One Last Fix!

I've been blown away by the response and feedback from my recent blog on abandoning manual therapy. In less than 24 hours I have had numerous emails and messages from many of you experiencing the same problems and pressures to use manual therapy by your colleagues, managers, and patients, not because it helps that much, but rather because it's expected.

It's great to hear that many of you now don't feel as isolated or alone knowing that others are in the same position. It's also great to hear that many of you are now prepared to challenge this culture around manual therapy, which is exactly what I hoped the blog would achieve.

However, there has been some criticism, some constructive, some not so much. This is good, it keeps me on my toes and thinking hard, and I always think it means I'm doing something right if I piss certain people off. There have also been a few fallacies thrown around such as I only critique manual therapy as I'm no good at it and that I need more experience and training in it.

Experience?

Well, there is no denying that experience and training can help you become a better therapist, but experience or training of manual therapy does not make you a better therapist. For example, some research has found that therapists experience, specialist training, and certifications do not improve patients outcomes with low back pain here. And, a systematic review here has shown that more experience may actually be a risk of lower quality of care, possibly due to overconfidence as discussed here.

However, the main point I want to talk about today is the most common justification I have heard from therapists for using manual therapy, in that is it helps patients buy into more active treatments such as exercise. I must hear this justification daily, and I will admit it was one I used to use and believe myself. I don't anymore.

The common belief that many therapists have is if a patient with back pain, shoulder pain, knee pain, or any other pain has a bit of manual therapy first it will help them do their exercises better and more often. This is unfortunately complete and utter bull shit.

There is zero evidence, nil, nada, zilch, fuck all... that patients who get manual therapy will do their exercises any better or more often than those who don't get manual therapy. In fact, there is evidence here that shows even using strong pain-relieving steroid injections in arthritic knees and subacromial shoulder pain here before exercise doesn't significantly improve the effects of exercise, so why would we think a bit of massage will?

Adherence?

There is no doubt or argument from me that exercise adherence of our patients when in pain is poor. In fact, it's terrible, as low as 20% as found in some research here. But don't be fooled or mislead into thinking that a bit of rubbing or poking will solve, correct or even significantly change this.

What will change patients adherence with exercise when in pain is talking about their concerns and worries, identifying any possible obstacles and barriers, and coming up with simple practical solutions to overcome them as discussed here. What won't significantly improve exercise adherence when in pain is a bit of massage or manipulation.

Over the years dealing with many types of people in pain I have come to the conclusion that the simplest and easiest way to get patients to adhere to their exercises when in pain, is to physically supervise, encourage, motivate, and reassure them as they are doing them. I find, and most research supports this, that around 6-12 sessions of exercise therapy (possibly up to 24 sessions for some) done under supervision over 3-6 months for most MSK conditions will ALWAYS outperform 6-12 sessions of any other type of therapy.

I truly believe that if more physios used their time and sessions with patients to actually do the exercises with them, sometimes multiple times a week, rather than faffing around with manual therapy and other passive modalities we would see far better results and outcomes. Patients then wouldn't then be tempted to seek other more invasive, expensive and risky treatments, and lets not forget that they would also get the many other positive health benefits of exercise as a pleasant side effect.

Yes ok ideally in a perfect world we would like all our patients to be motivated and dedicated to doing their exercises without us having to babysit them. But news flash people we don't live in a perfect world, we live in a world of reducing tolerance and low motivation, not to mention poor lifestyle choices and terrible health habits.

In my opinion, physios who spend their time with patients only talking, massaging, manipulating, poking or sticking them, leaving the exercise for the last 5 minutes of the session, handing them a poorly photocopied sheet of shitty exercises to be done at home are the bane of my life and a cancer in our profession.

This lazy, bone idle, disinterested, apathetic attitude towards exercise belittles and devalues the importance and benefit of exercise therapy for many MSK conditions. If a therapist is disinterested, bored, apathetic about exercise, you can guarantee patients will be as well. Is it any surprise that so many patients 'fail physio' with this lacklustre approach to exercise and rehab?

Weaning?

Also, don't think that by giving some patients a bit of manual therapy you will help move them away from wanting it, which is another common justification I hear for its use. I know there are patients who do only want a few sessions of rubbing and poking and then they will be fine, but there are also plenty of patients who ONLY want the rubbing and poking continuously.

I see a good few patients who are fixated on getting hands-on treatments and addicted to the crack, the joint crack that is. These patients only want a joint popping or a muscle rubbed and have little to no interest in the active side of their treatment.

Don't think you can change this by giving them a few sessions of manual therapy and then all of a sudden they will buy into what you want them to do. Giving a manual therapy 'addict' more manual therapy isn't going to help them want it less. 'One last fix' is often used as an excuse by many addicts but it often fails as it just perpetuates and continues the vicious circle of stimulus and reward. One last fix is never one last fix!

To break a habit a clean break is needed with support, motivation, and sometimes a distraction. The best way to move someone away from manual therapy is not to give them more but instead give them something else to focus on, like exercise.

Finally to wrap this up please remember that you don't need ANY treatment to keep patients coming back. Also, remember that focusing on getting patients to come back is actually a pretty shitty way to work. Instead, physios should be focusing on getting patients better and NOT needing to come back as quickly as possible. Also, remember that patients will return to a therapist who they trust and believe is able to help them with the issues and problems they have, and this has NOTHING to do with what type of treatments you do, or don't use.

As always thanks for reading

Adam