I’ve thought long and hard if it’s worth the time, effort, and no doubt aggravation this blog will create. But, after some consideration, I’ve decided to go ahead to highlight to others some of the risks that can occur from voicing your opinions that may be unpopular, and how some so-called caring empathetic clinicians in our profession can be malicious, vindictive, and downright nasty.
As you may be aware, I produced some t-shirts a few months ago with some cheeky, some will say cheesy slogans that take the piss mickey out of physiotherapy and express some of my opinions on it. This included one that says ‘Manual Therapy SUCKS’. However, it appears this satire and sarcasm was just too much for some of our ‘leaders’ of our profession to bear, and so the proverbial shit hit the fan!
A few weeks after I launched these t-shirts an official complaint was sent to the Chartered Society of Physiotherapy by nine ‘senior’ physiotherapists, and presidents of our profession who claimed that these t-shirts along with some of my blogs and social media posts were ‘damaging the reputation of the society and the profession’.
They insisted that disciplinary action be taken against me and the t-shirts removed. However, they didn’t stop there. They also went on and further accused me of sexism and bullying in an effort to discredit my personal and professional reputation.
After a couple of frustrating and stressful weeks defending myself and my reputation from these false and malicious accusations, I am pleased to say that a formal inquest could NOT find ANY evidence to ANY of these accusations and NONE of the complaints were upheld.
As great as this was to hear I can assure you it was a really unpleasant experience which I’m sure is what these so-called ‘caring professionals’ wanted. However, I do suspect that their real goal was for me to lose my licence, and to be publicly discredited, so that my opinions on manual therapy and other issues in the profession which conflict with their own, as well as threaten their personal and professional interests are censored.
This nasty, spiteful, and pathetic tactic of attacking another’s reputation and character instead of their argument is often used by those who want to divert attention away from things they wish not to be discussed anymore. This is a classic logical fallacy and has been used on me many times before, but this was, without doubt, the most conniving, cunning, coordinated, vicious and vindictive attack I have ever experienced.
Name Calling
Trust me when I say I’ve been called all manner of offensive and derogatory things over the years, as well as being accused of having all sorts of ulterior motives for expressing my views and opinions. I’ve also had numerous complaints, disciplinary meetings, legal letters, and even ‘open’ letters sent to me on social media.
All of these things have never bothered me that much at all as I know most are groundless scare tactics and nothing more than lame expressions of angst, frustration, jealousy, or envy. I do accept that my strong views and opinions will attract strong views and opinions back and so tend to just roll with the resistance.
I am also aware that I can have a rather direct and sometimes blunt way in conversing and discussing things, and yes, I am also aware that I swear a lot which I know upsets and offends some people! BUT… SO WHAT!
Any offence at what I say, where I say it, and how I say it is yours. Offence is more often than not taken rather than given. Simply put no one makes anyone listen to or read anything they don’t want to.
We all have a choice at what annoys or upset us, take this blog for example, if it’s pissing you off… STOP READING IT.
Being offended at someone expressing their views, their tone, their language, their t-shirts is essentially demonstrating to others that you are incapable of controlling your own emotions and expect others to do it for you. GROW UP AND DEVELOP SOME EMOTIONAL INTELLIGENCE.
However, this is not defending some obnoxious twats who do deliberately go looking to offend others, that is clearly indefensible. But offence is on a continuum and many need to be more tolerant of others views, opinions, expressions and language used.
I will admit I have made some mistakes in the past in how I have communicated, and I have no doubt that I will continue to make more in the future. This is called being a human. But believe it or not, I learn from them and I try not to repeat them, but this doesn’t mean I will change my genuine views, opinions or mannerisms.
Harmful
Many see public online disagreements and arguments as being harmful to our profession. They think that calling out nonsense, bull shit, or outdated practice is unproductive and damaging. I think the exact opposite.
I see ALL the discussions including the disagreements as useful and signs of progress, even the most raging flame wars which although can be a little tedious and pathetic at times, usually give me something to ponder. As Gandhi famously said ‘honest disagreement is a good sign of progress’.
