6 Myths of Manual Therapy Examined
This blog is my take on the podcast episode with Dr Chad Cook (1) – “6 Myths of Manual Therapy” – on the Physio Explained podcast (where you can learn from the best in 20 minutes or less).
I want to explore these myths and the impact they are having on our profession.
Myth 1 – Patient’s don’t report better experiences with manual therapy
At a surface level, for the manual therapy haters out there, it seems they do report better experiences with manual therapy. Chad Cook argues this quite well in the podcast (1).
However, when we dig deeper into the evidence and examine for any logical fallacies, we get a more nuanced position. The alternative is that meeting patient expectations has a positive impact on the patient experience (2-4). However, false equivalence fallacy can be a trap here, equating good patient experience with good patient outcomes (5,6). Unfortunately it isn’t that simple (5,7-9).
The real solution, however, is simple!
Stop guessing and ask. Find out what your patient expects and then put that into the funnel of evidence based practice pictured below. We’ll come back to this a bit in this blog so keep this picture front of mind (3,4,10-12).
Myth 2 – Manual therapy provides only short term changes
Luckily for all of us, particularly with spinal related pain, this myth seems to be false. It seems that those who have really positive within session changes in pain after a bout of manual therapy, are prognostically 3-4 times more likely to have a positive outcome. However, these findings haven’t been repeated in the peripheral joints, so need to be viewed with healthy skepticism.
These results do shed a bright light for all of us, no matter what side of the debate you’re on.
A malleable nervous system is a wonderful thing.
If someone’s pain can be that easily modulated within a session, then lean into that and celebrate this with your patient. However, if your patient doesn’t get these good within session responses, maybe it’s time to work with them on bigger rocks instead of quick fixes (13,14).
Myth 3 – Manual therapy doesn’t fit within value based care
There is a lot of shade thrown around in the physiotherapy profession about value based care. Most often it is used as a way to denigrate the other side with labels such as high value versus low value.
Personally, I think any debate equating modalities and value is silly and misses the point of patient centered care. Instead for me, our funnel analogy by Eric Meira comes back along with the 5 questions from the choosing wisely campaign.
The funnel of evidence based practice shows that the eventual treatment path that a patient decides is filtered down from an initially broad pool of all possible interventions, to a small number of logically and empirically sound ones. The final decision is guided by your best knowledge of the evidence at the time and your patient’s engagement with the plan (10,15).
The choosing wisely campaign outlines a great list of questions for all clinicians to ask themselves before suggesting an intervention.
- What would happen if I didn’t do anything?
- What are the costs?
- What are the risks?
- Do they really need this treatment?
- Are there other / safer alternatives? (16)
If after this rigorous process, manual therapy is still an available option, then go for it. However, it’s also useful to reflect and identify if the following fallacies could be clouding our reasoning:
- Sunk cost fallacy
- Appeal to tradition
- Appeal to consequences (6)
Myth 4 – It decreases patient self efficacy
If you were to try to negatively affect self efficacy, you’d make the clinical encounter about you, and your biases, while simultaneously disempowering the patient’s opinion. This would fly directly in the face of patient centered care. Chad Cook states on multiple occasions, that a patient comes into the clinic with “their own beliefs, narratives, and expectations”. The clinical encounter should be a dynamic and evolving dance to accommodate this. When we either dogmatically use or oppose manual therapy regardless of the clinical context, we make the decision about us and not our patient (3,4,11,12).
Myth 5 – Manual therapy builds patient reliance
If you are really solid at those honest conversations regarding informed consent using our funnel analogy and 5 questions from before, the resultant treatment path will be empowering for the patient. However, if you withhold, or push possible treatment options as they serve your biases, you may have to rethink your position as an evidence based clinician. If manual therapy is a viable choice, and is agreed upon with fully informed consent, then it can’t be seen as robbing the patient of self efficacy or building healthcare dependency (1,10,11).
Myth 6 – Manual therapy is based on made up philosophies that clinicians can’t divorce themselves from.
This myth is true in its historical sense. As Chad Cook states “with manual therapy, we were building the plane as we were flying it” (1). The early practitioners definitely stumbled upon some really useful techniques that appeared to get good results. However, without our robust scientific methods of inquiry we now enjoy, these methods often fell folly to post hoc reasoning (6). This ultimately led, in the past, to testing an outcome of an intervention but falsely attributing it to a hypothesized mechanism, without actually testing the mechanism directly.
These days most clinicians are clued into the fact that many of these mechanisms and treatment philosophies have been robustly falsified. Furthermore, the specifics of a technique don’t seem to matter that much.
So, my advice is:
Have a couple of basic techniques that you feel confident delivering and that don’t take up too much cognitive load. Make sure you don’t let the quest for technical expertise get in the way. Be specific to the patients needs and responses to your touch (11,17). That is what is specific here, not your technical skills themselves (13,14).
There you have it. Hopefully, I have navigated this emotionally charged area while dispelling some myths which may have been impacting your stance on manual therapy.
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- Moore, A. P., & Jull, G. (2013). The patient experience of musculoskeletal therapy. Manual therapy, 18(3), 175-176.
- Chi-Lun-Chiao, A., Chehata, M., Broeker, K., Gates, B., Ledbetter, L., Cook, C., … & Garcia, A. N. (2020). Patients’ perceptions with musculoskeletal disorders regarding their experience with healthcare providers and health services: an overview of reviews. Archives of physiotherapy, 10(1), 1-19.
- Subialka, J. A., Smith, K., Signorino, J. A., Young, J. L., Rhon, D. I., & Rentmeester, C. (2022). What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment. Musculoskeletal Science and Practice, 59, 102543
- Casserley-Feeney, S. N., Phelan, M., Duffy, F., Roush, S., Cairns, M. C., & Hurley, D. A. (2008). Patient satisfaction with private physiotherapy for musculoskeletal pain. BMC musculoskeletal disorders, 9(1), 1-13.
- Hansen, Hans, “Fallacies”, The Stanford Encyclopedia of Philosophy (Summer 2020 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/sum2020/entries/fallacies/>
- Kupfer, J. M., & Bond, E. U. (2012). Patient satisfaction and patient-centered care: necessary but not equal. Jama, 308(2), 139-140.
- Hills, R., & Kitchen, S. (2007). Toward a theory of patient satisfaction with physiotherapy: Exploring the concept of satisfaction. Physiotherapy theory and practice, 23(5), 243-254.
- Hush, J. M., Cameron, K., & Mackey, M. (2011). Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Physical therapy, 91(1), 25-36.
- Meira, E. (2020, December 10). Understanding evidence-based medicine using a funnel analogy. https://doi.org/10.31236/osf.io/kr6aq
- Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099-1110.
- Babatunde, F., MacDermid, J., & MacIntyre, N. (2017). Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC health services research, 17(1), 1-23.
- Cook, C. E. (2021). The demonization of manual therapy. Muskuloskelettale Physiotherapie, 25, 125-132.
- Cook, C. (2011). Immediate effects from manual therapy: much ado about nothing?. The Journal of manual & manipulative therapy, 19(1), 3.
- Page, P. (2021). Making the Case for Modalities: The Need for Critical Thinking in Practice. International Journal of Sports Physical Therapy, 16(5).
- Hiller, A., Guillemin, M., & Delany, C. (2015). Exploring healthcare communication models in private physiotherapy practice. Patient education and counseling, 98(10), 1222-1228.
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