My agenda…

I can both love and hate twitter at times, but it often does give me some ideas for blogs, such as this one which I had no plans to write until certain events unfolded recently over what I thought was a simple helpful tweet I posted on the latest NICE guidelines for low back pain here. The full guidelines are freely available here. However, this tweet soon created a lot of interest and some surprising and frustrating accusations of my deceit, distortion, and general skull duggary.
Now I often get accused of having ulterior motives and hidden agendas by many people when I question or challenge stuff. These accusations range anywhere from me being against all manual therapy and how I think it should never be used, to claims that I think the physiotherapy profession is completely worthless, and even accusations that I am only ever critical or skeptical to create attention for myself and to promote and feed my own ego and courses.

Usually these accusations don’t bother me, as most who throw them at me are simply trying to detract attention away from the point at issue I am raising, which is usually around some exaggerated or ridiculous claims about some other shitty course, crappy manual therapy technique, pissy rehab exercise, or a bull shit machine that goes bing.
But when a colleague like Alan Taylor, a fellow physio, university lecturer, cycle enthusiast, and skiffle band aficionado whose opinions I usually tend to respect accuses me of having a hidden agenda, deliberate deceitfulness, and distortion of the facts to suit my own paradigm and personal gain, I need to reflect, take stock, and consider what exactly is my agenda?

It’s no secret…

Well it’s no secret that I think my profession has some rather big issues, in fact I think it’s got some bleedin’ huge issues, and I have tweeted and blogged about them many times before. For example, I often question if our profession actually does much to help those in pain or with disability. I question if too many physios are focused on the short term, quick fixes to consider the bigger more challenging issues of poor lifestyle and habit choices, low physical activity, and reduced tolerance to pain, and other stressors.
It’s no secret that I think physiotherapy is surrounded by a lot of over complex pseudo science and is too dependant on passive interventions, particularly manual therapy, electrotherapy, and needles. It’s no secret that I think physiotherapy is a fad driven, guru worshipping profession that in the majority doesn’t think for itself. It’s no secret that I think physiotherapy has an archaic, hierarchical, and dogmatic infrastructure with some of our leaders hopelessly out of date and out of touch. It’s no secret that I think our profession has an academical/clinical divide that doesn’t readily promote or welcome equal collaboration, critical thinking, and open discussion from everyone and anyone, despite lip service given.
So I think my ‘agenda‘ is and has been pretty clear for a while, and I will continue to highlight all of the above issues in an attempt for us to ultimatley be a better profession, to become better at helping those in pain and with disability bulid resilience and self efficacy that will optimise their function and mobility. That in a nut shell is my agenda!
Basically I critique and challenge a lot of what occurs in physiotherapy, not to bring it down, but because I want it to be better. Despite accusations I do love and respect my profession. Ok it frustrates the hell outta me a lot of the time, but I think when done well, physiotherapy (and all the other therapy’s) do an amazing job in helping people and society, and I do try to promote the good it can and does do, including these recent NICE guidelines.

Riled and pissed off!

So i’ll admit that Alan’s recent accusations of me deliberately twisting and distorting these guidelines to suit some other agenda has surprised and riled me, and then to see the usual manual therapy advocates and their sycophants, many of whom I have had ‘debates’ with before, get all excited and jump on the back of this discussion and use it as an excuse to retweet away and promote their own brand of shite also pisses me off.
Now as much as I can work it out, Alan’s angst towards my summary chart (see below) seems to revolve around two main issues. First is me using the words recommend and offer on my summary chart rather than using the word consider as stated in the guidelines. And secondly me saying ‘do not use manual therapy without exercise or education‘ rather than ‘do consider manual therapy but only with exercise or education‘ as stated in the guidelines. Allegedly Alan thinks these subtle changes and emphasis are deceitful, misleading, but also a sign of my genius, and that his amended version is the ACTUAL guideline key points and has #NoBias.

Well first things first, I simply think Alan is splitting hairs for what ever reason, and lets not forget that everyone has a bias, a stance, an opinion, an interpretation, and #NewsFlash they are not going to always be the same as yours. Secondly I don’t know about you, but I can’t see any genius at work here, rather just two people, with nothing better to do, arguing the toss about saying the same things differently. Personally I can not see any significant difference between saying recommend, offer, or consider an intervention. If anything ‘considering‘ as stated by NICE could be interpreted as to be done in isolation by the therapist, whereas ‘offering‘ or ‘recommending‘ as I state implies involving the patient more in the decision making process.

Do or do not?

