What is Skilled Manual Therapy?
There seems to be a rising conflict in physical therapy in regards to the use of manual therapy. We have some who say we need to abandon it completely and that the short-term effects it generates are not worth the hands on care and possible dependence it could generate. On the other extreme there are some who feel we still need to be doing very specific fine segmental specific mobility assessments, positional palpatory assessments/diagnostics, and basically still feel peripheral biomechanical and pathoanatomical issues are the prime issues driving a pain experience. This leaves many of us concerned that people are extrapolating the lack of long term effects of manual therapy as reason to abandon the pursuit of skillful handling of a patient in pain and skillful assessment of tissue loading responses and the resultant skillful treatment with specific active or passive tissue loading or movement strategies that may result. Yet my concern also is that we cannot look at manual therapy and the patients who get good outcomes and simply chalk it up to the theoretical mechanism of effect that is based on a few flawed research studies and someone who teaches it in continuing education coursework. The mechanisms behind a manual therapy effect are very complex (1,2).
Science Demands Skepticism
The definition of skilled manual therapy is one that, in my opinion, needs to shift from past considerations. Prior to our improved understanding of the homeostatic system’s roles (3) in pain modulation, theory in manual therapy was dominated by peripheral explanatory models when it came to treatment effect. Research was dominated by peripheral biomechanical and pathoantomical theory around pain. It was the theory that had someone tell me my hands could detect a facet meniscoid causing a joint dysfunction. Due to this peripherally dominated view, skilled manual therapy was thought to be the ability to have masterful hands to detect millimeter movements or positional faults that were the main driver of the pain experience our patients come to us with. In light of our modern understanding of the complexity of pain, it makes sense to me that when this limited understanding of pain and peripherally focused treatment failed to generate significant improvement in outcomes. In the face of outcomes not improving we just continued to make our theories more and more complex to the point you could take manual therapy course level XXXLVI.
These theories were simply the product of our level of knowledge at the time. People were not creating them with malice in their hearts. They were creating this theory because we needed something to guide our efforts in achieving what I believe is the common goal we all share – HELPING PEOPLE. Very high level scientific thinkers of the past believed the earth was flat. Were they bad people? Were they dumb? NO!! In this case and in many cases in the history of our progressing understanding of the world people were simply wrong and that’s okay. Kudos to those in our profession who made efforts to better understand our craft by theorizing. What does this mean in PT? It means that many newly minted and even gray-haired experienced clinicians will hold beliefs and practice in ways that science is questioning. The best approach is to respect the other person’s view but never stop considering the earth may be round despite the prevailing theory that some still ascribe to is that it is flat.
In the care of those in pain, once healing times have passed is where many theories have been created to explain this. Many of these theories often directly oppose each other yet they both can have very happy and satisfied patients. What gives????
The problem in my mind is when we park our beliefs and thoughts in theory and bias our thinking when science is clearly questioning things. A recent podcast pointed out that in fields such as psychology the length of time a research finding takes to be proven false is 7 years. This is more reason to never conclude that we have it all figured out and that includes our understandings of the science of pain. (Sorry students, your learning doesn’t stop once that degree is conferred.) Science is not stationary and does not work by us just trying to prove ourselves right and seeking and interpreting data to fit our confirmation bias. We can create quite an insulated echo chamber of confirmation bias in our practice by selectively attending manual therapy courses/conferences and read literature that supports our biased views. That goes for any treatment or view. Alternatively we could adopt a degree of professional skepticism in regards to our theories and look for ways it may not fit instead of ways to prove our bias. We could purposefully listen and read articles and critiques against our beliefs and views. Science works that way. In research we should not be looking to prove how we are right, but to take what we think is right and see if we can prove it wrong or not completely correct. Proving something right is okay to do in the clinic when we are testing hypotheses to determine what is right for the patient in front of us but it creates a huge amount of bias in research.
