When involved a debate or an argument it’s very easy for the main points to get lost or twisted amongst the claims, counterclaims, or the general shit flinging that tends to occur. This happens a lot in many discussions, but it occurs the most whenever I’m involved in a debate about manual therapy and its role within the physiotherapy profession.
It’s no secret that I have had my fair share of disagreements over the years with many of the leaders, gurus, and celebrities of all the manual therapy treatments such as joint manipulations, mobilisations with movements, soft tissue massage, and myofascial release. I have made public and voiced my frustrations, dislikes, and even hatred of all these interventions many times on social media and in my writing for years, and I will continue to do so.
It’s also fair to say that I have some strong polarising opinions about ALL manual therapy, but believe it or not, I welcome the disagreements they create. Despite many of the physiotherapy top brass and elite claiming that these arguments are harmful and detrimental for the profession, I think the opposite.
As George Patton famously said, “if everyone is agreeing, then someone isn’t thinking”. In my opinion, open, honest, passionate, heated disagreement is a sign of a profession and the individuals within it trying to sort out what’s good from bad, better from worse, less wrong and more likely right. It’s disagreements that often drive change and progress.
However, as much as I welcome the disagreements and debates around my views and opinions on manual therapy what annoys and frustrates me the most is when people twist, contort or misrepresent them. This usually occurs due to others ignorance, stupidity, or simply because they dislike me.
So when I read a spectacular misrepresentation of my arguments around manual therapy by someone I consider neither ignorant or stupid and who I like and respect, I am a little surprised and taken aback. These were my feelings when I read Roger Kerry’s recent piece titled ‘Hands on, hands off: is that even a thing?
In this article, Roger references a few of my blogs and appears to have highlighted me as the reprehensible social media pariah of physiotherapy! Underneath all his extensive vocabulary, fancy words, and charming rhetoric, Roger attempts to paint me and others who question and challenge manual therapy on social media as ‘non-differentiating, tired, and vacuous’ and more annoyingly that we advocate a ‘hands-off’ approach.
This is a breathtakingly inaccurate and frustrating straw man argument that I hear often from many manual therapy supporters in an attempt to undermine and distract attention away from my real arguments against manual therapy as a healthcare treatment.
I find it ironic that at the start of this article Roger states the hands-on, hands-off debate is a false dichotomy when actually none of my arguments against manual therapy are about hands on or hands off. Rogers choice of words in using ‘hands-on, hands-off’ rather than ‘manual therapy, or no manual therapy’ is a deliberate ploy to misrepresent my position and in doing so he has essentially created his own false dichotomy, which is kind of strange for a professor of philosophy.
My arguments for reducing, removing, and even abandoning manual therapy by the physiotherapy profession is not, nor ever has been about suggesting or implying that physiotherapists stop touching their patients. This is an absurd but clever distraction of attention away from my position against manual therapy as a healthcare intervention.
I will reiterate once again why I think manual therapy ‘sucks’ and why I think it should be abandoned by most physiotherapists. My first reason is due to the constant and continued misinformation about what manual therapy does, and how it does it. Despite it now being 2019 and there being a huge evidence base many physios still stubbornly and dogmatically teach and explain that manual therapy corrects and adjusts faulty joint positions or mobility issues, that it lengthens and releases muscles, fascia and other soft tissues when it simply can not, and does not (ref).
Another reason I think manual therapy should be ‘abandoned’ is due to it being over-complicated, over-hyped, over-used, and over-priced for what it achieves (ref). Most manual therapy does very little in the grand scheme of things, at best it gives some people, some small, short-lasting transient effects on their pain which may or may not affect their function (ref). If manual therapy were a drug it would never be prescribed as its effects are so low and cost so high when compared to other simpler cheaper alternatives (ref).
My other argument for ‘leaving’ manual therapy behind is that its a huge distraction for therapists and patients, stealing their time and attention away from active rehabilitation interventions that have bigger and better health benefits (ref). In the UK most MSK physios have very limited time with patients, anywhere from 2 to 8 sessions that last between 20-45 minutes on average (ref). In this time they have to gain a history, do a physical exam, consider any imaging and investigations, develop a working diagnosis, formulate a treatment plan, give advice and education, and practice and rehearse rehabilitation strategies.
If all of the above is being done thoroughly and to the best ability there simply can not be enough time for the application of manual therapy in most MSK physiotherapy. When manual therapy is used in physiotherapy what often tends to get compromised is the active rehabilitation. I know many physios disagree with me here and they say they can do both manual therapy and active rehabilitation well, but I call bullshit on that.
When I used to use manual therapy in my practice it always reduced the time I had with patients to explore, experiment, rehearse movements, exercises, and loading parameters. I know this is anecdotal so can’t be trusted but I still hear many patients tell me about physiotherapy sessions in which they had manual therapy and how either no rehab was given at all, or if it was, it was at the end of the session as an after-thought, usually, by the physio handing them a shitty sheet of photocopied exercises to do at home, with no explanation or practice to ensure they could do them, or that they were even beneficial for them.
Finally and by no means least, I simply hate ALL manual therapy for the pompous arrogant elitism and showmanship that surrounds ALL of it and most of those that use it. No matter how well presented and explained manual therapy instils a belief of skill, specialism, and superiority that it doesn’t deserve. Manual therapy also instils a notion and belief that physios ‘fix’ patients rather than help them. All manual therapy takes our profession away from our rehabilitation and exercise foundations and closer to the loons and quacks in the complementary and alternative medicine fields with their crystals and chakras.
I believe that most physios use manual therapy more for their own benefit than that of their patients. Manual therapy is often there to make the therapist feel special and needed as well as to pander and pamper to patients rather than genuinely help them by focusing on the harder, tougher more difficult factors around their pain and disability.
I know many think that I am unprofessional and harmful to our profession for saying this! Tough shit, because I actually think physios fannying around way too much with manual therapy distracting patients from things they need to do and adversely affecting their outcomes is far more unprofessional and far more harmful to our profession.
NO manual therapy doesn’t mean NO touching
However, as much as I dislike/hate/loathe manual therapy for all the reasons above, I will state again that I have never suggested or implied that physiotherapists should stop touching their patients and go ‘hands-off’. In fact I recently wrote a blog saying just the opposite here.
Touch and palpation is a basic, fundamental, and vitally important part of any good thorough evidenced-based physical assessment. Although its use diagnostically is poor I cannot emphasise enough the importance of all physiotherapists taking the time care and attention to palpate their patients.
Not only does palpation stop you missing important and vital signs of pathology such as swelling, heat and deformity, it also gives patients the reassurance that you as a healthcare professional have taken their issues and concerns seriously and have examined them thoroughly. One of my ‘many’ pet peeves is listening to patients tell me that some bone idle, lazy, and incompetent healthcare professional didn’t even observe or palpate an area of concern of theirs.
However, as frustrating as it is listening to that, listening to patients who tell me that some other therapist has palpated them and found a bone out of place, or something misaligned, or a muscle knot, or fascial adhesion is far more frustrating, far more common, and a damn sight harder to deal with. The biggest reason these ridiculous, fear-inducing explanations are given to patients is due to therapists being taught and lead to believe that they can feel and diagnose things with palpation that the evidence and simple common sense tells us they cannot (ref).
Physiotherapists often develop these beliefs during their manual therapy training and why I think most of it is best avoided as it continues to be surrounded by so much outdated, non-evidenced nonsense. Roger talks in his article about the reputation of our profession being at risk if we were to go ‘hands-off’ and I agree. But I also think the reputation of our profession is in danger of being adversely affected by the woo and pseudo-science that manual therapy is riddled with.
Until manual therapy is taught in a more simple, rationale, and evidenced-based way I think most healthcare professionals are better off without it. More therapists and patients need to recognise that there is no magic, skill, or specificity in any manual therapy that costs thousands of pounds, euros, or dollars to learn, or that takes years of dedicated practice to master and perfect.
This leads to another of my arguments for physiotherapists to abandon manual therapy, that is they are not the best professionals to be providing it. Physiotherapists are autonomous diagnostic healthcare professionals who studied for 3-5 years to assess, diagnose, and manage those in pain and with disability. They are not best utilised cracking necks, giving back rubs, or applying hot or cold packs.
For any manual therapy to be effective I believe it needs to be given by therapists who are solely focused on it, who work in calm relaxing environments, who can take the time and attention to work on the patient’s body slowly, methodically, and holistically. This is just not how physiotherapists use manual therapy, usually, it’s rushed and done in a few minutes or less, in environments that are far from relaxing, and often they are focused on other things around the patient’s care.