As for saying do, or do not use manual therapy, with or without exercise or education. Well again you can argue the toss as much as you like, they are simply saying the same thing differently again. OK the emphasis on do or do not is the key difference here, but as I’ve openly, clearly, and transparently stated many times before I do object to the over hype, over use, and over reliance on all manual therapy by physiotherapists, especially in low back pain, which in the grand scheme of things offers very little other than some short lasting, small pain reducing effects, for some, and lets not forget it also has many iatrogenic risks as well.
So again I will be clear and state that my emphasis/bais is not to routinely offer manual therapy to patients, and I guess this is why I worded as such in my summary chart. But to state this is for my own benefit or gain is just ridiculous. Do people really think I gain benefit from or enjoy finding ways to deliberately antagonise and irritate the skin draggers, fascial releasers, and joint crackers out there, enduring their persistent whining and moaning about how unfair, mean, and closed minded I am… Well ok I do a little bit, but seriously it ain’t all a barrel of laughs I can assure you!

2009

Also just because I am not an advocate of manual therapy it does not mean that I think or expressly state that it has absolutely no place or benefit for anyone at all. Believe it or not I’ve used the odd bit of manual therapy from time to time… I used some in November… in 2009… I pushed a stiff shoulder joint backwards a little bit… it kinda helped… I think… for a few minutes!
However, joking aside when I do use manual therapy, just as the guidelines state it most certainly is only ever with exercise or education, and only because the patient has expressed high expectations or preferences for it, and only then if I think it will not cause a loss of self efficacy, or develop a reliance, or reinforce any false or negative beliefs.
I personally think the recent NICE guidelines for low back pain and sciatica are a triumph for sicence and evidence based practice at last, and all those involved with them should be proud. I’m also glad that this little spat with Alan, and these summary charts of ours has perhaps made a few more people go and read them. I think they offer a clear, simple framework for healthcare professionals to follow when dealing with patients with back pain and sciatica, and I still think my summary chart is a fair interpretation of the key points they make, but hey i’m biased!
Lets also not forget that these are only guidelines, and so are going to be open to everyones interpretation. Exercise advocates will focus on and emphasis the exercise bits (just to be clear again, I’m an exercise advocate). Manual therapy advocates will focus on and emphasis the manual therapy bits. Psychological advocates will focus on and emphasis the psychological bits. Acupuncture advocates will focus on and… oh hang on… no one really cares about what they think any more!
Finally, I will once again declare my preference and biases to all who care to read or listen to anything I have to say, that I will always be an advocate for, and will always promote active and educational interventions over any passive ones. And unless strong robust evidence tells me other wise, I will always continue to steer people away from all the passive interventions, such as manual therapy, electrotherapy, needles, tapes, braces, corsets, injections etc and direct them towards increased physical activity, behaviour and lifestyle changes, and ultimately self management.
And I will never, ever apologise for this.
As always, thanks for reading
Adam

Thank you once again Adam, for bringing my attention to current guidelines in the management of LBP and also reminding me of the current ‘forward’ thinking of Physiotherapists like yourself.
I left Physio many years ago to train as a Psychotherapist, as I felt that my focus on the body was ‘missing something’ and that our medical view of wellbeing split our considerations in two. That is: physio’s do the body and psychiatrists do the mind. Physio departments are found at hospital entrances and psychiatry departments are usually found at the end of a long corridor at the back of the hospital somewhere near the incinerators. But having spent a few years developing personal insight while attending counselling training courses and eventually a degree (I had a lot of work to do on myself having suffered the sudden loss of a family member in a car accident) I found that sitting down and talking about problems was counterproductive in that it highlighted the problem rather than the solution more often than not. In the history of counselling, this is how CBT developed as it helped counsellors to focus on goals rather than the problem. Another reason for the acceptance of CBT is that it can be scientifically measured and therefore sits well in our need for hard scientific fact when working with people. Having said all of that, the ‘problem’ in whatever form that may take, needs to be recognized and more importantly ‘understood’. The subjective experience of the patient, that entails thoughts and feelings about the problem, are difficult to measure, and whether that patient has felt genuinely ‘understood’ is equally non-tangible. Once one has fully ‘understood’ the problem, we can have genuine empathy with that patient, we can walk in their shoes for an instant, we can know what it feels like to be them without loosing our self in all of it, and then step out of it, with their full attention and willingness to follow our lead whether that be ‘take this pill’ or ‘do this exercise’. This is the true gift of empathy I believe.
Now as a Physiotherapist again I find that manual therapy, like you say has a tendency to be problem focused, focusing on the site of dysfunction rather than the cause. The cause is a lot more complicated and often difficult to find. However, if a patient is experiencing chronic pain and some manual therapy can provide them with relief and the knowledge that their pain can be affected in a good way and in turn feel ‘understood’, then I am more than happy to warm up these cold little hands of mine and get stuck in!
It’s a very fine line, we tread as Physiotherapists and we are so finely tuning our processes that even the words we use become significant! Maybe even ‘words’ are inadequate eventually. If my job is ultimately to get people moving then maybe I really should have trained to be a DJ and followed my old friend Sasha to Ibiza and not wasted money and years on an education!!
Thank you once again….this so beats Christmas shopping!