Pain is a massively complex phenomenon and to best understand it we are going to have to look outside our professional body of knowledge. (I recognize that his is not the entirety of all that goes into the pain experience)
Tissues Do Matter
Let’s move back to talking about manual therapy and specifically around the spine. It is important to understand that spines do get injured. Sprains, strains, disc herniations, and other injuries occur. Often injuries may require specific treatments or movements to improve the course of recovery. We have no issue telling someone to avoid inversion after an acute inversion ankle sprain yet when we tell someone to avoid movement at the spine temporarily people get uncomfortable. When you watch some of the results of well meaning therapists putting people in movement jail you can understand the discomfort. There is a place for specific peripherally-aimed treatments. We just need to have a process to test this hypothesis and not go into treatment encounters assuming there is a true tissue issue and have an understanding of the complexity of pain. Speaking from my own personal experience, there was a time when I had an acute disc herniation that flexion made things significantly worse and it was best for me to avoid it for a period of time and focus on movements that were comfortable and kept me mobile. The key for me is that I did not put myself in movement jail and confine myself to a life of avoidance. Tissues heal and the worse thing we can do is put them in movement jail.
Using Symptom Response
Despite the claims of some theories out there, most often in clinical practice we are going to have a difficult time determining what specific tissue is at fault. This is why symptom response often is a much more reliable way to determine treatment effect and why McKenzie and Maitland reasoning frameworks really re-invigorated my career as it freed me from the paralysis by analysis I was suffering from trying to discern mm differences of position or movement. These attempts to be extremely specific in our treatments for some populations also has been questioned not only by my frustration but by research (4,5,6). The symptom response of pain has seemed to be the more reliable finding with segmental assessments(7,8). To help us better understand tissue contributions a comprehensive examination strategy is important. We can use it to determine if there are specific loading responses present that may indicate there is a peripheral nociceptive driver to the patient’s condition and thus warrant a specific tissue loading or unloading strategy to help. Let us be honest here, it is impossible to be 100% certain in this pursuit, but to me it is a worthwhile way to reason and test your hypothesis with the human in front of you in your N=1 encounter. We also must not forget that the context around any treatment can exert powerful pain modulating effects and most importantly be willing to give it credit when it deserves it.
The Common Thread in Successful Therapists
I have had the privilege of working with some amazing physical therapists. Some of them were amazingly skilled manual therapists and some used manual therapy minimally. One thing in common was a masterful way of delivering their treatment narrative to a patient. The skillful delivery of technique, the supreme confidence that was unwavering even in front of the most skeptical patient, and the overall positive healing context they had created in the treatment encounter were impressive to witness. These are the “soft skills” that cause a novice who has mastered the technical aspects of technique not achieve the same clinical outcome despite the technical performance being similar. The lack of context engineering is often the major limitation in these instances. I would love to go back in time and tell myself that especially when I was on the verge of quitting physical therapy. I just concluded I stunk and couldn’t feel what all these instructors were telling me to feel. As I reflect back I believe the reason I came to the brink I refused to lie to myself and convince myself to believe something that made no intuitive sense. I would have saved a ton of time and money if I had only realized this sooner in my career. This does not mean that we just should scrap all training in technique. Skillful technique is the foundation of creation of a context of change for a patient. It is being able to apply passive movement masterfully in a way that communicates empathy and support to a patient’s homeostatic system that best generates a sense of safety whether through specific loading/unloading that creates a reduction of peripheral nociceptive drive to possibly simply maximizing top-down positive pain modulation. The key is to recognize that we’re truly just playing with processing and always recognize there is a suffering human attached to the tissues we are touching. The most important thing to recognize is that our passive treatments do not exist in the context of their life outside of the clinic where their thoughtless fearless movement truly matters.
Not Often Helpful with Homeostatic System Dysfunction or High Central Sensitivity
The other things I saw in common was the inability to help the highly centrally sensitive patient or patient with homeostatic system dysfunction in the majority of cases. Occasionally if the narrative a therapist provides can generate a shift in thinking, belief, and behavior then powerful changes can occur that have little to do with peripheral mechanisms outside of an input delivered to a homeostatic system primed to react positively from the context surrounding the intervention. The challenge is whether the therapist will have their technique take the credit in this case instead of the context surrounding the technique. When we use comparable signs in centrally sensitive patients, we can find them everywhere and I would argue where we find them is more to do with the bias of the clinician than the specifics of the patient. When after passively poking and prodding the patient to the point specific passive or active mechanical loading strategies failed it is common to go with an old mantra you just need to “find the hurt and hurt it”. The science of conditioned pain modulation and endogenous analgesic mechanisms in the body now make that make that approach make complete sense (9). It definitely worked on some, but I have also seen it make people much worse. The problem in manual therapy reasoning is that we often do not consider the fact that the central nervous system and the contextual mechanisms are always in play with every patient and it is important to understand to the best of our ability if they are helping or hampering us. Truly, I think a lot of manual therapist at least take some of this into account implicitly but the problem occurs when the instruction of manual therapy fails to include this thought. The key skills that are a must in manual therapy instruction in my opinion are listening to your patient’s story and the expectations and beliefs they carry with them that shapes their nervous systems perception and response to the touch and treatments you deliver. If your goal with a patient is to apply a technique to change their pain would it not be common sense to go in with the best understand of pain possible? To me any clinical reasoning framework MUST have some consideration of this if we are going to align our thinking with what science is telling us in regards to pain. Manual therapy coursework that does not discuss this is behind the times…period.