Personally, I think by dragging the difficult and taboo topics out into the light from behind the closed forums and specialist echo chambers, and laying out different views and opinions for all to see, more will become aware, and more will feel confident to add their own views, and the more chance things have of changing and moving forward.
I like to make my views and opinions clear on many things such as taping, injections, motor control exercises etc etc, and often many disagree with them. This is great, and partly why I do it, and also why I occasionally take a stronger position to play devil’s advocate. I enjoy many of these debates and disagreements.
Low-value
Now just in case, anyone is still unclear on what my position is on manual therapy I will lay it out for you again. I believe that ALL manual therapy used in musculoskeletal physiotherapy for pain is a low-value treatment and not worth the time, energy, and cost to learn, teach, or provide it due to its non-specific, unreliable, short-lasting, tenny-tiny small effects.
In a nutshell, I think ‘Manual Therapy SUCKS!’ as it is surrounded by so much elitism and ego, bluff and bravado, bullshit and bollocks it should be abandoned by all critical thinking, evidence guided, musculoskeletal physiotherapists as it offers little for the effort and resources it consumes.
I do accept that manual therapy can reduce pain, a bit, in some, for a short while, but so can a hot or ice pack, going for a walk, just chilling out, and these are far cheaper and simpler to do. When you compare manual therapy to other interventions for pain relief in many musculoskeletal conditions it’s hardly impressive, and this is why I believe that it has NO place in a public tax-funded health care system.
Manual therapy uses up valuable resources, clogs up services, wastes time and detracts attention away from the simpler higher value interventions. Of course, there are many other interventions besides manual therapy that also do this, but manual therapy without a doubt is one of the biggest and most pervasive ones.
Many think my ‘hands-off‘ position is too black and white, and that I am too harsh in my critique of manual therapy, after all, it’s a low-risk intervention with very little adverse effects when compared to things such as medications or surgery. Although this is true it still doesn’t mean manual therapy is worth using. Low risk, doesn’t mean its worth using.
Low Risk
I do accept that manual therapy rarely causes any serious adverse events that medications and surgery can do (ref). But what many don’t understand or recognise are the other adverse issues manual therapy can cause. The first is manual therapy has the potential to create reliance and dependency.
Some patients can associate the temporary pain-reducing effects that these interventions create as essential and necessary to continue, and this can lead to a loss of time, money, but more importantly self-efficacy.
I also don’t think many recognise the detrimental effects these low-value interventions have on our economy and healthcare services. As a clinician in a busy, overstretched, underfunded, NHS orthopaedic department I am constantly frustrated daily when I see and hear patients who could have been managed quickly and easily with some simple advice, guidance, and reassurance.
Instead, they have been passed from pillar to post and forced to wait months due to departments and services clogged up with patients being rubbed, poked, clicked, pricked, taped or zapped for things that just don’t need it.
Finally, I don’t think many understand or recognise the detrimental effects these low-value interventions have on our society as a whole. The constant desire to reduce pain when it’s not necessary I believe is making our society less tolerant of pain, and many healthcare professionals are to blame for this
More clinicians need to understand that there is nothing uncaring, unprofessional, or unethical in advising patients to endure some pain from time to time. Many healthcare professionals need to understand that for most musculoskeletal conditions they often just need to confidently, respectfully, compassionately advise patients to carry on as normal.
However, this is not easy to do, in fact, it’s hard, really hard and requires a clinician with empathy, great communication skills, and even better reassurance skills to do it well. A clinician needs to have an in-depth understanding of pain, pathology, and psychology, and this is why many do not do it.
Many ‘elite’ ‘skilled’ manual therapists are just not skilled in these more difficult and challenging areas and are either unable or unwilling to have these awkward difficult conversations. It’s far easier for them to give the crappy muscle knot, pelvis twisted, joint stiff explanations, give it a poke or a crack, strap on the buzzy machines, or stick a needle in rather than talk to a patient about the complexity and uncertainty of pain.