cliff 3 December 2016 At 10:42

Hi Adam, as ever respect your honesty. I have zero experience within physiotherapy so state my opinion on purely a patient’s one.
During the 90’s I was a drayman for Courage Brewery and can tell you most there had bad backs. I used to do a lot of martial arts training and go to the gym and never succumbed to any low back pain.
I do think exercise/strength training a great thing in fending off injuries and if I have understood properly what you write agree exercise over acupuncture (or other manual therapies) any day of the week works infinitely better.
Sorry if I missed the point to all of this but do feel intelligently applied exercise a crucial part of keeping folk fit and well…………..which isn’t THIS your truest agenda?
Keep up the good work
From an unbiased patient’s perspective
- Adam Meakins 3 December 2016 At 11:20
  
  Hi Cliff, thanks for the comments and your story is my experience and what the evidence base tells us, if you can stay strong and physically active and use physical activity ‘intelligently’ then risk of pains and dysfunctions can be minimised, this as you say is my agenda and what I want to promote!
  Thanks again for your comments
  - cliff 3 December 2016 At 11:29
    
    Absolutely agree…no lie or bull this was the case with me.
    At least somebody like yourself has the guts to stand up and speak out
Rob Jones MCSP 3 December 2016 At 13:21

Hi Adam,
Where do you stand on the “mind–body group exercise programme within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica” ? We all know any exercise helps but why single this out? Good blog,
Rob.
- Adam Meakins 4 December 2016 At 10:24
  
  Good question, to which I don’t have a good answer!
louisebernard 3 December 2016 At 13:25

Thank you once again Adam, for bringing my attention to current guidelines in the management of LBP and also reminding me of the current ‘forward’ thinking of Physiotherapists like yourself.
I left Physio many years ago to train as a Psychotherapist, as I felt that my focus on the body was ‘missing something’ and that our medical view of wellbeing split our considerations in two. That is: physio’s do the body and psychiatrists do the mind. Physio departments are found at hospital entrances and psychiatry departments are usually found at the end of a long corridor at the back of the hospital somewhere near the incinerators. But having spent a few years developing personal insight while attending counselling training courses and eventually a degree (I had a lot of work to do on myself having suffered the sudden loss of a family member in a car accident) I found that sitting down and talking about problems was counterproductive in that it highlighted the problem rather than the solution more often than not. In the history of counselling, this is how CBT developed as it helped counsellors to focus on goals rather than the problem. Another reason for the acceptance of CBT is that it can be scientifically measured and therefore sits well in our need for hard scientific fact when working with people. Having said all of that, the ‘problem’ in whatever form that may take, needs to be recognized and more importantly ‘understood’. The subjective experience of the patient, that entails thoughts and feelings about the problem, are difficult to measure, and whether that patient has felt genuinely ‘understood’ is equally non-tangible. Once one has fully ‘understood’ the problem, we can have genuine empathy with that patient, we can walk in their shoes for an instant, we can know what it feels like to be them without loosing our self in all of it, and then step out of it, with their full attention and willingness to follow our lead whether that be ‘take this pill’ or ‘do this exercise’. This is the true gift of empathy I believe.
Now as a Physiotherapist again I find that manual therapy, like you say has a tendency to be problem focused, focusing on the site of dysfunction rather than the cause. The cause is a lot more complicated and often difficult to find. However, if a patient is experiencing chronic pain and some manual therapy can provide them with relief and the knowledge that their pain can be affected in a good way and in turn feel ‘understood’, then I am more than happy to warm up these cold little hands of mine and get stuck in!
It’s a very fine line, we tread as Physiotherapists and we are so finely tuning our processes that even the words we use become significant! Maybe even ‘words’ are inadequate eventually. If my job is ultimately to get people moving then maybe I really should have trained to be a DJ and followed my old friend Sasha to Ibiza and not wasted money and years on an education!!
Thank you once again….this so beats Christmas shopping!
- Adam Meakins 4 December 2016 At 10:27
  
  Hi Louise and thanks for your fantastic comments.
  I think physio and psychology are extremely interwoven professions and that we (physio’s) need to learn more and more from you (psychologists)
  Maybe we should pay more visits to the incinerators down the back of the hospital ???
  Thanks again for your comments
  Adam
jerryhenderson 3 December 2016 At 14:47

