Why I Hate Manual Therapy!

If you’ve known me for a while, you will know that there is no love lost between me and manual therapy. I’ve had more discussions, debates, and disagreements over manual therapy than anything else, and yet again I now find myself discussing it some more.

Now hate is a very strong word and one I don’t use a lot, but I do hate manual therapy. I didn’t use to hate it, and I didn’t start hating it immediately. In fact, in my early career as a physio, I was fascinated by manual therapy and wanted to learn as much as I could about it and master all its technical secrets and mysteries.

However, as my training went on over the years I slowly began to realise that manual therapy is surrounded by a shit load of bluff, bluster and bravado, and often wraps itself up in a very thin disguise of being an evidence-based treatment when it is often nothing more than placebo, quackery, and woo!

I started to have doubts about manual therapy early on in my career as it often promised me a lot but delivered very little. I also started to resent it for misleading me with high expectations of how it can reduce pain and improve disability in my patients, only to find it did neither very well.

I then started to hate manual therapy for wasting my time and money on expensive drawn-out courses with overly complex unnecessary tests, accreditations and assessments, claiming I had to use it in a specific way to achieve specific results. I also hated it for constantly trying to make me feel stupid and inferior if I couldn’t feel, release, manipulate, or achieve what I was supposed to, often being told I need more practice, more training, and of course more expensive courses.

And then finally I hated manual therapy for all its ego, elitism, and arrogance, with many of its gurus, teachers, and practitioners walking around with their noses up looking down on others believing that they are better therapists due to some divine extrasensory skill and mystical powers of healing that permeates through their fingers tips

I also started to hate how so many patients and therapists are sucked into this delusion being easily fooled by the flashy, fancy, gimmicks and gadgets and false promises and claims of how it makes you better quicker, sooner, faster than anything else and that it is an essential treatment that must be used on everything and everyone.

However, although I hate manual therapy I have also seen it help many people in pain, a bit, for a short while, so I don’t completely reject or ignore its utility or effectiveness. However, I do reject the notion that manual therapy is some form of superior, special, skilful, or specific treatment that takes years of training to perfect.

I have now abandoned all manual therapy in my role as a physio putting all its bravado, showmanship, and pseudoscience behind me and I don’t miss it one little bit. I now don’t massage, mobilise, or manipulate anything anymore.

But I do still touch, poke, press, and prod patients during my examinations, and I still use my hands to guide, facilitate, and assist patients during rehab. But this is not formal or fancy manual therapy as peddled by the gurus and special interest groups.

And although I hate all manual therapy, I don’t hate all those that use manual therapy, especially those clinicians who use it in a sensible, rationale and evidence-based way. What I hate are the outdated and ridiculous narratives around manual therapy such as it corrects misalignments, faulty mechanics, breaks up scar tissue or adhesions, releases fascia or knots in muscles.

Utter nonsense!

These biomechanical structural narratives about what manual therapy does are frustrating and inaccurate. They can also be extremely detrimental and harmful to some patients, producing nocebic effects, and possible reliance and dependence on certain manual therapy treatments.

We know that as clinicians our words and explanations can often be misinterpreted by our patients (Barker 2009) and create nocebic harmful effects (Richter 2010). And I have seen this first-hand in many patients who are fearful to move due to a manual therapist telling them their pelvis may come out of alignment, or that they have to do a specific exercise or stretch to prevent some fictitious imbalance or fascial adhesion occuring. 

Many of these harmful false beliefs are created totally unintentionally and accidentally by therapists who have themselves been misinformed and mislead in their outdated manual therapy training. There are some unscrupulous therapists who do use this to their advantage to keep patients coming back regularly for expensive, ineffective ‘treatment’ top-ups, however, thankfully these are rare.

Soft tissue isn’t soft!

One of the most common explanations of how manual therapy works is that it releases loosens, or frees up a soft tissue, be that a muscle, a ligament or the dreaded fascia. However, the term ‘soft tissue’ I think is a bit of a misnomer as our soft tissue is really not that soft!

In fact, our soft tissues are bloody tough, resilient and hardwearing tissues, and they are not bent, stretched, deformed or altered as easily or as quickly as many believe.

All our soft tissues have to be tough to not only hold us together and protect us from the external environment but also to move us around by transferring large amounts of force regularly.

Our soft tissues just can’t afford to be fragile, delicate, or easily malleable as they have to withstand huge amounts of stresses, strains, shear, compression and friction forces hourly, daily, weekly, for year and years.

Our ‘soft’ tissues don’t simply yield, stretch, give, or release easily when rubbed, poked, prodded, stretched or scrapped by a therapist.

I mean if our tissues could be affected that easily then we would be constantly elongating and releasing things as we moved around and knocked into things during our day to day activities, not to mention changing the shape and length of some other body parts that we all like to self rub and tug now and then. 

Does manual therapy change tissue?

No manual therapy, no matter the type, style, intensity or duration can change the physical ‘structure’ of any human soft tissue significantly.

What’s that? You don’t believe me and want some evidence?

Well, how about a study by Vardiman in 2014 for starters. They looked at the use of instrument-assisted soft tissue massage (or IASTM for short), this is the type of massage in which they use metal or plastic tools to scrap and stretch the skin and muscle in a belief it releases adhesions and loosens muscles. In this study, they used this type of massage of the calf muscles of 10 volunteers looking at its stiffness, thickness, viscosity, density, as well as a host of other biological tissue markers taken from small muscle tissue samples taken before and after IASTM tools

They found that after a single session of vigorous IASTM to the calf muscles there was absolutely NO change in ANY of the physical or biological parameters of the calf muscle. Nothing, nada, zip, diddly squat.

OK, so it could be argued that it was only after a single session of manual therapy, and maybe some changes would appear after more treatments over longer timeframes. But that’s still very unlikely. 

What’s that? You don’t believe me again and want some more evidence?

Well ok then, how about this study by Konrad 2014 who looked at an aggressive six week, three times a day self-stretching regime of the calf muscles again, and demonstrated absolutely NO physical change on the structure of the calf muscles in any way.

Surely you have to ask yourself if the forces of vigorous daily stretching for six weeks doesn’t change a muscles structure then what chance does a bit of manual therapy have that’s given, at best, a few times a week have?

This lack of structural change or physical alteration after manual therapy isn’t new news. In fact, it has been questioned for a long, long time! Papers by Threlkeld 1992, Bialosky 2009, Zusman 2011 and a host of others, have all questioned the physical effects of manual therapy and the notions of changing tissue or structure in any way, yet these beliefs still continue and if anything are becoming more widespread and pervasive.

Why do these explanations still continue?