Make no mistake, the physiotherapy profession is at a vital crossroad in its history. It can either continue on the way it has offering low-value treatments to anything and everything putting us alongside the other complimentary ‘professions’ on the fringes of healthcare with their energy crystals and chakra realignments.
Or we can choose to abandon the low-value interventions and focus on doing the simple things better. Things such as good advice and education, encouraging physical activity and reducing sedentary behaviour, and helping other physical and psychological stressors that contribute to pain and poor health.
Vested Interests
It is these views along with my concerns about the motives, ethics, and vested interests of many within the training and education ‘industry’ that has built up around manual therapy that make me a question and challenge it so much.
All postgraduate manual therapy training overcomplicates its application, over-exaggerate the skill needed to apply it, over promotes its effectiveness, and finally overcharges for its training and administering of it
However, this does not mean, I think manual therapy can never be used again. I know many other health care professionals that use manual therapy responsibly, wisely, judiciously and to good effect, without charging extortionate fees for it. These licence massage therapists, masseuses and soft tissue therapists are uniquely placed to provide manual therapy, most physios are not.
In my opinion manual therapy can be most useful outside of healthcare in other environments such as health clubs, beauty salons, even in sports settings. It is in these environments where manual therapy belongs, as an extra, a bonus, some fluff and fanciness around the edges of sport, some sprinkles on the top of life, a nicety rather than a necessity.
As a physio working in both public and private healthcare I now do not use ANY manual therapy. I used to, but over the years I have realised it’s just not needed to do my job well or effectively. And I don’t miss it, and neither do my patients.
OK, I do get some who ask me for a rub or a click now and then, but when I calmly, tactfully, and compassionately explain how it won’t help them that much, and how it detracts away from what we need to be focusing on, most patients understand and continue to do an extra set of squats.
But not all, some do go and get it elsewhere, and that’s ok, that’s their choice, and probably my failing for not explaining why they don’t need it better.
Now one final thing, just because I don’t use manual therapy doesn’t mean I don’t touch my patients as I am often falsely accused. There is no argument from me that touch is powerful to those in pain and/or distress.
Touch can and does calm, soothe, comfort, and assist both physically and psychologically, and I will occasionally use touch to guide, assist, or encourage a movement that a patient is scared, fearful, or lacking the strength to do.
Sometimes a few simple reassuring confident guiding touches during a painful movement is all that’s needed to get a patient going forward. But this is not manual therapy per se, this is not joint cracking, pressing, or soft tissue rubbing, and there is no special technique or magic to it.
Summary
So if you’ve made it this far, well done. I will finish by saying some people can be nasty, spiteful, vindictive people who will attempt to sabotage another’s reputation and career if their views and opinions are challenged and especially if their vested interests are threatened.
However, I am now more determined than ever now to continue to call out the bull shit, and nonsense, and outdated practice, and will continue to promote a more simple, honest, pragmatic way forward for physiotherapy.
I will continue to push for a monumental shift in how all physios manage people in pain and will continue to argue that we need to phase out, remove, and abandon many low-value interventions and adjuncts from healthcare including a lot of manual therapy.
As always thanks for reading
Adam
Bravo!
Although I cannot fully agree that Manual Therapy sucks ( I am biased by MWM’s as part of movement strategies ), I will always defend your right to says the things you say and the way you say it. Cheers, mate
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Well written Adam.
Sad to read that attacks become so personal. There must be space for disagreements.
In a profession as ours, there is no truth but assumptions.
Keep voicing your opinions as you wish.
If we had clear answers to all our questoins there wouldn’t be room for arguments.
Hehehe … “if you don’t have to defend your opinion, than your opinion does not realy matter”
I agree on the manual terapy topic …
I have tried to make a blog once but I did not have self discipline to do it for longer time period …
All I can tell you, if it matters, is keep up with the good work …
I understand your need to use strong, emotive language.
I also understand your position, and the way you have coming about reaching it.
However, I like the view that Diane Jacobs uses when it comes to manual therapy “always optional, but sometimes optimal” (paraphrased).
