“Mark and Jarod hate manual therapy”. If we had a dollar for every time we’ve heard this eavesdropping on conversations, been told this directly to our face or via social media, or found that other clinicians were berating us behind our back about our “disdain” for manual therapy we certainly wouldn’t have to work near so many long days and over 40 hour weeks.
The most interesting tid-bit about this statement/assumption/projection of emotion that so often gets hurled our way is the fact that it isn’t even true.
Have we been critical of some of the narratives that surround many manual therapy approaches? We sure have.
Have we called into question some of the mechanisms by which many claim certain manual therapies work? You betcha!
Have we skeptically investigated the “you just haven’t put your hands on enough people 10,000-hour master rule” in manual therapy joint/tissue/passive motion assessments? Absolutely.
Have we been hesitant to recommend in depth manual therapy courses and certificate programs that seek to give students their stamp of manual therapy certification all while quietly lining their wallets with money that will go on to be the root of many a sunken cost fallacy-based decisions and behaviors? You bet your sweet ass.
BUT, have we ever stated that we hate manual therapy? That one is going to be a hard no.
We’d like to go a little further here and shed some light on our manual therapy background and close this somewhat brief narrative with what we do actually think about manual therapy.
“I came into PT school with an already biased view that I was going to work outpatient orthopedics, learn to pop backs, crack necks and cash checks, learn to release tissues, learn to correct malalignments, learn deactivate trigger points, scape away people’s pain, and be that magical guru clinician who could fix anyone who walked through the door with the power of my golden hands.
I thrived in manual therapy coursework and loved every second of it. I picked up on manipulation fast and felt I had a natural knack for hands on treatment and “feel”. I manipulated every person’s spine who would let me and had an unquenchable thirst for learning and refining my skills more. While still in PT school I signed up for 3 levels of KT tape coursework, worked as an aid in 3 dry needling courses in order to learn for free, took an IASTM course, and sought out a 3 month specialized internship with a “guru” manual therapist in town who had taken all of the AAMT, St Augustine, and NAIOMT coursework all in order to become the best manual therapist I possibly could.
In my first year after graduation, I proceeded to take all of the AAMT coursework myself, completed 3 more spinal and extremity manipulation courses from different companies, took another IASTM course from a different company, and took dry needling courses from 2 more entities to increase widen my dry needling breadth across multiple approaches and understandings.
All of this coursework obviously influenced my practice. Every single patient that stepped through my clinic doors was going to get several different forms of manual therapy…because that’s what they needed. In fact, I had determined that people seemed to “respond best” to myofascial release either by hand or tool, followed by joint manipulation, and then dry needling to address all possible aspects of underlying dysfunction and prime them to be able to complete my haphazardly prescribed corrective exercises afterwards in the few remaining minutes of their visit.
Then something extremely uncomfortable happened…I “accidentally” ended up being introduced to social media friends and discussion platforms where hard discussions were taking place. Discussions in which I wasn’t prepared or educated enough to even make coherent comments. It may not be hard to believe, but I really hate to feel stupid and hate not knowing things. This is both a strength and a weakness for many reasons. In this case, it was a strength, as these discussions drove me to take a deep dive into reading much more about pain, meaning response, human psychology, neuroscience, as well as the mechanisms of manual therapy. I chased deep down the rabbit hole in order to even be able to contribute to the discussions without sounding like a complete bumbling idiot and in order to have my ideas peer reviewed and refined. This reading lead me to taking several courses that dove deeper into the human experience of pain… and all of this lead me to face the cognitive dissonance I was avoiding, sharpen my critical thinking skills, become a bit more skeptical, and have the courage to question “foundational” narratives and practices.
All of this is to say, person who thinks I hate manual therapy because “he’s just an exercise guy”, “he just isn’t that good at manual therapy”, “he just hasn’t learned enough about manual therapy”, or “he’s just one of those pain science guys”, that I have my thoughts on manual therapy from a long hard road of a ton of courses, thousands of patients treated with it, thousands of dollars spent on it, and countless hours spent self-reflecting while reading research not only about manual therapy, but human cognition/biological plausibility/pain/logical fallacy/neuroscience/etc.”
