Manual Therapy Demon Strawmen

When people are confronted with an argument or criticism against their current position, they tend to challenge the opposing view. This is perfectly normal behaviour and something I, you, and everyone else does. However, what often happens when doing this is we attempt to weaken our oppositions argument by either inadvertently or deliberating misrepresenting it. This is called straw-manning.

A strawman is a common and devious form of argument that gives the impression of refuting an opposing argument by distorting it to make it easier to attack. Using a strawman appears to challenge an opponent’s argument when it actually attacks a version of that argument which an opponent hasn’t stated or doesn’t necessarily support.

I often encounter strawman arguments around my criticisms of manual therapy, such as I advocate a no-touch or hands-off approach, or that I think all manual therapists are malicious or malevolent which is utter nonsense and nothing I have stated or implied at all. Recently two editorials have been published here and here which have further straw-manned many of my arguments and criticisms towards manual therapy and these are now doing the rounds on social media.

In these articles, some of my blogs and opinions have been described as demonising, destructive, and unfairly and inaccurately attacking manual therapy. They go on to explain how this is causing international concern, has adverse consequences to the profession and patients, and how they wish to provide evidence-based information about manual therapy.

Well, that’s also what I want to do and these opening claims in these articles are the first, but by no means the last strawman arguments. Attempting to position my real and valid criticisms about the over complexity, over-promotion, overuse and general ego and elitism around manual therapy as demonising, destructive, or inaccurate is a classic tactic to deflect attention away from the points I am trying to make.

However, I must admit that I’m a little surprised and flattered that the blogs I wrote many years ago are still creating such strong and emotional responses from some of the higher ranks of the manual therapy world. This does give me hope that if I can do this, anyone can, and if more of us continue to question and challenge the nonsense around physiotherapy it can create change for the better.

As these articles are now circulating widely I feel obliged to respond to these allegations of ‘demonisation’ and destruction, and so will in this blog highlight what I consider to be the strawmen arguments and reiterate again what my actual arguments are against manual therapy. I will attempt to keep this short and sweet, and hopefully as calm and rational as I can, but I make no promises.

Strawman No1: Manual Therapy Has No Unique Specific Effects

This first claim is an absolute doozy of a strawman. My actual argument against the specificity of manual therapy is and always has been around the training, beliefs, and ideology that it needs to be administered or applied in a specific way, not that it doesn’t create any physiological effects as claimed.

My argument against the specificity of manual therapy is that it doesn’t matter who, where, how or what type of manual therapy you use, you get similar results based more on the ritual and contextual effects of manual therapy, not its specific or technical skill (ref, ref, ref, ref, ref, ref, ref). My argument against the specificity of manual therapy is that no type or technique needs extensive, extended, or expensive training to do it well.

My argument about specificity is also NOT that manual therapy doesn’t create any neurophysiological effects, rather that it doesn’t create the many structural effects often claimed it does such as repositioning or loosening joints, releasing fascia, or breaking down scar tissue or adhesions (ref, ref, ref, ref)

Finally, all the so-called specific neurophysiological pain modulatory effects described as occurring due to manual therapy in these articles are actually not unique to manual therapy, being seen to also occur during exercise and activity (ref, ref)

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

I absolutely do believe that some manual therapy techniques given by some manual therapists have the potential to lead some patients’ to dependence, reliance and reduced self-efficacy. I will accept, as I have done many times before, that I have no evidence to support this other than my own anecdotal clinical experiences. I will also admit that this is not unique to manual therapy treatments and can also occur with other treatments such as acupuncture, electrotherapy, taping, and even corrective exercise treatments as well.

However, I regularly see and hear far more patients tell me that they need to get their pelvis pushed back in, or a muscle knot released, or adhesions broken down by a therapist regularly. I have had patients tell me they have seen therapists weekly for years on end having manual therapy treatments in a misguided and misinformed belief that they are essential for a pain-free life and necessary to prevent things from getting worse.

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

The strawman presented here is the classic fallacy of “absence of evidence equals evidence of absence”. Now, this quote is often used and abused by nut-jobs and quacks to claim all sorts of stupid and ridiculous things but that doesn’t mean the statement is invalid. Just because something hasn’t been formally investigated or researched doesn’t mean it doesn’t exist.

I believe that well-controlled studies are needed on large samples of patients who routinely see manual therapists for regular treatments, and they are surveyed in an unbiased way about why they attend and what their beliefs and understanding of what these treatments are doing. I’m sure this would highlight that there is indeed a lot of potentially detrimental narratives and behaviours being promoted widely around many manual therapy treatments.

Failing that anyone who thinks that there is no issue here could simply and go onto Instagram and search the hashtags #Physiotherapy #PhysicalTherapy #Chiropractic for about 5-10 minutes to get a sample of some of the utter nonsense and bullshit in and around manual therapy that I witness daily.

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

The claim in these articles that manual therapy produces short term changes which in turn leads to better long-term outcomes and prognosis is actually not that well supported (ref). However, there is no denying that those who do get quick and dramatic changes in their pain within treatment sessions usually do go on to do well in the long term.