I believe these false narratives around manual therapy persist mostly due to the fact that it’s very hard to get someone to change their views and opinions about something, especially when their income depends on them not. There are many gurus, teacher and tutors of manual therapy who are invested to keep the magic and mystery of it alive, who exaggerate and elaborate its effects the most as they profit from it the most.

These misleading explanations and false narratives also continue to thrive because not many dare speak up, question or challenge the influential guru’s, tutors, and institutions who are often quick to attack anyone who challenges them.

Believe me when I say it can be daunting to challenge the manual therapy elite having myself been personally rebuked, reprimanded and even reported to the authorities for allegedly being unprofessional or bringing the profession into disrepute just for questioning the claims, nonsense, and pseudoscience promoted around manual therapy.

I know only to well that many of the so-called kind, caring, warm and cuddly manual therapy gurus can be very aggressive, nasty and downright vindictive and malicious when their beliefs, practices and positions are questioned.

Speak up!

However, despite this, I still think it’s vital to speak up and question and challenge the utility and effectiveness of all manual therapy treatments a lot more. As mentioned this can be tricky and awkward to do but if we continue to do nothing, nothing will change



So I hope I have explained a little more as to why I hate manual therapy and demonstrated why a lot of the narratives about what it does are inaccurate and potentially harmful. My plea to any clinician using manual therapy is please stop using outdated explanations about what it does and to also realise that it’s not skilled, specific or essential in any way.

As always, thanks for reading




  1. Are we able to comment now? I’d just like to say agree agree AGREE! With all of the above. In a lecture the other day (in my new life as a physio student), the professor asked us ‘why do people stretch?’. He said that for the first time ever, he got some answers that included the nervous system, possible psychosomatic reasons, and ideas about changes in perception and sensation, so it would seem that these ‘new’ theories which go beyond the bio-mechanical model are starting to filter down into the population. Or maybe it’s just members of the population who have done a bit of reading because they’re studying the subject…? Anyway, battling the average Joe’s understanding of massage and acupuncture (give me strength), is one of my daily battles, but I REFUSE to resort to wanky answers about blood flow, adhesions and release, because my clients deserve better. The manual therapy industry is terrified to admit the lack of mechanical evidence for what they do in case it somehow harms their business. However, continuing to teach trigger point therapy, soft tissue release, frictions and massage as ways to ‘break up scar tissue’ is negligent and lazy.

    • Hi Liz, yes you are able to comment now, I have provisionally turn comments back on and see if the abuse has settled down. Its good to hear that things are changing slowly, long may it continue, and many thanks for your comments, and all the best with your studies

  2. Good post. I do enjoy a massage and do feel it is loosening me up, but I am under no illusions that it is breaking up adhesions etc. I am wondering though, if I am under no illusions, does it really matter if my therapist is?
    I mean so long as I am not being ripped off by paying extra to have the same massage done with some silly tool, I am not really bothered as long as I ignore any ‘woo woo’ explanations of what it’s doing.

    • Hi William
      Thanks for your comments, and you make some very good and rationale points.
      I think you’re are spot on, as long as your not getting ripped off, you find it helps, and not sold or given any BS fear inducing explanations as to the effects or mechanisms of massage then your right you dont need to know or care how it works

  3. Well Adam, there is more powerful problem which myth -busters must face on it. It’s a huge number of the patients and clients who already believe in the changes of tissue EVEN bones and spine?! such as discus hernia! The worst I’ve heard and know is that there are thousands of so called “exotic” massage practitioners and gurus recommend massage to the patients with a cancer !!! I had a great argue, and I still have and with such idiots (excuse me but I have to call them with a real name by my opinion). when you are asking them for a science proof they become a very aggressive as you mentioned. They KILL people and because these desperate people in their fear and powerlessness, they are ready for any therapy that help them to survive. These criminals rob them consciously and speed up growth of tumors! Here needs to be running – THE LAW! Anyone who uses medically and scientifically unproven therapy should be prosecuted and treated as a premeditated killer! massage is only for those who want to relax, thougheven then should be careful, due to medical reasons. Regards and Congratulations for the article !

    • Hi Per
      You have some strong opinions on the subject, I don’t think I have ever come across any evidence that anyone has died from massage, certainly a lot of charlatans ripping people off, but murderers that’s pushing it a little far!

    • …”And speed up growth of tumors! …massage is only for those who want to relax, thougheven then should be careful, due to medical reasons.
      to be fair you should call B.S. where ever it happens even in your own comments section!!!!
      Is massage safe for people with cancer?
      Light, relaxing massage can safely be given to people at all stages of cancer. Tumour or treatment sites should not be massaged to avoid discomfort or pressure on the affected area and underlying organs. If you have any concerns, talk to your doctor or call Cancer Council 13 11 20.
      Some people worry that massage can spread cancer cells throughout the body via the lymphatic system. The lymphatic system is a network of vessels, organs and nodes through which lymphatic fluid (lymph) flows. It is part of the body’s immune system. Lymphatic circulation occurs naturally as we move.
      Cancer may spread (metastasise) into the lymphatic system via the lymph nodes, or it may start in the lymphatic system itself. However, the circulation of lymph – from massage or other movement – does not cause cancer to spread. Researchers have shown that cancer develops and spreads because of changes to a cell’s DNA (genetic mutations) and other processes in the body.

  4. Thank you Adam for another very good post and interesting comment about Liz who, as a student, seems to be getting a different message.
    Much more emphasis should be on the role of nervous system in changes seen as well as changes in perception. I use manual therapy in very specific cases and I am indeed met with incredulous stares by my patients when answering the question “what are you trying to do?” as I give a very similar answer to the one Adam presented in his post. Much work needs to be done to inform, educate and kill myths that have been present for so long in the public psyche…I do feel like Don Quichotte sometimes.
    Keep on writing Adam and thanks for re-opening the comments option.
    Pierre Bonnaud

