There’s no skill in manual therapy!

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!

My experience

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.

Frustration

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.

The evidence!

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

Caveats

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).

Summary!

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

Adam

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  1. Excellent account or your personal experience.
    You appear as a critical mind giving witness to the element of quackery involved in manual therapy.
    Not only are the benefits of manipulation techniques superficial and ephemeral, with no real cure resulting, but, as you point out, some can be truly dangerous, especially those involving manipulations of the spine, not only cervical but also thoracic or lumbar
    Touting the special therapeutic merits of manipulation, as you describe it, resembles closely the marketing spiel of charlatans and circus barkers selling mysterious remedies.
    What is remarkable is that, with your training, your natural skeptical mind, it still has taken you years of practice, observation, and intense in-depth study to convince yourself that you had bought into a fraudulent “therapy”, and remove the veil of pseudo-science cloaking the commercial teaching of manipulation techniques.
    Bravo anyway for your courage to speak up and be ready to be confronted by irate manipulation experts whose livelihood they (rightly) fear you are threatening.
    There must be other critical minds like yours among physical therapists and kinesiologists who may remain silent because they feel themselves to be in a minority, but who may feel encouraged by your taking the lead in speaking up.

    • Thanks Roo for your comments, you are quite right there are many others like me who speak up and out against the pseudo science and myths around manual therapy far better, more eloquently and with more knowledge and intelligence than I ever could do, many of them are on twitter and they are a source of my awaking and I suggest you get on there and follow them too!
      All the best Adam

      • As the above named Menke of 2014, I applaud your synthesis of information. I too had the scales fall from my eyes. Once they fall, there is no putting them back in. As a chiropractor for many years, my research brain was seeing too much “hit and miss” with the outcomes. And everyone was better within a few weeks. When I found myself trying to get them in before they got better, I sensed I was perpetuating a lie.

      • Hi Micheal
        Thanks for taking the time to read my blog and for your comments!
        Your paper is very good and hopefully with more like it more will start to see that although manual therapy helps some it is not as powerful or as specific as most like to think it is
        Kind regards
        Adam

  2. Adam,
    You’ve done it again. Better get your bullet, mud and abuse proof vests out, if you ever take them off. You really must like the abuse, no wonder you ended up in sport!
    I am pretty much with you on most of you post, your flowchart should be put on a t-shirt and handed out at Physio and Massage schools. However, I think the real skill in manual therapy is in the assessment, and I know you have had a good rant about palpation but I am talking about broader assessment here, everything from gait to ROM to observation. Got to admit, it is a bit tough to feel heat and swelling from three feet away, and unless you have perfect vision, it can be tough to see too.
    As a manual therapist I agree, there is no great skill in general muscle ‘release’, the real skill is knowing where to apply your massage, hence the assessment. The caveat here is with lymphatic drainage massage, there is a skill to this, simple, yes, but a skill none the less. Could anyone learn it in a couple of days? Probably yes.
    You referenced Soma Simple and I am sure you are a massive Barrett Dorko fanboi. Awesome, his work is great, but don’t you think there is value in contact (manual pressure) when a patient is getting in ‘touch’ with dysfunctional tissue. Isn’t one of the great values of a swedish style massage the patient’s awareness that it creates in their body to feelings of tension? Can you not use pressure to help a patient to reduce hypertonicity of muscle? Is there no value in finding the right intensity of massage to help someone focus and switch on before a sporting contest? Is there no skill in find the right speed and depth to get someone to calm their central nervous system post contest to enter a recovery zone?
    I agree that the ‘giant-leap’ for manual therapy is that it is the patient’s brain that does >95% of the effect of treatment, but is there no skill in helping a patient to guide themselves to better function? Look at Dorko’s ideomotor work, no skill in guiding someone through motion? None at all?
    No GREAT skill, like playing a violin, maybe, but no skill at all? Come on!
    Aran

    • Hi Aran
      Thanks for your insightful comments, first of all re the mud slinging and ad hom attacks, yes I’ve got used to them, but I certainly don’t enjoy them, just recognise it’s to be expected, strong views = strong opinions
      You make some interesting points and I think I covered them in my caveats, eg being able to check for red flags for example an infection you will need to touch a patient to feel for heat swelling etc.
      With regards to having skill in assessment I sort of agree but this is going off topic, the blog is just about manual therapy application and as I mentioned the only skill you need here is in communicating that to your patient, so I guess you could argue that a skill needed in manual therapy is communication skills and more importantly a skill that makes your patient trust you to be able to feed back honestly to you
      In my opinion the skill of manual therapy comes down to the therapists interaction with the patient not the intervention
      Finally I’m no ones ‘fanboi’, which is a horrible Americanism of a word, those days of naivety and impressionablism are long gone now, all that’s left is just a dried up, withered, bitter, cynical, skeptical and twisted husk of a manual therapist ;0)
      All the best
      Adam

      • “At the end of the day in my opinion the skill of manual therapy comes down to the therapists interaction with the patient not the intervention”
        Word.
        This is the point where is still feel there is still value in manual therapy, I don’t think the mechanisms behind 90% of manual therapy add up to much. But if you can “hit the spot” in terms of patient need, then you get great results. And by “hitting” I reckon you could use any manual technique you care to choose, it just needs to be something that the patient can relate to as therapeutic.
        my .02c

  3. Could difficultly agree more… and also with the remarks done by Aran.
    Bravo for your honesty to share doubts and the courage needed to keep the stance…

  4. Wonderful article – thank you for your honesty and courage. There are more witches and wizards today than there were in Medieval days, and the faith they have in themselves doubles the placebo effect.

    • I absolutely love Diane Jacobs approach to manual therapy and think DNM has some promising aspects to it, in fact I should put this in the caveat section as an exception
      Thanks
      Adam

      • I’m a new grad PT here, skeptic, and don’t know who or what to believe anymore in the field of PT. I feel almost completely lead astray by my schooling and other PTs who have mentored me.
        In the link provided by the above poster it says that activated Ruffini endings can alter the tone of an underlying muscle. Is that supported by research? Isn’t that exactly what Kinesiotape advocates say it does? So is Kinesiotape BS or can it actually modulate tone of a muscle? Does it ‘inhibit’ or ‘facilitate’ muscles based on the degree of stretch? My colleagues swear it does. I’m skeptical although I definitely think it provides some sort of neuromodulatory effect that can decrease pain via these skin receptors.

  5. Adam – your diagram had me in stitches! bravo! A well written, reasoned and researched article. I am on that very expensive journey in expanding my manual therapy armory at the moment and haven’t yet paid enough to develop your cynicisim. However, I am also familiar with most of the recent research in chronic pain so understand the substance of your arguments. I think these are the debates our profession needs to be having on a much wider scale. You should share your post on the MSK section of ICSP and see the rebuttal. I shall look forward to reading more of your blogs. Nick

    • Thanks for your comments Nick and I might take up your suggestion of posting this on iCSP however I recently caused some panty twisting and knicker turning as well as some gnashing of teeth as I critiqued a SIJ post on there not so long ago that called one ‘unstable’ May let the dust settle a bit first…
      Thanks again
      Adam
      PS please don’t spend to much on these courses, it will make u bitter and twisted just like me!

  6. Interesting read Adam , In my experience good therapists would agree that the bio psycho social framework can house many elements and therefore they would agree that the interaction is key. I think in the main physios do exactly as you do and so I think in my experience you are preaching to the converted , thanks

    • Hi Neil
      Your right the BSP model is being used more, things are slowly changing for the better, but in my experience and dealings many many therapists are still mislead and misinformed about manual therapy greatly! I see it daily online, in course synopsis and in discussion with therapists across all professions, so I disagree, I don’t think I’m preaching to the converted, I think only a small percentage of the whole have converted, so I think there is a need to continue to preach (and I prefer to think I’m educating/informing rather than preaching) until a few more are, which is my ultimate goal believe it or not!
      Thanks for your comments
      Adam

      • I disagree , the context of the use of manual therapy is well placed in much of our profession, i believe the profession is not as entrenched in dated mechanisms that you allude to, so I feel that the informed generation are here, and your thoughts may not be as radical as you think. Thanks for getting back to me

      • Hi Neil thanks for your comments again!
        Perhaps you could explain then if my thoughts are not as ‘radical’ as I think, why is there all the upset, angst, commotion and gnashing of teeth with me questioning the need for over complicated and unnecessary attention to detail in manual therapy as I do in this blog?
        Surely if it was everyday common knowledge that manual therapy works via neuro modulation and other non specific effects, and that is doesn’t change physical structure or position and it doesn’t really matter which way you push, pull or poke something then surely no one would be interested in my ‘rants’ let alone commenting and questioning it?
        I’ll offer an explanation, and it will probably sound a tad arrogant and condescending Neil and I apologise in advance if I does, but I think many views on the current state of physiotherapy and its members beliefs, understanding and acceptance of the paradigm shift towards manual therapy is not as rosy as you would like to think it is, and dare I say it, a tad naive
        For example many out dated modalities and methods are still being taught at under grad level, I know I’ve seen the syllabuses, and it’s even worse on many post grad courses.
        Many teachers, tutors, seniors, mentors and managers of the new ‘informed generation’ of physios as you put it, are still believers in the old ways, fixed by years, decades of their own biases and beliefs, so their rhetoric and dogma to the old ways still continue to influence and mislead the new ‘generation’ quashing and suppressing progress, I see and hear of it everyday!
        And again without wanting to appear confrontational or accusational, in my opinion, many of the old elitist MACP disciples, are some of the worst culprits here.
        The emphasis that a lot of the old MACP gurus place on manual therapy is very strong, due to the many years, decades of indoctrinated belief and misguided structural and mechanical thinking, and this isn’t going to disappear as soon as you think!
        For example the fact the MACP only until a few years ago stood for ‘Manipulation’ Association of Physiotherapy is an example of time frames here, and it is going to take a lot longer than a few years to reverse the decades of pseudo elitist learning beliefs and biases that many in the MACP have.
        Please understand I’m aware and glad your group is changing, and it seems many MACP members have accepted neuroscience, biopsychosocial models and the other non specific effects of manual therapy, and I commend this, but its going to take a lot more time for all of your members to accept this and there are many still out there entrenched in dated mechanisms flying a MACP flag I’m afraid
        Just my perspective and opinion from an outsider with slightly judgemental eyes, please don’t take it personally!
        Thanks
        Adam

