Abandoning Manual Therapy

Over the last few months, I have received many emails from newly qualified physios who are already disillusioned with the profession because of the emphasis that is still being placed on manual therapy (see below). It appears many new physios are still being told that massage, manipulation, and mobilizations are an important and essential part of physiotherapy and should be used on everyone they see. This is not only disappointing but also complete and utter bollocks.

Before I go any further, I just want to state clearly and loudly that you do NOT need to use any manual therapy to be a great physio, and many great ones don’t.

However, It appears from the emails above that many physios are being told otherwise and chastised, reprimanded, and even threatened with dismal by their managers for not using enough manual therapy on their patients to keep them attending appointments. I find this not only sad but also extremely worrying that some clinicians seem more focused on patient retention and their profits than their outcomes.

I do understand that all clinicians need to earn a living and be fairly reimbursed for our skills, experience, and services. But I think physiotherapy (and all healthcare) reimbursement systems are pretty screwed up, be that in the public or private sector.

This is because all healthcare, including physiotherapy, is reimbursed for its time and what is done regardless of the results achieved. It doesn't matter if an episode of care or treatment is good, bad, positive or negative, physios still get paid regardless of the quality and outcome of their treatments.

If physios were financially incentivized for successful achievement of patient outcomes I wonder if there would be as much focus on treatments such as taping, needling, or manual therapy? If we only financially incentivize healthcare for doing treatments rather than the outcomes they achieve, then I fear many clinicians will continue to be disinterested in patient results.

At the moment in this current healthcare system, being a conscientious evidenced-based physio who consistently looks to develop a patients self-efficacy, encourage self-management, and strives to achieve a quick and efficient discharge once a patient's goals have been met is an extremely tough and shitty way to earn a decent living.

There is no doubt that manual therapy can help reduce pain and improve function for some people, for a short period of time. However, manual therapy is unreliable with variable effects that are only short-lived and minimal in size. In fact, I would argue that a simple hot pack has comparable pain-relieving effects to any manual therapy but is more consistent and reliable in its effect, not to mention a damn sight cheaper, and a lot less time-consuming to apply.

In my opinion manual therapy is often used to justify the therapist's existence giving them a feeling of purpose and responsibility, and often used to pander and pamper to patients rather than to genuinely help them.

Tools in the toolbox?

Manual therapy is often described as an essential tool in the physios tool kit, and that it opens the window of opportunity for patients. However, these are lame excuses as manual therapy is more a tool to help physios retain patients and it tends to open the window of opportunity for physios bank accounts rather than patients goals.

Over the years I've had numerous discussions and disagreements about the pros and cons of manual therapy with many of its advocates and gurus, and I'm sure I will continue to do so. I have discussed how manual therapy is not specific and doesn't do any of the physiological things many claim it does here. I have talked about how manual therapy is not that skilled or difficult to learn and doesn't require hours, days, or weeks of expensive training or courses here. I have highlighted how there is a large and profitable industry behind manual therapy with many individuals with huge vested interests in it here.

Over the years I have collected and shared a good deal of research that questions, challenges, and refutes many of the pseudo-scientific claims of manual therapy and demystifies its methods of effect, and you are all welcome to read some of this in part of my Google drive that is open access here.

I have mentioned many times how I was taught to use lots of types of manual therapy on patients, all with various degrees of success and failure. I have also mentioned many times how I NOW DON'T USE ANY MANUAL THERAPY AT ALL, EVER, AND I LOVE IT.

Dropping that half-arsed 10-15 minute massage or those 3 sets of 30 secs bouncing up and down on 3 or 4 levels of a patients spine isn't the end of the world. All I find that manual therapy does is wastes time, distracts patients, and doesn't really help that much in the grand scheme of things. Abandoning manual therapy now gives me more time to focus on the more important aspects of my job such as talking to my patients and getting them to move and exercise more.

However, I need to reiterate that just because I don't use manual therapy this doesn't mean I don't recommend that you don't touch your patients. I use touch to examine all my patients thoroughly although I know it often has little diagnostic use. I use touch during many of my sessions to help encourage, reassure, and assist patients to move or do things that hurt or cause them concern. I just don't use manual therapy.