I spent a career chasing the latest certifications and manual therapy techniques based on my thinking that the solution to the gray areas of clinical practice where patients were not responding in the black and white way I was taught in school. Because my conception of pain was firmly rooted as strictly a tissue-based issue, my way to make sense of the “complex patient” was to search for more complex technical skills. I was taught to lock out the spine from multiple planes and seek to discriminate theorized millimeters of motion loss that were affecting a patients pain experience. Manipulation was to be very specific and you never manipulated until you spent 10,000 hours perfecting your manual therapy handling skills and studied under a guru to give you the blessing to perform such a jedi-level skill.
I never felt I could convince myself that I was feeling what weekend course instructors would confidently tell me was a motion loss. I remember multiple times being asked, “Can you feel that?” from a course instructor and simply saying yes to not appear as an idiot and a failure in front of my peers. It was that internal struggle that nearly had me quit the profession. I was ready to submit my application to DO school as that was going to be the solution.
Then I was introduced to Evidence in Motion's programs. First, let me say that I am forever grateful for the skills I learned in fellowship in the form of clinical reasoning and critical thinking. Going into fellowship gave me renewed passion that now the research was going to hold the answers for the complex patients I encountered and was failing with. I also was going to get clinical mentoring from some of the most highly respected manual therapists in the field. My ability to disseminate research and the mentoring I received was great, but what I found was research did not solve the difficulties I encountered in practice when dealing with suffering human beings going through a complex pain experience. Clinical prediction rules definitely did not solve this. The most disappointing part of my journey was seeing the best mentors manual therapy has to offer fail with the very same patients I was in fellowship to stop failing with. I still saw a history and clinical encounter that was dominated by questioning and reasoning that moved a clinician to choosing a tissue-based way to interact with a complex pain experience.
What really were the light bulb moments for me that I will be forever grateful for is a “Why Manual Therapy Works” course taught by Steve George and Joel Bialosky and a Pain Science course. These courses helped me with the two major internal struggles I was having. Why manual therapy works showed me that it wasn't that I wasn't good with my hands to feel the mm of movement all the weekend course instructors and mentors were proclaiming. It's that that narrative and theory holds minimal water when studied as far as its reliability and relationship to outcomes. It was like I was finally free of the incessant search for biomechanical and arthrokinematic bogeymen that were the root of issues. I have not thrown these concepts away by any means but I have recognized their limitations in helping a human in pain and how that incessant focus can have you focusing on a tree and missing the forest.
Pain science coursework also was a massive ah-ha. It showed me that I needed to expand my reasoning beyond the tissue with patients and not go into encounters trying to figure out where to apply manual therapy to this person. Now my reasoning was to consider whether to apply manual therapy at all and I now go into encounters with a thought of attempting to not apply it unless that specific scenario dictates it. Many factors play into this – patient expectations, specific back pain (10-20% that may respond to specific movement strategies that the patient is not currently succeeding employing actively), expectancy violation to show people pain is changeable,
I will admit there when I shifted away from a “how to fit manual therapy to every patient” approach my outcomes dipped. The interaction I had practiced and performed in front of patients no longer was being performed. I was like an actor who had new lines that I had not practiced enough to captivate my audience. How would I create a new interaction where my job was to captivate a patient and help them regain hope in themselves and be the Alfred to me instead of the Batman I had spent my career trying to be? It was freeing in a way as I no longer needed to be defined by being a manual therapist. I no longer had to attempt to convince myself that I could detect facet meniscoids and millimeters of movement dysfunction to help someone. I expanded my education to stop attending the same old manual therapy courses and conferences where all I received was a confirmation bias pats on the back from people wearing the same branded polo and further moving into a mindset that manual therapy is a complex skill that needs to be in the care of our patients.