Just as manual therapy has non-specific effects, as does exercise, lifestyle interventions and education.
That is not to say they aren’t high value interventions, because most people could stand to improve their health in some capacity, it just begs the question whether it is necessary to have 4 year undergraduate physiotherapy programs to do so? Why not put the resources into psychology (behaviour change, stress management) and exercise physiology (physical activity)?
I think the key challenge, is recognising when it *is* optimal, utilising it accordingly, and recognising when it isn’t, and not wasting time and money “chasing pain”.
Thanks for raising the topic.
PS I am an osteopath, and you could swap osteo/chiro for physio in my comment.
Thanks Nick
Hi Adam, sorry to hear what happened to you. This is a prime example of why our profession has always struggled to progress. It’s our own physios dragging us down. You are doing a great job of challenging the so called dinosaurs of physiotherapy. I agree with everything about people in the profession who can be vicious and vindictive. I certainly believe that the younger generation of physios are much open to discussion which is promising. Keep up your good work.
Fucking great post Adam. As ever, you’re on point; I agree with every fucking word.
Well said. Thank you for making my morning coffee even more enjoyable.
I agree with your view and i ‘m trying for 7 years in my own practice changing what I learnt so far. It’s a continuing effort against so many misconception. To convince patients and healthcare Collegue take time and lot of work. We have to continue the battle and Your blog is precious for encouraging us in the same direction.
At thus time I fill raht we are more and more physio changing our practice .I don’t do anymore technic courses. Instead I learn how to manage better communication and helping people to be more confident in they own solving problem. Bravo et bonne chance from ??
Well said !
Hi Adam,
Those senior PTs have to evolve and learn how to communicate in a dialogue instead of attacking you. Manual Therapy doesn’t work longterm. It’s a passive coping skill. The only concept that has some short term benefit might be Mulligan’s concept. Ultimately, it’s explaining and educating clients and use an exercise approach that makes them move in a healthy way again and promoting self-efficacy.
I enjoy reading your blogs. You are a very inspiring physio to look up to. If I knew you before Peter O’Sullivan’s CFT course in London in June 2016 I would have said hi. Will attend one of your future courses when I’m back in Europe. Keep up the good work….
How lazy people are?!!!. Never read. Never think. Just want to maintain status quo and run behind fancy techniques. When we stop seeing patients as golden goose and have real concern for a patient, when really we want to remove their suffering, when we get self confidence on ourselves and our mental faculty … May be we might improve as a profession.
It makes me think a lot about what I am doing everyday. I think active movement is always the best way for proactive patients but getting some relief with manual therapy helps too even for a short time.
Well done Adam!
Here is the US we need shirt addressing these folks. “TDN sucks.”
Over here they’ve camouflaged their business model with “evidence.”
http://www.evidenceinmotion.com/blog/2017/09/28/turning-on-the-lights/
No worries… I’ve got that covered https://thesportsphysio.teemill.co.uk/product/dry-needling/
Extracted from “Needling Turns the Lights On”: “The problem is most tendons are very reactive and are unable to tolerate much load, especially when they are in a reactive and irritable state. The cortical side of things is very inhibitive in tendons, and the patient will be unable to load the tissue due to all of these variables.” We need a new terminology to encompass this revelation! How about DNT (Dry Needling Twaddle)?
Will there be a framed certificate for DNT™ if so I’d love one… ?
Well said. Disappointing, though not surprising you have been attacked personally. Not everybody can let go of their beliefs quite so easily and will defend them until the cows come home, turning nasty if they feel their beliefs and therefore their sense of self is being threatened. Don’t forget, cracking necks is not just something they/we do, it is who they are and they rely on it to put bread on the table. I have not given up manual therapy all together…. yet. I have however given up holding on to my opinions and beliefs as if they were the truth that needs to be defended with aggression and anger.