  5. I am a physiotherapist who puts his hands on patients at times but certainly not in all cases – so i maybe the one who gets the abuse in this scenario – here goes anyway, the risk is mine i guess. I am genuinely pleased when there is discussion and i really am in the same position with regards to the claims of individuals who use misleading interpretations of their mechanistic intervention. Positional palpation has no grounding, the notion that we put anything in or out or that we increase tissue length are not ones that i hold at all, mobilising tissue does not change the extensibility, i cannot see anything that would support these suggestions and so I am very much in agreement with the comments and proposals.
    As a Physiotherapist who uses hands as part of a multi-modal treatment process (bit wordy but I feel I cannot class myself as solely a manual therapist as this term is not indicative of the scope of my practice – this would be very limiting) – i place far more emphasis on understanding, empathy, education. Simple movements, and shared decisions to (try) to ensure the patient feels they have a sense of control. Solely using hands without doubt (in my mind) really fails in that process. I believe (rightly or wrongly) that the sensation of force and touch interpreted at a number of interactive neurological processes has a part to play in altering the perception and interpretation of pain for a short period of time, force i feel also links to low level mechanoreceptors involved in the perception of position and movement – again only for a short period of time. The context in which it applies will modify these processes and so it is a way to pain modulate (DNIC) perhaps, link to proprioceptors – maybe, to possibly help in certain patients to begin the motor pattern movement alteration and help interpret their emotional perception associated with that pattern to be subsequently challenged, and then enhanced with exercise and movement –re-education. There is also a great sense of empathy associated with touch that I feel again in the right context is relevant – but this is not mechanistic at all in the true sense of the word. It is vital that the patient does understand the relevancy and importance of what they do, how the clinician is really just enhancing their own ability to recover and respond.
    Of course, there are ranges of ways to do this and I don’t believe that MT is better than others. It is a method that under a clinical reasoning methodology is chosen selectively, rationally with the patient at the heart of it rather than clinician bias (or though i do recognise we all bias our selection to things we are comfortable with) that can be used with the right patient group.
    I now am going to possibly get really shouted at – i also am involved in facilitating courses that involve using your hands as a physiotherapist (I am certainly no guru – and what an awful term that is) – i without doubt agree it is ethically unsound when given this opportunity to be in an educational environment (a privilege)to not give the context and the balance to the argument – i don’t wish to offer anything more than a reasoned physiological (logical) answer with course participants and university students that i work with, and I actively look to dispel common misconceptions that clinicians may use to make themselves sound clever and detached from the patient as if they have “healed” someone – i really feel that this is unprofessional and massively unhelpful and painfully arrogant.
    So, although I use techniques that this forum would classify as MT, I do agree with the view of interpreting it and not over playing it – the key to pro-active practice (IMO) is to be reflective and I have made many errors, and will continue to do so, just try to learn from then to improve. I have a belief system that is underpinned by science and experience, this is a plastic process, and I enjoy considering this system and where it is in a learning continuum.
    Just my views of course – and of course time and others will continue to modify that – something to look forward to.

    • Hi Neil, many thanks for your thoughts and comments
      Firstly as I mention, I am also a physio who occasionally puts his hands onto patients, and although my wording is passionate at times there will be no abuse directed or tolerated towards anyone willing to discuss and debate manual therapy on this site.
      The theme of this post is about the explanations and language around manual therapy not the therapists per se.
      Many therapists use these terms and explanations due to a dogmatic belief that they can and do mechanically and structurally alter connective tissue with manual therapy (and believe me, there are many…) and I am under no illsuion that this post will not make one iota of difference in their fixed beleifs and mindsets.
      However many therapists still use these terms out of habit or perhaps from a lack of knowledge or understanding of the current evidence base and literature and are willing to learn and change practice, it is these I wish to reach out to.
      If this post makes one therapist question what they do and how they explain manual therapy to patients then it has done its job, and I am happy with that.
      Kind regards

  6. A delightfully opinionated and honest blog as ever Adam. Thanks for sharing!
    In this case I reckon the term ‘thanks for sharing’ ‘s association to the self-help-group industry is very apt!
    ‘I have a problem with manual therapy and here’s why’.
    It reminds me of Dr Neil O’Connell’s fave line: ‘I’m a recovering manual therapist’
    I very rarely hear anyone disagree that words matter and therefore most are starting to understand the need to move away from language that suggests causative structural and mechanical faults. I agree that the move away from language that suggests structural and mechanical mechanisms of treatment is a slower burner…
    What we mustn’t demonise though are the words themselves. Terms like ‘release’ and ‘break-down’ can be attached to abstract concepts, emotions and events, not only structures or other more literal constructs.
    For example;
    I share your hate for ‘release the upper traps’, however if the patient shares that massage ‘releases tension’, the word can be explored. In this case, if you were to rub said sore traps, perhaps this would be a perfect opportunity to discuss the semantics around the word ‘release’ and highlight mechanisms that might truly be caustive? Thus making manual therapy facilitatory to actual change.
    I’ve had some great conversations recently (panic not podcast fans, some are recorded) with some brilliant clinical and academic minds regarding the language used in their fields. The terms ‘entrapment neuropathy’ and ‘trapped nerve’ came up in one of these chats and we agreed that even the ‘diagnosis’ in this case can lead therapists and their patients to attribute symptom relief to ‘untrapping’, despite predominantly physiological mechanisms.
    Loving your work. But here’s hoping your groupies don’t blame the actual words!
    Jack Chew

    • Hi Jack
      Thanks for your comments
      Firstly… groupies… where are you!!! I seem not to be aware of your exisitance…
      Secondly… you’ve recorded conversations with ‘brilliant clinical and academic minds’… I dont remember being interviewed again!!!
      Thirdly… you make some very valid points, perhaps some words like ‘release’ ‘untrapped’ can be helpful in certain senarios with clear explanations, but I still argue there are simpler easier ways to describe what manual therapy does without the risk of misinterpretation of a mechanical structural effect.
      PS: Mutal appreciation of loving the work you and the team do at The Physio Matters Podcast… group hug…

  7. Hello Adam, first time reader, some-time manual therapist. Thank you by the way for having this conversation, I will be taking it to my students and continuing it. I am struggling/not struggling with what you are saying because I feel very much the same way, though not in any way as articulately. I do not hate manual therapy though. I LOVE getting treatment, but because I also treat, I struggle daily with the question – “what is this doing?” and when I’m a patient I really don’t care what you (therapist) think it’s doing – just do it.
    As an osteopathic manual therapist suspension of disbelief of magical thinking is really a necessary requirement to complete the education here. To continue to sustain that disbelief one must also be heavily affected by confirmation bias – an affliction too common in this industry.
    I teach Research Literacy as well (making my students evaluate a manual therapy claim using research), and I teach con-ed courses and have recently been altering them to address those language elements I am uncomfortable with. It is proving to be a LONG ongoing project but I frequently use “I don’t know the exact mechanism, but …. insert theory based on current biomechanical/physiological/anatomical/research considerations here”. Your suggestion also welcome, because ‘unlearning’ a rote reply is quite difficult.
    My other struggle is the use of research or what is often termed “evidence”. I read A LOT of research and most of it, with relation to manual therapies, is significantly methodologically flawed (whole host of reasons) and suffers from design and reporting bias in fairly obvious ways. This, however, makes the results (quantitative) not usable in the ways they are being used. Unfortunately these same results are continually used to make a point about one thing or another related to manual therapy (as a whole) without critique of the source and without specification to the research itself i.e. way too much generalization to the industry as a whole from one or two small, methodologically questionable studies based on throwaway “conclusions” from the authors. I tell my students and basically anyone who will listen that we cannot have it both ways – either the study is good, really good, and the results are usable, or the study is questionable and so are the results. Also, more than one study, please! This does not make the research unusable (evidence is a gathering process, small piece, by small piece), but like the problematic language around the mechanisms of how manual therapy works, the language around research evidence and the ways in which we take just those pieces of the evidence that suit our argument (for and against) is just as problematic. I have two ways of speaking to this – In order to believe the evidence you have to believe the EVIDENCE (critique, critique, critique), and my fave from a recent article – The Pendulum of Science Swings Again.
    The language used around MT is problematic with or without research evidence, and an uncritical reliance on the current available evidence (access is a whole other problem) is just as challenging and can equally contribute to maintaining a dogmatic approach on both sides of the fence.
    Challenge however is what we need to continue doing. My current solution is one student at a time, but I might just get myself a blog too rather than piggy backing of yours. (Verbose is a term often used to describe me – maybe why I don’t have a blog already)
    Please keep writing and challenging.