Maybe the Best Dance for Patient is a Solo?
Another thing I saw in common was a bias to see the human pain experience and attempt to affect it strictly through peripherally applied passive or active movements/loads with assessment of responses. Some went on symptom reports of patients, others use a combination of symptom response and what they were feeling in their hands, while others relied more strictly on what they were feeling. Now this is where people flip out. We all know the reliability of palpation for motion assessment and all other sorts of speculative faults or peripheral issues. One thing that is hard to capture in a highly controlled internally valid RCT is the human to human interaction skill. A highly controlled and often scripted treatment often does not allow for this skill to affect things.
Research has shown though, that a clinician’s beliefs will often affect the way they interact and the results they will achieve and has affected results of studies (9,10). This should not be surprising to us. If I am well versed in the waltz, then I will be much more effective at producing a dance of beauty with my partner than if I am trying the lambada for the first time with a partner and step all over her toes and produce an experience that causes cringing from those watching. It was the same cringe my possible partners back in PT school had when they faced the possibility of partnering with heavy-handed Kargela in manual therapy lab.
The ability to communicate with touch and feel when a patient’s body is more relaxed and amenable to movement is the dance we are all in. The problem here is that there are a million different theories (or dancing styles) with their own specific tissue target that can garner this response. As Benedetti has shown us, there are many factors outside the strict proposed theoretical mechanisms of treatment effect that exert influence on a positive clinical improvement. These are the common factors, that quite possibly could be the reason we can have so many theories out there which often are in complete opposition of each other BOTH get good outcomes. I would argue that many dancing styles have much more in common than they consider and really are not that different when we look at the all that goes into a treatment outcome.
Clinical reasoning and our understanding of treatment effect is very limited when we just see it is a linear process
OR ITS MORE COMPLEX…..
Fabrizio Benedetti has done amazing work to show us all that surrounds a treatment that can impact the treatment effect. An uncomfortable question that we must be willing to ask ourselves is “Is the positive response to my treatment due to the theorized mechanisms of the intervention or is it the context around the intervention and the resulting meaning response that a human ascribes to the context I created?”
There are times where specific movements and loads work best as in my example when extension and temporarily avoiding flexion helped me manage symptoms. Some patients will prefer the waltz while others may prefer the lambada and this is where expectations come in. The dances that felt best for me in my time of back pain were active movements into extension and shift correction and passive mobilizations that were adapted to my best symptom response. Being flexible and creative in treatments is something I thank my training in the Maitland concept for. Watching people like Peter O’Sullivan strip movement, postural, and core stability rules from people and letting them move freely and in a relaxed fashion was also a huge game changer for me. The focus now is designing treatments that show a patient a path to regaining their unique valued activities in life. My dance repertoire is ever expanding and it usually is dictated by the patient and not me.
Humans and The Pains They Experience Are More Than Their Tissues
Skilled manual therapy is also the skill of the dance we have when interacting with the human in pain and finding ways to get them moving more confidently, fluidly, and in a relaxed fashion. We better understand what dance may work best by listening to the unique story of each patient and what their preferences and expectations are. We also can recognize that our favorite dance is not the only one out there that may work well with the patient. We often encounter patients who are scared to dance at all or their life is devoid of any dancing or joy. Their life is a full time job of trying to fix and/or control pain and dancing is the least of their concerns. They need confidence to explore dancing and empowerment and to be sold on themselves and not simply sold on another dance led by someone else besides them.
Skilled manual therapy is also recognizing when the same could be accomplished without the use of our passive treatment and to have humility in our abilities. We have some amazing clinicians researching manual therapy and we have yet to see anything that produces significant benefit past the short-term. Many manual therapists recognize this and do not spend day after day performing manual therapy on the same patients.