Thanks for your comments and insights. I know I can come across harsh on manual therapists but it is the intervention not the individuals I challenge. And we should all be able to separate our emotions from our treatments. Interventions are not identities… if and when people critique exercise I don’t personally find it upsetting, rather intriguing… All the best, Adam
Same as Jonny, I am from the US as well. I have had similar thoughts from way back in PT school when they introduced spinal mobilization and manipulation. “So why are we doing this professor?” “Well, we are not really sure but it might help reduce pain… But make sure it is done this exact way”. Flash forward a few years and I start hearing and reading about “we don’t have to be as exact with the technique as we thought …”. I do some work in insurance auth for PT and I see the scenarios you have EVERY day
Some Physiotherapists may not support your views, however I’m fairly sure every Scientist would agree with you based on current evidence. Shame really.
Great post Adam, and considering your experiences so far actually pretty brave too as I am sure you could do without a lot of the stress and hassle that often follows these type of posts.
However it is really important what you are doing and to be vindicated by the CSP panel is a significant victory over the manual therapy advocates. Like you I work in public and private practice and over the 10yrs I have been doing it I have found myself becoming more disillusioned with the requests from patients for manual therapy. As you said it’s really hard work constantly explaining why exercise is the better option. In fact unlike you I am soon to be quitting the world of MSK physio as quite simply I don’t feel effective enough in the grand scheme of things. There’s too many other therapists willing to rub and poke that I feel it simply makes the conversations with patients too repetitive and frustrating. Instead I’m moving into NHS leadership roles. So massive respect to you for continuing to fight the good fight. And I will certainly continue to read your posts as they are always entertaining! So thank you.
Hi Chris, thanks for the comments, and its a shame to hear the profession is loosing your experience, but im sure you can still do ‘good’ in management. I hear this happening a lot, good therapists being ground down by the system and bull shit and so leave the profession completely or head into HR/management. Such a shame! All the best for the future pal
Love it ?
So, what size do the TV shirts come in ?
All the sizes…
Enjoyed the post Adam. I am proof that you can teach an old dog new tricks. I have been working in private orthopaedic practice for just over 20 years. I taught in the Canadian manual therapy system for 10 years. The change in my treatment paradigm was a slow one. I read David Butler’s “The Sensitive Nervous System” in 2007 which led to me questioning some ideas/concepts I was taught in university and throughout the manual therapy system. Frustration with inconsistent treatment results and an ailing wrist issue due to years of manual therapy also encouraged a re-thinking of my approach. Through lots of reading and introspection, my way of treating patients slowly started to change. While I was off work for 3 months following wrist surgery, I read Louis Gifford’s 3 books and was encouraged that patients could be successfully treated with good quality education and exercise. I still use some manual work with a select few patients but am very open regarding the short-term effects and that the best way for long-term improvement is through exercise and lifestyle changes.
It’s unfortunate that some people over-react to another’s opinion. I agree that the challenging of old school ideas is necessary for the betterment of our profession. Keep stirring the pot. Cheers.
Aaron
Thanks Aaron, your comments are much appreciated, especially from an old fossil… ??
I treated acute and subacute ACL reconstruction patients for years in a balls to the wall public in-patient surgical ward, up to my neck in people who really had something to complain about. My most sublime function was helping them adjust and move forward in their situation. I used my hands to show them they could mobilize scarring incisions and to help them work with normalizing ROM. This is sort of a mobilization with motion (MWM), but probably not in the way Mulligan intended. Anyway, as a research scientist with strong clinical experience that closely mirrors yours, people should know that nothing you say is particularly inaccurate in the framework of the scientific method and EBM. Keep it up Adam.
Thanks Jonathan… I hope you can get those balls away from the walls now and then… (new favourite saying now BTW) Cheers Adam
I agree and disagree. Manual therapy does have its place, but I think the conceptual framework behind the therapy does need to change significantly (IMO from biomechanical to neuromodulation). Only then I feel that it is validated within the ethical, practical, scientific and clinical physiotherapy practice.