      • Thanks Adam I used a quote as you seem to love them so much! Matt is great he was a student of mine on his bsc and msc so maybe I got something right, don’t get tired about my digs at you, they are meant in the spirit of discussion,

      • How very ‘clever’ of you to reflect a compliment meant for someone else back onto you!!!!
        I’ll think I’m going to leave this discussion here before I start my own ‘digs’… In the spirit of things of course!
        Regards
        Adam

    • Thanks for your robust reply Adam, naive is a new one, however I can see that your thoughts and feelings are perhaps as set as the therapists you comment on, the reason for the ‘gnashing of teeth’ from some is because it’s not what you say, it’s the way you say it. Your work is always worth a read but you talk of doctrines in organisations like the macp which I would actively discourage, let’s hope this forum does not inadvertently create the same,
      “Religion hinges upon faith, politics hinges who can tell the most convincing lies or maybe just shout the loudest, but science hinges upon whether it’s conclusions resembles what actually happens”
      Good luck
      Neil

      • Thanks for the feedback and I totally agree with you about the way I say and write things can be, and is often dogmatic in its style and approach, but I am trying to change, but there are decades of unlearning to do first so it will be a slow process!
        Although I have strong thoughts, feelings and opinions I don’t think they are ‘set’ as you accuse me off after only a few email and twitter exchanges just because they are different from yours, also the subtle ad hominem digs you seem to keep directing towards me in our exchanges are a little tiresome, but I’ve had worse
        And surely feedback regarding others views on your organisation positive and negative should be encouraged not discouraged, as I said it’s just my view but to keep things balanced I’ll add another one, that the MACP has some excellent clinicians and thinkers pushing this profession forward such as Matt Low and they should be commended, but there are others who do your organisation no favours as well
        As you like to end with romantic philosophical quotes heres one for you “There are none so blind as those who will not see. The most deluded people are those who choose to ignore what they already know” Heywood
        Until our paths cross again Neil
        I wish you success, I don’t believe in luck
        Regards
        Adam

  7. Really helpful article and I appreciate that you reference it well. Thanks so much for putting these articles up for us to benefit from!

  8. Love the article, I have always felt like this when attending an A.R.T. (the self touted “gold standard for soft tissue, aka pay them gold to have a title of ART practitioner) seminar. The neurological side, as you have discussed, is always a part, and is often overlooked.
    The only fault/criticism is using Edzard Ernst as a source. It has been shown that his research is pretty much out to discredit professions who use spinal manipulation as a treatment approach. I have bias, we all do, but his sole purpose (IMO) is to discredit manual therapy.

    • Hi thanks for your comments, and I totally agree with ur view on ART, think they are one of the worst culprits, so much so I’m thinking of starting my own Active Release Technique course in direct competition with those jokers but I’m going to make it Functional so its going to be called FART and we will see what they make of that!!! ??
      With regards to your comments about Ed Ernst, I know he is an out spoken critique of manual therapy, so am I, and as you say we all have our biases, and Ed has his more than most, but he does make rationale, logical, scientific and evidenced based arguements that do get us all thinking, which is good in my opinion
      Cheers
      Adam

  9. Yep, simply put the skill is in being a therapist, and selecting a mode of therapy that works for the individual patient. 20 years in & I’m starting to get the hang of it. A bit.
    I’m suspicious of anyone banging on about any one approach (hands on or off) being the answer.
    Cheers.

  10. Hi Adam, my one and only comment to you before ended up with me on the end of a 4 tweet tirade implying I was lazy and uneducated but I’ll let that slide as I agree pretty much with 100% of this article. I had 5 years training and have been in practice over 20 years now as a “manual” therapist. This realisation slapped me in the face early on in my career maybe only the second year out of uni. I got a postition with a really well respected Osteopath and was excited to learn more from him. Essentially he was just very good with people, got on well with all types of patients and was practice and sensible with his hands on work. I was chatting with his receptionist one day as I didn’t have a lot of patients at this stage and enquired how she began working there. She said, “I used to be a patient here”, interested I asked further ” what were you coming for?” Expecting to here her say sore knee, back,neck etc. She paused for a moment and said, ” sometimes I was just feeling a bt down and needed a laugh, so I would come to see Mr. X”. It kind of hit me hard , thinking what did I go to uni for, all I needed was a good joke book. Anyway I have been a sceptic my whole career pretty much but yet remain very hands on in my treatment. As you say if you get the connection with the patient, they feel heard ,and you apply your manual therapy in a non threatening manner you will probably get a lot of good results. There is good evidence for ischaemic nociception so it would follow that mobilising tissues ,whichever way you want, in an area effected by this would probably help.But as you say, importantly we are also a first screening point for a lot of people, and that’s probably what they are paying for, those rare occasions when there is a red flag present or the person needs further investigation. Cheers.

    • Hi Nigel
      Thanks for your comments and insights and although I cannot remember our previous encounter I don’t doubt or dispute it, as I was, and can still be a bit of a hot head, especially on Twitter, so I apologise profusely for my behaviour and comments if I did say those things!
      I’m maturing a bit now, I tend not to bite until at least three tweets into a debate nowadays!
      All the best
      Adam

  11. Well – the clear answer is yes and no. I’ve got 30 years of massage and strengthening coaching under my belt, that’s not full time – but it still adds up to a hell of a lot.
    I’ve also been treated by a fair number of therapists over that time.
    In that time I’ve encountered those, trained and untrained who I wouldn’t send anyone I didn’t hate to, and others – again trained and untrained to whose ministrations I would gladly trust my loved ones.
    Admittedly I’m a terrible patient, but some will put their entire weight on a small area – weight that would risk being damaging for my relaxed form but which is trifling against tensed muscle – so I tense – which is counter-productive as most manual therapy works far better on a relaxed victim – others will coax knots to loosen by a patience, indirect stimulation and a good line in patter if a patient is either obviously in pain or has just tensed several kilos of muscle.
    Clearly there’s skill involved in the difference, but how much of that skill comes from “training courses” or “methods”? Probably not much – except with things like acupuncture – which are a load of bollocks anyway.
    I can’t cure many things by massage – because in most instances manual therapy can’t – those who claim it can are singing in the wind – but I can make a pretty fair stab at making most clients feel as though I have – that can give a space for exercise, stretching, coaching, rest, time and proper nutrition to do so – or at least get them as fixed as they can be.
    For example I’ve treated a lot of shoulders for various reasons, and I could massage the same client 100 times and make them feel better each time – but without sorting out some sporting movements and strength training techniques their underlying injury will just get worse – fix the way they use the shoulder get them to get it strong and mobile and the sum total is often a cure after a few sessions at most – and they may not involve any physical contact at all.
    The role of the massage (if its needed at all) is to get them to the point where they are able and willing to effect the cure themselves – I’m not going to be there to live their lives for them or wipe their arses.
    Last but not least a 30 minute massage allows 30 minutes of getting the client to tell you about all of the things that might cause their pain, establishing trust and advising them of ways to avoid or mitigate it.

    • Hi Ed
      Thanks for your comments and insights you make some valid points and especially the last one, ‘doing’ manual therapy may actually not be the thing that gets the effect, its the listening, discussion and education that we are ‘doing’ as we do manual therapy
      Great point
      Cheers
      Adam

  12. Hi Adam, I am a student graduating in 3 weeks from a sports therapy degree, massage and many things you do not like is what we are being taught e.g. Electrotherapy and manual therapy. I like to use massage as it does make the patients feel good and provide pain relief. Following you on Twitter though makes me question whether I wasted my time doing sports therapy and I should have done physiotherapy, Hands on treatment was a big part of what we learnt but it seems like in the therapy world it’s laughed at, from massage to METS, PNF stretches, soft tissue release techniques, these are things I have used and they seemed to provide good results however, now I’m really questioning my knowledge and the things I have been taught. Also what physiotherapy authors\books can you recommend with good information on treating injuries.
    Regards
    Nile

  13. Excellent read, excellent content. As a new graduate physio I strongly agree that research based treatment is more in the realm of psychology than physical intervention. Obvious psychological or plecebo effects are seen after manual therapy. There is some good reseach on the parasympathetic effects of manual therapy which is why when I’m getting a “sports massage” I ask for it to be as relaxing as possible and with little trigger pointing. For an athlete it would be common for sympathetic responses to exercise to interrupt sleep. Que “healing hands”

