Manual Therapy – Where is it Going?

Over the past several months I have been thinking a lot about manual therapy, specifically the future of manual therapy.  Obviously there has been a large amount of literature diving into the topic of manual therapy within physical therapy, but where are we going now with our research?  Is manual therapy “all that”?  How do we blend it with other interventions?

If you haven’t had the chance to read the latest JMMT editorial by Drs. Paul Mintken, Jason Rodeghero and Josh Cleland, be sure to check it out here.  The article urges the reader to understand the complexity that surrounds the effects one may see within the use of manual therapy:

“The successful use of manual therapy depends on a comprehensive understanding of the complex interplay between multiple inputs, including the patient, the provider, and the environment. Relying simply on biomechanical mechanisms is a recipe for failure.” (Mintken, p.2)

This is a powerful statement.  If you want to dive into a recent article on the complex mechanistic interplay of inputs (and outputs) within manual therapy, read this recent article by Joel Bialosky and colleagues here.

Mintken et al go on to close their editorial with this quote:

“We need to embrace contemporary pain science as well as neurophysiological, psychological, and non-specific patient factors as potential manual therapy treatment modifiers to maximize our patients’ outcomes [19]. Saddle up, the future is now.” (Mintken, p.2)

This editorial, along with the Bialosky article, shows the progression of understanding behind manual therapy over the last 10 years.  I can’t help but think about what the future of manual therapy will look like, both in research and clinical practice.  As Collins et al state in their 2017 JMMT editorial regarding the future of manual therapy, we should have:

A focus beyond differential diagnosis, with an explicit clinical reasoning process for the application and sequencing of OMPT techniques, allows PTs to address the complexities of the entire movement system and its interrelationships. (Collins, p. 3)

I believe the future will continue to build on our clinical reasoning processes.  The future will look beyond the explicit use of manual therapy alone, but in addition to other interventions we commonly use like exercise and expanding our patient’s knowledge of pain.  I believe that we will see that manual therapy is not a passive intervention – that our brains are highly active during manual therapy – even if we are not moving.  The future research of manual therapy must work to include measures that help us understand the interplay of the many factors surrounding treatment effects.  Finally, I hope the manual therapy world will hear other people’s views and thoughts on its use, even if the message is that manual therapy sucks.  We need to challenge our biases in order to progress.

So, those are my thoughts, where do you think manual therapy is going?

@ShepDPT

16 responses to “Manual Therapy – Where is it Going?

  1. gb says:

    As I sit here day in and day out reading all the latest insights into the mechanisms of manual therapy I can’t help but wonder…where has everybody been?

    At least 12 years ago now I stumbled upon a specific blog site called Soma Simple and manual therapy had been discussed along these lines way back then…to significant push back despite overwhelming scientific and evidence based support.

    Manual therapy is a fine tool to use. As Diane Jacobs has stated….we are essentially primates with an evolutionary affinity towards touch. Manual therapy is not an operative tool….it’s an interactive one and yes…it’s the nervous system which is the target.

    http://humanantigravitysuit.blogspot.ca/

    1. Mark Shepherd says:

      Thanks, gb. I think we can all agree that all of these mechanisms behind manual therapy make sense and most probably say, “well, duh!” I think what may have happened over the years was people putting manual therapy on a pedestal – where ego over “my skill” was greater than any other factor. Chances are the person with the “ego” was convincing and confident with their touch which ultimately increased the treatment effect. I applaud the researchers who have really pushed to look into more factors beyond the technique used (i.e. equipoise, expectations, etc.) that play a role in the overall effect of care. This will help broaden our understanding of skillful touch.

  2. Ina Diener says:

    Thanks, Mark. Thoughtful write….. In my opinion there is a place for manual therapy – from its local physical value, to its distant neurophysiological value, to its ‘touch’ value…………..,,,,,,,,,,,,,,,,,
    I think there are 3 reasons why we are at this point today:
    1. Neurophysiological pain mechanisms in acute and persistent pain conditions did not get enough attention in undergrad teaching
    2. Clinicians [and especially the ‘specific joint approach disciples’] do not engage in good clinical reasoning to decide WHAT they should be treating: ‘an issue in the tissue’ or ‘targeting the brain’
    3. Many manual therapists do not combine their ‘passive’ pain relief with exercises/active movement – to sustain the benefits….
    I still vote for the combination of manual therapy + active movement/exercise + education.

    1. gb says:

      Although I believe the essential debate will end up being…what defines manual therapy?

      And I am going to say that the more coercive the technique (like manipulation) the better the short term placebo but at the expense of long term nocebo.

      Same goes for TDN.

      Some will argue that these techniques “open a window of opportunity” but I’d challenge that.

      It’s near impossible to strip those techniques of their mythical effects regardless of how we try to. They have ingrained cultural beliefs attached to them which presents challenges from a self efficacy stand-point.

      And to top it off…the bulk of the literature suggests these techniques are no better than others.

      The sooner we recognize that manual therapy is an interactive technique rather than an operative one…the better off our patients will be.

      1. Mark Shepherd says:

        gb – Your point regarding the beliefs that society has ingrained resonated with me. I often think that as a PT, I may go in with a specific intent of created self-efficacy, but despite this fact, the patient may internalize the manual aspect of “fix me” – even if that is not the intent. This just goes to remind one that we need to work quickly to create an environment of the patient taking control.