Refreshing piece, Adam. Well said. I’ve been a skeptical physio for many years. All that time and money wasted on electrotherapy and manual therapy …. As a physio, I’ve had most fun in my career working with the elderly, trying to stop them falling over – which involves a lot of problem solving, environmental changes, equipment prescription, education etc and absolutely no manual therapy – until I discovered lymphoedema therapy – an area wear touching someone could actually help them (and improve their mobility). So there is hope out there for some ‘manual therapy’. I’m living in the US at the moment – it was too hard to get my PT license (thank the Lord – healthcare system here is just about making money, it seems, for the most part) – so I’ve just gotten my massage license. I’ve got to say, if you like touching people and using manual therapy, then life as a massage therapist can be a whole lot sweeter than dealing with the snotty physio’s who claim that 60 seconds of joint mobilisations and a hot pack and some intereferential is going to make a difference to someone’s LBP. Don’t get me started on core exercises. Keep up the discussion and never assume that anything that is taught or dictated is effective or relevant. Bravo!
Hi Adam,
Long time reader of your blog and recent graduate in Physiotherapy. Interesting article and thought provoking in evaluating times I have used manual therapy in practice. In terms of managing pain manual therapy may have the placebo effects that provide pain relief for a pt. When I see pt. who I feel need a bit of poking as you say I refer to education on self management using foam rollers or hockey balls or whatever they find works in providing the pain relief. However I still find pt will complain about lack of manual therapy or think education on pain management and reassurance that moving through some pain is safe just isn’t enough. These pt cohort will swear they feel better after manual therapy be it massage, mwm, joint mobs etc… how do you suggest we keep these pt happy with non manual therapy based treatment ?
Sometimes you can’t and shouldn’t keep patients happy!!! Patient satisfaction is a terrible measure of effective management in healthcare. A lot of my patients if you asked them would say they are not happy to do what I ask… but they all understand why they have to do it!!!
I feel like your final paragraph undoes everything you wrote before it.
“Touch can and does calm, soothe, comfort, and assist both physically and psychologically, and I will occasionally use touch to guide, assist, or encourage a movement that a patient is scared, fearful, or lacking strength to do.”
Now I know you follow this up, by qualifying that this touch isn’t manual therapy, but it’s still the basis on which effective manual therapy is used. If you could perform a relatively quick technique that helps to reduce pain in your patients (albeit, temporary reduction) and allows them to perform more exercise, why wouldn’t you?
So long as they’re clearly educated on what manual therapy does and how exercise is the best thing for them in the long run, why wouldn’t you do it?
I think you have a lot of good points, and a lot of good other content on this blog, but it loses its oomph for me when it’s spoken in such absolutism… but I suppose that generates good conversation.
I disagree… caring reassuring touch is NOT manual therapy. Shaking someones hand, placing a hand on a scared patients shoulder to guide them to move is NOT manual therapy. Cheers Adam
Hi Adam,
I find myself largely in agreement. I consider myself generally a somewhat hands-off Physiotherapist and I certainly consider providing patients with the right education absolutely fundamental.
That said, I would be interested to hear why you suggest Manual Therapy should be completely abandoned:
“There is no argument from me that touch is powerful to those in pain and/or distress. Touch can and does calm, soothe, comfort, and assist both physically and psychologically, and I will occasionally use touch to guide, assist, or encourage a movement that a patient is scared, fearful, or lacking strength to do ”
As you have acknowledged here touch can help reduce distress, etc. Therefore if Manual Therapy is provided with the right/honest education, it can also be used to reduce distress and encourage movement. I feel that many patients would simply be more ‘on board’ with Physiotherapy if we could help to reduce their symptoms whilst advising them that any improvements are purely short-term. I’m sure we have all heard patients that have seen other Physiotherapists that have said ‘they only gave me a sheet of exercises’.
I also remember you hearing one of your that with some Shoulder Assessments you would conduct a ‘comprehensive assessment’ that parts of the assessment would purely be included just to make the patient feel more at ease. Just to note I do completely agree with this – but I also tend to see Manual Therapy in a similar light.
