The Sports Physio / June 16, 2014
I'm guessing if you are reading this then you are probably a manual therapist, and probably a little pissed off with the title of my blog that's just called into question your skill, training and experience! But before you 'blow a fuse' and decide to get all 'medieval on my arse' in the comments section, please hear me out and continue to read on a little further!
So a few weeks ago, just for a change, I posted a controversial tweet that said “There is NO technical skill needed in ANY manual therapy. Except for red flag/safe application”
It had a mixed response, some agreeing, some disagreeing and the odd smart arsed remark. So I thought I would expand on this a bit more and explain my reasons for saying this, why I think this way and of course, as always, some evidence to back it up.
Anyone can do manual therapy
I truly believe anyone can 'do' manual therapy, without training, without experience and without skill and get just as good, if not better results than a professionally trained therapist.
In fact know it!
This is purely anecdotal, but I've personally had an ongoing neck issue for years now, an old rugby injury that's often aggravated by spending too long on laptops blogging or tweeting. I've sought the help of many professional therapists over the years, but the best 'treatment' I get for this without a shadow of a doubt are my wife's neck massages (that's when I can convince her to give me one) but she isn't a trained manual therapist, in fact she doesn't even work in the healthcare industry.
And I'm not alone, I know and hear of many others who say the same, and I'm betting there are millions more out there whose partner, friend or 'acquaintance' who isn't trained in manual therapy gives a great back rub, head massage or even clicks something now and then that just feels ooooh sooooo good.
It's this, amongst other things that I will get to later, that got me thinking, how is it possible that my untrained, unskilled wife makes my neck feel so much better after she rubs it than compared to a £50 an hour trained professional?
Now many argue that this example isn't a fair comparasion, saying that it's either not true, and that I'm lying or exaggerating the benefits for my own purposes, for which I have no answer, other than to say I'm not. Or they say there are other factors that a professional therapist cannot reproduce making any comparasion unfair, such as higher levels of familiarity, relaxation, playfulness etc, and I totally agree, a massage by my wife does have these wonderful, non specific factors that won't happen with a therapy professional (well, not without paying a bit extra) but I argue that is EXACTLY why it works better and why it raises some BIG questions around the belief of technical skill within manual therapy.
Human touch can be powerful
Many mistake my critique of manual therapy as me saying I don't think it has a role or works, but that's just not completely true, yes manual therapy is over used, over hyped and surround by a lot of bull shit but, human touch can be a powerful tool and I'm not disputing that (well not much) there's reams of evidence to show touch is pain relieving, soothing, calming and relaxing (source, source)! But what I do struggle with and what I am strongly opinionated and critical about is those who make it over complicated, over technical and over hype the skill of its application, making it out to be something it's just not!
My experience
Also before I go any further, let me just reiterate, again, to all those that often mistake my skeptical and critical views as being ill informed or inexperienced, and remind you all, again, that you could not be further from the truth.
First, my own experience in manual therapy extends well over a decade, and I still continue to use manual therapy in my practice, although not nearly as much as I used to, my training and education in manual therapy has been extensive, lengthy and costly.
I've completed most of the popular and challenging post grad courses in manual therapy, having been taught by some of the worlds most influential figures in their field. I've gained qualifications, passed assessments, sat exams and even taught some manual therapy courses and techniques myself. Some would class me as 'skilled' manual therapist, but as I'm arguing against this I won't and I never do!
What is manual therapy?
Manual therapy means different things to different people, when I say manual therapy I mean anything that involves one person being touched, pressed, rubbed, poked, pulled or cracked by another with a hand, finger, foot, elbow, knee or even some tool or device in a so called 'therapeutic' fashion.
Manual therapy exsists under bewildering array of terms, names and descriptions, such as well known ones like massage, manipulation and mobilisation, some times they have more complex and 'scientific' sounding names like effleurage, petrissage, myofascial release, deep transverse frictions, some have more exotic and glamorous titles like Swedish Massage, Tunia, Anatomy Trains, Active Release Techniques and then there are those named after an influential creator such as Maitland, Mulligun or Bowen.
All of these techniques have different methods of rubbing, pressing, pulling or poking that normally involves a course to attend in order to learn the 'skills', some lasting a few days, others longer, with the cost ranging from a few hundred quid to thousands of pounds, or dollars, or euros etc. and if you want some help in deciding which course to take next, I've done a little helpful flow chart below to help!
Each technique/method is thought to achieve its effects via different mechanisms and all vary in their thinking and rationale behind how this achieves it. But one thing that is consistent with them all, is they are all based around the notion of changing a structures position, length or freedom to move, be it a muscle, tendon, ligament, fascia or a joint, they all attribute the positive affects of their manual therapy technique to these factors and generally ignore the central nervous system and other non specific factors. Finally they all think their method is far superior than the others, with such an air of snobbery and self imposed hierarchy that it is one of the reasons I dislike most manual therapy tutors, courses, training and teaching so much.
Frustration
But if I'm being honest the real reason why I'm so critical of manual therapy and why have been so vocal about it now for a good few years, is that after spending many thousands of pounds and many years of training, and being taught and lead to believe that manual therapy is a powerful tool that can help 'fix' or 'cure' people in pain, I have realised and learnt that this just isn't the case, it's not as powerful as many claim, it's certainly not as specific and there is very little technical skill needed!
And this frustrates me, greatly, immensely, firstly because I feel cheated, mislead and even lied to, and secondly because it continues to happen right now, all the time, the myths and misconceptions about manual therapy are still rife and if anything they seem to be growing stronger and nothing seems to be changing.