Physios training, skills and time are simply better used for other things. This is not meant to sound arrogant, condescending, or conceited just honest, rationale, and pragmatic.
Although it frustrates the hell out of me that the manual therapy debate is often contorted and bastardised into a hands-on, hands-off false dichotomy, I am happy that the debate is still here be had. Despite what Roger tries to present in his article, the well-rehearsed manual therapy debate is far from tired or vacuous, it is an important one to be had, and it’s not just a construct of today’s modern social media.
The debate about the pros and cons of manual therapy within physiotherapy has been raging for decades long before I got involved, and long before social media was around. The likes of the late great Robin McKenzie, Louis Gifford, Max Zusman, Jules Rothstein were all known for questioning and challenging the over-use, over-complication, and utter bollocks that surrounds manual therapy long before Insta-Google-Face-Tweetbook was ever invented.
Social media isn’t to blame for these debates and disagreements as they have been always been around. All social media has done is make these discussions, debates and arguments more known and accessible which is a good thing. Again, some will argue that this is harmful to our profession and we should be focusing on other more important things, I disagree.
If you’ve made it this far, very well done!!!
Physiotherapy as a science-based profession needs to accept that disagreements are essential for progress. Science and philosophy thrive on discourse. Discourse drives interest, intrigue and investigation. What is far more dangerous and harmful to our profession is dogma, apathy, and lethargy from stagnation and suppression of thoughts and ideas and beliefs, and that what we’ve always done is what we should always do.
Physiotherapy needs to evolve, advance and grow, and to do this it needs to shake off some debris and detritus from the good old days and this means moving on and away from massages and manipulations, but not from palpation and touch.
There is a saying in many professions that three of the most dangerous words used are ‘in my experience’ as relying on it can cause some big issues due to personal biases and general ignorance. However, I also think there are another three words being used a lot recently that can be just as dangerous, these are ‘research has shown’!
Over the last few decade’s healthcare has been trying to move away from individual experience-based practice to a more scientific evidence-based practice, to reduce clinicians biases adversely affecting their patients care and treatment. This is true for physiotherapy where clinical experience has been in the past, and still is today, very much respected and revered despite patient outcomes being quite poor.
Now, before you all go crazy in the comments section and start accusing me of ignoring the role of experience or saying its completely useless, I am not. Clinical experience is useful for many things, in fact, I think for some things it is probably the most reliable tool we have (ref). However, clinical experience has issues and should not be solely or fully relied upon. History is littered with examples of where experts have been wrong and huge mistakes have been made because of this (ref).
Fortunately, evidence-based practice within physiotherapy is slowly being adopted, and there is a shift of more and more physios reading, engaging, and participating with research which is a good thing. But, there are issues here and it needs to be recognised that using the research and evidence to help guide our practice can also have just as many pitfalls as using experience, if it’s not implemented carefully and sensibly.
Unfortunately, I see and hear many physios using research and evidence not so carefully and not so sensibly. In fact, I see physios using research much like a drunk uses a lampost, that is they use it more for support than illumination. Many physios, (and other healthcare professionals) like to find research to support what they already think and justify what they already do, or want to do.
This is NOT evidence-based practice! Many healthcare professionals think that if they find a research paper that has been published showing a positive effect of a treatment ‘working’ (usually with a p-value of >0.5) then they are evidenced based clinicians. They are NOT, and this is NOT how evidence-based practice works.
Evidence-based practice is the practice of using the BASE of the evidence to support our methods, treatments and interventions. It’s not using just one, two, or even a few papers. If you base your practice on one, or two, or a few research papers it’s usually because you’ve only read one, two, or a few research papers.
Many healthcare professionals tend to cherry-pick the evidence-base, using what they want, and ignoring what they don’t want. Most use Pubmed like they use Google, that is they do a quick keyword search, often don’t go past the first page of results, and click on the first link that catches their eye. This means they find often what they want to know rather than what they need to know. It also means they get skewed views and beliefs about what they think works, and what they think doesn’t.
One of the issues with the evidence-base is that there are literally papers published to support anything you want, especially in the field of physiotherapy which is notorious for publishing low-quality poor research (ref). For example, you can find papers showing how woolly pants cure low back pain, ultrasound applied clockwise is more effective, and even spinal manipulation reverses death. There is literally citable research out there to support what you want, or don’t want, such as K-tape helps, or it doesn’t, manual therapy helps, or it doesn’t, even exercise helps, or it doesn’t.
There is literally a shit tonne of research out there, but unfortunately, a lot of it is shit. This quagmire of turd being produced means you do have to wade waist-deep through the crap to find the good stuff, which is time-consuming, frustrating, and hard work and not many can, or want to do it. This often means good quality research can be hard to find and does go unnoticed, whereas bad research is very easy to find and often gets promoted.
Many say that research is broken because of this, but that’s nonsense. Research isn’t broken, it’s just very hard to do well, and often it’s abused and misused by those who don’t understand it. Research is simply a tool, and like any tool, it’s only as good as the person using it.
Unfortunately, levels of scientific literacy and understanding are terrible within the general public, with most people not able to tell the difference between good quality, rigorous, ethical research from poor quality, flawed, biased research. And many healthcare professionals are not that much better either.
It does amaze me how many healthcare professionals hold a Bachelor of Science degree yet couldn’t tell you the difference between specificity or sensitivity, reliability or validity, efficacy or effectiveness, statistically significant and clinically meaningful. And don’t get me started on many clinicians not understanding the role of p-values, effect sizes, blinding, control groups, randomisation, power, publication bias, data mining, p-hacking, and the reproduction crisis.
Some really useful resources for better understanding of all the issues I’ve just mentioned can be found here and here, also check out the Science Daily website and the Everything Hertz podcast as well as I often find these good resources to improve your understanding of research, statistics and the basic scientific method.
The other issue I find with evidence-based practice is that many think it will give them the truth and the answers to the messy and confusing questions they have in how they should help and manage people with pain and with pathology. It won’t, if anything the research and evidence can make things harder and more complicated.
A common misunderstanding and frustration of evidenced-based practice is that it will give clear and definitive yes and no answers, or simple do’s and don’ts. It can sometimes, but often it doesn’t. Research never really proves anything true, right or correct. Research actually tells us what’s more probable, likely and less wrong, not what’s true!
Research should actually give a clinician an appreciation of uncertainty and an ability to recognise the probability of what’s less wrong and what’s more right. But only if they’re able to think critically, have good scientific literacy, and be tolerant of uncertainty, which many are not.
Many healthcare professionals lack tolerance to uncertainty as they don’t want to appear ignorant or stupid which uncertainty can make you appear. No patient wants to hear or see a dithering dallying clinician stuttering and stammering scratching their head wondering what to do next.
A lack of tolerance to uncertainty is also due to societal pressures and deeply rooted constructs that healthcare professionals should always know what to do when patients come to see them. It is still assumed by many that the clinician alone decides what to do and how to proceed rather than it being a shared process between the patient and the clinician.
What often happens due to these issues is that many clinicians hide or override their uncertainty by abusing and misusing the research. They go and find some research, no matter the quality, that justifies what they do, or want to do. This saves them time and avoids having to have those difficult and awkward discussions with patients about ALL the treatment options and ALL of the pros and cons of them.
As I said at the beginning there is no doubt that clinical experience can be useful and important in some situations, but using it alone is fraught with problems and issues. However, there is also no doubt that relying on poorly conducted, biased, and methodologically flawed research has just as many problems and issues.
Healthcare needs to be careful that phrases like “We know this works” or “This is what we have always done” are not mindlessly replaced with “the evidence says” or “research has shown”. Healthcare needs to try and improve levels of scientific literacy in all its professionals, as well as trying to reduce the amounts of poorly conducted research published or referred to.
In fact, I would say any that any research trial that doesn’t show adequate blinding, sufficient power, and more importantly doesn’t have a control, sham, or placebo comparator is simply ignored.
Here’s a question; is musculoskeletal physiotherapy going through an identity crisis? I don’t mean the kind that makes it start dying its hair, wearing leather trousers, and trying to impress other professions half its age. Rather is musculoskeletal physiotherapy struggling to find its place and purpose in an evolving health care system as it continues to search for evidence of its effectiveness in treating pain and pathology?
Over the past few decades, the musculoskeletal (MSK) physiotherapy profession has produced a huge amount of research in an attempt to demonstrate its worth. Unfortunately, a lot highlights that MSK physiotherapy has little to no significant effect above and beyond placebos, natural history, or regression to the mean, and people are beginning to notice. Not only are patients realising that a lot of MSK physiotherapy doesn’t do much, but so are many health care commissioners, and physiotherapists themselves.