Not attacking any views – just interested to hear what you would have to say about Manual Therapy being a supplement to the more important components of Physiotherapy. For many patients I feel that could be the best of both worlds.
Thanks,
Ken
Hi Kane, thanks for your comments. In my opinion there is a huge difference in a caring reassuring guiding touch and what is often labelled as manual therapy. For me manual therapy covers the 3 Ms… massage, joint mobilisations, and manipulations. Cheers Adam
It has been a very needed breath of fresh air to read this article and see the support for the views expressed. My own professional journey over the last few years has been to arrive at similar conclusions regarding the evidence-base of much that the profession endorses, leaving me feeling isolated and disillusioned with the profession. So much of what I learned at University over twenty years ago has ben shown to be ineffective or is currently under question. My own professional body, the Australian Physiotherapy Association’s has only deepened that disillusionment with recent examples such as the endorsement of a lecture on Visceral manipulation as Professional Development and the the prominence of dry needling on the program of the upcoming national conference. Added to that is the reinstating of dry needling as a practice in my own Health Service District, after a review of the evidence by, surprise, surprise, practitioners who use dry needling.
Physiotherapy has maintained a privileged position, being considered an evidenced-based profession by the medical fraternity and the general public but I see this position being eroded and could eventually be lost if the majority continue to cling to practices that, although very profitable to many, can no longer be justified by high quality evidence.
Hi Karl, thanks for your comments and I completely agree with all you say, its embarrassing the rubbish that is labelled as physiotherapy and makes me at time ashamed to call myself one. All the best Adam
Hi Adam, as soon as I became an NHS outpatient physio (after those godawful ITU rotations) I remember saying to an ESP: “Surely if the patient likes you they will do what you need them to do?”. He smiled and said “yea. Pretty much”. WTF?? What about all those electrotherapy settings I learned by heart? (Actually,not true) or the Maitland grades and the thingy you pumped up and shoved under trans ab to detect if their contraction was just so? Was it all nonsense? So, due to my growing disillusionment with manual therapy, I ended up in the wildly unsexy world of chronic pain (well the older, dress-wearing physios pitied my retrograde step). My most satisfying customers to date were the ones attending the physio-led pain management programme we nicked from Guys and Tommy’s. All just sensible advice really. A bit of psychology, a lot of exercises, loads and loads of explanation and reassurance. Hard work but great, measurable results in the ones that got better. Now I’m in the private sector and feel under pressure to “do something” but I know it is mainly futile. Taping falls off and my thumbs hurt from all that mobilising. What am I doing?… Really good objective assessments are vital so there’s my manual therapy right there. The rest is rapport and explanation, maybe? So glad you wrote about this CSP shenanigans and just feel so sorry you had to go through all that nastiness. But, here’s the thing: you have steeled my resolve to do the simple stuff well.Thanks so much Adam. See you on the November shoulder course!
Hi Sarah, many thanks for your kind comments and glad to hear my experiences have reinforced your resolve… See you in November. Cheers Adam
Hi Adam,
I don’t agree with all aspects of your arguments, but i do think you are certainly doing the right thing in regards to challenging areas of our practice where evidence is lacking. Have you thought about conducting some research as to support some of your valid points?
Kind regards
Chris
Hi Chris
I have done three small clinical trials so yes is the answer, currently I am trying to get them through peer review however it is an issue due to limitations in small numbers and biases, but hey its the effort not the result thats important.
Cheers
Adam
Absolutely… Good on ya 😉
Hi Adam,
Depressing that some people within physiotherapy are trying to prevent dissenting views by launching character assassinations on the people who voice them. There is something quite unpleasant about all of it.
Well done for getting everything you’ve said vindicated by the CSP. Good to hear they took an impartial view and decided that the critics opinions were wrong. Finally thanks for writing about it.
I’m interested to know why you haven’t named the organizations that have been criticizing you? I would. They cant sue you if the CSP judged their attack to be unjustified. Go on, who were they?
Cheers Jim.
Thanks Jim, I did think about naming my accusers but thought better of it, I will only be accused of being petty or even bullying, so I will refrain from naming or shaming… for now!!!