So do I use manual therapy? Yes, but a heck of a lot less. Have my outcomes changed? Initially yes, but as I learned the way to being an Alfred for patients I help a lot more of those I could not help with a manual therapy narrative. My N=1 experience in my practice is that the need for manual therapy to be in a clinician's practice is directly proportional to:
- level of sunken cost,
- who a clinician looks up to as mentors
- the tribe that supplies their confirmation bias
- the conferences and continuing education one chooses to attend
- the belief that it must be applied to fit in and feel like one is doing the right thing.
Do I think there is skill in manual therapy? Yes, but not in the way I used to. Skillful handling of the complex experience of a human in pain along with an empowering narrative is a massive skill. In the vast amount of cases the biomechanical and arthrokinematic bogeyman search, while impressive to a patient and an impressionable DPT student or mentee, is not necessary and frankly can become a distraction to a focus on returning a human to valued movement in their life that simply will never exist on a treatment plinth. We need to skillfully deliver technique so becoming technically sound is important but recognize that is only part of what influences an positive response to treatment and positive outcome.
I will be forever grateful for the critical thinking and clinical reasoning manual therapy training helped me develop. Is was those exact skills that caused me to critically analyze my beliefs in manual therapy and the implicit beliefs and theories I was operating under. It has allowed me to help prioritize my care to include manual therapy at most as a supporting cast member and always prioritizing the patient as the star of the show. I enjoy my career more than ever in the supporting role of Alfred I play to the patient's leading role of Batman. It doesn't come with more letters but it has allowed me to provide the most rewarding care I have ever provided.
At this point, you’re probably thinking “Ok cool. Jarod and Mark have done a lot of manual therapy stuffs. That’s great and I’m glad you’ve given us your life story as an appeal to authority…but if you don’t hate manual therapy, what do you actually think about it?”.
Great! We're glad you asked. From here, we think it’s easiest to list what our understanding of what evidence based manual therapy does and doesn’t do based on the literature, our expertise, and reflection on those patients we’ve worked with.
What manual therapy doesn’t do (based on current evidence):
(It is important to note that when we are referring to manual therapy, we are implying a passive care in which a clinician uses their hands or tools to work on a passive recipient's body/system and cause some sort of change to their body/system)
Manual therapy doesn’t appear to actually be able to break down scar tissue, put bones back into place, release tissues, align organs, stimulate or speed up healing, reduce inflammation, increase blood flow in any special way, reduce delayed onset muscle soreness in any appreciable way, release repressed emotions in fascia, alter connective tissue length, accurately assess or correct accessory joint glides, or fix people all on its own.
So….what is it that manual therapy does/can do (based on current evidence):
Manual therapy does stimulate sensory nerve endings, cause spinal interneuron gating, induce a placebo effect/meaning response, provide a sometimes-novel stimulus to alter perception, facilitate relaxation, feel good and create short term relief from pain, provide non-threatening physical contact, meet expectations (that we likely set ourselves – more on this later), create an opportunity human to human contact (social grooming as it has been referred to), temporarily alter symptoms to prove to people they can get better.
Conversely, manual therapy also provides the opportunity to convey narratives of body as machine, increase passive care seeking, influence a person to believe they need another person's hands to fix them, create a strong mode of sunken cost fallacy influenced thinking by those that have been trained in a certain flavor, and creates potential to get stuck in “manual therapy” jail where a person is in an endless loop of coming to get their symptoms modulated with no real long term change or push towards independent self management.
To say we “hate manual therapy” is not accurate. We do not love nor hate manual therapy at all. Manual therapy simply doesn’t imply anything on its own, but instead becomes something more or less when utilized by a person and applied under the guise of their specific narrative, their biases, and the language they have at their disposal to give the manual therapy meaning.
With this knowledge and these perspectives, we do find ourselves using manual therapy less and less as time has gone on. Much of this is due to the evolution in our understanding of why a person might hurt and what it is that manual therapy is capable of physically doing. Each of us have agreed that we feared making this change, if nothing else, due to the concern we would have much less satisfied patients and would somehow disappoint those coming to see the physio who didn’t massage, manipulate, tape, or scrape them.