Not doing doesn't equal easy

I am a proud and vocal advocate that as a physio you don't need any manual therapy to do your job well. However, I will admit that this is not as simple or easy as it sounds. In fact, there are some pretty significant barriers and hurdles to overcome with abandoning manual therapy.

The first obstacle is the ridicule and rebuke you will get from other therapists, seniors, and managers who use manual therapy. I still have many therapists attempt to belittle me for not using manual therapy, mostly osteopaths, chiropractors, and even the osteopractors in the US (yes that is actually a title some physios in the US like to use, more on that stupidity here).

These weak wristed, chino wearing pillocks seem to have some misguided delusion that comparing me to a personal trainer somehow insults, offends, or upsets me. These idiots with their freakishly soft overly moisturised hands truly believe that they are more skilled and more effective than me because they think they can feel and correct subluxed ribs, stiff spinal segments, or muscle knots (they can't, go see my google drive for the research that proves it).

However, I don't let these elitist treatment table based therapists bother me and I suggest you don't either. Instead, be confident in the large body of research that refutes all the pseudoscientific bull shit and take comfort that most of them couldn't work out one end of a trap bar from the other or demonstrate a loaded squat if their life depended on it.

Patients do want it!

What will be harder to overcome will be the barriers you encounter with patients who want, insist, or demand manual therapy due to previous experiences or expectations of getting it.

Unfortunately, the physiotherapy profession has a very strong societal reputation for giving massages and rubs. If I had a pound for every time I heard someone say "I bet you give good massages" when I tell them I'm a physio I'd be a rich man. As frustrating as this reputation is, those of us who know the real benefits of physio lie in rehab, not massage just tend to grit our teeth, have a little fake laugh, and politely explain that this is NOT what physiotherapy is about.

What is even harder to overcome is when a patient has had previous positive experience of manual therapy and wants it again. When this occurs, which it does a lot, I find the best way to manage this situation is by asking the patient what they think it does. About 99% of the time they have either been misinformed or believe that it does something which it does not.

After some rationale explanations around the more evidenced-based and simple mechanisms of manual therapy based on basic science and good evidence, I find most patients are normally a little surprised, but also not that interested in getting it anymore now the magic and mystique is removed. Some still don't care and still want me to rub or crack them, then I try and explain that due to its unreliable and short-lived effects that they are better of using a hot pack or getting their partner to rub it rather than me.

Now I'm not going to lie to you and say this works all the time, because it doesn't. Even after spending time and explaining this all I still have disgruntled patients who just want me to shut the hell up and crack their back or rub their quads. In the old days I used to bite my tongue and do what they asked, but these days I don't anymore.

I have made a commitment to myself that as an evidence-based physiotherapist trying to provide the best quality care using high-value treatments that I will not lower my standards and do soft tissue massages or joint manipulations which are non-essential treatments. This does cause some disgruntled patients and a few complaints and I am well aware that some will go elsewhere to get it from someone who is willing to do it. So be it. This is their right and their choice.

When this does happen I do still see this as a failure on my part in that I haven't been able to convince a patient that manual therapy is not needed nor essential and that they should instead be focusing on other things. However, over the years I have also learnt to recognise that you can't connect with or help everyone you meet in this job and there will always be wins and losses. I just try to make sure you have more of the former than the latter!

A respected profession?

So to wrap this up I just want to say again that manual therapy is NOT an essential part of our profession, and if you feel pressurised to use it when you deem it's unnecessary or not needed then I think you have a responsibility as an autonomous healthcare professional to challenge and question it.

Personally, I don't think manual therapy should be part of our profession at all. Physiotherapy is striving to be a respected evidenced-based healthcare profession, to do this we need to recognise what is high-value cost-effective treatment and what isn't. Manual therapy isn't.

Finally, I want to close by saying that I never became a physio to learn how to massage muscles or manipulate joints. I didn't become a physio to rub, poke, or prod people. I became a physio to learn how to assess, diagnose and manage pain and pathology. I became a physio to learn how to plan rehab programs to get those in pain or with disability back to function and performance. I became a physio to help people become as robust and as resilient as they can, and I am going to continue to do this. Who wants to join me?

As always thanks for reading

Adam