This crisis causes a lot of debate and disagreement, with many advocates for certain physiotherapy interventions fighting hard for their cherished treatments, and others like myself questioning their worth. Some have talked about this crisis within physiotherapy before with blogs telling us how ‘physio will eat itself’ and books called ‘The End of Physiotherapy’ both of which I urge you to read.
Yet, MSK physiotherapy continues to limp forward and struggle on, desperately searching for its purpose and place within health care, with the debates and arguments raging on about whats the best treatment for this pathology, or for that problem. However, I think MSK physiotherapy and those of us who work within it are focusing our efforts and energy in the wrong place. I think MSK physiotherapy has lost its way and needs a drastic and monumental shift in its identity of what it does as a profession!
Treat or prevent?
The vast majority of MSK physiotherapy research and the physios themselves invest a lot of time, energy and effort into diagnosing and treating disease, disability, and illness. This is clearly important and should be continued, but what about the other side of the coin? What about our efforts in the prevention of disease, disability and illness.
Does the profession and those who work within it invest as much time, energy, and efforts into the prevention of disease, disability and illness? Does the profession and its individuals place as much importance, credence, and relevance on the promotion of health and wellness as it does on the treatment of disease and illness?
Simply put… HELL NO!!!
Most, if not all of MSK physiotherapy’s training and practice is entirely focused on the reduction of pain and the improvement of function in those with a disease or pathology. Very little, if any time, or attention, or opportunity is given to physiotherapists to work on the prevention of disease and pathology in individuals before they come to see them.
MSK Physiotherapy is a reactive profession, not a proactive one!
I am not trying to be hyper-critical or overly negative here, and yes I’m sure there are some physios who do work proactively in some health promotion roles, but they are in the minority, and they are not well seen or heard and this needs to change drastically.
Currently, MSK Physiotherapy, along with many other medical professions is bogged down in the endless ever-increasing pressures of treating pain, pathology, disease, disability, and illness to do much about the prevention or reduction of them. This is a classic vicious cycle if there ever was one, and it’s one that is leading us into a right royal shitstorm.
Tsunami of illness
With an ever-growing, ageing population, doing less and less physical activity, with poor lifestyle behaviours, declining health, and greater co-morbidities, our healthcare system is facing a tsunami of chronic illness and disability that is going to swamp the system and those who work in it.
For example, it is estimated that by 2050 the UKs population will have expanded by another 10 million people with a significant increase in those over the age of 60 (ref). It is estimated that this increasing elderly population will have far higher rates of chronic morbidities such as obesity, diabetes, and cardiovascular disease. In fact, it is estimated that in just 10 years half of the UKs population will be clinically obese and the associated health issues of this alone will cost the NHS a staggering £25 billion (ref).
There is simply no way our healthcare system can cope with this, and if it only keeps focusing on treating rather than preventing disease it will soon find itself overrun will the chronically ill and disabled. Therefore, more time, effort, resources and opportunity needs to be placed as a priority into the prevention of disease and illness, and I think the MSK physiotherapy profession is in a prime position to help and respond here.
However, as I said earlier theMSK physiotherapy profession is very much focused on and set up for the diagnosis and treatment of disease and illness rather than the promotion of health and wellness. And if you don’t believe me just take a look at its training, its career structure, and its position within health care and society in general.
Currently, most if not all undergrad and postgrad MSK physiotherapy training is focused on diagnosing and treating pain and pathology, very little is spent on health and wellness promotion and advocacy. This needs to change!
More emphasis, time, and energy are needed to train and enthuse physios on the importance of health promotion and advocacy in all those they see. They need more training and skills in how to develop and encourage behavioural change in people and how to overcome barriers and obstacles to healthy lifestyles, far more than they need training in what setting to use on an ultrasound machine or how to press a painful back.
Currently, most if not all MSK physiotherapy career pathways are focused on and dedicated towards extended or advanced skills in diagnosis and treatment, there are virtually no career options for those physios who want to focus on health and wellness promotion. This needs to change!
For an MSK physiotherapist to progress their career they have to do further training and get certification in either manual therapy, acupuncture, dry needling, diagnostic imaging, injections, or even prescribing medications. For an MSK physio to be seen as advanced, enhanced, or specialised they have to twist, contort, and turn themselves into some bastardised version of a doctor, registrar, or radiologist. I know this because I am one.
And this is not to be disparaging, negative or critical of all the ESPs, APPs, or FCPs or whatever you want to call them out there, as there are some excellent ones doing some great work. But where are the Extended Scope Physios in health promotion? Where are the Advanced Physio Practitioners in exercise and activity prescription? Where are the First Contact Physios in schools educating children on the importance of healthy lifestyles?
The MSK physiotherapy profession needs to take a long hard look at its career structure and stop placing emphasis and credence on skills that only diagnose or treat and start to place more on the skills that promote health. Simply put we need more young physios enthusiastic and striving to become health and wellness advocates, not junior doctors.
Physio in society
Currently, most if not all MSK physiotherapy is positioned in reactive roles, treating people with problems sent to them. It is also still very much seen as a junior, inferior, even subservient profession to other medical professions. This needs to change!
More MSK physiotherapy needs to position itself outside of hospitals and medical centres, and into gyms, health centres, and even schools. Health promotion and advocacy should begin from a young age and physiotherapy should be lobbying governments and pressuring policymakers about the benefits of placing physiotherapists and health and wellness teachers into the national curriculum.
MSK physiotherapy wants to try and position itself as being seen as a profession that helps promote health and wellness as much as it helps treat disease and illness. Our leaders and societies need to do more to push this forward using lobbying and other political pressure.
With the World Congress of Physiotherapy currently on in Geneva this weekend, it is encouraging to see the odd slide and comment about this already, but mpore needs to be done and I do wonder how much of this is talk and how much action will come of it?
As I mentioned at the beginning, the MSK physiotherapy profession needs a drastic shift in its identity and thinking of what it does, and where its role and worth lies. Is it in the diagnosing and treatment of pain and pathology, which hasn’t been shown to be that great or effective, or is it more in the prevention and reduction of pain and pathology through the promotion and advocacy of health and wellness?
Obviously, the answer is both! But at the moment MSK physiotherapy is very much focused on the treating more than the preventing, it’s more reactive than proactive, and if it wants to survive and be taken seriously as a ‘health care’ profession this needs to change!
I hear more and more physios and other healthcare professionals discussing and promoting the negative, detrimental, and so called harmful effects of using ice for the treatment of injuries or soreness after exercise, with some claiming that its use should be abandoned completely. Well, I think this is just crazy talk and I think some people just need to chill out about ice!
Even in 2019, there is still a lot of confusion and misunderstanding about the simple process of using of ice after an injury or exercise, sometimes called ‘cryotherapy’ to make it sound more scientific and sexy. Some say it’s the best thing ever and should be used all the time, others say it’s the worst thing ever and to never do it. So the aim of this blog is to see who is more right, or less wrong and decide if using ice is good, bad, or somewhere in-between.
There are many ways to use cryotherapy after an injury or exercise from the application of a simple bag of frozen peas, to immersion in buckets of cold water, to fancy enclosed pumped cold water circulation devices, even full body cryo-chambers that use liquid nitrogen at temperatures below -100*C! However one of the daftest applications I’ve ever seen has to go to the freeze gun below… especially when given down the shorts of a soccer player.
Time to stop icing?
Icing or cryotherapy after an injury or exercise has been around for as long as I can remember, and I’m sure it has been around a lot longer than that. However you do it, most methods are simple and safe for many things that hurt, ache, or niggle. However, more healthcare professionals are calling for a ‘cease and desist’ in the use of cryotherapy treatments because of some possible detrimental effects it could have on natural healing processes.
This even includes Dr Gabe Mirkin who first came up with the well-known acronym R.I.C.E for acute injury management, standing for Rest, Ice, Compression, Elevation back in 1978 (ref). The main argument made by Dr Mirkin and many others is that using cryotherapy after an injury or intense exercise causes blood vessels to close, called vasoconstriction which delays inflammatory healing processes (ref).
When tissues are damaged after trauma or intense exercise there is a period of inflammation due to increased blood flow via vasodilation. This increases the transportation of many inflammatory cells and nutrients that help tissue healing including macrophages that release a hormone called Insulin-like Growth Factor Number 1 (IGF-1).
Inflammation isn’t bad!
Now I do think many people, both patients and healthcare professionals alike still see inflammation as a bad, negative, and harmful process rather than good, positive, helpful one. So I support the position that the ‘anti icers’ take that inflammation after any injury or exercise is something that should be encouraged and not impeded or got in the way of.
