Moving Beyond the Bluetooth (Hands-free) Era: 5 Reasons Why You Shouldn’t Abandon Manual Therapy
So, there’s a narrative and some feelings within sectors of the Physiotherapy profession that hands-on Manual Therapy (MT) treatment is somehow harmful, creates dependence, is low-value care and needs to be eliminated from patients’ expectation of attending a consultation. The practitioners who espouse these views are affectionately termed ‘Bluetooths’ by some commentators .
There are evidence-informed and empirical counter-perspectives to these views [2-4] that really leave the discussion as moot – don’t want to use hands-on? Cool. Don’t berate expert clinicians who want to use it appropriately, and maybe consider asking patients what they want. Find yourself using hands-on excessively? Stop it. Use MT as an adjunct part of the package of care combined with education and exercises, get patients self-managing, and help to change their lifestyle long-term.
Here are 5 reasons why we shouldn’t abandon MT
1) Patients want pain relief
This is self-explanatory, and MT does do this via a myriad of mechanisms .
2) They believe and/or expect Physiotherapists can provide it
MT is a part of Physiotherapy’s history, and we are currently still known for this throughout the general population, particularly in private practice settings where patients may vote with their feet and seek alternatives elsewhere if we ignore it as an option [6, 7]. We can use it without feeding pathoantomically-focused explanations based on fixing “dysfunctions” .
3) Outside of social media Physiotherapy circles, no one cares about this discussion
Sorry to be a proverbial wet blanket here. The only exceptions I know of would be the Exercise Physiology, Strength and Conditioning, Massage and Chiropractic professions, who would be licking their lips watching Physios crucify each other online, knowing they are “reaping all the benefits” (cue Jon Lovitz from Wedding Singer) of patients disillusioned with inadequate Physiotherapy care (see point 2).
4) This distractive sideshow allows medical to continue to dominate healthcare
We have far bigger fish to fry than debate MT – in the meantime, following the traditional funding models and pathways, patients will continue to receive drugs like opioids, arguably harmful injectables, costly placebos, wasteful and harmful surgeries like medial meniscectomy, subacromial decompression and lumbar spine fusion, and nocebic-laden useless scans [9-12]. MT can be a powerfully persuasive tool to reduce patients’ pain instead of these measures, allowing them to grade towards function with less side-effects.
5) Experienced and trained Physiotherapists have the potential to become Jedi-like Robin Hoods in healthcare
You may not know, but healthcare spending in the Wealthy West is out of control – literally billions of dollars can be saved with a physio-first policy and fiduciary shift . For example, “…the estimated cost of shoulder arthroscopy by one private health insurer in Australia was A$12 500. Redistribution of this funding to Specialist Physiotherapy services in the proposed care pathway would facilitate a service costing under A$1200 (6 x 40-min consults over 12 weeks).”  Who wouldn’t want some hands-on as a part of rehab, as opposed to an unnecessary surgery?
We can flip the script on musculoskeletal management as fully funded, multi-modal first-contact practitioners, as had been seen in countries like Denmark and the UK, with fantastic feedback and outcomes both from patients and interprofessionally [15, 16].
Where are we headed with this topic? Do we want to keep wasting our time and energy machinating and showboating our biases in public forums? Do we have to perfect our profession over the next 100 years to the very last word, mobe or specific exercise, where all the while patients just want some pain relief, a listening ear, a plan of attack and someone to walk alongside them on their pain and injury rehabilitation journey?
Obviously over the next few decades we can continue to discuss where MT fits for individual cases; as always, a patient-centred approach fusing best evidence and guidelines while managing expectations and preferences is key [17, 18].
I invite all leading social media, academic and clinical expert Physiotherapists to lay our collective swords down on this topic, and like the rag tag mix of dwarf, human, wizard, elf, and hobbit heroes in The Lord of the Rings, see the bigger picture of how we can take on ‘Mordor’ together with patients to change their health trajectory towards independence, and truly shift Westernised healthcare for the better.
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- Lyons, P., Hands Off Physio Celebrates Empty Patient Schedule. 2021.
- Kerry, R., “Hands-on, hands off: is that even a thing?” 2019, Physio First.
- Falsiroli Maistrello, L., M. Rafanelli, and A. Turolla, Manual Therapy and Quality of Life in People with Headache: Systematic Review and Meta-analysis of Randomized Controlled Trials. Curr Pain Headache Rep, 2019. 23(10): p. 78.
- Eckenrode, B.J., D.M. Kietrys, and J.S. Parrott, Effectiveness of Manual Therapy for Pain and Self-reported Function in Individuals With Patellofemoral Pain: Systematic Review and Meta-analysis. J Orthop Sports Phys Ther, 2018. 48(5): p. 358-371.
- Bialosky, J.E., et al., Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. Journal of Orthopaedic & Sports Physical Therapy, 2017. 48(1): p. 8-18.
- Rabey, M., et al., Reconceptualising manual therapy skills in contemporary practice. Musculoskeletal Science and Practice, 2017. 29: p. 28-32.
- McRae, M. and M.J. Hancock, Adults attending private physiotherapy practices seek diagnosis, pain relief, improved function, education and prevention: a survey. J Physiother, 2017. 63(4): p. 250-256.
- Louw, A., et al., The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther, 2017. 25(5): p. 227-234.
- Tick, H., et al., Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY), 2018. 14(3): p. 177-211.
- Blom, A.W., et al., Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ, 2021. 374: p. n1511.
- Sajid, I.M., A. Parkunan, and K. Frost, Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ Open Qual, 2021. 10(3).
- Orchard, J.W., Corticosteroid injections: glass half-full, half-empty or full then empty? British Journal of Sports Medicine, 2020. 54(10): p. 564-565.
- Swan, N. Four Corners. Wasted. 2015; Available from: https://www.abc.net.au/4corners/wasted-promo/6804372.
- Beales, D., T. Mitchell, and D. Holthouse, Stepped care for musculoskeletal pain is ineffective: a model for utilisation of specialist physiotherapists in primary healthcare management. Australian Journal of Primary Health, 2021: p. -.
- Goodwin, R., et al., Evaluation of the First Contact Physiotherapy (FCP) model of primary care: a qualitative insight. Physiotherapy, 2021. 113: p. 209-216.
- Stynes, S., et al., Evaluation of the First Contact Physiotherapy (FCP) model of primary care: patient characteristics and outcomes. Physiotherapy, 2021. 113: p. 199-208.
- Wijma, A.J., et al., Patient-centeredness in physiotherapy: What does it entail? A systematic review of qualitative studies. Physiother Theory Pract, 2017. 33(11): p. 825-840.
- Bishop, M.D., et al., What effect can manual therapy have on a patient’s pain experience? Pain Manag, 2015. 5(6): p. 455-64.
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