Adam, great, thought provoking post as usual.
I may be over-simplifying, but relieving pain is easy… really affecting the natural history of a condition is hard: almost any intervention will offer your patient temporary pain relief: massage, heat, cold, estim, needles, ultrasound (whether or not it is turned on), manual therapy of any type, or, probably most effectively, an empathetic listener.
I don’t treat patients any longer, but toward the end of my clinical career, I came to find hot packs and estim to be effective tools in my arsenal… but only because I offered them to my patients to get their attention. I would simply state…. “Look this isn’t going to fix anything, but it will give you temporary pain relief. Let’s do this for now, and work on an exercise program together.” In fact, I have a little part of one of my talks called “In Defense of the Humble Hot Pack”.
Today, as I travel the country I many colleagues tell me about the wonders of dry needling. A few years ago it was laser, years before that it was micro current, and way back microwave diathermy was the next best thing, replacing short wave diathermy. (Really dating me, I know.)
One of the PTs that I have known for over 30 years is (in my opinion) one of the least technically knowledgeable I have ever met, while also being one of the most effective. But, he is an empathetic problem solver and he gets his patients moving.
Sorry for ranting a bit. Thanks again for this important post.
- Adam Meakins 4 December 2016 At 10:29
  
  Thanks Jerry for making a valuable point, in that the skill of good effective physio is in the interaction not the intervention! It’s one of the points I like to make often too! Much to the annoyance of others! Which I don’t understand!
  Cheers
  Adam
Jane Appleyard Physio 3 December 2016 At 15:24

‘Adams Agenda’ – Is a long time overdue.
Stay focused in 2017!
- Adam Meakins 4 December 2016 At 10:33
  
  Thanks Jane, will do!
Des 3 December 2016 At 15:28

As`a person with a long standing very painful shoulder issue (based in Ireland) I can tell you that I agree with nearly all of what you are saying. In the course of my injury treatment I have been to no less than ten physiotherapists all of whom had a different treatment plan, I can safely say nobody had a conclusive plan for me as to how to get my shoulder well again. I got advised to do stretches, not stretch, go to the gym & do weights, not do weights, accept it, go for dry needling every month for the rest of my life etc. After a while it became patently obvious that none of them had an understanding of the complexity of the shoulder or any idea how to give me anything more than a quick fix, it is my belief that most of them, once we got to session 6 started to give up hope. It was only when I found a truly gifted physio who really understood anatomy and my body limitations did I start to get better – now – over a year later I am nearly fully well but I dread to think how I would be if I had not looked for a better therapist.
The ‘industry’ seems filled with (often very young) therapists who are fixated on the quick fix and overlook the bigger core issues. A great blog post and one that resonated with me big time.
- Adam Meakins 4 December 2016 At 10:33
  
  Thanks Des!
rhinosilent 6 December 2016 At 17:16

Adam you crack me up entirely too much. I am currently receiving manual therapy/PT following a leg/knee fracture/dislocation as well as a ton of exercise. I do think the manual therapy is helpful but alone, it would not be. I am a therapist also and the people making the electromodality machines constantly bombard us with company funded “research” on how helpful it is.
Mettemaje Hansen 7 December 2016 At 12:32

Hi Adam, I would like to
participate your cource in Denmark in june 2017. Can you tell me how a sign up to your cource?
Kind regards Mettemaje
- Adam Meakins 7 December 2016 At 22:15
  
  Hi Mettemaje
  Thanks for your message about my course in Denmark.
  If you contact the host Christina Olsen i’m sure she can help you. Her email is [email protected]
  Kind regards
  Adam
Ben 5 January 2017 At 20:41

Simplicity doesn’t sell unfortunately. People feel the need to dress things up to get buyers. The most reasoned voice isn’t “loud” enough. It is really too bad.
terry Abrams 21 March 2017 At 16:47

HI Adam I do appreciate your honesty about your profession and for bringing to light many things you consider problems within your field. I feel like you do ask questions that will lead to further the field and help provide new answers to those questions. Keep up the great work!
Stan 9 October 2017 At 11:55

Hi Adam,
Do you consider anything helpful is left out of this guidelines?
I know you are fan of the active approach such an exercises, beliefs modification, load management ect. But in one episode of your podcast you mentioned that LBP doesn’t respond quite well to physical activities (compare to other issues), so what are your favorite steps to deal with LBP?
I’m a big fan of your work,
Stan.
- Adam Meakins 11 October 2017 At 12:56
  
  Hi Stan, exercise for LBP doesnt show huge effects, but its the best we have got. I am a fan of exercise as a core intervention together with good simple sound advice and education and reassurance. Thats it. Cheers Adam