A Crisis In Manual Therapy. An Opportunity. But First a Crisis.

posted in: News 2

I wrote and published this blog in 2016 and though I’ve edited it very slightly for clarity, not much has changed in the professions. A lot has changed in my thinking.

These ruminations on manual professions and pain science are ongoing, but they have led me here (perhaps my next step in the journey for which there is no actual destination): The CauseHealth Project, through which I’m slowly exploring and developing a dispositionalist, multi-causal approach to the unique patient.

For me, this is the next logical step forward, If anyone is having the same kinds of questions and thought processes about what it means to be a patient-centered evidence-based practitioner, please join me.


Post Originally Published July 10, 2016

There is a crisis in manual therapy. All forms. Physio, Osteo, Massage, Chiro; none of us are immune. Things are changing, fast.

In 2014, Roger Kerry wrote a reflection of the past 20 years of evidence and information:  Evidence-Based Physiotherapy: A Crisis in Movement. He directs his comments and pleas to physiotherapists, but the message is just as apt for other types of manual therapy.

“Allow data – if sufficient – to free yourself from traditions and habits.”

“Human observational biases can be easily controlled for by intellect.”

Stop inventing complex and unnecessary classification and diagnostic systems.”

Touch people who need touching, this is therapy. Don’t touch people who don’t need touching, this is battery.”

“Heed pain science data, but stop fawning over pain scientists. …There are no gurus. … If you are a disciple of such trends, stop posting random quotes from random ‘pain’ therapists as if this were some sort of confirmatory proof of theory. It’s not. The easiest thing is to stop being a disciple, and start to think for yourself.”

See what I’m doing here? I’m going for irony, but actually, that last *quote* hits home.

health-guru in manual therapyFor many of us, the guru culture is a familiar one, be it a person, institution, dominant paradigm or all of these things at once. Thinking for oneself can be an unfamiliar practice within a modality profession. That’s not to say we are stupid, but we have learned specific types of information. Other types of information, like critical thinking to encourage thinking about thinking about the information we have been given – not so much.

New information, like pain science in manual therapy is being spread via a small informed group of people or organizations. Some of it through official channels, like conferences, but much of through social media platforms. Though it may seem like guru worship, it is really more like desperation from those of us seeking out this information that is, comparatively, thin on the ground compared to the paradigms in which we exist. Unlike the biomedical and biomechanical world views that most of us were educated within and for which there is an abundance of available information, the biopsychosocial (BPS) paradigm that is supposed to envelop the bio in with psycho-social is just coming into a larger consciousness in manual and physical healthcare.

The crisis I see is three-fold. One, that pain science and BPS information is currently getting to us after we have spent our money and are already convinced that we can change a person’s anatomy with our hands simply because we know something about that anatomy. Two, that it’s only getting to a few of us in any meaningful way. And three, that new information about the nervous Hostile to manual therapysystem, psycho-social factors in pain, and the seeming inefficacy of touch on a biomechanical level are threatening pieces of information. Oppositional to what we know. Upsetting. Transgressing. Attacking.

That makes the people delivering these messages seem hostile. We’re being told, in no uncertain terms, that what we learned to do, that what we DO and SAY on a daily basis, is essentially a bundle of BS wrapped in a bow. So why stop and listen?

This is a crisis. Because a large part what we do and say to patients on a daily basis is, often, BS. We are not bad people because of that, but we are misinformed, or not informed enough. The biomedical and biomechanical paradigms many manual therapists live and die by are incomplete, and not good enough on their own to make a well-informed clinical decision WITH our patients about their experience of pain.

A very large number of us are not educated to include psycho-social dimensions as part of our clinical reasoning, and within that there are a substantial number who are not even aware of the biopsychosocial concept. In osteopathy we believe we are always treating the whole person, so that would include the psycho-social factors, yeah?

This is a crisis.

What happens when the new information starts to filter through to our comfortable, neatly contained, busy-clinic biased world view? The new information that is different, threatening, transgressing, and hostile. The new information that threatens to change our established way of treating.

How do we change our beliefs in the face of continuing and unrelenting challenge to our established worldview? That’s an easy answer … with difficulty. But change we must.

For many this is where the crisis lies. It’s not that there is new information to process, or that the new information is largely contradictory to the old. It’s that change itself is a necessary, challenging, active, difficult, and ongoing process.

a manual therapy manualThe challenges we face to change from the old world view to the new are many. For starters, there is no congruent, wholly inclusive, well-defined, comes with instruction booklet manual-therapy-inclusive-of-BPS-perspectives world view to be had. This means we have to create our own way forward and base our explanatory model on the individual in front of us who doesn’t follow the rules, the one who upsets our structural, or biomechanical, or fascial, or musculoskeletal apple cart. The patients who don’t respond are the way forward, but we’re responsible for holding ourselves back.