It does still amaze me when I hear a doctor or physio say that they need to reduce or stop inflammation as if its some kind of pathology or disease! Inflammation is a normal, natural, and amazing process. It is the first stage of repairing and remodelling damaged tissue. Without inflammation, you cannot have tissue adaption.
However, cryotherapy is thought to be detrimental to tissue healing and adaption due to it interfering with inflammation by causing vasoconstriction of blood vessels that reduce blood flow and transportation of macrophages to the damaged tissues, even possibly causing tissue necrosis (death) and neuropathy (nerve damage) (ref). However, before we all panic and lose our minds lets put these concerns into some perspective.
It doesn’t reduce inflammation that much!
Cryotherapy as a method of reducing inflammation is kind of weak, in fact, it’s kind of pathetic in comparison to other anti-inflammatory treatments like cortico-steroid injections or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) that have well documented strong and long-lasting anti-inflammatory effects (ref, ref).
Comparing cryotherapy’s anti-inflammatory effects to things is like NSAIDs or cortico-steroids is like comparing, and I am not over exaggerating here, the effects of a water pistol to a thermonuclear warhead.
Using some ice, or a bucket of cold water for 10-20 minutes may indeed create a temporary reduction in blood flow and therefore a temporary reduction of inflammation, but when it comes to impeding or affecting the natural inflammatory processes it simply is just insignificant in the grand scheme of things, and plenty of research supports this (ref, ref, ref).
It doesn’t change temperature that much!
Another thing to consider is that the application of cold or hot things to our bodies often doesn’t significantly affect the temperature of our tissues that much. Our bodies are very very good at maintaining a steady constant temperature of 38.7 +/- 1*C. This is called thermoregulation and is a vital process that keeps us happy and healthy. If our tisues temperature is easily altered for long periods of time then a whole host of catastrophic events would occur.
Most studies that have looked at the temperature changes with either topical hot or cold application only tend to find significant effects in the skin and very superficial tissues, anything below 1cm in depth is just not affected that much (ref, ref, ref)
Now, this is not to say that no significant temperature changes occur in any relevant tissues as there are some areas and some people that are affected by heating or cooling more than others. Adipose tissue, more simply called body fat, is a bloody good insulator and so body parts and individuals that are covered with more or less of it, will be more or less susceptible to temperature changes from things like cryotherapy (ref).
Therefore the thinner the individual or the less fat there is around a body part the more likely it will be affected by topical heating or cooling, with some studies finding temperature changes in some knee joints of up to 9*C which is very significant (ref, ref). However, the thing to consider is that as soon as the hot or cold source is removed from the tissues the rewarming or recooling process occurs very quickly, usually within a few minutes especially if the patients move around a bit (ref).
It doesn’t help or harm performance that much!
The next thing to discuss is the effects of cryotherapy on performance as again some are claiming that it should be abandoned completely as they think it’s more harmful than helpful. Now sitting in ice baths after marathons or rugby games is something that many do, myself included in the past, in a belief that it helps reduce the soreness after, or helps improve recovery, and there are some studies that support this a little (ref).
However, other studies have found that cryotherapy after strenuous exercise doesn’t significantly affect post-exercise soreness, and may actually impede the inflammatory process again that may have a detrimental effect on the tissues repair and adaption processes, even reducing muscle strength and power (ref, ref, ref).
Recent systematic reviews, however, are less clear (ref, ref). They find cryotherapy after sport appears to not significantly affect performance or recovery either positively or negatively, but it may be beneficial for athletes perceptions of recovery. It may be that cryotherapy works more via psychological effects such as expectations, rituals, beliefs and of course good old placebo effects than any true physiological effects.
Therefore my approach to any athlete (or potential athlete) who wants to do post-exercise cryotherapy is just that, if you want to do it because you think it will help, it most likely will. I don’t think it’s essential or necessary and so wont recommend it, but unless an athlete is using it all the time, for crazy long durations I don’t think it will have any significant detrimental effects if they do use it.
So if you as an athlete want to jump in that cold ice bath for a few minutes and get ya Wim Hof on, or use that crazy expensive cryo-chamber after a really tough game or run now and then, crack on, I won’t stop you! But FYI I don’t do ice baths anymore now that I’ve read what I’ve read… I find it’s hard to get the same psychological or placebo effects when you are better informed.
It does reduce pain!
However, the thing that cryotherapy can do is reduce pain. Don’t get me wrong its not the strongest pain killer, again comparing it to the effects of something like morphine or cortico-steriods is just silly. And it won’t dramatically imporve outcomes if it is or isn’t used (ref), and it appears to be better at reducing some pains more than others such as post operative knee and shoulder pain more than muscular back pain (ref, ref, ref, ref)
But applying an ice pack to something that hurts is a simple, cheap and more importantly safe method of analgesia, and for that, it should be promoted and used more than it is. I am always amazed at the number of patients I see who want a steroid injection for some recent mild annoying pain without even trying something like an ice pack or even paracetamol first. And I think the anti-ice brigade are not helping things by harping on about the possible small transient negative effects cryotherapy may have but overlooking the small transient POSITIVE effects it also has.
Again this doesn’t mean I think ice or any other cryotherapy has to be used for pain, as I’ve said many times before I think we, and I mean society as a whole here, look to remove or reduce pain way too soon way too often for many things that just niggle, ache, annoy, or frustrate us for a period of time. Rather I think more of us need to learn to tolerate pain a little more, for a little longer, but if you have to find something to help reduce pain why wouldn’t you first use something that is simple and safe like ice.
Of all the things physios and other healthcare professionals clinicians need to think about reducing, removing, or abandoning in their treatment and management of things that hurt, ice and cryotherapy comes waaaaaay down the list.
How about more physios and other clinicians first think about reducing, removing and abandoning the more expensive, more time consuming, more dubious, and infinitely more stupid treatments for pain like dry needling, cupping, spinal manipulations, and machines that go bing.
How about physios and other clinicians first think about reducing, removing, or abandoning the more dangerous and potentially life-threatening pain treatments like steroid injections, opioid medications, and unnecessary surgeries before worrying too much about telling people to stop using a bit of ice now and then.
I have been blown away by the response and feedback from my recent blog on abandoning manual therapy. In less than 24 hours I have had numerous emails and messages from many of you experiencing the same problems and pressures to use manual therapy by your colleagues, managers, and patients, not because it helps that much, rather because it’s expected.
It’s great to hear that many of you now don’t feel as isolated or alone knowing that others are in the same position. It’s also great to hear that many of you are now prepared to challenge this culture around manual therapy, which is exactly what I hoped the blog would achieve.
However, there has been some criticism, some constructive, some not so much. This is good, it keeps me on my toes and thinking hard, and I always think it means I’m doing something right if I piss certain people off. There have also been a few fallacies thrown around such as I only critique manual therapy as I’m no good at it and that I need more experience and training in it.
Well, there is no denying that experience and training can help you become a better therapist, but experience or training of manual therapy alone does not make you a better therapist. For example, some research has found that therapists experience, specialist training, and certifications do not improve patients outcomes with low back pain here. And, a systematic review here has shown that more experience may actually be a risk of lower quality of care, possibly due to overconfidence as discussed here.
However, the main point I want to talk about today is the most common justification I have heard from therapists for using manual therapy after this blog, that is it helps patients buy into more active treatments such as exercise. Now, I must hear this justification every day, and I will admit it was one I used to use and believe in myself. I don’t anymore.
The common belief that many therapists have is if a patient with back pain, shoulder pain, knee pain, or any other pain has a bit of manual therapy first it will help them do their exercises better and more often. This is unfortunately complete and utter bull shit.
There is zero evidence, nil, nada, zilch, fuck all… that patients who get manual therapy will do their exercises any better or more often than those who don’t get manual therapy. In fact, there is evidence here that shows even using strong pain-relieving steroid injections in arthritic knees and subacromial shoulder pain here before exercise doesn’t significantly improve the effects of exercise, so why would we think a bit of massage will?
Now there is no doubt or argument from me that exercise adherence of our patients when in pain is poor. In fact, it’s terrible, as low as 20% as found in some research here. But don’t be fooled or mislead into thinking that a bit of rubbing or poking will solve, correct or even significantly change this.
What will change patients adherence with exercise when in pain is talking about their concerns and worries, identifying any possible obstacles and barriers, and coming up with simple practical solutions to overcome them as discussed here. What won’t significantly improve exercise adherence is a bit of massage or manipulation.