  14. Hi Adam:
    Well I have to tell you, you touch a darn hot spot in my everyday thinking in the value of manual therapy. Let me tell you a bit of me, I always have been skeptic about everything!, but as an undergraduate of Physical Therapy I had a lot of teachers that built in, inevitably, a Structural Paradigm in my reasoning. So when I graduated, took a Master in Orthopedic in Manual Therapy (In fact I took the most structure-based aproach I think it´s available at the time and place: Paris method of U. Saint Augustine, USA). So I met lots of people only trying to make their therapy work for the sake of their patients, and a lot of magic in every class that make me wonder, there has to be something weird in there…
    Because of that I did some research that really don´t make sense of anything I was learning, so when I started treating patients and doing the reasoning for their problems, I had this: they felt great at the time of touch, but the effect was no longer than a couple of hours. So I started to realize that the efficacy of manual therapy was only the entrance of the relation between me and my patients.
    Now, I´m not as frustrated about manual therapy as you I think (but still bleeding money), because this help me to know other different aproaches, like CFT and the always great Explain Pain education aproach, and this really made my therapy go leveling up. Now I have 6 years of profession training, and have my own point of view about the topic, so I think we have the almost the same issues 🙂
    Clearly, we have to look in a more sensitive way of thinking about MT, but not discarding it at all. In fact, I think we can do a lot studying the sensorial training that we are doing with each manual therapy we do, rather than looking to mechanical effects, largely described as inexistant or minimal.
    I think this can really do the trick in some patients, when they tell you some sensory stuff its going on http://www.ncbi.nlm.nih.gov/pubmed/24021562
    Great post as always
    Cheers
    Felipe

  15. Hi Adam,
    I agree with your post, well said. Do you have any opinions as to how it should be taught at undergraduate level, for instance?
    Terence

  16. Well, I agree with the intent and the content. Less so the title as there is clearly some skill in manual therapy as you mention in your caveats etc. I guess you are just trying to get the article noticed, which is fair enough.

  17. Im thinking the emotional component plays a part but so does the skill level. Use sex as an example. You may love the individual who you have relations with but if their physical skills are not comparable to your last lover, whom do you think you will be pining for. 😉

  18. Awesome post Adam! I couldn’t agree more with your comments. I as well think manual therapy is important and there is a role for it in rehab, but I don’t think there is much skill in the actual application. The skill is knowing the most probably explanation for why it works, including it’s impact on nervous system and the abundcance of “outside” noise playing a role.
    I think commericalism like you mentioned is a huge factor in manual therapy heading in the wrong direction. When people have money (sometimes lots of money) invested in a certain technique/philosophy, it simply strengthens their biases and the chances of them straying from that way of thinking decrease dramatically. Sigh.
    Mark

  19. It seems the way of the Internet really… Apparently everything has to be black or white. Of course there IS skill in manual therapy but it’s a very grey area.
    My background is very similar to your’s Adam in both qualifications and experience. But I have a different view when it comes to manual therapy. In my experience (Australian physiotherapy) the best clinicians have all the attributes you have described above AND precise, comfortable manual skills. You only have to spend some time working with new-graduates to feel the difference. When it comes to manual skills alone, having a new-grad perform something like a mobilisation on an isolated cervical facet joint and then comparing this to the same technique from an experienced clinician who specialises and educates in the same field is all the evidence you need. However I still also SORT OF agree with you. It is not primarily the subtle differences in the application of the physical technique itself which separates the best from the “every day” clinician. It is also the effect of the intangible aspects of the patient interaction that you have discussed as well as the experience and superior clinical reasoning in deciding which manual technique to use, at what time, in which circumstances.
    A cornerstone of Australian physiotherapy, at postgraduate level in particular, is a very strong focus on assessments/reassessment to critically evaluate your intervention. Personally, I routinely reassess the patient multiple times within one session and can show distinct, objective improvement in things like range of movement or pain immediately following a manual intervention. You can’t tell me that refined manual skills are not at least a small part of this process.
    Of course non-manual therapy is a vitally important for our patients… But let’s not throw the baby out with the bathwater! I fear the day when new graduates have all read “Explain Pain” and offer the patient in acute or sub-acute pain a series of counselling sessions and exercises as their only intervention! (N.B. I highly recommend Explain Pain and have studied under David Butler- who, by the way, has excellent manual skills.)
    It’s not that there is no skill in manual therapy. There is. It’s just that the reason manual therapy works brilliantly in some instances and not so well in others can be due to a myriad of complex factors and interactions that we are only beginning to understand.
    I read your sentence claiming there is no skill in ANY manual therapy, and then I read your article… I don’t think they quite say the same thing. You could very well title your article with this long-winded, poorly-edited title instead: “Manual therapy doesn’t work for the old-fashioned reasons people used to think it did, it can work very well in the right situations, we just might not fully understand why… if we use it well and critically assess its effect it can be a powerful tool.”

    • Hi Lachlan
      Thanks for your reasoned, insightful comments, I understand what you are saying with students verses a physio qualified for a few years, however I’d argue (because I like to) that your confusing skill with experience!
      Having the experience to know what feels comfortable and uncomfortable through trial and error and patient feedback is something we all ‘learn’ but there’s no technical skill in this it’s something developed over time!
      Also the test and retest method is one I adhere to and a lot of other physio as well, but to say that the manual therapy plays a role in this hmmmm again I’m going to argue that very little change in a patients feelings after manual therapy are due to manual therapy per se .
      The pseudo scientific game of, I’m a professional clinician and your the patient and I’m going to make you feel better’ I feel does more for a patients sensations of improvement via their increased attention, expectations and of course the good old placebo effect all via neuromodulation, actual physical change from the manual therapy no! What if I get the same effects by get a patient to move and do some exercises, what if I get the same effects by asking the patient to lie down and relax and not touch them, what if it’s the discussion and education I’m having with the patient as I’m doing the manual therapy, etc etc
      Now don’t misunderstand me I don’t think we can ever say it’s one over the other, but I don’t place the actual manual therapy technique high on the ‘it matters list’ as much as I do say choosing my wording, or explanations with care, giving the correct advice and education, or ensuring they do some exercises / movement
      So yes test and re test to ensure that the patient is aware they are feeling better, but I attribute all of that to ‘treating the brain’ with manual therapy not the body, and that’s what I tell my patients, some get it, some don’t, some think I’m a quack but hey, at least I know I’m being honest and as evidenced based as I can be, for the moment, until the next paradigm shift and leap in our knowledge and understanding
      What do you think?
      All the best
      Adam

  20. Actually I think you’re the one getting confused… Your offering potential explanations as to why your manual therapy works, not saying that it doesn’t work. You can’t tell me that a patient walking in with acute or subacute pain of almost any sort would not get better a lot faster if a good manual therapy was applied AS A PART of your interaction. I defy any decent clinician to get someone better as quickly by “asking the patient to lie down and relax and not touch them”… I guarantee you don’t actually do that in the majority of cases in your own practice. Assessment/reassessment is not as simple as asking a patient whether they “feel better”, and if that’s all you’re doing then you’re not doing it properly. Objective measurements of range, power, et cetera are changeable within a couple of minutes of an appropriately applied manual technique… No doubt you know this. Even if you believe that all you are treating is the patient’s brain- the fact that you can achieve this through manual therapy still means that manual therapy works… You just believe it works for a particular reason. I’m sure someone of your experience is good at creating change with manual therapy… The underlying mechanism as to why this intervention produces a change might be up for debate, but the fact that it does produce a change is not – if you can prove it.
    And confusing skill with experience?? No, I’m saying that with experience your skill improves, they are 2 separate things. Can you honestly tell me that your manual therapy skills are no different now after 10 or more years of clinical experience and education than they were when you were a 15-year-old schoolkid? If they’re not, what’s going on??? We are talking about performing physical techniques, how can years of practising these techniques not result in some degree of refinement. You have mentioned a couple of times making your techniques comfortable… I agree that this is vitally important… An improvement in the comfort of the technique is an improvement in your skill at delivering it!
    Take the example of lumbar rotation mobilisation. I have tutored many employees and junior physios on getting this technique localised to the individual target level. Get an untrained person to try and copy what they see an experienced musculoskeletal physiotherapist doing with one of these techniques and most of the time all you will get is the patient feeling a quite uncomfortable sensation through their rib cage or the thoracic spine… A good manual therapist will isolate the same technique to the precise level of they are targeting. Yes this improves with experience, because experience improve the skill of doing it properly.
    If you’re so confident, then try this experiment…
    Go and grab some random punter off the street who has no training or background in manual therapy techniques. Do nothing more than quickly show him a few techniques and give him a couple of basic instructions. Dress him up to look well-qualified and professional. Now, when you’re patients come to your clinic you are only allowed to do the talking and the direction of assessment. Tell them you have an injury and that your very experienced and well-qualified colleague is going to perform the manual therapy on your behalf. Your random punter will perform the techniques that you decide should be used. Can you honestly tell me that he will get the same results you would? If your answer is yes then in my opinion you are either lying or there’s something really wrong in terms of your skill acquisition.