    • Hi Monica
      Thank you so much for your comments, and you are absolutely right lots of evidence is flawed and methodologically inept, and confirmation bias is EVERYWHERE in EVERYONE!
      This is a great blog on confirmation bias by Alan Taylor you will also enjoy reading http://alteredhaemodynamics.blogspot.co.uk/2014/10/confirmation-bias-physiotherapy-and.html
      However we must use the data and the best evidence and research wisely but as Sackett originally stated it is only one part of evidence based practice, clinical expertise and the patient values and expectations are also key
      The other point you make with regards to the patient not caring too much about the terms used with manual therapy just as long as it feels good has come up before, and I do understand this. But there is still a potential for reliance on therpay and its open to abuse by some charlatans and unscrupulous practioners.
      So I do think its worth trying to change the general perception of what manual therapy does that the general public has, but i am under no illusion this will take decades if at all.
      Kind regards

  8. Love your post. I am a newly-hired teacher of massage therapy at a private school. A lot of the curriculum has to do with the mesoderm, the muscles, bones, joints, and how we release adhesions and what-not. I’ve been a fan of Diane Jacobs, the ectoderm, Somasimple, Paul Ingraham, etc. to name a few (this is not a argument from authority fallacy – just trying to make a point of how they were a game-changer, a meme-breaker, and so on). I believe you are spot on. I do feel like a split-personality now and then, having to teach some notions that I don’t agree with. We have yet to speak about skin, cutaneous nerves, placebo, non-specific effects… we jump to “releasing muscles” too quickly, forgetting the foremost purpose of social grooming.
    I hope my post is not too horrific in syntax. Had a lot of ideas that I wanted to throw out there. Keep up the good work.
    ps: I’m getting all too tired of the “but it worked for me post-hoc fallacy” – lot of effort wasted trying to explain this one to students/believers/etc.

    • Hi Stephane
      Thanks for your comments. I too often read Diane Jacobs and Paul Ingrams work and think they do some awesome and great stuff, I try to get onto Soma every now and then and find it a useful and enlightening source, but do find the site a little pompous and condescending in tone at times, and can be way over my head with the neuroscience and philosophy as well.
      You mention having split personalities and I can relate to this, I think a lot of therapists can, and in a way that’s not a bad thing as we still have no conclusive evidence, and probably never will that one way or mechanism is the right way, so keeping some skepticism and not placing all your egs into one metaphorical basket is essential in my opinion.
      You are also right about post-hoc fallacy’s being extremely rife in the manual therapy profession and again can and is used for lazy clinical reasoning and quackary, not cool, we should always question whi why something works or doesn’t.
      Thanks again

  9. I am a Massage Therapist Adam and there have been great changes afoot. Perhaps we are not doing what we thought we were doing, but we do still get results. I have met Physios that speak of adhesions, muscle release, fascia, I have met physios that explain all problems as mechanical, a structuralist view that involves stretching, exercising. I believe both professions are changing radically.
    Will physio as it is today, still be around in 10 years? Maybe not, you guys also have to change your view, your understanding, you too are not necessarily taught pain science as we understand it today. I have just been on a course about the nervous system, full of physios. Their understanding seemed no better than mine. In my view Adam, you are not a perfect profession and nor are we.
    We know we need to calm the nervous system, what better way that touch, reassurance, education. Room for us all.

    • Whoa whoa Susan… please read my post again, you will see that I don’t name or point to any profession, instead I use the term manual therapist, this means physio, osteo, chiro, massage therapists, rolfers, ART, MFR etc etc doesn’t matter what you call yourself or what qualification you have or dont have, this post is directed at ALL.
      There are just as many ‘manual therapists’ in all professions that still cling to the mechanistic fallacy’s around manual therapy and I am in NO way saying phyios are any better or any worse than others, nor does it say this in my post, rather I think your own interpretation of the blog sees it as such due to your own biases and defense mechanisms being a tad high.
      And…. NO… physio will not be the same in 10 years time, just as it is not the same today than it was 10 years ago in the past, That’s normal scientific progress, but not all will follow it, it is easy for some to get comfortable and stay comfortable, when change and evidence dictates change in practice many don’t as it feels threatening.
      In my view Susan I think you may want to step down from hyper-vigilance and defense at little and see that I am saying just as you have said, that ALL manual therapy professions are as bad (and good) as each other.

      • Thanks Adam, yup, a bit defensive and biased I’ll agree. No doubt arising from a complete discombobulated concept of what we do and what I do in particular. Thanks for voice of reason.

  10. Adam, thanks for your raw honesty!
    Many in my [chiropractic] profession here in America insist that not only is it important to choose the one, precisely correct spinal segment to “adjust,” but they add magical, mysterious twists and torques to their hand contacts during a light thrust (often entirely absorbed by soft tissues) as they feign higher wisdom for their years of experience with their particular technique. Nauseating.
    With much of spinal manual therapy, does it really matter “where” or “to what spinal segment” our pokes and thrusts are directed? We don’t know (though many of us pretend to know.) When confronted with what many perceive to be a lack of segmental mobility (Triano’s “functional spinal lesion”) does it matter whether manual therapy is performed AT ALL? Still hard to say, and neither the Cochrane Database or prevailing meta-analyses are of much help at present.
    So what are we doing with manual therapy? Mobilizing intra-articular synovial folds, as Lynton Giles (Australia) suggests? Breaking up long-standing intra-articular adhesions? Or, in the context of myofascial tissues, are we initiating a molecular process when addressing “lumpy bits” or “fibrous adhesions” within fascia over time (purportedly shortening molecular linkages to the 5-dalton range) as Antonio Stecco (Fascial Manipulation, Italy) suggests? Are we simply creating dependence on passively-applied therapies? Is it really all just the laying-on-of-hands?
    You rightly point out that in our discourse with patients we must hold allegiance to the nothing but the truth. Eschew wandering explanations. Reject the blather. In light of the work of Lorimer Moseley and both yours and his BJSM podcasts with Dr. Khan this year, my own conversations with patients are tightening up nicely.
    Thank you for your bold work, Adam.

