Manual Therapy: Neither Panacea Nor Gateway To Despair
It is uncontroversial at this point to suggest that manual therapy doesn’t “work” for the reasons many of us have been taught. Muscles and joints aren’t so malleable that any manual therapy technique is capable of inducing immediate and lasting histological changes. Manual therapy can improve mobility, desensitize provocative movements, and alter one’s experience with pain. Manual therapy does seem to change something (sometimes), just not tissues. The research in this area is pretty definitive and futile are further efforts to legitimize manual therapy with explanations that are solely tissue centric. Additionally, while manual therapy appears to “do something” the effects are often either non-specific or experimental designs are unable to tease out specific effects.
That the mechanisms and specificity (or lack thereof) of manual therapy are not fully understood does not justify the anti-manual therapy backlash that is being perpetuated in some physio circles. To be sure, physios who perform manual interventions shouldn’t deceive patients into embracing theoretically implausible explanations to justify a particular technique. Additionally, every effort should be made to maximize a patient’s self-efficacy and reduce dependency on the practitioner. Nevertheless, manual therapy, when responsibly applied, need not promote psychological fragility or enslave patients to their providers. Paradoxically, some of the same people who vehemently oppose manual therapy for the helplessness it allegedly perpetuates are adamant about the robustness and adaptability of anatomical structures. Why must the spine be more resilient than the psyche? Demonizing manual therapy in this way promotes a false dichotomy between passive and active treatments.
Is it inconceivable that non-threatening therapeutic touch might allow a patient to return to the things he/she enjoys even in the absence of any other interventions? Self-efficacy is generally preferable to passive treatment but some patients aren’t interested in altering their behaviors. They shouldn’t be patronized about the importance of finding more time to help themselves. Some people’s professional and personal demands are overwhelmingly extensive. They might have neither the time nor the desire to implement self-care strategies outside of the treatment session. Periodic manual therapy might make them “feel” better while improving objective tests. Of course every patient is unique but these people don’t necessarily turn into helpless wrecks after they receive passive treatments. Instead, many of them return to assuming an incredible degree of responsibility in their personal and professional lives.
Other people prefer to be educated about movement and lifestyle modifications and don’t tolerate manual therapy nearly as well, particularly chronic pain sufferers who have been through the medical ringer. What “works” for a high level athlete or busy executive might be calamitous to somebody else, which is why we can’t generalize best practice from specific subgroups. Moreover, not every patient within a particular subgroup is identical. One can appreciate data collected across broader populations while also refining the plan of care for individual patients. Unapologetically embracing n of 1 need not render one dismissive of research or “evidence” to which it is often fallaciously referred. Published research is not the same as DNA or fingerprints at a crime scene, though what is known empirically about a particular phenomenon generally provides a solid cardinal direction when leaving port for clinical waters. However, burying one’s head in a compass does not ensure safe arrival at the destination. The implication that manual therapy is generally synonymous with defeat or disempowerment is intellectually dishonest.
Moreover, assuming an identical outcome, why is a “non-specific” manual intervention less legitimate or virtuous than a “specific” non-manual intervention provided the former is acknowledged as such? What if the non-specific intervention yields superior objective and subjective outcomes? These scenarios are completely plausible, ones that physios who overly fixate on mechanisms rarely discuss. What medical professions achieve clinical success solely via specific effects? Even many of the benefits associated with exercise are non-specific. So what? Exercise probably yields the greatest overall health rewards at the lowest risk regardless of the mechanisms involved. Puritanical and impractical is the notion that all physio treatments must achieve some utopian level of specificity and self-efficacy. Fortunately, the specific/non-specific dichotomy posed here is abstract and not an either/or clinical decision.
Some physios are emotionally and commercially invested in manual therapy nihilism. The identity of other physios is contingent upon “fixing” patients with their own hands. Neither position advances the profession. Outpatient physio has become too compartmentalized. Physios discredit themselves when they inquire about providers in a particular geographical region that are certified in a certain continuing education model or singular intervention. This type of tribalism is becoming all too pervasive and undermines the profession because it equates acronyms and tools, including manual therapy, with proficiency. Physios should demonstrate competence in every academic and clinical domain pertinent to the population they treat. Medicine is not lacking manual therapy specialists or manual therapy deniers. Specialization is not warranted in outpatient physio as it is in some surgical fields. But for the emotional and political cliff from which they hang, professions that define themselves by specific tools like manual therapy, spinal manipulation, or penetrating the skin with medication-free needles are obsolete.
Manual therapy can be ego driven. It can provide a theatrical platform for a practitioner to display his/her skill. Conversely, manual therapy opposition can be self-promoting pontification in disguise. Intransigence is typically maladaptive when so many variables influence an outcome. Not all statements deserve to be met with an open mind, however. Everything can matter to the point that nothing does. Often though, ego and the seduction of certainty confound the knowledge and context through which claims about manual therapy should be filtered. Anti-tribalism and diversity of thought allow for a more authentic filter.
Manual therapy is just another way to baby step...
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