    • Hi again Lachlan
      There’s a lot of points to discuss here and maybe best done over a beer rather than written as I’m sure things get lost in translation and in sure we have a lot more common ground than uncommon judging by your comments but lets go…
      I can tell you that all patients get better if u mean ‘heal’ regardless of manual therapy being applied or not, manual therapy doesn’t ‘speed’ up healing or any other such like
      With regards to reduced pain again may other ways other than manual therapy that can reduce pain and I’ll use the example again, just talking to some one does reduce their pain, as the late great Louis Gifford said ‘effective reassurance is a bloody good pain killer’ then let’s look at movement reducing fear, threat of movement by showing them its ok to move or move without pain also reduces pain, two examples without even touching them!
      Next objective markers are more important for the therapist rather than the patient, I absolutely disagree that test/retest is more about asking a patient if they feel better, its the ONLY reason to test retest, I don’t care if someone can move an extra 10° I’m more interested if it feels better for them to move full stop, objective markers have a place but a back seat way way in the gods
      Next a random punter to apply manual therapy scenario well I thought I touched in this in my blog, my misses although not a random punter makes my neck feel so much better than any pro has done in 5 years, and she has no training, so it would be an intriguing experiment but I would bet if we could duplicate the patients perceptions and expectations between the pro and random the difference would be zilch, none
      Next the skill in applying a manip mob to a precise level is a common fallacy and a comment left by Jack Chew below explains that in more detail
      As I said a lengthy debate best had over a beer or four would be best but again if like to hear your thoughts, especially as this week I have no work and do have time to do this, sitting in a villa in Greece drinking a beer by the pool… Just to make u hate me even more 🙂
      Good talking
      Cheers
      Adam

  21. PS: for the record, I agree that a lot of (maybe most of) the change from manual therapy is centrally mediated- not just brain but also spinal cord, modulated reflex loops would probably also be a factor… but I think it’s silly to write off manual therapy for this reason. I also think it’s silly to say these techniques can’t be performed better or worse.

    • Haha PS I’m not writing of manual therapy completely just those that twist, bastardise and misuse it to profiteer and promote non evidenced and fear inducing fallacy around it

  22. PPS: this is also why I try to avoid twitter- I can’t resist getting sucked into a debate like this- I would never get anything done!!

    • As per usual an interesting and evidence based approach to critical thinking Adam. On this occasion very clever of you to come at it from a ‘personal account’ perspective… not that I didn’t have you down as clever…ish.
      I can see why some consider the title pointlessly sensationalised but I have an insight as to why you like to provoke debate following our chat for the podcast and I think many will benefit from a listen when it’s aired in a couple of weeks.
      Your thoughts and experience with manual therapy are very much in line with my own so I haven’t, for a change, got much I fancy critiquing, BUT…
      The key thing that has piped me up on your comments section for the first time, is the above responses from Lachlan. Comments such as:
      ‘Take the example of lumbar rotation mobilisation. I have tutored many employees and junior physios on getting this technique localised to the individual target level. Get an untrained person to try and copy what they see an experienced musculoskeletal physiotherapist doing with one of these techniques and most of the time all you will get is the patient feeling a quite uncomfortable sensation through their rib cage or the thoracic spine… A good manual therapist will isolate the same technique to the precise level of they are targeting. Yes this improves with experience, because experience improve the skill of doing it properly.’
      …suggest to me that he might benefit from reading your article on Pareidolia (https://thesportsphysio.wordpress.com/2014/05/05/diagnostic-palpation-is-it-a-skill-an-art-or-an-illusion/) or this series by Diane Jacobs (http://humanantigravitysuit.blogspot.ca/2014/05/my-take-on-why-manual-therapy-works.html) prior to continuation of the debate.
      Personally, I find that safe, comfortable application of touch of any kind can be taught to a lay person and if anything can produce better results. In my practice, as explained several times on twitter, I will engage a patient with education, advice, rehab, forward planning and motivation as best possible. As part of my assessment I have inevitably touched them and may dabble with a bit of manual therapy to assess its pain relieving effects. If the patient feels that they require pain relief in a different form to counter medication and exercise, I direct them to a local beautician (an ex patient of mine) who gives a great massage. I have also taught her several manual techniques that she applies when advised by me or my team.
      Why do I do this when of course I could do it myself? She charges £20 an hour, my rates are £50 an hour. Patients appreciate our honesty, we save them money and dispel myths that they have been sold previously. It is this that often means my beautician friend gets ‘better’ ‘quicker’ results with manual therapy than I do. As my business grows I of course intend on employing therapy assistants that we can use in a similar fashion to keep it all ‘in house’. But for now, are outcomes are good and my hands pain free.
      I look forward to airing the next episode of the physio matters podcast in which we discuss all of the above in more detail. Keep up the good work.
      Jack

      • Hi Jack
        Thanks for those comments and thoughts and the links, even my own one!
        I also look forward to the podcast coming out so I can perhaps get my point across better than I do in blogs or on twitter
        As you say its not about demonising manual therapy per se, rather its about demonising those that look to bastardise and profiteer for untruths, myths and fallacy a that surround it
        I love your example of massage being just as good if not better no matter the qualifications if the care and attention is the same the results will be the same
        All the best Jack
        Cheers
        Adam

      • Jack… Thanks for your patronising advice champ! Unfortunately you have completely missed the point. Do I need to point out again that I am not arguing about WHY manual therapy can make a difference? Your 2 articles have nothing to do with the question at hand.
        I don’t even need to read the first one. The title itself shows that you’ve missed the point. I’ve never claimed to be able to diagnose through touch.
        The second one made me laugh. It’s a good article… But again you’ve missed the point. The article is mostly talking about WHY manual techniques might work. Very early on in the article it actually backs me up!! I quote: “But manual therapy sandwiched in there can be optimal, in my opinion. ”
        You haven’t actually addressed any flaws in my argument about lumbar rotation. Whether you think this technique is a good one or not doesn’t change the point that someone who’s inexperienced and therefore less skilled will have trouble targeting their force to the lumbar spine. Assuming you’re trying to treat the lumbar spine then this is just a simple example of how skill with a physical technique can make a difference to your outcome. I can’t believe need to point this out! (I wasn’t even talking about manipulation Adam).
        … And please, don’t ever again use massage as an example in a debate like this. Of course the beautician can do massage. I refer to a masseur as well, I employ one. Did I ever say that I was discussing the skill of massage? Anyone can do massage. I’m talking about the more difficult techniques we can utilise. If you don’t have any techniques in your arsenal that require practice to refine then I feel sorry for you. I do, and sometimes they’re very helpful.
        I have absolutely no doubt that the major reasons I am a far better practitioner than I was 10+ years ago are my abilities to build rapport, listen, communicate, educate, instil confidence, understand pathology, understand pain neurophysiology, diagnose and plan. Even the simple fact that I am older gives my patient more confidence and contributes to better outcomes no doubt. However where I disagree with Adam is that I believe I possess refined skills with SOME manual techniques and these can be a powerful tool for patient outcomes in addition to what I have already mentioned.
        And Adam- I can see we’re going to go round in circles if I keep arguing with you. Touche. Let’s agree to disagree. Physiological healing doesn’t need to occur for a patient to feel better or improve. Next time my patient presents with an acute neck that hurts, will only turn halfway and is referring a headache I will confidently rely on my refined manual skills to send them out the door 10 minutes later with full rotation, no pain and no headache. I’ll be impressed if you can do that with a chat, or get your wife/punter to do it for you.

      • Anyone who reports that they can “fix” a patient in 10-minutes has to be a bull-shitter. Relying on one’s own hubris in the context of treating patients is another example of how some therapists bring our profession into the gutter….are you a chiropractor??

  23. I think one of the big questions to tackle in the whole manual therapy conversation are;
    1. Does it work? According to Menke 2014, not so much…. But I guess that in the big picture at least a part of the jury is still not convinced.
    2. Does specificity even matter? Studies done point towards specificity not mattering so much.
    3. How specific (segmentally) can we even be? Can we honestly prove that when we manipulate someones facet that nothing else moves? Then to speculate even further, if it doesn’t matter how specific we are, do we even have to try to be specific in the first place?
    And to add for specificity question, can we actually measure this phenomena? Can we define, validate and reliably prove that something needs to change and manual therapy changes it? We cannot reliably assess joint play, it’s nonehow measurable and quantifiable (then does it have to be) since it is something we must “feel”. We can only observe the indirect effects of this intervention.
    Also one part of the controversy in my opinion is that of the methodological quality of the studies and the many times the interventions used as control. Quite often it looks like the control group has been designed to fail, which of course is not too good.
    But, not to be too skeptical, I do believe manual therapy has it’s time and place in the right patient population, but it surely is no panacea.