    • Hi Dr Carmichael
      Many thanks for your comments and wise words. As you say there are many explanations for what is thought to happen with various manual therpay, and really simply put know one truly knows, certainly not me! Thats why I say as much to ALL I do rub or poke and simply ask that others consider doing the same

  11. Another good one Adam, you seem to be going through your own personal journey with your blog, your comments are softening,but maybe the comments you are getting are more sensible now. I basically agree with all your saying but feel we have such a long way to go with the patients getting on board with all this, as it is, we are not even close with the therapists. I’m a bit torn as I feel instead of balance, we now have the manual therapists versus the “non” manual therapists. The strict manual therapists clinging to crazy alignment, tissue release,fascial release, shifting molecules etc, and the “non” manual therapists who feel like its a badge of honour to say “I don’t touch patients”. After 20 plus years in practice ,try as I may turning the tide is proving very difficult. Even the patients who “get” what I’m saying, don’t get it. After explanations of change in perception, affecting the nervous system (not de tightening muscles etc), I get a look like “so what, just do what you do”, I.e. They don’t care. 2 patients this week highlighted the medically educated and uneducated expectation of treatment. The first a real estate agent, I had not seen them for 8 months, have you been exercising I asked, answer “no”, have you done the exercises I advised last time, answer “no”, the patients response, “I just need that rib popped, I feel 10 years younger when that’s done”. I did my examination of his shoulder ,gave advice, stretched some ribs a bit, but it didn’t “pop”, he left almost crest fallen because the rib hadn’t been popped. I’m not really asking for advice but someone like this is almost unchangeable in their opinion of what is required, yet these are the tough nuts that need to be changed. The second was a highly regarded radiologist in my city who I had not seen for a couple of years and they proceeded to talk in terms of alignment , asking me if they were “out”, going on tell me they got a CT scan of their spine and there was a little bit of arthritis at one level so that’s why they had pain there. Then going on to tell me about their new imaging centre and how good it was as they were doing a lot of facet injections, PRP injections and other interventions that anyone who was up to speed would know are considered a waste of time now. I was a bit gobsmacked. Sorry for the long rant but that is just a small slice of the week that seems to go on and on! These days I generally take a long metaphorical sigh and wonder if there is any light at the end of the tunnel. Cheers.

    • Hi Nigel
      Thanks for your comments, you are not the first to say i am softening! I cant see it, I still think I am a cantankerous, stubborn git, maybe I am a little more tolerant, maybe I have learnt a few things over the year or so I have been blogging, maybe it is as you said just not having as many ad hom attacks.
      I think there has always been a hands on v hands off war in physio for as long as I can remember I just think its more public nowadays, but I think this is good, having the two sides will help keep the balance, there will always be outliers with extreme views the rebels, mavericks and agitators, but its these that ask the difficult questions, push the status quo and promote progress in my opinion.
      Thanks for sharing your story or rant as you call it, I can relate totally, all I can say is, your are not alone, take the rough with the smooth, the good days with the bad and in general all tends to find balance.

  12. Thanks for this healthy discussion topic. I don’t want to discuss the need for a deep critical revision in the way manual therapists comment on what they actually do.
    I would like to say two things :
    1. Radiologists, rheumatologists and GPs may benefit from engaging in the same critical revision. There’s quite a gap between those who conduct and publish RCTs and other research, and those who treat and explain things to patients. My opinion is that the problem you describe in Manual Therapy is not, alas!, limited to Manual Therapy
    2. Your point is focused on “what’s happening when a patient is treated through manual therapy”. I would be interested to read your opinion on “what happened when pain/stiffness/distress suddenly occurred”. I’ve got my idea, based on the same danger signals, complex nervous system interactions, etc. but I would sincerely be happy to read yours.

    • Hi Marco
      Thanks for your comments. That is an excellent point that many other healthcare professions are far worse in the terms and explanations they use. I wrote a little about this in my previous blog on how long things take.
      With regards what happened or happens when pain stiffness occur I agree fully with your view that its the threat sensed by the neural system of potential tissue injury or overload that creates a lot of it, however lets not fully forget the structure and nociception which also has a role in pain stiffness perception
      Kind regards

  13. Thank you very much for your blog that I follow with a great attention.
    Your post is very true, I work as an osteopath, and I use the neuromatrix model (neuroscience education and motor graded imagery) with my patients. I agree with you about the dogma of the biomechanical model in manual therapy. Unfortunately, most of the patients believe in that model wich is very Cartesian and easy to understand. It’s difficult to find the good pedagogical way to change their beliefs. If you want to shift their paradigm about pain, you need to be smooth, and maybe the way you wrote your last post is a little bit too agressive for manual therapist who received their training course based on the biomechanical model. Belief is hard to change. Regards. Laurent

    • Hi Laurent
      Thanks for the feedback, and I agree, you are not the first and wont be the last to criticise my rather forth right abrupt style when it comes to these things.
      I take your points on board, and will try as I can to stop being a bull in a china shop at times
      Thanks for a rather gentle voice of reason
      Kindest regards

  14. Hi Adam,
    I am relatively new to this game, and though I love doing ‘manual therapy’ I am aware of the limitations of this and always tell patients this is for short term relief and will require some commitment from them to change their posture/ do their exercises etc. I am not familiar with the level of intensity with which you argue your point(s) (surely discussion can be engaging without being vehement?) and tend to agree with a couple of the gentler comments above that touch, reassurance and confidence in the therapist are all effective ways of improving a patient’s perception of their pain or their overall problem.
    I tell my patients that massage and acupuncture stimulate an increase in circulation to the area, and that the body, via the blood, then gets going with its nutrient supply / healing mechanisms, with a bit of endorphin release from the brain. That seems to cover all bases, informs the patient and reassures me that I am giving some benefit to them, but now I am not sure if this is ‘right’…?
    I’d be very interested to be pointed in the direction of any research that refutes the existence / relevance of trigger point therapy etc because I have used this and experienced this and it has worked well, again within the context of not letting the problem build up again (e.g. postural problems).
    Thanks for the post, though it makes me very uncomfortable I guess that’s the point..?! I’ll keep reading, in a take-your-medicine kind of way… 😉

  15. Adam
    Out of curiosity, what interventions to you use for the treatment of your patients and do you know the respective evidence for those interventions (i.e. exercise, modalities, etc). Thanks!

