Manual therapists, Keep off! (to read this blog)
ATTENTION you could be shocked by reading this if you are a health professional practicing any form of therapy with your hands. Please read twice to carefully get the right meaning of this text that only has as a goal to make everyone progress towards more efficient practices.
Some physiotherapists define themselves as manual therapists. They took postgraduate courses and proudly sign CAMPT letters or idolize gurus having alleged magical hands. For my part, I'm not a manual therapist... I'm a therapist. I’ve always striven to become a more effective and more efficient therapist. I would thus question the knowledge that was passed on to me, criticize ways of doing things and challenge my own beliefs. Through this process, manual therapy (which was actually the first teachings I received after university) was also put to the test. Would you like to know what I think of manual therapy? Here it is, with no sugarcoating.
My own beliefs
I graduated in 1998. Several (the majority for that matter) of the best physiotherapists I have met in Quebec/Canada were experienced manual therapists. For a long time, I thought they were good because they were manual therapists.
I later found out that they had become manual therapists because they had a strong desire to be good and that we shared the same belief: to become better, we had to be manual therapists.
Manual therapy is a set of tools that have actually nothing to do with the quality of a therapist. Acquiring these tools is a long process that takes time and money, with a relatively slow learning curve (you need to “manipulate” several patients for nothing to become a good “manipulator” J).
The thinking behind the theories taught are “teacher-dependent”: meaning that some rightfully know the science and bring to light the limits of a given model while others are more “guru-like” and only expose their personal beliefs as facts and best practices.
Manual therapy as a therapeutic practice remains a passive modality that does not make patients responsible for their own well-being. It is a relatively expensive therapy whose effects depend on the client. Furthermore, science has shown that, most of the time, evaluation and testing in the field of manual therapy is mostly unreliable, mobilization/manipulation techniques are not specific and the reason for manual therapy being effective, in addition to not being fully known, is more likely not related to the presumed mechanical effect. As patients are led to believe that their body parts are displaced or misaligned, they can easily become dependent on such services.
I felt a strong desire to become a “good” therapist. I then quickly made my way through the curriculum of the Canadian Academy of Manipulative Physiotherapy (CAMPT), passed the national examination for part “A” and took a course on spinal manipulation. I practiced manual therapy. I also learned the theory along with the alleged effects of the techniques taught. I even called out other types of manual therapy, those that were different.
Then came my awakening to scientific evidence, which in turn led me to read more and be more critical... this fueled quite an upset as I started questioning my own beliefs about the true effects of manual therapy. I gradually changed my practice and, most importantly, my discourse on the subject.
The clinical tools I now use seek to address three key principles. They need to show low cost/time-effectiveness and risk/reward ratios as well as show long-lasting effects. For these reasons, I use manual therapy as a targeted tool designed for specific conditions. Consequently, the treatment plans I use with most clients don't include “touching” as it doesn’t result in any added therapeutic value... and if it does, it’s only to reassure patients and show empathy in order to strengthen the therapeutic relationship, and certainly not for what I have “aligned” properly!
Don’t get me wrong, though: I still do touch clients during my assessment! I would even say that my background in manual therapy has provided me with interesting assessment tools, for example as it relates to joint mobility.
Since direct contact for manipulation/mobilization of clients was only carried out when required, my skills in this regard are not optimal. I therefore refer more complex cases to my colleague Sébastien (FCAMPT physiotherapist with amazing hands) when I think they will respond better and quicker to manual therapy (actual exceptions in my clinical practice as well as in the practice of a general physiotherapist)... In the process, I always make sure to remind Sébastien that he became so good just because he performed manipulations on many people who did not actually need it. J
Young musculoskeletal health professionals, why not start with the basics!
You love to “touch” people? You wish to develop a specialization for more specific conditions and patients? Aim for a course in manual therapy provided by rigorous organizations and teachers... but not before you know how to properly educate your client and use mechanical stress quantification. Manual therapy is NOT the key to treating musculoskeletal pathologies.
You think I’m being tough? Go ahead and read Adam Meakins’ blog post entitled “Manual therapy sucks”. And I have to admit that I agree, even though Adam is not being politically correct and lashes out at manual therapy!