    • Hi Jukka,
      Some great points you make and I agree, manual therapy does have a role to play for some and the effects are not that big nor what a lot of others make it out to be ie a change in structure position etc but rather neuro modulation and other aspects of neuro physiology
      Cheer
      Adam

  24. The same could be said for carpentry. You do not need a qualification to hit a nail on it’s head and bang it into a bit of wood. I could do it,however I choose to pay someone to do it for me. You are in the unenviable place that you have a loving wife who will rub your back/neck for you. Many peole don’t. And if there is no evidence of therapists actually doing anything, (not that your like have been able to measure anyway) what IS T that your untrained therapist of a wife manages to do to get you to feel better than any trained person of whatever therapy? (Keep it clean please)

    • Hi Beauty from within, good name by the way
      As I mentioned in my blog the evidence on the effects of manual therapy is shown its due to reduced sensations of stiffness, pain etc via neuro modulation which is also effected by other things such as mood, beliefs, attention etc etc, so the best manual therapists are able to tap into these other non specific effects, just as my wife does, and so its has greater effect when combined with the rubbing and massage, it’s not the act of the manual therapy that helps its the other stuff around it as you do massage that’s far more important, hence no skill in manual therapy per se!
      Thanks
      Adam

  25. Again…a divisive title to an otherwise insightful article that again fails to get to the heart of the matter.
    Neuroscience is demonstrating that most changes with regards to pain or function are a result of alterations in the nervous system. The question is what techniques are most effective in bringing about these changes. Clearly helping a patient change negative beliefs, improving self image and changing behaviour are powerful. Clearly there is an arguement that movement (less so exercise) will make stable changes to the nervous system, and clearly we can interact with the nervous system in a positive way through touch. I feel manipulation can have a powerful impact on the nervous system evidenced in my own clinic by dramatic changes in range of motion and pain following manipulation. all these modalities are of use and their efficacy will vary with the type of patient, their attitudes, beliefs and their presenting condition and comorbidities … something most research woefully fails to account for.
    Does skill alter the impact of treatment. The perception that the practitioner is skilled is maybe of key importance. Could we all save ourselves some time and money and just provide some simple education on pain, rub the painful area a bit, reassure people and encourage them to keep moving and practice and progress difficult movements at a level below the threshold of pain? I think this is logically where your line of arguement may lead but I think you may be missing some of the art in the science. I think Skilled manual therapy has a very important role to play for many people as part an integrated treatment plan.

    • Hi James
      Thanks for your comments, firstly I’m sorry you thought I didn’t get to the heart of the matter, will try harder in my response here!
      To discuss a few of the points you raised!
      First to manipulations creating dramatic changes in ROM or pain, do you believe then that there is a mechanical reason for this change? If not, do you think these dramatic changes in ROM or pain could then be achieved via other mechanisms and ways?
      I do, I see just as dramatic changes in my clinic and I don’t do manips hardly at all, yes I do do them occasionally, but I often see dramatic changes when I do other things, like simply clearing up a patients understanding of a condition or pain, reassuring them they won’t do further damage and showing them how to move without pain!
      Most ‘losses’ in ROM are not mechanical but due to pain, fear and avoidance, both conscious and subconscious, remove this, and see dramatic changes, your manips do the same thing they tell the nervous system its ok to move, as well as the other effects such as patient beliefs and expectation of coming to see an osteopath (you are an osteo aren’t you James apologies if not) so they expect to get a crack and expect to feel better, a kind if self fulfilling prophecy
      And there’s nothing wrong with that, if careful, comfortable and safe, crack away, but is there skill in it, well I guess a bit with regards to safety as I mention in my caveat section but not ‘technical’ skill
      Next pain education isn’t just ‘simple’ as you kinda of flippantly threw in here, its bloody hard work, many many therapists see the advice and education as the bit to do at the end the simple couple of minutes chat, its NOT, having a clearer deeper understanding of pain and all the biopsycho issues around it is an immense topic and one that needs far more skill in applying than a back rub or manipulation in my opinion
      Lastly the ‘art in the science’ debate, that I’ve had plenty of times before, I’ll use the same reply here, the art is in your patient interaction the science is in the intervention, never is there an art to back rubs or manips that’s just Derren Brown showmanship nonsense I’m afraid that wind me up hence the blog!
      Thanks again for your comments hope I wasn’t too ranty or too high up on my horse
      Let me know what you think
      Cheers
      Adam

      • Hi Adam, appreciate the reply. Think my own combative tone is just in response to your title but I do appreciate the thought behind your work so I hope you don’t take offence.
        I am an osteopath and do manipulate as well as rubbing tissues a bit… but I also integrate movement and exercise into all my treatment plans and believe that positive patient interaction and education regarding pain and movement is key to lasting positive outcomes. But patients do not need to know in depth neurophysiology…..simple education (pain does not reflect damage) and reassurance (movement will help) from a trusted professional is enough. Is there skill in patient interaction… Probably about as much skill as in manual therapy… I think none of us (including myself…no offence intended) are as clever as we would like to think.
        If managing patient beliefs and subconscious perceptions is key …. maybe we all have a lot to learn from Derren Brown.

      • Hi James
        Thanks for your reply and I don’t think your tone is combative at all, I’m very much enjoying the discussion
        Firstly I agree that patients don’t need full detailed scientific education about pain, but they usually want more info than they currently get, this read by Adriaan Louw springs to mind http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education#footnotes_86 highlights this! And the effort to educate patients about pain I still think is under recognised by most, I’m amazed that when I ask patients to tell me what they understand after I’ve given my best explanations as to what they perceive it as some times
        Next I totally agree re none of us being as clever as we think, me more than most, I class myself as an ignoramus stumbling around in the dark, occasionally bumping into things and going ah ha!
        I also know my thoughts and opinions on manual therapy are one sided and heavily biased by my own woeful and disappointing training and education in it over the years which is different from many others experiences
        Lastly regarding learning things from Derren Brown… Yes to psychology, sub conscious beliefs and perceptions… No to smoke and mirrors, showmanship and dodgy fascial hair!!!
        Cheers again
        Adam

  26. Well, I understand the juncture in the road that you hit. I hit it too.
    If you are a thinking and engaged therapist then you realize that one method does not work all the time, but if you keep thinking then you also realize that it does work sometimes. The other road that I have taken has been to try to figure out when to use what tool and how to use it to its full advantage. There are times that general techniques work. But there are times that only specific techniques work. There are patients that only need a neurophysiological intervention to get them going in the right direction – is manipulation or dry needling with electrical stimulation better, or just a light touch? There are patients that have huge emotional components to their problem. Some need ergonomic education… Some need better nutrition. Until the research is better at the inclusion criteria for any particular intervention I am not going to throw out one of my tools. Plus, when you isolate a technique for research then you take it out of the context of a real treatment. Who only uses one tool while treating?
    Perhaps your manual therapy training was just a set of cookie-cutter techniques. A lot of schools are doing that. If so, I can see why you are disappointed. Mine was focused on anatomy and clinical reasoning, differential diagnosis and safety. The training I went through taught me to think. To me OMPT = clinical reasoning. http://naiomt.me/2014/03/19/its-about-clinical-reasoning/
    What I really applaud you on is creating controversy for dialog and engagement. You do it very well!!!

    • Hi Rebecca
      Thanks for your comments
      First I’m not advocating to stop using manual therapy, as I’ve said it can be a powerful tool and touch does help a lot, but what I am advocating is removing all the smoke and mirror technicality and pseudo science that surrounds it
      No matter where you go or who teaches manual therapy there is the notion a skill is needed to be learnt and that this way is the right way and its just not the case
      The clinical reasoning of who will benefit from manual therapy I get, the inclusion criteria for the same I sort of get (although not convinced this will ever come to fruition due to some many variables confounding) but what I don’t get is the notion of skill and technicality in manual therapy when it doesn’t really matter what you do when you pull, poke, rub etc the end results are more or less the same!
      Thanks
      Adam

  27. Again Adam is doing well. You don’t have to agree, you can choose to disagree. Because it’s hard to change what you were taught through uni (by respected professors/academics -they must know what they are talking about), or what you practiced for years, and more it affects and the less likely you are to accept views that challenge your survival (income). I work in China, and i see it all too common, old dr’s who belief they don’t need to know what the west is doing, and think what can some guy 20yr’s younger then them know that they don’t, they are threatened and rightfully (it’s their whole life for 40 or so yrs). Now if i was a explorer in ancient times who believed the world was flat & explored to the known limits for my whole life, now someone comes with a GoPro footage showing me clearly they sailed right around the non-flat world i for god sake would not accept that or listen to them. And if i truely believed their evidence was right, i would put all my effort into challenging it, or proving it was wrong with any piece of evidence i had that may suggest the earth is flat, i would probably even get some “Pirates of the Carribean” movie footage as evidence.
    And so everyone has the right to criticise and challenge. And hey keep doing what they think. Chiro’s got no evidence, yet they seem to still be making money easily and very popular in USA. Simply the general population doesn’t know what evidence or research says, they just want to ‘buy-in’ to whatever you can sell them. Your the professional, and most patients will accept what you tell them.
    The fact Adam’s getting criticised and hate mail, is great. It means these people who want to prove the world is still flat, are ‘threatened’ that he may be right, and what to do everything to prove him wrong so they can keep doing what they were.
    Ps.I love the chart by the way. Should be given out back in undergrad school. If i had that back then i could of saved a lot of money.

  28. PPPS: Adam, good on you for promoting the debate, damn you for sucking me in and sinking my to-do list for the past 24 hours!

