Manual therapy it is.
This blog doesn’t discuss what works and how (Whys and Why nots) in manual therapy in detail, for that you have much better options available in Paul Ingraham’s works, Adam Meakins’ blogs, posts, lectures, and much more. I aim to discuss here the claims and reality of it all probably, rather crudely but to the best of my abilities.
What even is manual therapy?
Simply put, Manual therapy is a set of physical interventions (mostly passive) used by a ‘specific lot’ of Allied and Health care providers (namely Chiropractors, Osteopaths, Physiotherapists, massage therapists, etc.) aimed at the treatment/management of various musculoskeletal, neurological, and circulatory disorders.
Classically defined by Lederman in his book “Science and Practice of Manual Therapy” as “the use of the hands in a curative and healing manner, or as the use of 'hands-on' techniques with therapeutic intent.”
It is an umbrella term which covers a lot of different modalities, such as:
Soft tissue work: Massage applied to muscle, tendons, ligaments, or skin, Muscle Energy Techniques, MFR (Myofascial release) or MTrP (Myofascial Trigger Point) Release. Recently a lot of tool-based soft tissue work has also become quite popular which is essentially the same thing just done using tools for example: IASTM (instrument-assisted soft tissue manipulation or tool-assisted massage) and Dry needling (or instrument-assisted MTrP ‘release’).
Manipulation & Mobilization techniques: These techniques are the speciality of Chiropractic or Osteopathic practitioners, wherein they use passive movements to try and produce (joint-play-like) motion at the targeted segment, which is aimed at reducing the ‘malpositioning or misalignment’ of said segments. These interventions are popularly known as the ‘Pop-Clicky’ social media treatments.
(The only difference between mobs. and manips. Is the amount of force and speed with which they are performed.)
Some Traction or modifications of these techniques based on slightly different approaches (Kaltenborn, Maitland, Cyriax methods, Craniosacral therapy, etc.) or maybe adding active movements with the passive ones (like the MWM- Mobilization with movement concept by Brian Mulligan) can also be listed under the same category.
On an average Manual Therapy visit a person can expect any mix and match of these modalities as ‘treatment’.
But is that all there is to manual therapy? Just a list of techniques with vague explanations, patho-mechanical rationales? And some slightly different ‘treatments’ for the same vague explanations? Nope! It’s much more than that. Especially, the claims, the way it’s sold, the way it is practised, and the whole elitism and gatekeeping problem.
Let’s discuss these ones by one.
[Just a note: for the explanation and scope of this blog, I’ll use manipulative and mobilization techniques as examples if not specified.]
The Rationales and Claims.
Manual techniques stand on a lot of generalizations, assumptions, and hypotheticals. For example, the PFH ‘positional fault’ hypothesis is historically considered to be the mechanism through which MWM works.
Brian Mulligan in his 1993 paper stated: “I attribute the success of MWM's to the "fact" that bony positional faults must contribute substantially to painful joint restrictions”. These ‘bony’ positional faults are nothing but subjectively assessed heterogeneity in the positioning of surface bony landmarks (for example the vertebral spinous process). Simply put a Manual Therapist touches and feels for a difference in the positioning of these landmarks and determines whether or not a fault is present which can be ‘corrected’ by MWMs.
The only and biggest drawback of these rationales (such as PFH or Chiropractic subluxations) is that the entire premise relies on a person’s ability to touch, feel (palpate), and determine the presence of these ‘faults’. Especially when a whole host of clinical data has shown manual palpation of bony landmarks to be less than poorly reliable.
Preece et al. (2008) Is a remarkable read for this instance, wherein they established that individual morphology is so heterogeneous and unpredictable that one can’t even be sure of side-by-side differences among an individual let alone comparing people with an arbitrary standard of ‘normal data’. (Check out the image below)
Similar findings are maintained in the results of a cadaveric study done by Fausone et al. (2023) in which upon a bilateral comparison of Transverse process and Spinous process lengths they simply concluded that “a finding of a clinical positional fault of a vertebra through palpatory exam may be flawed.”. This shouldn’t be surprising because the idea of pathologizing the otherwise ‘normal’ is quite strange and even if it were possible to reliably palpate (It isn’t: ref. ref. ref. ref. ref. ref.) the subtle differences in anatomy it’d be erroneous on our part to consider it a causal factor without good enough evidence.
If this seems absurd to you, ya’ll must be unfamiliar with the fascial distortion model of manual (hands-on or tool-assisted) massage/’release’ techniques. The proponents assert that ‘fascia’ (a connective tissue that binds the musculoskeletal system) and its 3D distortions can be directly traced to most if not all musculoskeletal disorders.
It is not as if these generalizations are made based on otherwise solid evidence, rather it’s based on ‘expert opinions’ and subjective assessments of questionable validity (palpation and visual inspection).
Even crazier is the fact that all of these modalities have one central claim. That is: “X is responsible for your aches and pains, my technique can get rid of X for you.” [insert positional fault or fascial distortion]
There need not be any complex explanation for the implausibility of fascial distortions if you are familiar with the works of Chaudhry et al. (2008). They devised a mathematical model which showed that to produce even 1% of compression or shear at dense fascia like Plantar fascia or Fascia lata the amount of force required is way beyond the physiological limit. Additionally, if it was so easy to manipulate the fascia and alter the anatomy of our bodies, we would crumble just by running, jumping, lifting weights, and maybe even by a jerk or while rolling in bed!