  16. Adam,
    Nice to see the comments opened up again. I just graduated and over he course of my internships and own critical thinking I have changed my perception on manual therapy. I have worked and interned at about a dozen places at this point and looking back they all did everything differently, mostly everyone got better, and the people that get better the quickest are those that do some sort of HEP and or are in decent shape. I now feel vindicated for getting the SIJ tests, FRSR, upslips/downslips, nutations, trigger points, MET, and alignment wrong when asked by my clinical instructor what was wrong after she “assessed” the patient. I felt like I was a complete idiot for a few months because I thought I just couldn’t get it.
    However, I do perform about 8 minutes of manual therapy each session for a few reasons. 1 patients seem to enjoy it and I feel without it I would question their compliance with attending therapy. 2 It appears that I am assessing them and doing a good a thorough examination. 3 Whatever I am doing seems to work at times. 4 I feel it’s somewhat expected by the patient. Without manual therapy I feel the patient would just say I can do these exercises at home and then not do them resulting in a failed intervention.
    Thanks again for your blog, of all the PT pod casts and blogs I read this is the one I look to the most.

  17. Not really of benefit to the discussion but having spent the last 12 months studying MT & discovering this blog and alternative thinking early on (probably to the detriment of my scores as most of my papers included a massive chunk of uncomfortable reading for the markers) I both love & hate you Adam .. but you get people thinking and debating.
    My scores were average but my eyes are open. And I enjoyed using STSSOAUO when discussing ‘trigger points’ …

    • Yeah i get that a lot, love / hate thing… More the hate but hey, haters gonna hate!!!
      I absolutely love the thought that someone used my acronym of STSSOAUO in a viva or osce ??? great work
      Thanks and keep thinking and debating…. ?

  18. Hello Adam, given my position (Chair of the SMA and Chair of GCMT) you might be surprised to hear that I agree with the premise of your article–and I suspect many of my colleagues will also agree. It is absolutely right to challenge ‘conventional wisdom’ and to ensure that any claims made are backed by evidence based research. I think most of the people I work with are pretty comfortable with the “I’m not sure why this works” response–although I’m not sure every client would understand the “I’ve just changed your perception of pain” explanation, even if it is backed up by the latest research. I’ve only just picked up on your post so missed the abusive responses–a little disappointing if I’m honest as there is no need for us to be defensive–manual therapy works on some level, why this might be we are not yet entirely sure, but any profession should be constantly challenging the status quo if it is to develop. By the way I don’t hate Physiotherapy (or Osteopathy, or Chiropractic) Physiotherapists were largely responsible for creating and sustaining the SMA and we continue to work with you in multidiscipline teams across a variety of sports and in private practice.

    • Hi Paul
      Thank you for your message.
      I think you may have misinterpreted my meaning of the strong word hate here, I don’t hate manual therapists, i hate the bull shit around manual therapy
      I’m glad to hear that your colleagues may share my views but beleive me when I say that the majority of manual therapists dont, the ‘i’ve changed tissues, stretched fascia, broken adhesions, increased blood flow, removed waste products, etc etc’ are what most think and explain what they are doing, I see it day in day out…. A lot!!!!
      And believe it or not many if not all my patients do understand the altered perception explination, try it, i think many therapists under estimate what patients can understand, its a simple concept and doesn’t involve any technical jargon and paints a much simpler realistic picture of what we are doing when we rub and poke them, as I said give it a go, i’d be interest to hear what you experience

  19. I’m really enjoying all of your posts that I’ve read so far, clear cut and honest opinions no matter what the subject is.
    Throughout the first year of my degree I sat through manual therapy lectures being told it was magical, only to spend the next few years actually researching and learning what the evidence-based reality was. If only you’d written this article a few years back!
    You said you do use MT, albeit rarely…are there any specific cases where MT is your go to treatment? If so, why?
    Thanks for the great work you’re putting out, this blog is a favourite of mine.

    • Hi Karl
      Thanks for your comments
      There isnt any really go to ‘conditions’ that I use manual therapy on, its more there are go to patients that I use manual therapy, they are the ones with high expectations of it, those that have had good positive experiences with it in the past, and they are well informed about what it does and how it does it and don’t rely on it for pain relief or rehab and use it as a small part of an active rehab program, they are the go to patients I will use manual therapy on.

  20. I have learned more from your blog and twitter debates than in my schooling thus far. It is reassuring that some of my disbelief in what we are taught is justifiable.
    Please keep it up!

  21. Well – here we are again – neither of us have been prosecuted for tearing a client limb from limb so I think we’re still safe in the assumption that fascia is way tougher than massage.
    My two penn’th is based on my experience of what massage/manual therapy seems to do when I do it and what it does when done on my (right and wrong).
    It mobilised tissue – hey – we’re physically moving it
    It puts heat into tissue – can’t move it without
    As we’re moving tissue we’re also stimulation passive fluid flows in the body
    When done right it promotes relaxation and trust (both in their body and the therapist) – the whole touch/comfort thing – (conversely do it wrong and you get an increase in muscle tension and elevated pain levels)
    This “seems to” make active exercise easier for the client in the bast majority of cases.
    Clients report a reduction in pain levels after a manual therapy session
    It “appears to” boost confidence in the client’s ability to move and exercise – and do do so without excessive pain.
    My inference is that when manual therapy is used right it provides the combined benefits of a warm up and stretching session with a bit of feel good factor and confidence, this could be considered a smoke and mirrors thing – warm it up, move it around and hey its warm and been moved “TADA – CHING”, but at times active stretching or exercise causes pain and undesired muscular reactions in a way that MT doesn’t – the knock on appears to the following.
    1) They’re better able to start/resume physical activity safely
    2) They’re more likely to listen to keep up exercise regime/modified behaviour suggestions you give them
    p.s. – yes there’s the occasional something went clunk and the pain went away either during or shortly after a session, but poking people till they go clunk without a very clear set of symptoms is asking for trouble in my view
    p.p.s. a lot of these stupid tools strike me as likely to reduce the beneficial effects of touch as well as cutting the amount of heat that is likely to be put into the client, they also make it harder for me to sense whether the punter is responding well to what I’m doing or whether I’m hurting them unnecessarily.