Over the years dealing with many types of people in pain I have come to the conclusion that the simplest and best way to get patients to adhere to their exercises when in pain, is to physically supervise, encourage, motivate, and reassure them as they are doing them. I find, and most research supports this, that around 6-12 sessions of exercise therapy (possibly up to 24 sessions for some) done under supervision over 3-6 months for most MSK conditions will ALWAYS outperform 6-12 sessions of any other type of therapy.
I truly believe that if more physios used their time and sessions with patients to actually do the exercises with them, sometimes multiple times a week, rather than faffing around with manual therapy and other passive modalities we would see far better results and outcomes. Patients then wouldn’t then be tempted to seek other more invasive, expensive and risky treatments, and they would also get the other positive health benefits of exercise as a pleasant side effect.
Yes ok ideally in a perfect world we would like all our patients to be motivated and dedicated to doing their exercises without us having to babysit them. But news flash people we don’t live in a perfect world, we live in a world of reducing tolerance and low motivation, not to mention poor lifestyle choices and terrible health habits.
In my opinion, physios who spend their time with patients only talking, massaging, manipulating, poking or sticking them, leaving the exercises for the last 5 minutes of the session, or more commonly just handing them a poorly photocopied sheet of shitty exercises to be done at home are the bane of my life and a cancer in our profession.
This lazy, bone idle, disinterested, apathetic attitude towards exercise belittles and devalues the importance and benefit of exercise therapy for many MSK conditions. If a therapist is disinterested, bored, apathetic about exercise, you can guarantee patients will be as well. Is it any surprise that so many patients ‘fail physio’ with this lacklustre approach to exercise and rehab?
Also, don’t think that by giving some patients a bit of manual therapy you will help move them away from wanting it, which is another common justification for its use. I know there are patients who do only want a few sessions of rubbing and poking and then they will be fine, but there are also plenty of patients who ONLY want the rubbing and poking continuously.
I see a good few patients who are fixated on getting hands-on treatments and addicted to the crack, the joint crack that is. These patients only want a joint popping or a muscle rubbed and have little to no interest in the active side of their treatment.
Please don’t think you can change this by giving them a few sessions of what they want and they will all of a sudden buy in and do what you want. Giving a manual therapy ‘addict’ more manual therapy isn’t going to help them want it less. ‘One last fix’ is often used as an excuse by many addicts but it often fails as it just perpetuates and continues the vicious circle of stimulus and reward. One last fix is never one last fix!
To break a habit a clean break is needed with support, motivation, and sometimes a distraction. The best way to move someone away from manual therapy is not to give them more but instead give them something else to focus on, like exercise.
Finally to wrap this up please remember that you don’t need ANY treatment to keep patients coming back. Also, remember that focusing on getting patients to come back is actually a pretty shitty way to work, you should be focusing on getting them NOT to come back. Also, remember that patients will return to a therapist who they trust and believe is able to help them with the issues and problems they have, and this has NOTHING to do with what type of treatments you do, or don’t use.
Over the last few months, I have received a few emails from physios who are disillusioned with the profession because of the emphasis that is still being placed on manual therapy (see below). It appears that many young physios are being told that massage, manipulation, and mobilisations are an essential part of physiotherapy and should be used on everyone they see. This is not only disappointing but also complete and utter bollocks and I want to say a few words about this.
It appears from the emails above that many physios are being chastised, reprimanded, and even threatened with dismal by their peers and managers for not using enough manual therapy on their patients to keep them attending appointments. I find this extremely sad, worrying, and frustrating that some physios seem more focused on patient retention and profit rather than evidenced-based practice and patient outcomes.
I do understand that we all need to earn a living and be fairly financially reimbursed for our skills, experience, and services. But I think physiotherapy (and all healthcare) reimbursement systems are screwed up, be that public or private sector and not focused on the right thing. Basically, all healthcare, including physiotherapy, is reimbursed for its time and what treatments are done regardless of the results achieved. It doesn’t matter if an episode of care or treatment is positive or negative, physios still get paid.
If we only financially incentivise physiotherapy for its time or for doing treatments rather than outcomes achieved, then physios will continue to be disinterested in patient results. However, if physios were financially incentivised for successful achievement of patient outcomes I wonder if there would be as much focus on taping, needling, or manual therapy etc?
At the moment in this current healthcare financial reimbursement system, being a conscientious evidenced-based physio who consistently looks to develops a patients self-efficacy, encourage self-management, and strives to achieve a quick and efficient discharge once a patient’s goals have been met is an extremely tough and shitty way to earn a decent living.
Now there is no doubt that manual therapy can help reduce pain and improve function for a short period of time, for some people. However, all manual therapy is unreliable with variable effects that are only ever short-lived and minimal in size. In fact, I would argue that a simple hot pack has comparable pain-relieving effects to any manual therapy but is actually more consistent and reliable in its effect, not to mention a damn sight cheaper and a lot less time-consuming to apply.
In my opinion manual therapy is often used to justify the therapist’s existence giving them a feeling of purpose and responsibility, and often used to pander and pamper to patients rather than to genuinely help them.
Tools in the toolbox?
Manual therapy is often described as an essential tool in the physios tool kit, and that it opens the window of opportunity for patients. However, these are lame excuses as often manual therapy is a tool to help physios retain patients and it tends to open the window of opportunity for physios bank accounts more than patients goals.
Over the years I’ve had numerous discussions and disagreements about the pros and cons of manual therapy with many of its advocates and gurus, and I’m sure I will continue to do so. I have discussed how manual therapy is not specific and doesn’t do any of the physiological things many claim it does here. I have talked about how manual therapy is not that skilled or difficult to learn and doesn’t require hours, days, or weeks of expensive training or courses here. I have highlighted how there is a large and profitable industry behind manual therapy with many individuals with huge vested interests here.
Over the years I have collected and shared a good deal of research that questions, challenges, and refutes many of the pseudo-scientific claims of manual therapy and demystifies its methods of effect, and you are all welcome to read some of it in part of my Google drive that is open access here.
I have mentioned many times how I was taught to use lots of types of manual therapy on patients, all with various degrees of success and failure. I have also mentioned many times how I NOW DON’T USE ANY MANUAL THERAPY AT ALL, EVER, AND I LOVE IT.
Dropping that half-arsed 10-15 minute massage or those 3 sets of 30 secs bounces on 3 or 4 levels of a patients spine isn’t the end of the world. All I find that all manual therapy does is distracts patients, wastes time, and doesn’t really help that much in the grand scheme of things. Abandoning manual therapy now gives me more time to focus on the more important aspects of my job such as talking to patients and getting them to move and exercise more.
However, I need to reiterate that just because I don’t use manual therapy this doesn’t mean I don’t recommend that you don’t touch your patients. I use touch to examine all my patients although I know it often has little diagnostic use. I use touch during many of my sessions to help encourage, reassure, and assist patients to move or do things that hurt or cause them concern. I just don’t use manual therapy.
Not doing doesn’t equal easy
I am a proud and vocal advocate that as a physio you don’t need any manual therapy to do your job well. However, I will admit that this is not as simple or easy as it sounds. In fact, there are some pretty significant barriers and hurdles to overcome with abandoning manual therapy.
The first obstacle to deal with is the ridicule and rebuke you will get from other therapists, seniors, and managers who use manual therapy. I still have many therapists attempt to belittle me for not using manual therapy, mostly from osteopaths, chiropractors, and even the osteopractors in the US (yes that is actually a title some physios in the US like to use, more on that here).
These limp-wristed, chino wearing pillocks seem to have some misguided delusion that trying to compare me to a personal trainer somehow insults, offends, or upsets me. These idiots with their freakishly overly moisturised soft skinned hands truly believe that they are more skilled and more effective than me because they think they can feel and correct subluxed ribs, stiff spinal segments, or muscle knots (they can’t, go see my google drive for the research that proves it).
However, I don’t let any of these elitist treatment table based therapists bother me and I recommend you ignore them as well. Instead, be confident in the large body of research that refutes all their pseudoscientific bull shit and take comfort that most of them couldn’t work out one end of a trap bar from the other, or demonstrate a loaded squat to a patient if their life depended on it.
Patients do want it!
What will be harder to overcome will be the barriers you encounter with patients who want, insist, or demand manual therapy due to previous experiences or expectations of getting it.
Unfortunately, the physiotherapy profession has a very strong societal reputation for giving massages and rubs. If I had a pound for every time I heard someone say “I bet you give good massages” when I tell them I’m a physio I’d be a rich man. As frustrating as this reputation is, those of us who know the real benefits of physio lie in rehab, not massage just tend to grit our teeth have a little fake laugh and then politely explain and educate them that this is NOT what physiotherapy is about.