However, what these quick short-term improvements in symptoms most likely highlight is an individual with fewer complications and confounding factors adversely affecting their presentation and natural prognosis, not the effects of the treatment itself (ref). Individuals with fewer medical and psychosocial complications are more likely to have a favourable natural history of their condition regardless of the type of treatment they receive. Often the treatments they receive are unfairly given credit for what is essentially natural history with some placebo and contextual effects sprinkled on top.

There has never been an argument from me that manual therapy cannot quickly reduce symptoms in some people. My argument is simply this is not unique to manual therapy and often affects those with favourable natural histories. My other bigger question is should we be judging our success in how much or how quickly we reduce symptoms in those we see, especially in those with favourable natural histories?

Would it be better to clearly, carefully, and compassionately reassure those we see with mild to moderate pain and favourable natural histories that this is normal and ok to experience and endure for a short period of time. Should we be encouraging more of those we see with MSK pains to tolerate them more rather than reduce and remove them all the time?

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

Actually, this one isn’t a strawman as it’s not contested in the article, and it’s good to see this finally acknowledged by others in the manual therapy world. The amount of ego, elitism, and arrogance of many of the gurus and others who promote, practise, and teach manual therapy has always been one of my biggest criticisms against it.

The number of therapists who are made to feel worthless, inferior, and unskilled simply because they can’t palpate some fictitious dysfunction or pseudo structural abnormally made up by some half-witted manual therapy egomanic is astounding. If more manual therapy advocates and teachers were less elitist and exclusive and more honest and rational then I’m sure myself and many others would not have as much of an issue with it as we do.

However, I do find it really hypocritical that this article labels this criticism I have of manual therapy as demonising and destructive yet agrees with it.

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

This strawman misrepresents my issue on manual therapists communication completely here. It’s not that manual therapists can’t communicate, reassure, or emphasise well with their patients, rather it’s WHAT they communicate and HOW they reassure their patients that’s my concern. Many patients who are told their spine is out of alignment, or their pelvis is unstable, or their muscles are unbalanced are told this by manual therapists taught and trained to believe these things by those gurus and egomaniacs mentioned above to justify using their manual therapy treatments.

Many manual therapists are actually very good and very proficient communicators when they explain to patients why they have pain and how it can be solved. They often display lots of empathy and confidence which adds credibility to their outdated and inaccurate narratives giving patients the reassuring impression that they are in the hands of an expert who knows what’s wrong and how to fix it… usually in 8-12 weekly treatments, with regular monthly maintenance sessions to ensure it doesn’t come back.

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

You can argue if manual therapy is a high or low-value treatment as much as you like, but this won’t change the fact that currently in the UK, and most of the world, the National Health Services are at breaking point. Public Health Services simply cannot afford the resources to give patients with MSK issues passive treatments to temporarily modulate pain when self-administered hot water bottles or over the counter analgesia can do the same thing.

Decades of underfunding, chronic mismanagement, and a rapidly growing obesity and sedentary epidemic, with an increasingly ill and infirmed population, not to mention the current COVID pandemic, means all healthcare services are stretched. Some difficult and tough decisions need to be made in terms of prioritising what treatments are considered effective and efficient and it is my belief that manual therapy is just not one of them.

Yes ok, the argument in private healthcare settings is different and it may be argued that if an individual has the finances, time, and resources to have manual therapy then there is little issue here. But my argument on the value of manual therapy has always been about public healthcare services.

Strawman No7: Manual Therapy Causes As Much Harm As Help

There is no argument that severe adverse events from manual therapy are rare and most of the transient adverse reactions are also not that common (ref). However, what these articles do not take into account are the potential nocebic and psychological harms that could be occurring due to the outdated and inaccurate narratives and explanations around manual therapy treatments and the burden these may take on some individuals. As mentioned there is no evidence on this, but as also mentioned absence of evidence doesn’t equal evidence of absence.

Strawman No8: We Cant Identify Candidates For Manual Therapy Which Means Techniques Are Unnecessary.

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

Well as mentioned those that get good responses from manual therapy treatments, most likely would get good responses from any other contextually and placebo rich treatments, or even just time alone due to favourable personal circumstances and natural histories. Again my argument here goes back to the misguided belief and teaching that manual therapy needs to be given to those who have a detailed skilled and specific assessment looking for pseudo dysfunctions and made up structural abnormalities.

Conclusions

So that’s my response and rebuttal to the so-called demonising of manual therapy. As I said I found these articles disappointing and hypocritical that some real and valid criticisms of manual therapy within physiotherapy have been twisted and distorted and perversely demonised.

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

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

I also do not think most manual therapists who fall foul for many of the things discussed here do it knowingly or maliciously, rather they are only following the guidance of what they have been taught and lead to believe by others they trust and respect.

I am also aware that outdated misinformed beliefs, ideas, methods, and treatments are not unique to just the field of manual therapy, with corrective exercise, electrotherapy, dry needling, strength and conditioning, even surgery and medicine all having their fair share of the above. I also want to stress that being taught and hoodwinked by manual therapies training about these things is not a sign of stupidity or ignorance. I myself at the start of my physiotherapy career and during my extensive post graduate manual therapy training was taught and believed many of the outdated, non-sensical, pseudo-scientific things mentioned here.

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

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

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

As always thanks for reading

Adam