  22. Thank you for posting this information. I have a “severe shoulder tendinitis” with a small tear, diagnosed by an mri, so I don’t need surgery. I am on my fourth month of PT and have had manual therapy that caused me to have severe pain for weeks. I was told that it works for most people. Thinking I was just the odd duck out there all by myself, I waited for my pain to subside. PT went easier on me also. I feel a bit more empowered now thanks to your post. Never having had any problems with my shoulder, how would I know what to expect? I was fearful that not letting the therapist do manual therapy on me would set me up for future problems with my shoulder freezing up or not being able to move correctly. Logical thinking doesn’t always enter into the picture when you are in pain and afraid.

  23. I always find your articles interesting and it makes so much sense but I am a massage therapist (Sports Therapist) and most of the time people feel better after seeing me and this includes physical parameters such as ROM as well as perceptions of pain. I also feel better after manual treatments such as manipulation and massage. I’m not sure why but it does happen and I want to know why!
    You must use and get positive effects from manual treatments? If it can’t be done by altering the tissue I guess it must be circulatory or neural effects?

    • Hi Ben
      Why do people feel better after massage or soft tissue work, wow, thats a whole blog in that question right there.
      Lots of reasons, most is due to neurological modulation through afferent information from the skin mechanoreceptors to the central nervous system creating sensations of less pain, stiffness etc allowing greater freedom of movement, then also there are the psychological and placebo effects not to over look or to be sniffed at either.
      Please don’t misunderstand me in my critique and strong wording against manual therapy, I am not saying there is NO role for it, as you say people like it, all I am against is the nonsense and ridiculous claims that surround it, the mis information and mis selling of what it does and the over use of it that some therapists do, causing patients to become reliant and spending lots of money on it based on false beliefs with no long term benefit
      All the best

    • Having someone tend to your needs feels good. The fact that PT cannot accept this simple, yet universal truism, and instead, it looks to create and then measure phenomena as anything but a proxy for basic empathy and nurturance, is why the profession is so stale. And stalled.
      Perhaps It’s time to create a new model for therapy, one that cuts across the petty protectionist tribalism that is severely underwhelming insofar as effectiveness, and that engages the client AND the therapist in more than a biomechanical dimension of health. I won’t hold my breath though.

  24. The problem with most Manual Therapy is that it requires a therapist, making it prohibitively expensive and time consuming. Self-care is usually not offered because there is no money in it for the therapist. The best a patient may get is, ‘use a tennis ball..’ or the much improved ‘place two tennis balls in a sock and use it as your trigger point tool’… We are working to change this, and hopefully someday we will be able to afford a prohibitively expensive study to convince you.
    Seriously, why not have some quality tools laying around for your clients to use and see if they say it helps them? Certainly you agree that there is a % of patients who appreciate trigger point therapy and perceive a significant benefit.
    Being the Sports Physio you are in the unique position educate clients on the larger structural issues they face, and advise against manual therapy if it clearly will be of no benefit. There is tremendous value in teaching patients about their condition and offering the more traditional stretching and strengthening that will help them in the long run.
    I think your position was best said with: “what chance does a bit of manual therapy given at best a few times a week have? None I’d say!” — well at least you were honest enough to include your bias and presumption.
    Curious if you have seen any studies on multi-year self-directed therapy at the moments immediately following a strain and for weeks there after?
    As you know, there are plenty of professional athletes and their trainers who wholeheartedly disagree with you.
    Great write up, thanks for allowing this post!

    • Hi Tom
      I’m afraid i have only just seen your message as it was sent to my spam folder due to the website you linked, and I have removed it as don’t really want my site used for advertising products.
      I agree that self management techniques for soft tissue are probably more beneficial than therapist applied techniques as they can be done more often, more regularly, and cheaper
      However just because it can be done more often doesn’t mean the mechanical effects are any greater, tissue doesn’t change by pressing, rubbing, pulling it, christ 6 weeks of strong regular full body weight stretching didn’t, rolling on a cricket ball wont either

      • And I’m well aware many, many don’t agree with me, and many still believe in the mechanical structural changing effects of manual therapy, but that just means I have a lot of work still to do to educate and highlight the current recent research and evidence that disproves it

      • Adam,
        You won’t have much work to do to disprove that connective tissue does not change with manual therapy for me. I already knew this before reading your rant from all the current literature that supports this. I feel that you are quite an intelligent man, and my 1st impression of you (this blog post) is not a very accurate snapshot of who you really are. Please take what I have to say as constructive criticism. I suggest that you spend some time looking for articles to improve your style of mass communication to support your cause. It’s possible that you may be stuck in a rut of dispersing the script you created “We are not fully sure, but the current evidence is showing that I’ve just changed your perception of stiffness/pain” because of the way you delivered it. Even though I love that statement and plan to use it from now on, I struggled through all the insults to get to that quote. I trudged on to continue reading your rant with an open mind and imagined increasing cortisol levels running through my veins with each word. Shaming and insulting people that may not yet have this knowledge may cause you to do more work than you have to. Persuasion sciences show that being likeable may make it easier for you to change the way manual therapists like me educate our clients/patients and students. I think being less insulting could potentially allow someone like me to listen more intently to what you have to say with an open mind rather than a defensive mind. Though I do plan on supporting your cause one colleague, student, and patient at a time. However, I am embarrassed to share this particular link. If you decide to ever consolidate all the links to the literature you have here in a new “G” raged post, please email that to me and I would be happy to share it with all my professional contacts.
        Wishing you the very best,
        Ken T

      • Dear Ken
        Thank you for your comments. I do take some of what you say on board, you’re not the first and won’t be the last to try and get me to become ‘softer’ in my approach.
        However, I can assure you I won’t change, I am too long in the tooth and too stubborn, my style is, and always will be direct, often blunt and not always the most politically correct. In my opinion this is needed in this day an age of pussy footing around, if it looks like bull shit, sounds like bull shit, smells like bull shit, then call it bull shit.
        Out of interest what articles do you suggest I read to improve my style of ‘mass communication’? Not that I have any great desire for mass communication or improve my style. This is just blog, one of millions out there, its a hobby of mine that I do in my spare time, that has got a little bit popular, but is nothing in the grand scheme of things and will never be.
        Also please point out to me all the insults you mention you had to struggle and trudge through? There are some harsh words, bull shit for example, but if you can not read that without becoming offended then I politley suggest to you that you go read some articles on how to not take things personally and toughen up a little.
        I don’t force you or anyone to read anything I write, if you didnt like it, you wouldn’t have read on, but you did.

