I’m guessing if you are reading this then you are probably a therapist who uses manual therapy, and I’m guessing you are either curious or slightly pissed with the title of my blog that’s just questioned your skills, training, and experience!
Now, before you head straight to the comments section to tell me what an asshat or ignoramus I am, I urge you to read on further and hear me out as to why I think there is NO skill in manual therapy.
A few weeks ago I posted the above controversial tweet and it had a mixed response, some agreeing, some disagreeing, many not caring. However, I thought I would expand on this a bit more and explain why I think that there is NO skill needed in any manual therapy.
Anyone can do manual therapy
I know that anyone can ‘do’ manual therapy without formal training, qualifications, experience, or expensive courses, and get just as good, if not better results than the so-called ‘experts’.
This is purely anecdotal, but I’ve had ongoing intermittent neck pain issues for years that flare up now and then usually due to stress, too many snatches, or spending too long on laptops blogging or tweeting. It usually manifests as sudden and severe right-sided neck pain that grossly restricts my range of movement. I have no other worrying signs or symptoms and my self-diagnosis is its some form of muscular or other minor mechanical issue.
Over the years I’ve sought the help of many professionals for this, doctors, orthopaedic specialists, and many many therapists. However, apart from being told I’ve moderate age-related changes at C5/6 on the right seen on an MRI after a particularly bad episode after a rugby tackle went wrong, nothing has been found or helped that much to reduce the number of episodes or the time it takes to settle when it comes.
However, without a doubt the best ‘treatment’ I have found for this bothersome issue over the years out of all the pills, injections, scans, corrective exercises, tapes, massages, manips I’ve had is… my wife’s neck massages.
Now my wife isn’t a trained therapist, in fact, she doesn’t even work in the healthcare profession, but when she does her ‘thing’ I get the longest-lasting most effective pain relief and improvements in movement. And I hear of many others who tell me similar stories of a partner, a friend, an ‘acquaintance’ who isn’t trained in manual therapy giving them the best back rubs, head massages or even a click or a pop of something now and then that feels ooooh sooooo good.
It’s these kinds of stories, among other things that got me thinking, how is this possible? How is it that my wife and other non trained ‘therapists’ can make people feel just as good if not better than a £50+ per hour highly trained professional?
Well, many therapists argue this example isn’t a fair comparison because there are many other factors with my wife’s ‘treatment’ that a professional therapist just cannot reproduce. Things such as high levels of trust, familiarity, relaxation, and even playfulness.
But its exactly these non-specific factors and NOT the so-called skilled qualified technical application that makes manual therapy effective, and this is EXACTLY why it raises some BIG questions around the beliefs that many have about the skills needed with all manual therapy.
Touch can be powerful
Many mistake my constant, some say savage, critique of manual therapy as saying it doesn’t work or doesn’t have a role. That’s just not true, and a false dichotomy, and pisses me off hugely, so please stop it.
Yes, I think manual therapy is overused, over-hyped, and surrounded by a shit tonne of pseudoscience, gimmicks, showmanship and some absolute throbbers who teach and promote it. And as a consequence, I now hardly use it as a physio, however, there is no denying that touch can be very powerful and can help patients enormously.
We have developed touch to not only help us function and make sense of the world around us, but it also to help us bond, connect, and form social groups. Touch can help relieve both physical and emotional pain. Touching another person in the right context can be highly rewarding, soothing, calming and relaxing (source, source).
However, what I am highly critical and sceptical about is those who try to make this process of simple, caring, soothing touch over complicated, over technical, over-hyped, and overpriced in its application!
Let me tell you a little bit about my story with manual therapy just in case you think my opinions are ill-informed or inexperienced. My training and education in manual therapy is extensive, long-winded, and really bloody expensive.
It started when I first began my training as a physio back in 1999 and extended for well over a decade after. I’ve completed many of the well-known well-recognised post-grad courses in manual therapy, and many of the other not so well recognised ones.
I have been taught by some of the worlds most influential institutions sitting their exams, jumping through their hoops of assessment and examination to gain their pseudo-qualifications, which in the real world mean very little.
With this level of training many would class me as ‘skilled’ and experienced manual therapist, but as I’m arguing exactly against this point I don’t, but believe me, when I say I can click, crack, rub, roll, press and pull a patient in all the ways you can imagine just as well as the rest of them.
What is manual therapy?
Manual therapy exists under a bewildering array of names, some well-known like massage, manipulation and mobilisation. Sometimes they have more complex and ‘scientific’ sounding names like effleurage, petrissage, myofascial release or deep transverse frictions. Some have more exotic and glamorous names like Tunia, Graston, Active Release, and then there are those named after their influential creators such as Rolfing, Maitland or Bowen.
Although these techniques have slightly different methods of rubbing, pressing, pulling or poking, they all have a series of courses to attend and tests to pass to show you have acquired their ‘skills’. Each technique is thought to achieve its effects via different mechanisms, and they all vary in their thinking and explanations of how this is achieved.
However, regardless of the explanations used what is the same with all of these methods, is they all base their effects around the notion of changing a tissues structure, position, length or freedom to move, be it a muscle, tendon, ligament, fascia or a joint.