However, what is harder to overcome is when a patient has had previous experience of manual therapy and wants it again. When this occurs, which it does a lot, I find the best way to manage this is by asking the patient what they think it did or does. About 99% of the time patients have either been misinformed or believe that it does something which it does not.
After some explanation around the more rational and simple mechanisms of manual therapy based on basic science and good evidence, I find most patients are normally a little surprised but also not that interested in getting it anymore now the magic and mystique is removed. Some still don’t care and still want me to rub or crack them, then I try and explain that due to its unreliable and short-lived effects that they are better of using a hot pack or getting their partner to rub it rather than me.
Now I’m not going to lie to you and say this works all the time, because it doesn’t. Even after spending time and explaining this all I still have disgruntled patients who just want me to shut the hell up and crack their back or rub their quads. In the old days I used to bite my tongue and do what they asked, but these days I don’t anymore.
I have made a commitment to myself that as an evidence-based physiotherapist trying to provide the best quality care using high-value treatments that I will not lower my standards and do soft tissue massages or joint manipulations which are non-essential treatments. This does cause some disgruntled patients and a few complaints and I am well aware that some will go elsewhere to get it from someone who is willing to do it. So be it. This is their right and their choice.
When this does happen I do still see this as a failure on my part in that I haven’t been able to convince a patient that manual therapy is not needed nor essential and that they should instead be focusing on other things. However, over the years I have also learnt to recognise that you can’t connect with or help everyone you meet in this job and there will always be wins and losses. I just try to make sure you have more of the former than the latter!
A respected profession
So to wrap this up I just want to say again that manual therapy is NOT an essential part of our profession, and if you feel pressurised to use it when you deem it’s unnecessary or not needed then I think you have a responsibility as an autonomous healthcare professional to challenge and question it.
Personally, I don’t think manual therapy should be part of our profession at all. Physiotherapy is striving to be a respected evidenced-based healthcare profession, to do this we need to recognise what is high-value cost-effective treatment and what isn’t. Manual therapy isn’t.
Finally, I want to close by saying that I never became a physio to learn how to massage muscles or manipulate joints. I didn’t become a physio to rub, poke, or prod people. I became a physio to learn how to assess, diagnose and manage pain and pathology. I became a physio to learn how to plan rehab programs to get those in pain or with disability back to function and performance. I became a physio not to rub people but to help them become as robust and as resilient as they can, and I am going to continue to do this. Who wants to join me?
I spend a great deal of my time with patients trying to correct lots of misinformation or misunderstandings they get from many other sources, such as the media, or the internet, or from other therapists. One subject I seem to challenge the most is when patients have been told that their pain is due to a part of their body being too stiff, too tight, or too lumpy, as discovered by another therapist touching it.
I am still astounded and frustrated at the number of myths, misconceptions, and general ignorance that exists around the use of diagnostic palpation within musculoskeletal therapy. I have discussed this topic before over the years here and here, but I feel I need to again as many therapists are still peddling some absolute bull shit about what they can diagnose with touch alone.
However, before I begin let me make this crystal clear for all my usual haters and those who like to sling ad homs, false dichotomies, and straw men at me around this topic. I am not questioning the THERAPEUTIC benefits of touch here, although I do think this is an over-egged and over-exaggerated point as most therapeutic touch is given to pander and please patients rather than genuinely help them. What I am challenging here are the many common and incorrect claims of DIAGNOSTIC palpation tests.
I am also NOT saying here that we shouldn’t touch or palpate our patients. I actually think and advocate that all therapists take the time to thoroughly examine their patients, which includes palpation. This is both a critical and essential part of an assessment and there is nothing worse than hearing a patient explain that last clinician they saw didn’t even bother to look at the area that concerns them let alone touch it.
This lazy, sloppy, and downright dangerous approach to palpation is just as bad as those who make ridiculous, nonsensical, far fetched claims about it. Taking the time to examine a patient’s painful area with palpation feeling for any swelling, heat, or gross deformity is a simple basic part of all assessment but one that is often overlooked and done poorly.
However, when some therapists come to palpating patients I am still seeing and hearing lots of outdated, unevidenced and downright ridiculous things. For example, some therapists still think they can feel specific vertebra in spines that are too stiff, or not moving correctly when performing passive accessory movement tests, despite evidence showing little reliability or utility of these tests (ref, ref,ref, ref, ref, ref).
A post of mine on Instagram a few weeks ago @adammeakins
Some therapists still think they can feel the teeny tiny movements of the sacroiliac joint under many layers of thick muscle and dense ligaments despite this being refuted many, many times (ref, ref, ref, ref).
Some think they can feel knots and taut bands in muscles despite evidence demonstrating, again and again, no reliability (ref, ref, ref, ref, ref). Some even think they can feel blockages in lymphatic and cerebrospinal fluids under skin, muscles, and even skull bones, which defies any scientific rationale or common sense (ref, ref). And finally, there are the crackpots who think they can feel blocked energy, distorted auras, and other mystical claptrap.
I remember as a physio student some 19 years ago being taught to feel for stiff spines and muscles using these palpation tests. I was taught to push joints in the spine, pelvis, and periphery to feel if they moved too little, or too much. I was taught to press into soft tissues and feel for overactivity, tightness, spasm, and knots. Yet despite hours and hours of practice and seeing others all around me saying they could feel this stuff, I couldn’t feel shit.
I was told that I was just too inexperienced and that I had to keep practising and if I did then I would be able to feel the things my peers and tutors could and I would become a better physio. So I did, for years and years, but I still couldn’t feel shit, and I still can’t feel shit 19 years later.
The first problem I found was trying to decide what is too stiff or too loose. To be able to identify whats abnormal I first need to establish what’s normal. However, during my training when I was pressing, poking, prodding normal pain-free fully functional people I found them to all be variable in feelings of stiffness, tightness, and lumpiness. With this wide variation in texture and feel in normal people (if you can class physio students as ‘normal’), how the hell am I supposed to decide if someone in pain is too stiff or too lumpy?
Another problem I found was any feelings of stiffness were highly dependant on the force I applied to an individual. When I pressed lighter they felt stiffer, when I pressed heavier they felt looser. This variability in force meant I could change the feel of something being too stiff or not. Lots of research has demonstrated huge variation in the forces that therapists apply when assessing patients with these tests meaning any interpretations of stiffness will also be hugely variable (ref, ref, ref, ref).
The final issue I had with diagnostic palpation tests was trying to feel what I was supposed to feel. For example, I had difficulty in determining if a lump felt in a muscle was an abnormality or a normal anatomical structure. I also had issues with trying to interpret what I was feeling was actually the structure I was supposed to be palpating and not the other tissues above it.
I even had difficulty finding something as simple as a specific spinal level, and I still do. For example, I could be thinking I am palpating a C6 or L4 vertebra when in fact I could be 1 or 2 levels out, and it’s not just me that can’t reliably find them, many other experienced and skilled clinicians have been shown to be very poor at identifying specific vertebral levels (ref, ref, ref).
Ignorance, ego, and fear
So why is it that despite these issues and decades of research demonstrating poor reliability of diagnostic palpation tests do so many therapists continue to use them, and are adamant that they can feel things that evidence says they cant?
Well, I think its a combination of ignorance, ego, and fear. Most therapists who continue to use these palpation tests simply haven’t kept up with the research, and are unaware of these reliability issues, and more importantly that these tests are not correlated with patients pain or problems.
Those therapists that are aware, or have read this research yet still continue to use and teach these diagnostic palpation tests usually do so due to cognitive dissonance. Usually, their ego refuses to let them abandon something that they have spent so long working on to perfect, and which has involved investing a lot of time, energy, and money to learn.
And believe it or not I do empathise a lot with these therapists, as someone who also spent many years of my life and thousands of my hard earned pounds on further training in palpation and manual therapy seeking to become a better physio, I also feel annoyed, frustrated, and cheated, but I got over it and moved on.
The final reason I think many therapists refuse to abandon these unreliable and unevidenced diagnostic motion palpation tests is fear. A fear of inadequacy. Many therapists are just not comfortable or confident with themselves or their position within healthcare, feeling inferior and subservient to our medical and surgical colleagues. So to inflate their position and give them more confidence they often claim to be able to do highly specialised and skilled things which others can not. This is both sad and embarrassing.
Therapists don’t need superhuman powers of palpation to be respected. Therapists don’t need Jedi manual therapy skills or belief in mysterious, mystical forces to be confident in what they do. If more therapists just had more confidence in the basic simple things such as getting people in pain and with disability back to the things they want to do, with advice, reassurance, encouragement, activity, and of course exercise, then I think we would be respected even more by our colleagues.