However, in contrast with our concerns, we have gone on to observe no real noticeable decrease in outcomes (outcome measure questionnaires, satisfaction rates, cancellation rates, patients referring other patients, etc), and come to the realization that much of our concern and perception that patients wouldn’t find value in our care or only see us “as an over-educated personal trainers” were simply own projections upon them, our own insecurities in our ability to educate and provide value without some form of manual therapy, and the stories of those other clinicians who place their own value and self-worth on what they feel they can do with their “magic hands”.
At this point, it is worth making clear that even though we utilize manual therapy much less than in the past, we would like to explicitly state again that we do not hate manual therapy, and in fact still find manual therapy occasionally valuable. Though, we do not find it valuable for changing tissues, fixing people, or because patients “need” it, but instead for building therapeutic alliance via the intimacy required for human to human touch, a means to decreasing fear of movement for those people who have come to believe any pain means they are broken, decreasing anxiety and attempting to influence protective responses, garnering patient buy in by demonstrating to them that their pain is modifiable and not necessarily permanent, and as a gateway to talk more about the wonders of the ever complex human nervous system and contextual influences on pain perception.
We believe, that if there is skill in manual therapy, that this skill lies in the ability to seamlessly build the power of novel, familiar, and/or purposeful human touch into a well-rounded treatment approach that reflects well the complexity of the human experience of pain. It is knowing when specific tissue-based methods are indicated and not operating under the assumption that tissue issues are always driving the experience. This approach must have the patients and their values at the center, stand on a foundation of the evidence, and embody the adaptability and resiliency of the human being. It is a no-guru zone where independent patient-centered critical thinking and clinical reasoning rules the day. Active movement toward valued movement and activities in a patient's life must be the star of the show and our manual therapy should play a supporting role if it even plays one at all.
Importantly, it is also worth noting that for subjective reports such as the experience of pain, much of a treatment’s effect arises from the meaning a person places on that treatment. The greater the meaning and expected response, the greater the actual response and influence of outcomes tends to be. It is certainly the case with manual therapy that many people have come to place value (valid or not) on manual therapy's abilities, expect manual therapy to have certain effects on their bodies, and believe manual therapy is necessary for their condition to improve. In these cases, it would be reasonable for a clinician to claim they are meeting this expectation of the patient as an important aspect of evidence-based practice and this recognition of patient values is provides sufficient rationale to utilize manual therapy.
However, it is worth stopping to reflect and examine the flip side of this very same coin. We must ask ourselves where the person we are treating developed their belief and expectations regarding manual therapy. Interestingly, even in the modern day technology driven world, studies demonstrate that most often these beliefs originate with clinicians. Of course, in the business of science, we are always updating our beliefs, progressing forward, and updating practice. It's important to recognize that those clinicians in the past were well meaning, caring, and smart humans functioning under the best theories they had at a time when understanding was even more incomplete than it is now.
It is at this point that we may recognize the potential for cyclical propagation of unfounded beliefs and patient expectations that are not in line with objective evidence when we make the choice to continue with sustained utilization of a treatment simply to meet expectations. Could it be that when we oblige in meeting preferences without supplying an updated narrative around that treatment, we may be eliciting a prolongation of potentially harmful narratives that convey the message of “body as machine” and a drive for passive care seeking. Could it be, that in our efforts to hear our patients and employ patient centered care, we may enact the continuation of the preference for manual therapy intervention as a form of positive feedback loop?
The topic of manual therapy is one that is complex and often emotionally charged as anyone should expect with such an entity that has garnered as much money, time, prestige, perceived value, and ascribed self worth as that of manual therapy prowess and skill. As stated above, it is not manual therapy that we hate, but instead many of the narratives and guru like tendencies that have developed around the practice of manual therapy. In closing, it is our opinion, that if we are not at least discussing these ideas with those who are in process of learning, we are cultivating new generations of clinicians that have practice patterns and beliefs rooted in poor rationale and overly structural models. We are continuing the propagation of shaky science that is only strengthened by appeal to authority and tradition, rooted in products rather than processes, and imply our role as an operator rather than an interactor.
Thank you for reading,
Jarod and Mark