Another similarity that all these manual therapy courses have is they all think that their method is superior to all the other methods, usually with an air of arrogance, snobbery, and self-imposed superiority, that would make a monarch blush. This is without doubt one of the reasons I dislike the manual therapy industry and many of it’s guru’s and teachers so much.
The other reason why I dislike the manual therapy profession so much, and why I am highly critical of it, is that after spending many thousands of pounds, and many years being taught and lead to believe that manual therapy is a great big powerful tool that can help ‘fix’ or ‘cure’ people in pain, I have come to realise that this just isn’t the case.
Manual therapy is just not as powerful or as useful as many claim it is, and it’s certainly is not as specific or as skilful as many make out. So I feel cheated, mislead and lied to, and what’s worse I continue to see it happening right now, all the time.
In fact, I see more lies and falsehoods about manual therapy now than before, and they appear to be growing more fanciful as time goes on, and nothing seems to be changing. I simply don’t want young, keen, eager, dedicated therapists getting sucked in and making the same mistakes I have.
I don’t want them wasting their time, money, and hopes on manual therapy. I don’t want them going through the anger, frustration, bitterness, and disillusionment with the profession that I did due to this one shitty intervention.
Personally, I think a lot of good physios are lost from the profession due to frustrations with manual therapy. I think many physios feel disillusioned because they are lead to believe that you can not be a good or successful physio without achieving your black belt in massage, or Jedi like skills in joint manipulation. This is utter bollocks and needs to stop. Physiotherapy is so much more than f**king manual therapy.
A slow realisation
I’ve come to realise that manual therapy isn’t what I’ve been taught or lead to believe. I’ve learnt that the results of all these manual therapy methods are highly unreliable and variable, despite my extensive training, despite my detailed assessments and my skilled application.
I’ve also realised that when I don’t do the technique exactly the way I was supposed to patients still feel better. I’ve realised that actually it doesn’t matter how I poke, prod, or rub patients. I can go AP or PA, I can go proximal or distal, I can go transverse of longitudinal, I can go clockwise or anticlockwise. I can rub-a-dub-dub, or patter cake bakers man. It just doesn’t matter.
So gradually I stopped all the ritualistic, pseudo-scientific assessments that I had been taught, such as feeling for a joints position or lack of movement. I stopped poking soft tissues trying to feel for knots, bands, spasms etc as it just doesn’t matter.
I went and looked deeper into the manual therapy research and what I found was most of it is grossly flawed with methodological design issues and biases so big they dwarf my own. I also found that manual therapy can’t increase blood flow, break down scar tissue, melt adhesions, ‘release’ muscle or lengthen fascia with manual therapy (Shoemaker 1995, Chaudhry 2008, Chaudhry 2007, Schleip 2003, Threlkeld 1992)
I’ve learnt that rubbing, pulling, or stretching soft tissues in a specific way, for a specific amount of time is not necessary as it just won’t affect it’s structure in any significant way (Solomonow 2007, Weppler 2010, Katalinic 2011 Konard 2014)
I’ve learnt you don’t need to mobilise or manipulate any joint in a specific direction, based on a pattern of pain, or specific assessment of movement or joint feel (Chiradejnant 2003, Aquino 2009, Schomacher 2009, Nyberg 2013)
I’ve learnt that palpation of muscles, joints, trigger points are all unreliable and lead therapists to misdiagnose and direct treatments down wrong and ineffective pathways. More here
I’ve learnt that when all the different methods of manual therapy are examined through the process of systematic reviews and meta-analysis, most of the research is poor and even the good research shows that it doesn’t do much (Menke 2014, Kumar 2014, Artus 2010, Kent 2005)
This has been a revelation, an awaking. A slow and gradual opening of my eyes, but they are wide open now, so I can now confidently say…
There is NO skill in manual therapy
Now having said all that there are some caveats that I think a therapist does need some skills in to achieve good results with manual therapy techniques. Although the risk of causing any structural damage is small, there are some high-velocity techniques that do potentially have a small risk of harm of damage with some potentially serious consequences to delicate vascular structures.
High-velocity neck manipulations, end of range tractions, and even some joint mobilisations to the neck have been documented to cause some rare but serious injury’s (source) So it goes without saying that a full awareness and identification of those at risk is a must before contemplating these techniques. Although there is the argument of if there is such a high risk albeit small but also small and minimal benefits why even bother with them at all (source).
So there you go, my rather lengthy explanation, some will say rant, of why I think there is NO skill in manual therapy. This is my own story of my genuine desire and curiosity to learn as much as I could about manual therapy, followed by my disillusion and frustration by the elitism, egos, and utter throbbers who teach and promote it
I now find myself (unexpectedly) as a well known cynical, sceptical and often misrepresented critique of manual therapy for which I’m hoping this blog will provide some clarity of where I am coming from.
Let me also state that my aim here is not to attack or target anyone who uses manual therapy. Instead, I just want a more honest, simple, less egotistical use of manual therapy that recognises its many non-specific contextual effects.
I also hope to continue to highlight and debunk the mystical biased crap that surrounds manual therapy, and to be a thorn in the side for the unscrupulous, arrogant, hot-headed ‘guru’s’ and other throbbers out there pedalling their egos, courses, and fanciful teachings for profit rather than helping physios or patients.
As always thanks for reading