Shhhh! Don’t tell anyone… I still use manual therapy with some of my patients.

We’re writing this blog to explore the right, the wrong, and the grey when it comes to using manual therapy.

Manual therapy (MT) has become a four letter word in some circles, and there are reasons for this. For a long time, clinicians and researchers have searched for magic bullets to cure musculoskeletal pains; in doing so, we’ve created overly complex models with the trappings of theoretical plausibility to help us make sense of our world. Unfortunately, these misguided theories likely caused as much harm as good, and contributed to growing disability and medical costs as patients were labelled as having instabilities, rotated pelvises, upslips, downslips, subluxations, and other nonsense that needed to be put back into place. So where does this leave us? Do we toss MT, do we change our paradigm, or do we just flounder onwards?

To start the conversation we should explore what modern EBP physiotherapy should look like?

1. Care should reflect and recognize the elements that make us human: the biopsychosocial approach.

2. Instilling and/or restoring patient self-efficacy using active treatment strategies is paramount.

3. Healthcare interactions should utilise principles of therapeutic alliance and shared decision making.

4. Patient preferences and clinical experience should then guide what evidence-based treatment we apply and how we apply it.

NAVIGATING THE PITFALLS OF MANUAL THERAPY

There are some good arguments against the use of manual therapy:

1. It’s effects on pain and function are short-term and deemed low value.

2. Language surrounding manual therapy can be nocebic.

3. Manual therapy can lead to patient dependency and may reduce self-efficacy.

4. It interferes with natural history leading to prolonged disability.

Some arguments against manual therapy usually begin with its transient nature, discuss its low value and continue to point to its minimal effectiveness over the long term. However, this is by no means conclusive. In a well conducted trial for cervicogenic headaches, Jull et al. found that manual therapy and exercise were both highly effective in reducing headache frequency and intensity1. Similarly, Abbott et al. conducted an RCT which found that a manual therapy group and an exercise group had similar benefits on function and other physical performance tests in patients with knee and hip osteoarthritis that was sustained at one year2. Additionally, it has been demonstrated that patients with neck pain only receiving manual therapy recovered faster and more cost-effectively compared to GP care or physiotherapy3. Despite these findings, what is very clear from the research is that manual therapy is not a magic bullet cure for, well, anything. That said,

manual therapy can still have a place in multimodal musculoskeletal care; however, significant changes need to be made to the way it is typically implemented.

Traditionally, the clinical reasoning and language that has accompanied manual therapy has been complicated, confusing, and far from falling in line with the evidence. Past paradigms have focused on specificity, pathoanatomy, tissue changes, scar tissue... the list goes on. For the most part, these models were developed to help clinicians make sense of a MSK world of uncertainty. There’s a seductive complexity to some of these explanations, and it often takes earnest clinicians down a rabbit hole to a wonderland far away from what physiotherapists are supposed to be best at - exercise/activation and education. This kind of complexity has been known to take the ‘physical’ out of ‘physical therapy.

Clinicians who embrace these complex models often transmit this knowledge to their patients in an attempt to ‘educate’ and justify the use of their interventions. We’ve all heard patients tell us about how their physio told them they had twisted hips, a rib out of place, a shoulder that sits too-far forward, etc. These examples are seemingly benign, but they seed a belief system of physical fragility, and can grow into thought processes that lead to increased threat. A thought virus under the influence of genetics, previous exposures, the environment, and stress may easily manifest into a real and recurring problem.

LANGUAGE, CLINICAL REASONING AND DECISION MAKING - AN ALTERNATIVE APPROACH

Education delivered by well-intentioned therapists based on outdated patho-anatomical clinical reasoning models does not help explain pain, it can make it worse. The previous anecdotes from the clinical trench (twisted hips, rib out of place, etc) are all too common and the language that accompanies old school manual therapy is likely in part, contributing to a growing culture of pain and disability in developed nations.

The words we use can harm patients and we must consider what narrative to construct in order to explain someone’s pain. Not only can patients adopt these words as their new truth or in some instances their new self-identity, they often tell their friends, family and colleagues to keep the ‘thought virus’ fed, watered, alive, and well. These are just anecdotes, but consider the following study.

In a qualitative study by Darlow and colleagues, it was demonstrated that words from one or multiple healthcare practitioners had the potential of affecting a patients beliefs about their pain for years (up to 30 years in one subject) in a sample of subjects with chronic low back pain4. One of the subjects reported, “basically all I’ve kind of been told to do by physios is to work on my core...I’ve been tested by various different physios, and Pilates, and I’m apparently ridiculously weak....I had an abortion because I didn’t think I could have a baby. I didn’t think I could handle it...carrying it, and having extra weight on my stomach.” While this likely represents an extreme outcome, it does highlight the potential to impart a fragilistic narrative and brings meaning to the old saying that ‘negativity is a place for pain to flourish.’

To this same end, a recent article by Stewart and Loftus delivered a very clear message: language can impact the clinical outcome. Language has the power to tip the scale in favour of recovery or non-recovery as “words are capable of corrupting or enhancing thoughts…[they] can generate good or bad emotions and prompt actions that can lead to positive or negative behavior change5.” Thus a new saying goes: “sticks and stone may break my bones but words can sustain a injury.”

Let’s pause here and review. First, it is clear manual therapy provides short-term changes. Hopefully there is some doubt now that MT is conclusively ineffective in the long-term too (sorry for the double negative). Next, the language we use creates the context and narrative for all our interventions in some cases for the better, and in some cases for the worse.

With some of the potential pitfalls discussed what should manual therapy look like in a modern physiotherapy practice? Stay tuned for part 2.

1. Jull et al. A randomized control trial of exercise and manipulative therapy for cervicogenic headache. Spine. 2002.

2. Abbott et al. Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness. Osteoarthritis Cartilage. 2013.

3. Ingeborg et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ. 2003.

4. Darlow et al. The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine. 2013.

5. Stewart and Loftus. The Impact of Language in Musculoskeletal Rehabilitation. JOSPT. 2018.

About the authors:

Accelerated Motion Physiotherapy (AMP) is a passionate group of physiotherapists (Curtis Tait, Steve Young, Brad Jawl and Sean Overin) all practicing between two clinics: Tall Tree Integrated Health in Victoria and Vancouver, British Columbia, Canada.
We try and stay up-to-date with the research almost in the same way as you would read the local paper, but find enormous value sharing and discussing this information to see where it fits in our practice.
AMP delivers regular free online evidence-informed resources, hosts high-caliber speakers that present clinically relevant and evidence-based courses. We also lead courses and inservices grounded in critical reasoning touching on pain science, exercise and manual therapy.
We mentor kinesiology and physiotherapy students and physiotherapists, in addition to running education sessions to various health disciplines in the local community. You can find us on the web at www.ampphysio.com, Facebook (@AMPPhysio), Twitter (@AMP_Physio) and Instagram (@AMP_Physio).