    • Apologies that you were patronised… champ. If I have missed your points then I either assumed you’d be able to ‘join the dots’ so to speak, or your points are so philosophically deep that I’m not grasping them. It wouldn’t be the first time for the latter, if that’s the case.
      What I was getting at:
      How are you identifying a target level for a lumbar rotation mobilisation and what makes you think that it matters? This is why I referred to the first article.
      The second article is a great series which explores the fact that of course MT has a place but it doesn’t matter how or on occasion where we go pressing. I assumed it relevant in a discussion about ‘skill’.
      Massage is manual therapy. It was a broad and basic example. I have also taught said beautician to do lumbar rotation mobilisations and C-spine SNAGS, which are what she does when I have deemed it appropriate. Please apply same story in light of her extended menu.
      Our ability to influence change in patients of course improves with experience. The skill, in my opinion, is the way in which we interact to instil patient confidence. This process can of course involve MT, taping and a variety of other passive modalities, however when our results improve I think it is easy to attribute it to technique ‘upskilling’ rather than context, reputation, interaction and explanation. All of which are shown to play a larger part in patient experience, and therefore symptoms, than the specifics of techniques used.
      Its extremely difficult to do and I know because I’ve been there myself (apologies if this again patronises) but the brave modern clinician interferes less and reflects on the lack of dissimilar outcomes.
      Your own acute neck and headache patient is a good example. What might have happened to her if she hadn’t have come to you or another clinician? You have essentially administered pain relief, no doubt reassured and advised her then sent her away reassured. The key variables as to why she mightn’t self resolve without you are her thoughts and beliefs as to why it hurts which will affect what she then does with her body as it recovers. Your pain relieving intervention could have been many other things.
      Was it therefore skilful?
      Hope this makes sense enough that you get my points whether you agree with them or not. If they don’t then I’m out!
      I wouldn’t word my opinion quite as strongly as Adam has in terms of ‘NO skill’, but I think that said upskilling tops out at about 6 months of experience.
      Cheers for your thoughts, and I agree with you re:to do list.
      Ridiculous digression from what I should be doing but healthy all the same I reckon.
      Jack

  29. A wonderful post. So now my question how can a Physical (manual) therapist influence pain. With pain science growing a paradigm shift is happening in the way we see pain, where do you think the shift is taking us.
    Thanks a lot for this post.

    • Hi Krishna
      A good question that has many answers, simply I think we are looking towards the neurophysiology of pain and the role immune endocrine systems play here and of course the psychology behind the other factors that affect the output we all perceive as pain!
      Regards
      Adam

  30. Well stirred and great healthy comments. I think that a healthy questioning attitude has always been around, just not by many. My WTF look on being told to “bend the flys legs” got me in trouble in the 80s. Just touch was helpful I was sure, just had no evidence!!
    I have been on the “Staring at Goats” course. Which was pretty effective if done with a positive attitude and a smile, but adding touch achieved another dimension of positive response. Maybe those pioneers of physio ( Society of medical Masseurs) were onto something? 🙂 Keep writing.

  31. You’ve boiled a bit of blood again! Nice work Adam!
    Most of the discussion so far is centred around the “no skill required” idea. I want to look at your piece from a bit of a different perspective.
    But I will quickly chime in with regards to skill. How could I resist?
    Clearly if you do a lumber rotation PIIVM, 10,000 times you are going to refine that motor pattern in your brain, you will be more “skilful” at performing it. Would it be fair to say your argument is that this doesn’t really matter? As it’s the broader context of the treatment that really seems to help?
    What is it about this broader context- confidence in treatment, reassurance, relaxation etc – that causes neurophysiological events which subsequently result in a reduced conscious experience of pain (assuming neurophysiological states are the prime determinant of pain)?
    In my eyes the important factor would appear to be engaging the patient and therefore their brain, or inducing salience to put it in different terms. I feel this is where the true skill lies. Using subjective questioning, active listening and experience to find a window in to the patients brain, to induce, hopefully, long lasting and positive neuroplastic change.
    Thanks again for a good read.
    Jack

  32. Hi Michelle, This is the blog I told you about on the trail today. Food for thought… Do you know if that September course is going ahead? We might be here at that time. Good to see you! Mary

  33. Hi Adam, fairly recent Physio graduate and agree with manual therapy being mainly interaction/patient expectations over intervention, was wondering if you could share how you explain to a patient in simple terms how manual therapy may/may not work.
    (And I appreciate all your twitter/blog posts as well, really helpful for a new Physio)

    • Hi Luke
      Thanks for your question and simply put I tell the few people I do rub and poke the same thing….
      I’m not treating the tissue or the joint, I’m treating your brain, I explain about the millions of mechanoreceptors and nocioceptors in the skin that constantly fire off signals to the brain and that by rubbing, pressing or poking them it reduces or alters the rate and amount they fire, so gives the SENSATION of less stiffness, tightness or pain, not done anything to the tissue or joint at all!
      Hope that helps, I do occasionally go into more detail about the central nervous system and brain areas that also are affected if they ask, but that’s not often
      Cheers
      Adam

  34. Nice blog happening here. I came across from BiM to have a looksee.
    Nowadays I treat most conditions exactly the same way. The patient gets some interferential (mainly because the machine looks very impressive with the flashing lights and buzzing – read ‘placebo’) and a bit of a rub with some massage cream. Just a bit of a rub, like your good wife gives you. Absolutely no skill required… at least in the physical sense.
    In any interaction – clinical or otherwise – there are unseen elements at play and we’re all familiar with them, or should be. These are the things I mentioned on BiM. Back when I was trained, I think the word ‘rapport’ was mentioned only a few times in passing, and from what I hear it’s not much better for modern day students. Instead they are taught “well there’s no evidence to suggest manipulation is any better than placebo, and there’s no evidence to support using trigger point needling and well… there’s no evidence for anything really, apart from fear reduction techniques”. All of which is absolutely true, but they don’t seem to give them much that they CAN use. 4 years of expensive training, and what do you get for that?
    The person doing the ‘rubbing’ needs to be present, attentive, relaxed, congruent, open and ‘vibing’ with the patient at some level. If he can vibe nicely with the patient, he can choose whatever “technique” he likes because they are all equally ineffective. It’s the interpersonal connection that makes them effective. Going back to your example, I bet there are some days when your wife rubs your neck and you think “hmm, that didn’t really work as well as usual”. Why is that? Maybe she’s a bit tired. You will feel it in her hands and it simply… won’t…. work. This is not just about having relaxed hands – it’s MUCH more than that.
    Imagine a 4 year degree course crammed into the space of a weekend. It could be done. Learning how to rub someone’s neck or knee can be learned in a weekend, but the other stuff – the real crux of it all – might take a lifetime because it has almost endless scope and depth.
    Cameron
    [disclosure: I’m no master therapist. However I have spent thousands of hours reflecting on and deconstructing clinical outcomes and matching this with the modern pain science and psychology research. Just like you, I was gobsmacked by what I found.]

    • Hi Cameron
      Thanks for your comments and visiting from the awesome BiM (love that site) Lorimer is about the only charismatic Aussie I actually pay attention to what he is saying ?
      I totally agree with your views, the technicality of manual therapy can be done and dusted in a few hours, the ‘skill’ of interaction, connection, attention, compassion, plausible empathy and rapport is something that takes a lifetime to learn
      But I don’t think it can be really taught, you either have what it takes or you don’t, if you do, you learn and get better over a lifetime, if you don’t you don’t and find another walk in life
      Just my thoughts on what a therapists is, it’s not just a job, it’s not a skill, it’s a personality
      Cheers
      Adam

  35. Hey Adam,
    Sure, a high midi-chlorian count helps. Heh.
    I taught myself how to apply a mental technique, and when I apply it, the results are vastly superior to those times when I don’t. So I’d say it’s definitely possible to teach this. But in terms of how natural this feels, and how easily it is applied, I agree that there would be big differences between therapists.
    In sport, there are those who readily pick up new skills, and there are those who work their arses off to reach a skill level which is maybe 75% of the naturals. I think it’s a similar sort of thing with Physio. The thing is, the true ‘naturals’, the ‘miracle workers’ in Physio are very few and far between. The rest of us do what we can to learn the process.
    Cheers,
    Cameron

  36. An excellent piece Adam where once again you point out some of the rather hubristic assumptions endemic to the therapies. After all formal training in most is, historically, a relatively new phenomenon.
    We overestimate our value and continue to underestimate the harm we can do. Time to get rid of the professional smoke and mirrors.
    ANdy

  37. I do seem rather late in responding to this now, but after reading through many comments, I do still feel compelled to do so.
    Firstly, I am not going to go back through all of the tedious and frankly irrelevant debate of hand on/hands off. Evidence can be wielded around by both sides to attempt to champion people’s own beliefs. My word of caution about much of Adam’s discussion is that we need to consider the limitations of much of the research that is out there. I will give an example of one of the pieces of literature which Adam has used to support his statement of no skill needed in Manual Therapy- Chiradejnant et al., (2003). I am using this study, not because it is worse or better than any other, but just so we can consider the problem with lumping bits of evidence together to prove a point. As Adam rightly says, we need to not only look at the abstract (not because of bias always, but because it simply does not give sufficient information about the study, which allows you to consider the limitations, and therefore ability to extrapolate into your own clinical practice). Chiradejnant et al. (2003) found that there was no difference between therapists specifically treating the painful region, or randomly mobilising another lumbar level. I have picked up a few points which are worth considering about this paper. One of the outcome meausures used was active ROM using an inclinometer, but do not reveal the error meaures of the tool. This simply means that we have no idea of what differences (pre to post) we would need to be sure that this difference is due to a real effect, and not to error alone (quite important in a pre-post design). They use 2 x 1 minutes of mobilisation, which may not be sufficient to show a therapeutic effect, but there is no justification for this dose. A recent study suggested that 4 sets of 30 secs or 1 minute may be more benefical in provdiding a hypoalgesic effect (Pentelka et al., 2012), although granted this was in asymptomatic participants (the point here really is that we just don’t even know the basics of what makes an effective treatment dose- this may because as Adam says it doesn’t matter what you do with your hands, or that we just haven’t worked it out yet). We don’t know if the individuals which were chosen to particpate in the study would have been treated with PAIVMs at all in practice- it is possible that the Physiotherapist might have decided to use other management strategies. Percentage changes scores have high risk of bias when it comes to analysis (Bonate 2000), which might boost the risk of a type I error (i.e. falsely accepting the null hypothesis), so it is worth remembering that not all statistical analysis gives us the truth. There was no comment about the marked difference in duration of symptoms between the 2 groups (184.1 days for the specific level group compared to 89.3 for the random group)- and no attempt was made to adjust the analysis to take this into consideration. The lower lumbar levels provided better results than upper lumbar levels, but the authors did not give an indication of where the pain emanated from (ie, did it hurt more when the lower levels or upper levels were mobilised?).
    Ok enough already- the point here is that there is no such thing as perfect research- all studies have limitations which seriously limits their extrapolation into clinical practice. Which ever side you choose to sit on, you can find evidence to support your point of view, but it must always be countered by the critique of that literature.
    My concern about Adam’s post is that it is a one sided, biased account of the nature of manual therapy (very useful for stimultaing debate though!). Skill aquisition is based on multiple factors. I don’t see skill being only about where or how you put your hands on an individual, but in the whole interaction with the individual, the respect you give them, the value you place upon their own values and beliefs, whilst acknowledging your own. I appreciate Adam that you do bring these sorts of issues up when you are talking about skill, but bringing them low down on your list lessens their relevence, and suggests that clinicians who use manual therapy do not consider these as highly as the laying on of hands. That is certainly not my experience of today’s manual therapists. Is it not time that we started to accept that the biopsychosocial model is alive and well in today’s manual therapy society?

