In this blog I argue that even under the guise of a good scientific explanation manual therapy (massage, manipulation, ART, fascial release) should be used sparingly, if at all.
The blog is written in a question and answer format as I think this best illustrates my counter arguments. I don’t want to be in a fight with “manual therapists” as I know awesome, respectable therapists who use these techniques. I do however, think it is worthwhile to answer difficult questions on the state of healthcare and how physios can best serve our communities. I am also writing this to clarify why I made the switch from manual therapy and passive treatments to a more active, “hands off” approach to care. So here we go:)
If manual therapy only provides a short term change why do you need it? If we agree manual therapy does not offer a long term solution, does it then create a reliance on us for pain relief? You can argue that it does no harm but the treatments, much like any medication, reduce a person’s efficacy for self-management. With the best intentions this is hard to avoid.
If certain care providers have a full hour to provide manual therapy why would a physio chose to spend ten minutes on manual therapy in an environment that cannot compete with a nice massage clinic or spa? Again if we agree that our job is to help patients self-manage and understand their condition shouldn’t this take up a greater portion of the hour? I agree that manual therapy feels nice and can relax our system but why not spend our time on the more difficult work of buy in, behaviour change, motivation, and self management? Leave the feel good treatments to someone who can do it right, start to finish (Adam meakins talks about this at length here).
Don’t you want to reduce a person’s pain? This is touchy but I no longer agree that our sole purpose is to reduce people’s pain in the short term. I think for too long healthcare has done everything in its power to stop pain. I don’t think this is a good. Pain can be a part of a healthy life. It shouldn’t consume us and limit us, but reducing it all the time has costs. I believe the more patients feel pain, understand pain, and work with pain the better their ability to self manage will become. Take this scenario: a young age athlete takes Advil or Tylenol any time a bout of soreness arises. The athlete has always quickly managed pain. This works at the beginning but as training intensifies the medications loss their effect. He seeks care from a PT and their treatments help alleviate his pain. It seems harmless but the treatments have further engrained the notion that pain must be stopped. These treatments slowly lose their effect and he either reduces his activity and / or seeks out more and more alternative treatments. I don’t think this is an uncommon scenery and I for one don’t want to be creating a new generation of patients who rely on us for pain reduction. When a patient comes to you seeking pain relief you have to be prepared to challenge their beliefs and their expectations. As medical professionals you have a duty to provide best care, not just meet expectations. This isn’t straightforward, it can be a dance, but if your are a good clinician you can find ways to alter expectations.
I am going to assume that manual therapy is only a percentage of what you do in a treatment – say 30%. If your goal is to create empowered, confident clients (we know this is difficult) shouldn’t you be spending more time on tools that will help you reach this goal? Similar question, similar answers. As a physio you have to decide how you fit into the health care system. I see as us as rehab specialists and experts in healthy exercise. One of the biggest challenges in both rehab and exercise is the implementation and long term follow through of a plan. If a tendon can take months to heal, is it not in your best interest to focus on creating long term action plans, answering questions, providing exercise guidance, creating fall back mechanisms, and identifying barriers? Empowerment, is hard and I for one don’t want to waste a minute of time on treatments that take away from this.
Why do we assume patients will quickly understand the neurological explanations of manula therpay when we know if takes multiple sessions to change a patients perception of pain and healing. Manual therapy effects the neurological pathways between the brain and the injured site. It does not put things back in place, lengthen, or melt tissue…it modulates or changes chemical signals through the nervous system. This makes sense to a physio but for the general public the concept of neuromodulation can be confusing. Instead of patients thinking we fixed their boney structures, they think we fixed their nervous system. They are correct to shift their focus from bone to nervous system, but the implication of “fixing” is still apparent. It is hard for patients to make the distinction between hands on fixing and hands on facilitation (another common term now used to explain MT mechanisms). Isn’t it more powerful if you can get the patient to facilitate their own recovery? As Lorimer Moselely so elloqunitly says, “the body has an irresistible urge to heal, we need to stay out of the way or help facilitate it.” We should facilitate healing through self-management not manual therapy.
What do you if a patient is in an acute stage of back pain and is moving with difficulty. In this scenario you might need to use your hands to support the client through movement. You might touch their back while showing them short term alterations in movement to allow for better function. You can reassure them the pain will subside with time, that some rest is ok, and that learning to manage the pain will set up them for greater success over the long term. Even in acute scenarios it does a disservice to clients to lie them down to poke and prod. Anytime you go to passive treatments, even with the best of intentions, you run the risk of patients fixating on a specific treatment. If your goal is to relax the patient there are plenty of self-management tools you can teach them. They will relax in your clinic and leave with tools to relax at home.
When you chose to offer a multiple treatments within a session, are short changing your patients? Patients often face a breadth of challenges to recovery – limited time, understanding, fear, cost, etc. I believe meeting the breadth of challenges, with better depth in treatments is key to good care. If you commit to discussion, education, exercise and planning as your treatment tools you can offer better depth. If you split time between treatments you risk losing the full effect. With focus, your clients may actually leave the clinic with the tools and empowerment to get better on their own in a timely fashion. Let’s look at reverse scenario: A patient goes for a massage. The RMT spends 50 minutes providing great self care, soft touch, and a relaxing environment. The RMT, then proceeds to tell the patient that they are tight in their hips and should do a stretch to relieve their pain. The patient leaves happy with the massage but confused about the tight hips and the prescribed stretch. Why are my hips tight? How often should I do this? I already stretch, do I really need more? Oh shit I am tight, that can’t be good. I think you would agree this scenario is not ideal and I many physios fall into the same trap – I know I did!!. When you do manual therapy and are squeezed for time you end up offering mediocre treatments.
I think a clinician of the future is a master of listening, motivational interviewing, behaviour change, and creating relationships. They will be able to offer management strategies for pain, action plans for exercise / load management, and follow up / follow through strategies to keep patients on task. They will use touch to relay care and empathy, as a crude diagnostic tool for certain conditions, and to promote movement through certain exercises. They will be tactful in their efforts to alter expectations. They will be ambassadors for preventative care but also aware of their limitations and refer on when necessary.
So there you have it. A few of my answers to why I think physios would serve their patients better my limiting their manual therapy and focusing more on self-management and behaviour change strategies.
Thanks for reading
A good list of resources on effects and mechanisms of manual therapy.