible which is a good thing. Again, some will argue that this is harmful to our profession and we should be focusing on other more important things, I disagree.

Conclusion

If you’ve made it this far, very well done!!!

Physiotherapy as a science-based profession needs to accept that disagreements are essential for progress. Science and philosophy thrive on discourse. Discourse drives interest, intrigue and investigation. What is far more dangerous and harmful to our profession is dogma, apathy, and lethargy from stagnation and suppression of thoughts and ideas and beliefs, and that what we’ve always done is what we should always do.

Physiotherapy needs to evolve, advance and grow, and to do this it needs to shake off some debris and detritus from the good old days and this means moving on and away from massages and manipulations, but not from palpation and touch.

As always thanks for reading

Adam