Universities need to change!
I want to finish by asking why in 2019 are physio students still being taught these diagnostic palpation tests. Why are many universities still teaching students spinal PIVMs, PAMs, SIJ palpation, and trigger points assessments? Why are students still being asked to feel for things they will never be able to feel. Why are students are being made to feel inadequate or unskilled just like I was 19 years ago?
I know very well why there are so many postgraduate courses out there teaching this kind of bull shit due to the very strong financial incentives. These palpation/manual therapy courses cost a lot and reward those teaching them very well. But here’s the thing, these postgrad courses would soon be redundant and obsolete if undergrad students were taught in university about the issues with these tests, and shown the research about diagnostic palpation, and not made to feel inadequate so that they felt they had to keep searching and practising to feel like good therapists.
So I will sign off by once again reiterating that these diagnostic joint motion palpation and muscle trigger point tests are unreliable and not needed to help patients or to be a good therapist. But, please do take the time to fully examine and palpate your patients, just remember to use your common sense, and the evidence, to help inform you what you can and can not feel in a patient.
“He’s making a list, he’s checking it twice, he’s gonna find out, who’s naughty or nice, Santa Claus is comin’ to town”
Mariah Carey 1994
So its that festive time of year again when feelings of goodwill and cheer are with us all as we try to be a little nicer to each other. However, without ruining the mood too much I want to talk a little about some who are not so nice, and how we all should remember to NEVER judge a book by its cover, or a patient by their attitude, or a physio by their social media posts.
As this will be my last blog of the year and as its the holiday season I don’t want to be too negative, but I do want to mention how this year has reminded me again how some so-called nice people can actually be horrible nasty gits, but also how some so-called nasty people can be the nicest most honest and genuine humans I know.
Now I don’t claim to be perfect in my interactions with people in any way shape or form, far from it. In fact, I know at times I can be a stubborn, annoying, pain in the arse who often engages his mouth before his brain, and have made many mistakes and will continue to do so. I am also very aware and well used to not being liked and having many disagree with me, but I don’t think this is a bad thing, far from it. I think its good to have disagreement and difference of opinion, as George Patton famously once said…
Most of the discussions and arguments I get involved in are often frustrating and annoying but I tend to see a positive in them to a lesser or greater extent, as they do get me reflecting and thinking a little bit harder about my initial views and opinions, and although I may not change them they may get ‘amended’ a little.
Nice but nasty?
However, yet again this year I have had some influential and well-known physios with PhD’s, professorships, and even a few presidents with so-called nice, kind, caring, open and honest personas attempting to discredit my reputation and my career behind my back with some nasty and malicious accusations around my personal and professional life.
These individuals do this because they think I am unfair in my questioning, challenging, and criticising what I consider to be outdated or ineffective treatments. They object to my strong criticisms of many physios over using and over promoting passive treatments such as manual therapy, taping, needling and electrotherapy and neglecting exercise and active treatments.
These individuals dislike my bluntness, directness, and style of communication, often claiming that I am rude or lack of respect. They think I am unprofessional for expressing my frustration, anger, and annoyance and for using some ‘bad’ language.
These individuals often accuse me of attacking others, or them directly, without any evidence or examples. This is because its actually their interventions I am attacking which they are emotionally and financially attached to and so have difficulty separating their identities from them.
These individuals tend to ignore my work that supports and promotes the physio profession and its role in using education, exercise, strength and conditioning and all things active. They also ignore my consistent sharing, disseminating, and reviewing of current and past evidence across all social media platforms.
I suspect that all these individuals are in fact envious, jealous, and threatened of the reach that my views and opinions now have on and off social media. They don’t like how it questions and challenges their own views, practice, but more importantly their teaching.
However, rather than discussing this openly they choose to snide and snipe behind my back working in the shadows spreading their accusations in an attempt to discredit me and shut me up. As I said, these individuals and their actions have reminded me never to take someone’s reputation, position, or appearance at face value, because behind a mask of a caring, compassionate person in authority there could be a nasty git full of hate, jealousy, and malice.
Nasty but nice?
However, just because some nice people can be nasty, it’s worth remembering that some nasty people can actually be very nice. This year I have been surprised, humbled, even taken aback by some of the messages and acts of goodwill, assistance and advice from people, especially from those who I thought disliked me.
This has also reminded me how I need to be careful in making judgements about others motives and attitudes, and not make assumptions about their opinions and comments based on my online interactions alone. And this is also true with some of my interactions with a few of my patients this year, as some of my greatest successes have come from those I found the hardest to communicate and connect with.
I’m sure you all have had patients who have been angry, aggressive, rude, frustrated, and annoyed when you meet them, and as easy as it is to make judgements about these patients, try not to. I have had a number of cases this year with patients who I didn’t connect with immediately, who I thought were ‘hard work’ and ‘rude’.
However, with a little bit of patience (something I work hard on every day) as well as pushing back my immediate knee-jerk opinions and judgements, and instead just deciding to listen to them a bit more, trying to see where these emotions were coming from allowed me to understand, empathise, and eventually build bridges.
Never underestimate the power of just sitting back and listening to patients like these more. Never underestimate how powerful just a few minutes of talking through and showing some genuine interest can be in getting a ‘nasty’ patient to actually be nice.
What I have realised more and more this year is human communication, especially when online, is messy and complex, just like pain can be, and just like pain, there is no right or wrong way in how to manage it. However, if I am being brutally honest I think most of us should deal with the vast majority of online communication no differently than how I think most of us should manage the vast majority of pain… just fucking ignore it and crack on.
But in all seriousness, I think more people need to recognise and tolerate the different and diverse ways in which people communicate with each other, and even if they don’t agree with it, learn to ignore it more rather than think they can intervene and change it to their preferred way.
It’s also worth remembering that there are some people who appear to be argumentative, annoying, blunt, even rude, yet who can be more genuine, honest, and caring than those who are polite, measured, balanced and politically correct. Often it’s the rough around the edges, grumpy antagonist who is being genuine in their thoughts and feelings, whereas the polite, measured, well ‘balanced’ individual may actually be hiding their true thoughts and feelings.
Wrapping it up
So there you go, a short review of some of the communication and other difficulties of the year and how there is often blurring of the boundaries between naughty and nice.
Often those who challenge, criticise, and call out poor or bad practice are seen as naughty, nasty, and mean but it’s not that simple. Often these are frustrated individuals who just want to vent or just highlight these issues.
We all need to recognise that highlighting poor practice is just as important as promoting good practice. It’s not an either/or thing. It’s a both thing.
I will continue to promote all things active and exercise based and continue to criticise all things passive based, and I make no apologies for this nor the way I do it. I will not let those in positions of power or authority with their vested interests and their fake personas of niceness put me off with their pathetic and petty attempts to discredit me just because I annoy, challenge, or threaten them.
Finally just like Mariah said at the beginning, I think its worthwhile having a list of those you think are naughty or nice, but make sure you check that list twice because first impressions can be deceiving.
As always thanks for reading, and I wish you and yours a very Merry Christmas and a happy and healthy New Year
So I gave a talk this weekend at a Dutch Physio conference and laid out my “Rehab Rules” for most things that hurt and cause disability in musculoskeletal physiotherapy. It seemed to go down well so I thought I would give a brief overview of them here and see what you lot think.
These rules, or rather guidelines are how I tend to approach most of my rehab exercises with most of the patients I see, however, I will be the first to admit that they are not perfect and there are always exceptions to every rule/s. But I find if I stick to these and don’t stray too far then things tend to work out for most patients I see, so here they are…
No1: Individualise it
One of the things I hate loathe and detest the most about physiotherapy rehab are those pre-printed sheets of exercise. This lazy, lethargic, bone idol, couldn’t give a shit attitude towards patients problems and exercise needs to be banished and eradicated from our profession.
If you are the type of physio who hands out pre-printed sheets of exercise, hang your head in shame. You are a scourge on my profession and the reason I and many other good physios struggle to improve the reputation of our exercise interventions and get patients to engage with them. If I had £1 for everytime I heard a patient say “all I got was a sheet of exercises” I could have retired years ago.
When giving patients exercises its vital to remember that they and their problems are unique, therefore the exercises to help them will also need to be unique. Now don’t get me wrong I give a lot of patients the same exercises but never the SAME exercise, there is always differences in the load, effort, dosage, frequency, volume etc etc.
We all see a wide, diverse, and varied population in physio with wide, diverse, and varied problems. Therefore our exercise interventions also need to be wide, diverse and varied. Using any treatment homogenously for a hetrogenous problem is never going to work well.
