The Decline of Manual Therapy Skills?

For those of you who followed the #IFOMPT2016 conference on social media or were lucky enough to be there it was apparent that the pain revolution was at the forefront of the meeting.  Lorimer Moseley, Jo Nijs, Joel Bialosky among others were there and pushing us to consider factors such as emotions, pain mechanisms, and the overall neuroscience of pain when applying manual therapy.  If we could go back in time we likely would not have heard any of these concepts in manual therapy conferences of the past.  A person would not have even been considered to present this type of information at conferences of yesteryear.  As any profession should, ours seems to be moving forward as science pushes us along.

It likely comes as no surprise that I am ecstatic that our profession seems to be embracing our new understandings of pain. I used to be a toolbox-obsessed therapist for a good portion of my career.  No matter how many tools I added the more I seemed to fail with the same patients.  My outcomes seemed to be more tied to my new found confidence in the tool as, once the confidence waned, the tool on its own disappointed me. With all of this said it is refreshing to see that our conferences are no longer filled with a myriad of techniques with different explanatory models utilizing unreliable methods of motion palpation and palpatory positional diagnoses.   I know this last statement will draw the ire of many traditionally-trained OMPT.   Instead of getting mad at me I think we need to get mad at our literature and the logic that created the theories in the first place.

Traditional OMPT pain reasoning was all about the periphery

These theories were created at a time where pain was seen as a only a peripherally generated event.  As a result of our lack of understanding of this complexity we just made our theories of how the periphery holds the key to unlocking pain ultra complex.  This way when you failed to unlock these hidden mysteries of the periphery you could be told you simply do not have the jedi hands that are needed to sense millimeters of movement that are key to unlocking this mystery.  There became 18 different ways to title pelvic positional faults and we were told we should be able to determine if a meniscoid in a facet joint was at fault.  These theories nearly drove me from practice as it did a great job convinicing me I had crappy hands and could not feel all the faults everyone else confidently claimed they could.   IF motion palpation and palpatory positional diagnoses are so important then why has research failed over and over again to prove they are reliably detected and associated with outcomes.  It has long passed the time of put up or shut up for these theories and frankly when asked to show literature supporting them I am tired of hearing crickets.  In my opinion it is time we move on.

Theory created on faulty logic

The question though becomes when does moving forward mean unnecessarily leaving things behind.  We all have heard the classic, “well I’m not ready to throw the baby out with the bath water” remark.  My reply would be what if there was no baby at all and what you thought was a baby really was a clump of suds in the soapy bathwater. Some of the traditional manual therapy theory and beliefs seem to be founded on flimsy logic.  We basically theorized and created entire systems of belief and treatment based on often only  knowing or considering 1/3 of the story – the periphery.   Every positive change we achieved with this limited version of the story only served to strengthen the systems even though the clinician was often suffering from the post hoc ergo propter hoc fallacy.  The ability to modulate pain and produce short-term changes successfully with a myriad of techniques had clinicians traveling down various paths of creating their own systems or interventions.  I would argue the that skilled handling of a patient in pain is where I feel the true skill of manual therapy lies.  We can argue which technique is better than the next but the commonalities of “good technique” (especially when healing times have lapsed) are expert handling paired with non-specifics that create a context that maximizes the potential for change.  The change that results is much more complex than how well a facet is moving.  Whether it is a manipulation, a mobilization, or whatever we technique we trumpet to the patient, the commonalities remain the same.  As I have said before we need to stop getting so excited about short-term changes unless they are reinforced in a way that achieves true positive LASTING behavioral changes from our patients.

I am a physical therapist who uses manual therapy techniques

This is not to say there are not plenty of things we do in OMPT that remain vital to our practice.  A solid subjective and physical examination remains a hallmark of what we do.  Truly listening to the patient and learning their unique story from a biopsychosocial point of view is something the pain literature has pointed out as not being optional.  Being able to perform: a screen for red flags in a patient presentation,  vascular screening,  a thorough neurologic examination including cranial nerves, and a solid orthopedic examination are all things that remain important pieces of our practice.   Of course in the presence of tissue damage some movements depending on stages of healing and patient perception can be better than others.  Peripheral treatments can be perfectly ok when indicated.  Acute inversion sprains will not like to be moved into inversion for a bit and flexion strains to the back will not like flexion for a bit.  We need to be careful not letting the pendulum swing too far and start trying to talk someone out of their pain when there clearly are true peripheral “tissue issues” that need tissue-based treatment not simply pain education.  It also would be nice if we stopped giving pain such a bad wrap.  It is a vital output we all need for survival.  Sometimes a simple explanation of its normalcy  and usefulness can go a long way with a pateint.

The power of touch

The ability to touch a patient can be a powerful empathetic input to a patient.  We must never lose this ability to show this empathy, but we also have to recognize when our hands may be contraindicated.  In persistent pain states we often just become another temporary pain modulator with our hands and allow the patient to hide behind our hands instead of confronting the psychosocial factors and maladaptive behaviors/beliefs that drive their condition.   We all can see impressive change early on with peripherally-focused techniques that often fizzle when they miss the bigger issues driving the patient’s presentation.  Hence why we need to be bigger than short-term changes. Instead of just blaming the patient and letting them fall off our schedule to continue on their journey of endless professionals could we instead consider that the problem may be that we need to think beyond the periphery?

Do you feel manual therapy skills are declining?  What skills do we need to ensure are not left behind?

Mark Kargela

Mark has been practicing physical therapy since 2003. He spent the his career pursuing expertise in manual therapy treatments. When he recognized that manual therapy had limited success in chronic pain he began intense study of pain neuroscience and advanced training. He practices in Glendale, Arizona where he is a Clinical Assistant Professor and runs Midwestern University's Physical Therapy Institute. He also teaches nationally for Modern Pain Care and lectures across the country on spine care and persistent pain.