Cheers Adam.
Hey Adam,
Thanks for this article. I am a new grad in NC in America working for a relatively large physical therapy corporation. I guess my frustration with your take is this: I feel like listening to your podcasts and reading your articles you make excellent points about low level research etc… But then I think a bit further and think, well if realistically so many people are actually inappropriate for PT in general and if so many of these people just need “reassuring” and education about healthy lifestyle, well then what are we even doing here? Why is orthopedic pt necessary? It would not survive on the tiny sample of people it seems you imply need it. I apply and use psychology in my treatments every day, but I also do a lot more. In same way we can give a squat to someone, well so can a personal trainer, and they can also give healthy life advice and all that for much cheaper. I guess my point is that so just because the research is not there yet does that mean that its all shit? Because then our whole profession is shit. And I guess furthermore my frustration is, as a new grad when I listen to these podcasts, many times my patients do get better and they appreciate what I try to do, but I think well, what the fuck am I supposed to do then if what I am allegedly doing is wrong? What is the right way?
Hi Adam, I am a student physio and have an assignment where I can choose a clinical experience and then ask if it has a a place as a relevant treatment in physiotherapy.
On placement (MSK) I was asked to use electrotherapy even though my educators views on it were negative. Another educator said I could use it if I could justify it with evidence(even though I didn’t want to) and then there were other senior physios that used it on every patient just for good measure. I am trying to write an essay with a balanced argument for and against the use of electrotherapy. And after reading your blog on the use of manual therapy I wondered if you had any further thoughts on electrotherapy? Is there a place for it? or is it out dated? Any thoughts or reading suggestions would be appreciated.
Cheers,
Charlie
Hi Charlie
As with manual therapy I dont use any electrotherapy. This isnt my area of interest but the last time I checked there is little to no evidence for laser, ultrasound, diathermy, and interferential. I think muscle stim has a role in some populations and post surgery however.
Cheers
Adam
Based on the scientific evidence, I can’t disagree with you. However, a personal anecdote compels me to keep an open mind. For years, I had recurrent issues with SI/back pain. Lots of flares, and with the more severe ones I would see a physio, though I would search for people who didn’t do manual therapy due to the lack of evidence behind it. After a few courses of various exercise progressions, loaded this and that (focusing at various times on hip hinge to deadlift progressions/KB swings/squat/antirotation core/antiflexion core/hip mobility), I had minimal improvement, and the same issue would flare. This went on for a decade, during which time I saw various physios 4 times for the significant flares, and just took it easy during the minor ones. Finally, at the recommendation of a professional dancer, I skeptically saw a PT who does manual therapy and some exercise prescription for their professional dance group. I was surprised and satisfied with the degree of improvement; my pain was gone after three weeks. Sometimes some tightness around the left PSIS, but the home soft tissue work he prescribed for me takes care of that, and even this minor discomfort has been less and less frequent. A year and a half of lifting/sprinting later, I remain without significant flare-ups.
So…anecdotal? Of course. But I for one hope that all physiotherapists do not abandon this therapy. Does the evidence support it presently? Maybe not. But I question the thoroughness of this evidence. Are we measuring the correct things? With the heterogeneous nature of musculoskeletal pain, are we able to identify the patients that may most benefit from soft tissue therapy, and screen them out effectively to direct studies towards these patients? Do we truly understand what happens during effective manual therapy? I.e. the mechanism of its action? Is it possible that we just haven’t hypothesized correctly its true mechanistic effects, and therefore haven’t really studied it correctly? Being a nonphysio, I certainly don’t know the answers to these questions. But I do know that working with people to improve my hip hinge and squat and hip mobility and core and thoracic mobility didn’t solve the problem. After visiting this manual therapist, however, I was able to reengage these movements and progress them without reinjuring myself, and have even been able to get back to sprinting/cutting/jumping without reinjuring myself. So, for me, manual therapy has been a game-changer.
Thanks. Im from holland and always thought I was the only one thinking like this. #nosheep