    • Hi Collette
      Thank you for your detailed lengthy and eloquent response to my little blog.
      You bring up a lot of points for which I won’t respond to all but there are some I feel obliged to reply to.
      Firstly my bias… Absolute agree, we all have out biases, even you Colette, and I am the first to admit and own up to my bias against the notion of skilled expert manual therapy due to my horrible, woeful, inept, mechanalislistic teaching and tutoring I had with it, which I clearly mention in my blog and make it clear to all to see my biases, no hidden agenda here!
      Next, your experiences of therapists views on the effects manual therapy are vastly different from mine, in my experience the structural mechanical and medical model of manual therapy is alive and flourishing in many many areas and by many many therapists, the BSP model is growing and neuroscience is beginning to influence more and more, but there is a long way to go yet, hence my blog and my continued effort to promote it.
      Of course evidence and research needs to be critiqued and I’m glad you have done this for us, but I’m intrigued that you discuss the need for the BSP model and the effects of interaction but then critique and discuss the specific effects of manual therapy with regards to needing to apply 4 sets of 30sec not 2 sets of 1 min for PPIVM’s as per Chiradejnants paper
      This debate of minimum or specific dosage of manual therapy intrigues me, if I was to say do 30 sec less or 30 secs more would the effects be that noticeable for the patient when there are so many other non specific variable that contribute to manual therapy effects, I doubt it
      And it’s this exact specific application and ‘skill’ in the use of manual therapy that I am arguing AGAINST, manual therapy isn’t a hard science, that needs exact application or position or direction, it’s much more than that and it doesn’t involve any technical application skill, instead it involves a therapist to use a caring, soft, reassuring, confident yet comfortable touch much much more than remembering to to poke a vertebrae for 4 sets of 30 secs at 2Hz, and these ‘skills’ are learnt with experience, hands on trial and error not taught in the class room or from reading a book or research paper!
      I could go on but I will leave it there with this final thought that therapists need to stop thinking themselves as skilled technical healers, applicators or operators of manual therapy and rather consider themselves as interactors or human primate social groomers as per Dunbar 2009
      Regards
      Adam

      • Thanks for your lengthy reply Adam. I worry that the term biopsychosocial seems to have been shortened often to only cover psychosocial. To ignore the bio is just as ridiculous as to ignore the psychosocial. My main point really is that evidence is not really the correct word to use when we look at the literature because it will only ever tell us a very simplified aspect of the whole story, but we might use small aspect of it, e.g. treatment dose if we have an idea about what might be more likely to have a beneficial effect and apply it to our patients where and when appropriate. If after a thorough and “skillful” assessment and examination (meaning careful, competent questionning, following the patient’s lead, ensuring that the patient is really heard, and careful, competent handling to name but a few aspects), it becomes apparent that manual therapy would be useful for this individual, then we want to try to apply the technique in a way that might have the best effects (now of course as you know this is absolutely not just about changing the biomechanical properties of the tissue, but a complex interaction of descending inhibitory pathways, possible reduction of excitatory facilitatory pathways (see Bialosky et al., 2009), alteration of the perception of the body region etc etc). The point here is that in a way it doesn’t matter why it works (I know some people might not like the idea that we don’t know why, but I wonder if we will ever really know), but it is important that we aren’t doing our patients a disservice by not attempting to incorporate both manual therapy (done as well as we possibly can) and many other approaches to the patient.
        I see the difference that careful, skillful handling makes to the patient’s perception of the therapy, as well as helping the therapist to see if the treatment (be it manual therapy, exercise, advice or any kind of intervention) has been effective. Going back to the original point you made in this blog-the skill is in every aspect of care for the patient including what you do with your hands.
        By the way of course I am biased- it is part of human nature- another thing which takes skill to deal with during any interaction with a patient!
        Cheers,
        Colette

      • Hi again Colette
        I think evidence is the correct word to use, and should be used by all, but not to confirm what is happening but rather what is NOT happening, there is a lot stronger more robust evidence that rules out the mechanical notions of manual therapy, than it rules in, there is less biased evidence to refute any tissue change in structure with manual therapy than those that do!
        Evidence should be used to show what isn’t happening or occurring more than it attempts to show what is supposedly happening, but unfortunately due to massive publication bias most ‘negative’ research never makes the cut
        I agree with you that to fully understand and evidence all of the effects of our hands on methods will probably never be achieved, well not in my lifetime I guess, but we do know what it doesn’t do and what it doesn’t need and that’s specific application in terms of a set direction, position, amount, rate etc, and so I still argue that the technical skill of manual therapy is over rated
        Kind regards
        Adam

      • Please excuse the interruption, but which publication are you referring to specifically with Dunbar 2009?
        Aran

  38. Hi Adam
    You state: ‘to talk and listen to my patients more and find out their personal beliefs, experiences and more importantly what their expectations and preferences where towards manual therapy! I found asking patients these questions allowed me to gage IF manual therapy was suitable for a patient based on their preferences’
    Absolutely! In my opinion this is the most important aspect of therapeutic interaction with patients, one that I would strongly advocate on the University of Brighton MSc Neuromusculoskeletal Physiotherapy course (MACP accredited), of which I am course leader. I am not informed enough about the finer content of all MSK courses but the incorporation of motivational interviewing and some of the principles of CBT, ACT and solution focused therapy are a fundamental part of the course.
    I absolutely agree that manual therapy isn’t for everyone and when examining physiotherapist (on a route to MACP membership) treating patients in a clinical setting, I am as likely to be taken through to the gym as behind cubicle curtains.
    It is great to hear in your comments to this blog that you recognise the changes in MACP members views (similar to the changing views of non MACP members). As you say MSK physiotherapy is changing and some individuals will be resistant to change (MACP and non MACP members alike)
    It would be great to see you at this years’ MACP conference ‘Exercise Rehabilitation and Patient Engagement’ (not a ‘manual therapy’ session in sight). Alternatively Joel Bialosky (who you mention in your post) will be presenting in IFOMPT 2016 in Glasgow. Might see you there?
    Best wishes
    Clair Hebron (MACP Chair)

    • Hi Clair
      Thank you for your comments, I am very very interested in hearing Joel speak so I may well see you in Glasgow 2016
      As I have said before I am aware and delighted that the MACP are embracing and moving with current evidence and best practice with regards to manual therapy, especially after my own unfortunate terrible experience with ‘old’ MACP training many years ago
      I also work with and know many excellent MACP physios, just as I know and work with many excellent non MACP physios, however… there is always a however… I do think that due to the likes of the MACP (and other organisations) there is a legacy of a lot of manual therapists out there who were trained 5-10+ years ago on what we now know to be a flawed structural, mechanical and overly technical model who are still teaching and preaching poor practice and continuing the biomedical structural nonsense, and they have lost contact with current evidence, and I don’t think it’s all due to resistance to change, i think it’s also just naive misinformation or misinterpretation
      It’s these therapists I’m hoping to reach when I write things like this! I am however well aware most who read my blogs are very well informed therapists so I will be mostly preaching to the converted, but maybe, hopefully one or two who aren’t might stumble across my rantings and it may just instigate a change!
      That’s also what I’m hoping to achieve when I enter the lions den at the Therapy Expo in Manchester this September when I give my talk about the ‘Myths of Manual Therapy’ wish me luck…
      Warm regards
      Adam

  39. Adam,
    I saw your diagram float through twitter a few weeks back and retweeted it and your blog post. Finally, I’ve had the time to sit down and read it. MAGNIFICENT! BRAVO! I can’t even come up with enough adjectives to describe my support for you hitting the nail on the head. Well done. Thank you for bringing to light what feels like so few of us know is true, but so many of us need to hear (and hear again and again). I reblogged you on my own blog http://www.youthsportspt.com. Keep up the great work!
    Julie
    Atlanta, GA

  40. Nice read. My apologies, VERY, VERY NICE READ. Thank you God for your critical, excellent mind.
    Interaction more than intervention! ??
    Nathan
    Manila, Philippines

  41. Couldn’t agree more. I’ve been at the game for 40 years. Taken courses from many practitioners and angles dating back to “Fat Jack” Cyriax himself. I have come to view manual therapy as more of an art than a skill. I had the great honor to have the late Dick Erhard as a mentor and friend. Privately he could be quite cynical about manual therapy, but there was no denying the man’s genius for evaluating the patient and determining what it would take to improve that patient’s situation, and it often came down to a couple of simple exercises. His gift was knowing the patient, something you can’t teach in a post-grad manipulation course. The same can be said for the family doc I knew as a kid whose familiar voice, concern and assurance were more effective treatments than anything he carried in that little black bag.
    I will continue to seek to develop any skill that I think may help my patient. That pursuit can, at least, sharpen my thought processes. At the same time I will remember that my most gratifying results come from developing a relationship with my patient and letting him dictate the treatment. As you said….interaction, not intervention.

