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