No2: Keep it simple
Physios often fall foul of what I call the rehab paradox. That is they over simply why things hurt patients and then over complicate how to treat them. In fact, more physios need to realise that things hurt patients due to many complex reasons and factors, but our interventions to help them can be really, really simple.
For example, many physios tend to focus on improving the control or the complexity of a movement or task that’s painful or difficult for a patient, and not on building the patients capacity, tolerance, or resilience to the movement or task. I think if more physios focused on simply getting their patients tolerance and capacity to movements increased rather than focusing on the control and complexity of the movement they would see far greater results.
No3: Keep it challenging
Exercises can be challenging not only because they hurt, but also because they are effortful or even fearful. I think if more physios got their patients to focus on the effort of an exercise rather than just the pain, then again I think we would see far greater results
Now, how much pain, effort, or fear is needed or ok to ask a patient to push into is very difficult to say as it will depend on so many different factors and will need to be decided on a case by case basis. But suffice to say I think physios need to be better at reassuring, encouraging, and motivating patients to push harder than they want to.
No4: Be patient
The saying patience is a virtue is one I think more physios need to remember. It is understandable for patients to be impatient when in pain, but when physios fail to recognise how long things take to show signs of improvement with exercise it can and does lead to unnecessary further investigations and treatments for patients.
Of course, we need to be alert to patients who may be deteriorating or not improving due to other factors, but more physios need to realise that the effects of exercise are not immediate, and it takes time for muscles to get stronger, tissue tolerance to improve, and sensitive nervous systems to calm down. Just because there isn’t any significant or noticeable change after a week or two doesn’t mean the exercises are not working for your patient.
More physios need to hold their nerve better and reassure patients to stick with their exercises longer before they start to panic and send them on for further tests and investigations, which often lead to over diagnosis and over treatment for things that could have got better if they just gave it a bit longer with rehab.
No5: Think movements not muscles
Physios need to understand that one exercise does not mean one muscle. Just because a patient has 3 or 4 weak muscles, doesn’t mean they need 3-4 separate isolation exercises. Sometimes one compound movement can get all of these muscles working as well as if not better than 3-4 so-called isolated exercises. And because a patient has fewer exercises to do the adherence and compliance often tends to be better.
No6: There are (almost) NO bad exercises
There is no doubt that there are many daft, silly, ridiculous, and over the top exercises. but there are in my opinion very few dangerous exercises. However, physios, trainers, and many others including patients often tend to get hung up on the technique and execution of exercises waaaay too much worrying that if they don’t do them in exactly the right way they will hurt, harm or damage themselves.
In my opinion, there are in fact very few dangerous exercises. The danger with any exercise tends to arise from poor load management rather than poor technique. Doing any exercises too much, too often is far more likely to cause issues than doing an exercise with so-called incorrect technique.
This is not to say that we don’t worry about technique or performance of an exercise at all. There are times when some advice and coaching of an exercise to do it more efficiently or comfortably or even just better looking can be helpful. But when this coaching and advice becomes too prescriptive, too constraining, too limiting for patients this can be even more harmful than letting them do it unsupervised.
So there you go these are my six rehab ‘rules’ that I think will make physio rehab more enjoyable and more effective. Let me know what you think.
So I have been involved in a few more frustrating discussions around manual therapy recently and why some therapists justify using it. During these discussions, therapists often tell me they use manual therapy as they believe its a form of graded exposure to painful movements or tasks and helps patients return to function and activities. Well, this is bull shit and manual therapists need to find another excuse to justify their rubbing, poking, and pressing people.
Now manual therapists often come up with weird, wonderful and whacky reasons for using their interventions, some less plausible than others. Things such as releasing fascia, breaking adhesions, or freeing muscle knots, reducing muscle spasm, or just to neuromodulate the nervous system. So when they say manual therapy is a form of ‘graded exposure’ it sounds not only plausible but also scientific, evidence-based and contemporary. However, it’s just not correct, manual therapy is not a form of graded exposure treatment.
The entertaining but no less wrong @wokephysio on Instagram… go follow him!
Many therapists have poor understanding and some rather skewed ideas of what graded exposure treatments are. Often they confuse, bastardise or completely misrepresent graded exposure mechanisms to justify the use of their treatments.
For example, therapists often tell me that they use taping, dry needling, manipulation, or joint mobilisation to allow patients to do movements or tasks with less pain, fewer restrictions, and less fear and anxiety. They tell me that by performing some form of passive treatment to a patient in pain it opens the window of oportunity and allows them to move more frequently and therefore this is a form of graded exposure therapy.
Graded exposure is a specific behavioural treatment designed to reduce or remove fear, anxiety, and avoidance by exposing a subject to a fearful stimulus. Graded exposure is performed by exposing the subject to the feared stimulus, not by first removing or reducing as many manual therapists seem to think.
For example, if you have a fear of spiders, you don’t become less fearful of spiders by avoiding them, you need to be exposed to them. Also if you are fearful of spiders being exposed to some fluffy bunny rabbits also won’t reduce your fear of spiders.
They all freak me out… bastards
This is no different with pain on movements or activities. If you are avoiding bending forward because it hurts your back and you are worried, scared, or afraid that it’s harming you, having some needling, massage, or a manipulation first and feeling less pain when you bend forward won’t reduce your fears of bending when the pain returns.
Likewise, if you are afraid to lift your arm up overhead because it gives you a sharp catch, having a nice young physio apply a Mobilisation With Movement or a silly Scapula Assistance Test as you reach up which reduces the catching sensation won’t help you with your reluctance to reach when they stop doing these things.
Symptom Modification ≠ Graded Exposure
Simply put manual therapy is not a form of graded exposure treatment, its a symptom modifying treatment which is completely different (ref). Now you may be thinking this is just Meakins being pedantic over semantics and yes it may be a little, but it is also an issue that is causing some misunderstanding and misuse of two very different approaches to patients in pain.
For example, if you have a patient who you assess not to be displaying any signs or symptoms of fear or avoidance to movements or tasks that hurt. That is they are continuing on with daily tasks, work, and sports despite their pain, and in the exam, they show no signs of apprehension or reluctance to move despite their pain, then I would say modifying their symptoms with some passive interventions could be useful, its not essential or necessary but could be an option.
However, for these kinds of patients, I prefer not to apply manual therapy anymore but rather I prefer to discuss activity modification options, even advise some short periods of rest. Yes, you heard me, rest, it’s not a dirty word and it can be an effective treatment for some people in pain in some situations if not used for long durations (ref). And of course, I will look to load them in ways that don’t provoke or aggravate their current symptoms if possible.
However, if you have the more common type of patient in front of you who you assess is displaying some signs of fear, reluctance, or avoidance to movements and tasks because of their pain, then modifying their symptoms with manual therapy or any other passive treatments may not be the best thing for you or them to do.
Despite it being wanted by patients and despite it being far easier for therapists to do, removing pain when there is no need may actually be more harmful than helpful. If you want to help a patient reduce their fear of a painful movement, or if you want to get them to return to a task or an activity they have stopped because they are afraid, then they will need graded exposure to it without first reducing, removing or modifying their symptoms.
Hardest thing to do!
However, getting patients to do the things they most fear and are avoiding is the most challenging, difficult and unnerving thing to do. To be able to recognise who does and who does not need to be pushed into pain, when it is safe to do so, and how far to take it, takes a shit load more skill, effort, experience, confidence, and bravery than just using some manual therapy or other symptom modification treatments.
Also, one of the biggest misconceptions I hear about therapists who don’t use manual therapy to reduce patients pain but rather push them to do things that hurt or are challenging is that they are reckless, cold, discompassionate and uncaring, this is also complete and utter bull shit.
To be able to calmly and confidently get a patient to do something they don’t want to do requires far more skills in communication, rapport building, and motivation than anything else. Believe when I say its no easy task to ask a patient to do something that hurts them, in fact its the hardest thing I do day in day out, with me always questioning and second guessing if I am pushing them too much, being too harsh, or just worrying about flaring them up and then losing their trust and confidence in me.
It was so much easier and simpler when I could just tell patients to avoid, reduce, or stop doing things that hurt, but this often didn’t get people any better or back into doing the things they wanted.
So that’s my two cents on how manual therapy is NOT a form of graded exposure but rather a form of symptom modification which works through completely different mechanisms and processes still not fully understood. However, manual therapy and most other symptom modification techniques will always have small effect sizes, last very short periods of time, be unreliable in who they work on and dont work on, and in my opinion are generally not worth the time and effort for most MSK issues.
So if you are using manual therapy and are telling patients, other physios, or yourself that its a form of graded exposure therapy, its time to find another excuse.