A slow realisation
I came to this realisation that manual therapy isn't all I've been taught or lead to believe after a few years post graduation, with my very strong natural skeptical side always whispering in my ear “this just ain't right mate” but I kept suppressing it, thinking all these 'experts' and other therapists can't be wrong!
Well yes they can…!
I began to notice more and more often that the effects and outcomes of all these techniques were highly variable, this despite my training, despite my assessment and application being as consistent as I could make it. I also began to notice that when I didn't do the technique exactly the way I was supposed to it didn't change the outcome or result, they still got better anyway!
So I began to 'experiment' more and more, realising more and more that it didn't matter how I poked, prodded or rubbed someone, until eventually, I stopped completely all the ritualistic, pseudo scientific assessments that I had been taught, such as looking and feeling for a joints position or movement, or poking a soft tissue feeling for its firmness or softness. Instead I started 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, not mine nor what I was taught to believe based on some flawed assessment process!
Research, evidence and an awaking
Next, I began to read more, a lot more, a lot lot more, I looked at the 'evidence' with an increased critical mind, looking at the method and result sections of the research papers first, not the introductions, discussions and certainly not the abstracts which are all heavily biased, and what I found was a revelation, most if not all of the research that backs a certain technique or method is flawed with methodological design issues and biases so big they dwarfed my own.
I then found research that supported my experience with manual therapy, from therapists and researchers such as Bialosky, Zusmann and Lederman, I leant more about neuroscience, human behaviour, psychology and pain from the experts such as Sapolsky, Shacklock, Moseley, Butler and many many others.
I found like minded therapists online in forums such as SomaSimple and of course on Twitter who were also disenchanted with the myths around manual therapy, they pointed me towards more research and more evidence, questioning more and more the structural and biomechanical effects of manual therapy.
For example, I learnt you can't break down scar tissue, adhesions, 'release' a muscle or fascia (Chaudhry 2008,Chaudhry 2007, Schleip 2003, Threlkeld 1992)
I learnt that by stretching a muscle in a certain fashion, in a certain way, for a certain amount of time doesnt effect it's structure (Solomonow 2007, Weppler 2010, Katalinic 2011)
I learnt that you don't need to mobilise or manipulate a joint in a specific direction, based on a pattern of pain or specific assessment of movement and joint feel (Chiradejnant 2003, Aquino 2009, Schomacher 2009, Nyberg 2013)
I learnt that palpation of muscles, joints, trigger points are all unreliable and leads therapists to misdiagnose often and direct treatment down wrong and ineffective pathways. (I have done a blog on this topic recently with all the supporting evidence here.)
I learnt that when all the methods and techniques 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)
It has been a revelation and an awaking, a slow and gradual opening of my eyes, but they are wide open now, and combined with my decade of experience and 'skill' with manual therapy together with my knowledge of the research, I can now confidently say that manual therapy just doesn't do much, and it really doesn't matter how you do it.
Caveats
So I hope this explains my reasoning when I say that there is no technical skill needed in manual therapy, that the effects are not structural, not related to a tissues tightness, not effected by a joints stiffness or position, instead it's down to other non specific psychological and neurological factors!
But having said all that there are couple of caveats with regards to 'skill' needed by a manual therapist!
Although the forces produced with manual therapy are low and risk of causing any structural damage to connective tissues is near impossible, there are some techniques that do potentially have a risk of causing structural damage and injury and potentially life threatening injuries. High velocity thrusts or manipulations to the upper neck have been known and documented to cause serious and severe vascular and neurological injury and in worst case scenarios, death (source)! So it goes without saying that full awareness and identification of those at potential risk as well as safe application and training for these particular techniques is a must, although there are big questions over the need to do these types of treatments in the first place in my opinion (source).
Next as a manual therapist is someone who regularly sees and treats people in pain or after surgery, a skill in identifying and recognising serious pathology and complications is very much needed. Being able to recognise when someone coming for some manual therapy has sinister signs of serious non mechanical pathological pain is a skill of highest importance.
Lastly but most importantly, is a manual therapists skill in interaction! Being a people person who can connect, relax, reassure and calm people is a trait or dare I say it a 'skill' not to be taken for granted and it's this together with confident, comfortable handling skills that I truly believe distinguishes a great manual therapist from a good one, it's not the skill of their technique nor the qualifications or courses attended, as I often say, interaction over intervention.
Fighting against the tide!
So there you go, my slightly longer than 140 letters explanation of why I think there is NO technical skill needed in manual therapy! It is my own story of my initial desire and passion to learn about manual therapy followed by my disillusion and disenchantment of the bullshit and rubbish surrounding it!
I now find myself (unexpectedly) as an out spoken, cynical, skeptical and often misunderstood critique of manual therapy for which I'm hoping this blog will provide some clarity to my own critics.
Let me also state once more that my aim is not to put people completely off manual therapy nor negate or belittle the non specific effects of human touch or even say that manual therapy doesn't have a role or place, at times, instead my aim is to try and debunk most of the biased, flawed and generally crap manual therapy research, claims and marketing and also I guess to be a thorn in the side for a lot of the manual therapy 'guru's' pedalling their non sensical made up courses pushing their fanciful teaching and wild claims.
And unfortunately, I seem to be doing this bit more and more as the manual therapy industry continues to grow a huge, ugly, immoral cash hungry commercial business, motivated by income & profit, feeding on thise in pain and with injury, built heavily around selling courses, workshops, manuals, books, DVDs, webinars, etc, all pedalling and promoting techniques or methods that everyone must have as they are better than anyone else's and that their course will get better results than others blah, blah, blah….
So please expect and be prepared to hear me rant, moan and wail on this ugly, greedy and at times ineffectual manual therapy machine for a lot, lot longer!
As always thanks for reading