Bias is probably our biggest challenge to overcome. Most healthcare practices and modalities are rife with the superiority illusion, where, for instance, each practitioner believes they or their profession are better and more skilled than their peers. Challenges to that kind of bias are not going to be taken lying down.

This is a crisis. To ignore is to remain ignorant.

Where there is crisis there is also opportunity, or so they say. It’s just that this kind of opportunity is a double-edged sword. The old model is working … for the practitioner. Having our own classification and diagnostic systems allows proprietary knowledge and helps to bolster the superiority illusion. It’s inaccessible to other healthcare professions, but also to the patient. That means that any positive outcome from the therapy remains within the domain of the therapy, and any negative outcome … well the patient doesn’t often stick around if there is no help to be found. The old model is working for some patients and that means it is still working for the practitioner. We can point to our successes, by name if necessary, and they can point back to us and say “you helped me.”

The old model does not work for all patients … but neither does the new. We can incorporate BPS thinking, change what we do and say, even how we think. But why? So we can tell our patients, with the utmost confidence, that there are no guarantees the journey we begin together will make a difference to their pain?

This is a crisis.

At the very least it’s a crisis of honesty. We need to make money, sure. Many of us work in privately funded areas of healthcare and uncertainty is bad for business. The therapist, the patient, and the bottom line doesn’t like it. Except that with all we know, reflecting on 20+ years of research and evidence in the manual and physical therapy fields it’s now undeniable that uncertainty IS our business. Even though we cannot offer a guarantee that a particular treatment will change our patient in pain, we can at least provide the tools and education for the journey our patient will, inevitably and necessarily, continue without us.

This is an opportunity.

2 Responses

  1. Nicholas
    | Reply

    This is an interesting post. However, why go after manual therapists, who leave no side effects, when there is not the same sort of attack towards giving medications? I say this, as I have heard so many Doctor’s, Physio’s, Chiro’s and Osteo’s, all who believe they are ‘for the patient’, but few to none (maybe except the Chiro’s) actually address the drug dependent culture, that actually underlies that whole problem?

    In my opinion, manual therapy, good advice, and some pain free exercises are often just what the patient is looking for. And giving in the right context, helps the patient get back to their ADL’s faster, with patient satisfaction. This, brings up what is important for the patient. Patients, know what they want. For example, a lot go to massage, they know when they’ve had a good massage they will feel relief. Or sometimes patients will come in saying they need their back ‘cracked.’ If it works for the patient, and they are seeking this, then tell me what is incorrect with that?

    And then some patients want exercise, saying things like ‘which exercises do I need to do?, when they have severe chronic shoulder and neck pain, headaches, knee pain, lower back pain. And these patients expect one appointment with some ‘magic’ exercise will fix them???

    The point I am making, is there is all this gun fire towards manual therapists, who understand the BPS model, and are doing their best to help the patient, from what the patient wants, to what the therapist can give, and what the patient will do, or can do.

    Thus, it is my opinion that the bashing up of manual therapists should stop. It is likely generated from the pharmaceutical companies anyhow. Why do I say that, they can fund large studies.

    My last point will be that the Guru, has earned his or her place, they can hand down valuable knowledge, that can never be learned from some narrow study.

    There is a place for everyone, so why always attack the weaker group?

    • Monica Noy
      | Reply

      Hi Nicholas, thanks for commenting. You write. “The point I am making, is there is all this gun fire towards manual therapists, who understand the BPS model, and are doing their best to help the patient, from what the patient wants, to what the therapist can give, and what the patient will do, or can do.”

      Actually this isn’t aimed at manual therapists who understand a BPS framework, quite the opposite. Most manual therapies come from a biomedical/biomechanical perspective and that becomes a problem when you have to provide an anatomical or biomechanical ’cause’ of pain in order to fix it. A BPS and pain science perspective understands pain to be multifactoral, anatomical variation to be the norm and movement alterations as quite possibly pain behaviours that are normal under the circumstances.

      As for the guru, they have not earned a place, they have created it with knowledge fabrications that are valuable in a monetary sense only to them. Knowledge of how manual therapy works is not proprietary, and despite the names we invent or the slight tweaks applied to standard techniques or modalities, there is nothing inherently new in how the nervous system works when they are applied.

      You also write: “In my opinion, manual therapy, good advice, and some pain free exercises are often just what the patient is looking for.” I agree. If the advice could avoid including telling the client there is something inherently wrong with their anatomy first, then we’d all be on the same page.

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