      • Adam,
        “Regular readers to this blog will know that there is no love lost between me and manual therapy. We have had our disagreements, we have had our arguments, and we have had our falling outs. We don’t like each other, and to be honest, we are best kept apart.”
        This statement was my first impression of you and felt like a judgment toward what I enjoy practicing. I went back and re-read your post two more times and felt that biomechanical minded manual therapists might find their intelligence being insulted. Not because of what you are saying, but rather how you are saying it. I realized that I missed out on a lot of great information that this post has to offer because the word “bullshit” attracted my lizard brain away from points you were trying to make. I am a retired Marine and have found that attractive writing draws more interest than repulsive writing when getting my point across to civilians (and most female physiotherapists in my life).
        “Hate is a very strong word, but simply put, I hate manual therapy. I hate it for the way it is over used, over hyped and over complicated. I hate it for being surrounded by myths, fallacy’s and complete and utter bull shit. I hate it for promising much and delivering little. I hate it for cheating me and millions of others with false beliefs, expectations and explanations.”
        Multiple splattering of the word “hate” within this paragraph (along with use of harsh words) may make it difficult for a reader like me to listen more openly. I do believe that harsh words have their place. A good example of this is when I try motivating a squad of Marines deploying into battle. I really didn’t have any plans of having you change your writing style to something softer. I mostly wanted to offer some tips that may allow your good advice to influence professionals in my field of work to become less biomechanical rather than irate.
        “if you cannot read that without becoming offended then I politely suggest to you that you go read some articles on how to not take things personally and toughen up a little.”
        When I left the military nearly 20 years ago, I actually had to deprogram myself to become less offensive and more sensitive- maybe I’ve overdone it- haha! Most of the way I speak and present myself now is from learning customer service tactics. I’ve found that it has allowed me to connect and communicate better with any audience I try to present an idea out to (from family and friends to a larger group of 200 people that I may lecture to). These are some books I’ve read that have improved both my professional and personal communication experiences. There are also a lot of YouTube videos out there that tap into the neuroscience of how to make a more powerful impact to what you have to say. Because I also believe that the medical profession in general has to change to a more biopsychosocial model when explaining to our customer/patient what it is that we do to them when they ask us questions.
        Talk Like TED: The 9 Public-Speaking… by Carmine Gallo
        Delivering Knock Your Socks Off Service (Knock Your Socks Off Series) by Performance Research Associates and John Bush
        How to Win Friends and Influence Peop… by Dale Carnegie
        “I don’t force you or anyone to read anything I write, if you didnt like it, you wouldn’t have read on, but you did.”
        Then again, maybe your writing is perfect the way it is, since I did end up reading this post 3 times.
        Wishing you the very best,

      • P.S.
        I forgot to mention that if people like me and you are trying to change the mindset of physiotherapists and other medical professionals away from biomedical models, then a softer writing style should not be ignored.

      • Hi again Ken
        I agree a softer approach would probably be the best, it just wont be coming from me. I also have an ex military background in the UK but without the detraining… I blame our government, may explain my ‘style’
        Maybe you should start a blog Ken, maybe you can convert them
        Thanks for your comments again
        All the best

  25. Much of your argument fits with why I got into the Feldenkrais Method. We do “manual therapy”, in that we’re moving the client around with our hands, but we aren’t raking or scraping fascia or knots or anything. (And the party line is that we don’t do therapy, we help people learn, and that can have therapeutic effects!) Most of our manipulation involves moving the bones within the client’s range of comfort and ease, thereby clarifying cortical maps and interrelations. Sometimes we’ll squeeze/support a muscle that they seem to be holding tight to take over its work, but even then, any change is due to the nervous system deciding tension is no longer necessary, or more generally that particular motor organizations can safely be changed (at least for the moment). Ideally the client learns new motor patterns and can move on, but I have heard from some pracittioners that they have people who come by for years upon years….
    We also have movement lessons that students can do on their own, although often led in groups by an instructor giving verbal direction. Many practitioners sell recordings too. This is much less expensive for clients/students than 1 on 1 manual sessions, but both have their place. I know I was getting little benefit from group lessons until I got some personal attention for some specific blind spots I had in my own self image.
    Have you had an experience with the Feldenkrais Method? If so, how do you think it compares with typical manual therapy?
    (By the way, regarding some comments above, Moshe Feldenkrais had similar problems interacting with the medical establishment in his day, and many of his followers still do. 🙂

    • Hi Nik
      Thanks for the comments, I will admit to being naive with Frldsnkrais, I have seen some videos and spoken with some practitioners and clients but that’s it.
      My initial impressions are good, it seems realistic and not full of BS, and as you say encourages people to explore movement in a safe and controlled way and environment which is just what people in pain need, not more pain, more fear and BS explanations of this out or that knotted
      I may have to go and get my ass down to a group and have a go myself

  26. I’d like to hear you thoughts on Stecco’s concept. Personally I found this as a very interesting http://www.sciencedirect.com/science/article/pii/S1360859213002027
    Its my last semester with physio degree. Ive found your blog very interesting and as a newbie my thoughts about manual therapy and physiotherapy has changed because of your texts.And because of that i feel more comfident as I will start my carwer as a physio in a few next months.
    So thank you.

    • Having read some of the Steccos work on fasica I find it interesting but do I think or agree with them in saying we can affect it significantly with manual therapy… Nope
      Effects of 20-30mins of manual therapy will have very very little effect to any tissue.

  27. You apparently do not understand the physiology of manual therapies. Vardiman’s study was performed on HEALTHY tissue, not pathologic, and he looked at the IMMEDIATE effects of IASTM. The remodeling phase takes days / weeks / months. Regarding the effect of controlled microtrauma: Damage to fasciae always causes an inflammatory reaction that promotes the healing process. The fibrous layers of the fascia can be perfectly restored; indeed, they are formed by collagen type I, the key molecule involved in the process of scar formation. When deep fascia is disrupted, three sequential, yet overlapping, phases of the reparative wound healing process occur: inflammation, proliferation and remodeling. During the inflammation phase, cell debris is phagocytosed and removed from the wound by white blood cells. Blood factors are released into the wound that cause the migration and division of cells during the proliferative phase. The proliferation phase is characterized by angiogenesis, collagen deposition and wound contraction. Fibroblasts grow and form a new, provisional ECM by excreting collagen type III and then type I collagen and fibronectin. In this phase, the collagen forms an irregular connective tissue that has the main function of closing the wound gap. But for the correct healing of the deep fascia to occur, it is fundamental that collagen be remodeled and realigned along the correct lines representing components of local tensile stress. (Stecco)

    • Hi Mike I really don’t have the time or the inclination to refute all you have said here other than to say you are waaaaaay of the mark my friend…

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