        You point about MT being an interactive technique vs. an operative one is well taken. I am curious to read your thoughts on how we can better measure this (if at all possible)? I think folks like Chad Cook, Paul Mintken, Louie Puentadura and Joel Bialosky are helping bring this to life a bit more, but where do we go from here?

        1. gb says:

          Well since you asked I’ll straight shoot:

          1) First we have to be science lead as a primary entry point. This is foundational…without it we may as well accept that we are just another brand of short term, placebo driven treatment providers.

          I think we are getting there as it pertains to manual therapy which is making some folks very uncomfortable and quite frankly….not sure what to do with themselves or patients.

          2) Which eliminates TDN from any treatment discussion and places manipulation in a very precarious position as well.

          3) Then we have to get comfortable doing nothing….or at least very little.

          4) Primary aspects of care are: Excellent differential screening abilities which then leads naturally to re-assurance. Follow this with well structured TNE, a tincture of motivation and straight forward guidance (MERG: Motivate, Educate, Reassure and Guide).

          5) Then get comfortable with the fact that a great number of patients will not be willing to accept this advice (this is generally culturally driven).

          6) Things like manipulation and TDN are simply by-products of feeling uneasy not “doing something”. This then opens the door to all sorts on nonsense pandering about “windows of opportunity” and “if not us then the patients will go elsewhere” (tu quoque). As if this somehow justifies doing coercive things to patients despite dubious science and scant evidence.

          7) The first patient encounter is probably crucial and developing the soft skills to explain is important:
          http://humanantigravitysuit.blogspot.ca/2012/02/new-treatment-encounter-i.html

          8) We need to get back to our roots…identifying barriers to exercise and movement and re-assuring patients that they can do these things.

          9) We need to be comfortable with being “non-glamourous” because this is where the important things lay.

          10) Stop letting our own professional self esteem issues interfere with giving patients what they actually need: Motivation, Education, RE-assurance and guidance.

          May not make mom and dad proud but it’s what patients need.

          They DON”T need manipulation and TDN. No matter how glamourous and enjoyable the patient finds it.

          In terms of measuring the above I don’t think that’s even a possibility quite frankly. But I’m willing to bet that anyone willing to self reflect for a moment would have a hard time disagreeing that an Occum’s razor approach is probably the correct way forward.

          I figures we’ve over-complicated things probably in a “one-upmanship” battle with other providers.

          The only measurement is going to be personal accountability and mirror reflection: are you part of the problem or part of the solution?

          Pretty blunt but there it is….

          1. Mark Shepherd says:

            Appreciate your thoughtful reply, gb. I like your thoughts specific to self-reflection and following an “Occum’s razor” approach – we often make things way more complicated than needed (not to mention over treating folks). Regarding your #6 point, you mentioned: “This then opens the door to all sorts on nonsense pandering about “windows of opportunity” and “if not us then the patients will go elsewhere” (tu quoque).” With this in mind, what specific language/education are you employing to meet patient beliefs that something must be done to me? I have my own thoughts and approach here, but am always curious to see what individuals are doing to balance expectations/beliefs.

    2. Mark Shepherd says:

      AGREE x 100.

      1. gb says:

        To be honest Mark, I believe the elixir here is a really challenging one to replicate. It requires a few things: 1) An intricate knowledge of the relevant pain science 2) The soft skills to deliver the information in a manner which is both empowering and non accusatory and 3) completely devoid of any ego driven or financially inspired treatment modality….ie….the patient is primary.

        I would argue few have the knowledge and even fewer have the soft skills. And then there is the elephant in the room….the ability to remove oneself from their own personal confirmation and financial biases.

        How many clinicians meet those criteria do you think Mark?

  3. Brian says:

    Manual therapy debates between different MTs remind me of old Kung Fu movies with two Kung Fu masters deciding who’s Kung Fu is stronger

  4. gb says:

    Brian,

    Except the manual therapy master who still utilizes manipulation or TDN should probably be stripped of their black belt.

    Both are needlessly invasive, overly coercive, lack sufficient evidence and only serve the ego of the one applying it.

    Yes…I just said that.

    1. Curtis says:

      Just the TDN should be stripped. If you consider yourself a manual therapist and only manipulate you are missing the boat and took some weekend manipulation course….

  5. Theresa Locke says:

    This thread reminds me of something that I learned many (many) years ago from Gregg Johnson (IPA); it is that our orthopedic patients have neurological problems and our neuro patients have orthopedic issues. So after you perform your great manual techniques, you must re-educate the neuromuscular system to expect a lasting change. Test, treat and train and retest or you might not make a difference. It’s a shame to waste your time and energy by missing the retraining component.

    1. Curtis says:

      You are correct, just don’t use the dog bone…….Gregg loves the dog bone……to mobilize

  6. Phil gainan says:

    Not sure why their is a debate. A good practitioner will use many tools in his/her tool belt. A carpenter would not only carry a hammer would he ?

  7. gb says:

    Hey Phil,

    The human body is not a set of kitchen cabinets or hardwood stairs….

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