Lastly, skilled manual therapy is understanding the complexity of pain and all that goes into a treatment encounter and response to hands on care. Our speculations need to broaden to consideration of the spinal cord and scrutinizing brain. People thoughts, fears, beliefs result in changes in their physiology that we previously would only have considered tissue-based explanations for. Manual therapy education must start incorporating this type of considerations in application of technique if we are truly to move our profession forward. Are we any different than non evidenced-based chiropractors clutching to subluxation if we continue to clutch to peripheral explanations for our treatment effect?
Let’s put it all together. Skilled manual therapy is the ability to test and recognize when specific movement strategies or loading strategies are necessary. It is removing the chains of immensely complex movement assessments and a greater focus on symptom response that is coupled with a modern understanding of pain and which informs what the possible factors are in a reported change in pain or improvement in motion. Skilled manual therapy is the therapist being humble to step out of the hero role and teaching patients to lead their own dance in life. If manual therapy helps a patient in that journey then I am all in!
Time for Manual Therapy Die?
To say manual therapy should be abandoned is a bit extreme for me. It would be nice if people in pain independently would confidently return to thoughtless fearless movement on their own accord. Unfortunately, we live and practice in a culture that reinforces disability and dependency. We also live in a culture where humans have evolved to seek a “healer”. For some people healing means touch and sometimes specific touches or manual guidance can be helpful. We cannot control what beliefs and expectations reach our door. Our skilled touch can be necessary and comforting but in the end it also can be limiting and recognizing when we may be limiting our patients is vital. Our end goal should be to have a human being that can function within the confines of their world where our touch is not available to them.
Many people trained in manual therapy have declared themselves manual therapists with their treatment becoming their identity. As for me, I will always be a physical therapist who employs manual therapy techniques. I cannot define myself on a technique that has good research for short-term benefit but minimal long term. For me, to so strongly identify with a treatment creates too much opportunity for bias. That bias is one that can easily make it hard for a clinician to consider other things besides the theoretical mechanisms of effect of their intervention to be generating the outcome. I already have a bias for manual therapy and use it regularly, but the biggest improvement in my practice has come when I realized when not to use it. I know many manual therapists also use it as part of a treatment package that moves away from passive intervention and toward active patient-driven movement and self-efficacy.
Time for Manual Therapy to Grow Up
Manual therapy, like any field, needs to mature the science it uses to support its use and gain some humility. The best thing I ever did as a human being, let alone physical therapist, was deciding that it is okay to be wrong. In science you better have a thick skin as the moment you propose theory there will be people lining up to tell you you’re wrong (as they should). Those are the people to engage with and learn from provided they stick to criticizing the theories and ideas at hand and do not resort to attacking the person proposing the theory. Let’s not declare mastery and stop our pursuit of greater knowledge around the why behind our outcomes. We should be relieved that pioneers of discovery in science such as Einstein didn’t simply join the crowd of those patting each other on the back and chose to challenge accepted beliefs given to us from Isaac Newton and others. The insecurity I have seen in our profession by some of its leaders in the face of criticism has been truly disappointing. Too many people are too invested in being right in their beliefs around manual therapy. It is not the solution to every patient’s problem. There are a many people with episodes of pain who do not hit any health care practitioner’s schedule. Those are people we should be talking to, studying, and learning from.
Manual therapy does not need to die, but it risks committing suicide if it decides to park itself in theory science is swiftly passing by. It cannot become a static field. Patrick Wall said it nicely when he told a group of clinicians, ‘if we are so good why are our patients so bad’. Pain is only getting worse in the world. We can grow with science and be a part of the solution or we can park our knowledge in dated beliefs. If we are truly about the patient then choosing the former is a no-brainer.
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**Footnote – I am not the authority of manual therapy. I reserve the right to be wrong and update my thinking. Any manual therapy teacher (or teacher in general for that matter) should have this in their course manuals and syllabi. Students and young clinicians, please retain a skeptical critical process of inquiry in regards to manual therapy when discussed by me or anyone else including those with gray hair. Also please refrain from the ad hominem attacks or the classic, “well Mark must struggle in manual therapy and not have spent his 10,000 hours developing skillful hands so that is why he’s critiquing manual therapy”. Develop a way to think, critically analyze, and test theory even if it is a N=1 setting.