  42. I believe the problem lies in having the right perspective or medical model that increases the accuracy of choosing the right intervention for the patient’s specific problem. When all you own is a hammer… everything looks like a nail. I can train a non-professional in how to provide some of the interventions I use. I can even have them perform the intervention on a patient and results are generally positive (with pre-test and post-test findings). But, I am not ready to conclude that some interventions do not require high level of skill to execute properly.
    My question for you, whoever-thinks-they-are-a-manual-therapist, is: Do your interventions have immediate effects of markedly increased ROM, increased force-generation capacity, improved fluidity of movement, and increased speed, along with long-term pain relief in the focused area where you applied the manual therapy intervention?
    If your manual therapy interventions do not fix the underlying problem, then it either means you are doing something wrong (poor selection of intervention and/or poor execution) or that manual therapy is not the correct treatment of choice. You may not be getting to the problem in a way that can correct it. It is just as possible that another intervention that was properly targeted and executed would correct the problem immediately.
    Think about the example of nurse-maids elbow. The elbow is dislocated and then 2-minutes after the proper manual therapy intervention the child is happy again, ROM is restored, etc. Shall we do a study of the effectiveness of relocating a nurse-maids elbow? Do we need to? Or shall we just continue our clinical practice of manual therapy, where it absolutely takes skill to interpret the findings, select the intervention, and execute?

    • Hi Howard
      Thanks for your comments, you make some interesting points
      First you state that if we dont get immediate results after manual therapy then our technique or selection was wrong, i may agree that selection of manual therapy may be wrong here in a hands on hands off kind of way, we all have had those patients we think manual therapy will help only to touch them and feel them stiffen tense up in fear pain etc and despite or best efforts they dont respond
      But immediate effects due to the direction of push pull poke or press is something i do not agree with, as long as the MT is comfortable and the patient feels and gives feedback as such then it doesn’t matter, just because I think a right unilateral L5 Grade 3 mob is needed doesn’t mean diddly squat if the patient doesn’t feel its right and thats my point re skill in manual therapy the skill is in communicating and interacting with your patient not the intervention
      Lastly you use a an example nurse maids elbow, which is a gross traumatic dislocation that needs correcting just as a dislocated GHJ does this is not the same as manual therapy for a low back pain of stiff neck
      Regards
      Adam

  43. Is it possible that there is a better way than what we “know” now as a whole group? Is it possible that skill is required to execute the specific intervention that is needed for the individual? I really believe that manual therapy will either immediately correct the problem that is specifically addressed or the problem cannot be fixed by manual therapy. I see immediate solutions every day. It does take a high level of skill and a knowledge base that is not widely known. And the reality is that the solutions are as simple as understanding anatomy and neuroscience and how both can be corrected when in a dysfunctional state. Fascia can be immediately corrected and faulty muscle spindles that restrict normal ROM can be reset. But, it takes a paradigm shift that many are not willing to make. Again, I disagree with your hypothesis.

  44. I have one LARGE issue with this blog. A sneaky snide comment thrown in which sets manual therapists back to the dark ages. It’s comments like “if you pay a little extra” that hurt the profession. And arrogant guys like you seem to be the worst for it. I stopped reading after that comment. Sad.

    • Im sorry you think me arrogant from one light hearted quip, I think you are being a little unfair and would ask that perhaps you get to know me before making such offensive ad hom comments, and also maybe see the light hearted nature of the comment

      • I would have liked the same treatment from you when you bashed my presentations at the world golf fitness summit without knowing anything about it or me. . I am in agreement w the premis that there is much we don’t know and we need to be citizen scientist and learn for ourselves in a safe collaborativeffort. Look me up … We are not that far off.
        Marcwahl.com

      • Hi Marc, I’m sure I didn’t bash you! Just the dubious use of ‘cupping’ critiquing methods, is not critiquing people! Thanks for the comments thou! Cheers Adam

  45. Nothing light hearted about posting a comment about the stigma of manual therapy that manual therapists have been trying to overcome for decades. Seriously, get a grip.

      • Hi Adam
        I agree about your comments on professionals that think they are god’s gift about manual therapy. I currently work in New Zealand and although a pioneer of his time McKenzie is still the gold standard over here. I mean c’mon people, really??
        I laugh at the comments other professionals make (although to be fair it is individuals such as yourself that do and can destroy their bread and butter), this however to me shows a lack of insight into keeping abreast of EBP and considering the alternative methods such as, improving your people skills?
        I was recently ostracized by a student chiropractor for claiming that I was taught manipulations by a chiropractor that they were not true manipulations because I am a physiotherapist, what an utter load of big fat BS!
        Really enjoying your rants it makes for excellent comedy, it’s great that some people are narrow-minded as it makes it all the more entertaining for me when a rant exchange commences!

  46. Hey Adam,
    Very, very, very interesting blog post. I am one of those guys who has spent quite a lot of money in courses and I am still waiting for an explanation that convince me about the way some techniques are supposed to work.
    I would have liked to be the one writing about this topic, although it sounds much better in proper English. I am Spanish and my English sounds awkward sometimes!!
    Many thanks for the post

  47. My sentiments exactly. I’m in the first year of my career and I see and read so much bullshit that I actually became quite depressed for a while. Then I thought…well everyone feels good when they get off my table. They feel relaxed and a bit more limber for a while and that is enough for me. There aren’t many things these days except alcohol, drugs and sex that make you feel a bit more cheery and relaxed. I charge half of what others charge because I think massage rates are FAR too high and i don’t want people to think of it as a luxury for wealthier people. I read a lot, watch technique videos and talk to more experienced therapists.
    Thank you for your simple, no bullshit or jumbo jumbo views!

  48. Hi Adam,
    I am (partly) glad I came accross this article, it certainly insights a lot of thought and discussion as is represented throughout the comments!!
    I could go into details on my views however much of these have been discussed previously and I found myself agreeing in parts with both sides of the discussion/argument while reading through the comments, like most people I guess.
    The point I will make however is that justifying parts of this discussion by evidence seems a tad worthless due to the fact that for every paper claiming manual therapy ‘doesn’t do much’ there is another representing its benefit in treating numerous musculo-skeletal conditions http://www.sciencedirect.com/science/article/pii/S1356689X15001745. Admittedly I wasn’t keen on spending $35.95 to view the whole paper to then find the likely numerous floors in the evidence but this is no different to most other studies such as Shoemaker 1995 who concluded no impact on tissue bloodflow following a study on just 10 persons.
    I use manual therapy with every patient I can (those without contraindications to it) and get the right results (most of the time). I do also use re-assurance, activity modification and exercise, arguably it may be those things which impact on a patients symptoms, although I am far from convinced, but more importantly in my view I do doubt my patients would be half as happy if they left their appointment following a chat and an exercise sheet.
    I understand you are not rubbishing manual therapy completely, however some of your points are less agreeable than others.
    Great effort in getting such a discussion going, it’s been a good read and a good opportunity to look into the research a bit more.

    • If your manual therapy techniques are not the primary cause of the improvements then ethically you should not be applying the techniques. If the chat and exercise sheet is improving their condition then you are actually worsening their condition by letting them think that its the manual therapy. Persisting with innefective or minimally effective treatments is a reason why health and medicine has not been able to reduce the prevalence and impact of musculoskeletal pain syndromes despite massive advances in medical care as a whole.

  49. Great post….I have been practicing “manual therapies” for 21 years now, my training is primarily Craniosacral Therapy to advanced level, whatever that means, biodynamic cranial, visceral manipulation and some traditional osteopathy. I also have a allopathic medical background.
    What I learned from all that training was anatomy, distinctions and frames of reference, but where I learned the most was in practice. At this point, my hands are extremely sensitive, and I can feel systemic, inter-related patterns contributing to a person’s symptoms, fascially, neurologically, vascularly and lymphatically.
    I’ve witnessed some seeming miracles with clients, even having several who were able to cancel surgeries after one session. Assessing and treating this stuff does take SOME skill-knowledge of anatomy, the ability to get quiet mentally to focus on and perceive extremely subtle tissue interrelational dynamics, mechanics and releases, a caring heart and true love for the patient to be able to be present with them, create a safe space and listen to them, like you said, and truly wish to serve their highest good.
    Did I need to pay for any of this knowledge? Looking back, I would say no because where I learned the most was in hundreds of hours of client sessions as well as studying anatomy and neurophysiological dynamics on my own. Truly. Gotta love “google university.”
    So I really have to agree with you. Just like healers of old had a “gift” and a caring heart, with a little motivation and perseverance, anyone who truly wants to can become an excellent manual therapist. My two cents! God bless.