Why manual therapy is still useful and ethical to use DESPITE current evidence.

If you're struggling with the usage manual therapy in your practice because you feel that you are 'lying' to your patient, let me show you why this isn't necessarily the case. In fact, I think it is a perfectly appropriate modality in physiotherapy care as long as you do not exaggerate the benefits it provides.

Here's what we know about manual therapy:

• Provides short-term pain modulation
• Does not 'move' joints as purported by prior clinicians
• Gives patients short term strength or range of motion increases likely due to the pain modulation effect
• Has no statistical difference when compared to long-term placebo (I believe it's at 6 or 12 weeks)

Anyway, this isn't a scientific article, but rather a use of logic which I think is missing from clinical practice.

As a physiotherapist AND having been treated by physiotherapists, I cannot deny the short term clinical effectiveness of manual therapy. Firstly, on musculoskeletal symptoms but secondly - on psychological distress.

Almost everyone in the MSK world has done a calf release that has improved a patient's knee to wall by 2-3cm. They walk away 'pain free' for the next few hours, and return within the next 48-72 hours ready to continue their journey of rehab. Biomechanically, you've just helped restore their gait pattern and range of motion.

Look, we all know the analgesic effect will run out after a few hours and they'll have pain again.

But during that consult, and in fact, the next few hours post - they attain a psychological effect. That they are going to be okay. The impact of this memory cannot be understated. I have coached many athletes who perform better than they have the last few weeks simply if told that their injury won't get any worse if they train at a certain training threshold.

If it applies to athletes, I don't see why it won't apply to people of the 'general' nature - the mums, dads, and grandmothers who are concerned whether they can go back to normal walking or work because they have experienced this injury.

That moment of pain free moving, although short, AND proven to not have much of a statistical difference in the long term, is valuable to patients because it gives them confidence and reassures them that they can be okay again.

Of course, if you tell your patient that you have 'magic hands' and they must come to see you every week for the rest of their lives - then you are lying and an unethical shit bag.

However, if you tell your patient that the first two weeks of injury healing is more to do with restoring range of motion, which is highly sensitive to their pain tolerance, and that manual therapy is a proven, non-invasive and pharmaceutical way to manage pain - I believe there is absolutely zero wrong with that.

This brings me to my next point - manual therapy is a highly appropriate form of analgesic.

Why? Because depending on your modality - your patient does not ingest any drugs or take any injections. In recent times, there is plenty of distrust regarding pharmaceutical companies (for good reason), and most simple analgesics can be bought at your local supermarket despite the negative effects it can have.

Take Nurofen - the standard Ibuprofen compound that is shown to reduce pain and inflammation. I did a google search and found 9 side effects; anxiety, dizziness, tinnitus, stomach ulcers... (that's just four). Yes, it works quick and is quite potent. But if your patient asked you for pain relief and they don't want to ingest drugs, then manual therapy seems like quite an appropriate choice.

As far as I'm aware, there is not much side effect to appropriate manual therapy (don't be manipulating people for no reason now, guys). They don't have stomach shredding issues. They don't get anxiety (in fact, most people find good manual therapy quite relaxing), and it definitely doesn't give you tinnitus.

So as a substitute for pain management, I think it would be outright stupid to throw manual therapy away because it can help your patient prevent ingestion of drugs that they don't want to use. I repeat - it's non-invasive (if you don't use needles), and it most definitely can't shred your stomach lining.

My final case for manual therapy is the terrible logic that some clinicians and researchers argue against the case of manual therapy - that since there's no statistical long term difference, that it shouldn't be used as a form of treatment.

Can we just be human for a second and step into the shoes of the person you're treating?

Imagine poor Timothy from HR who comes to see you because they've woken up with excruciating back pain after spending a weekend moving, and your best advice to him is... 'yeah, not going to do any manual therapy - you're going to be okay in 6 weeks either way.'

Timothy from HR would be gracious as shit not to leave you a 1-star Google Review. Evidence is great - it guides our practice. But part of treatment also includes addressing patient needs. Tim is here to see you for pain management - not what the evidence says in 6 weeks time. He is going to be the one going through 6 weeks of healing, with the first 1-2 weeks being the most painful.

How the hell is he going to have any comfort with what you've told him? In fact, I'd borderline argue that you're being unethical if you don't perform any pain management techniques on him. I mean, if releasing his erector spinae and glutes gives him pain relief - why not? And as an extension - why wouldn't you teach this to him whilst he goes through the initial stages of healing?

Because if you go by 'the evidence' then, most lower back pain issues resolve on their own at 6-12 weeks - with or without intervention. Which means... there's evidence that you (the physiotherapist) is wholly unnecessary for most lower back pain issues. Would you say to the patient who comes to see you for back pain...

'Hey, the evidence behind physiotherapy and nothing is basically the same so you shouldn't come here at all.'

If you do - I think you're better off in another job because you'll only be treating like 3 or 4 conditions in your entire career.

Now that I've made a strong case FOR manual therapy - I'm going to summarise when you become a liar.

1. You tell your patient that consistent manual therapy is what they need for the rest of their lives - no they don't, and you know this. Why? Because I bet you don't do it for yourself either.
2. You tell them that you'll move joints or muscles back into place. Unless you're doing a true relocation of a dislocated joint, you're probably not. There are imaging studies that've confirmed this.
3. Basically, you make claims about manual therapy that have zero scientific backing based off your training. If you don't come from the physiotherapy field, then I have a bit more empathy for that because Chinese medicine for example, does teach certain things that contradict empirical evidence. But you wouldn't know that unless you also knew what 'the evidence' is.

In summary, to throw away manual therapy would be a disaster, not just for the patient but for the entire profession. Manual therapy, now that it has been investigated more thoroughly is a great tool to help someone. It helps you:

-Reduce short term pain

-Avoid oral analgesics

-Provide psychological reassurance

-Restore short term range of motion and strength

And when used at appropriate stages of care, is a wonderful modality to help you progress your patients onto supervised exercise, then individual exercise plans.

P.S I actually never really liked performing manual therapy since I'm lazy, so I should probably be against it, but I'm not. I think it's a great tool.

P.P.S If you're a clinic owner and you want to learn how to improve your sales and retention skills of your staff, PM me 'trust' and let's chat!