The author’s closing comments summarize the point that I am trying to make. - “Although some manual therapists anecdotally report palpable tissue release in dense fasciae, such observations are probably not caused by deformations produced by compression or shear.” [note that the word ‘release’ often used by manual therapists is quite ambiguous and doesn’t explain anything]
As for the mobilization and manipulation disciplines. Manual therapists take immense pride in the ability to reduce these ‘positional faults’ or ‘subluxations’ (which IMHO are just nocebic extrapolations of otherwise normal anatomical variations or transient changes in bone/joint position secondary to nociception (which may or may not be protective)).
Studies have shown this to be quite true, YES! These positional faults can be corrected. As long as you keep holding the ‘treatment’ position for posterity.
Hsieh et al. (2002) did an MRI study that showed transient ‘correction’ of a 4° pronation PF immediately after the treatment, which wasn’t retained at the follow-up examination (3 weeks) but the symptomatic relief did last, which according to Vicenzino et al. (2007) signifies that “the long-term pain-relieving effects are independent of permanent changes in the positional fault”. This in turn begs the question “Is it generalizable, given most of these results are based on case reports?”, “Are positional faults as subtle as a couple of degrees identifiable in a clinical setting?”.
McGregor et al. (2001) did a fascinating study to observe these claims of joint motion and ‘corrections’ by manual mobilizations. They produced quasi-static images of C-spine motion using MRI during a PA (posterior-anterior) glide. Unsurprisingly (surprising to the MTs) they found that a PA mobilization produces “Minimal if any” motion of the spinal segments but quite a lot of commotion in the soft tissue structures around it. (again if it isn’t moving what corrects the faults?)
Next up…
The way manual therapy is sold and practised
Like many commercial disciplines Manual therapy also has a pretty evident and enormous ‘elitism’ problem. And it’s only natural considering the way that Manual techniques are marketed.
It is common to hear the words ‘magical’, ‘miraculous’, ‘instantaneous’, and ‘jaw-dropping’ (often spoken in a hybrid traditional-hipster manner) when manual techniques are sold. It often creates the illusion of ‘quality’ and some mysterious property that must be missing in one’s approach.
The result: Instant credibility and gratification of the proponents, amassing a huge following (albeit cultish) and the illusion of magnificence but, if it makes you ‘unilateral’ and biased towards a ‘technique’ or a ‘school of treatment’, problems emerge.
There’s a frequent clash of claims and evidence in this sphere. [The boundary between practice and papers]
A. Does specific techniques matter?
Not really,
B. Is the pop/crack necessary?
Nope. It hardly makes any difference if there is an audible pop or not. (ref.)
C. Is Manual therapy any better than other modalities for back pain? (ref.)
Upon comparing various guidelines and their recommended, and non-recommended techniques (and unclear: Acupuncture) techniques with spinal manipulations, Rubinstein et al. (2022) found that:
Spinal Manual therapies are no better than non-recommended (Massage, no-treatment, control groups, waiting lists, etc.) treatments for pain, but might be slightly useful for functional status. (Statistically significant results mean nothing if the effects are clinically meaningless)
SMT does no better than Sham SMT for pain but again slightly better for functional status when compared with sham(placebo mobilization). [same as an adjunct] (ref.)
D. Does a therapist’s experience in the field change outcomes for the better?
NO! Experience doesn’t seem to increase the treatment effects (or change anything). (ref.) Neither does having experience and a ‘speciality certification’ [might help in intimidation though}
E. Can we practice and apply forces for mobilizing joints according to a grading system?
Unlikely. The force applied by human hands is quite variable at all points of range (beginning, end, others) thus it’s quite difficult to follow the techniques & grades which are quite subjectively defined (eg. end range high amplitude). (ref. ref.)
F. Can a Manual therapist provide patient-centered value-based care?
As it turns out they can! But… with the use of significantly less ‘Manual’ stuff. (ref.)
Ref: Keter et al. (2023)
What works when we say Manual therapy ‘works’?
Very little is understood about the specific effects of manual therapy and how it works, that is the mechanism of action of manual techniques (to an extent some physiology of pain modulation (that applies to almost all Manual techniques) is understood and discussed in our Blog: Trigger points and Controversial Treatments. And Quick Bite: DNIC: The Body's Pain Relief Mechanism).
It’s simple. The clinical context in which the intervention is applied can explain quite a bit about its effects. This is especially true for manual therapies.
Clinical context is the clinical environment and its components “e.g., physical therapist's and patient’s features, patient-physical therapist relationship, characteristics of the treatment and the healthcare setting, etc.” (ref: Ezzatvar et al. (2024))
“But how much can mere context explain?” you ask. Check out Figure 2 (ref: Ezzatvar et al. (2024))
Effects ranging from ~70% to upwards of 85% can be explained by contextual effects, for all major Manual techniques. That’s probably a lot to take in as a Manual Therapist but it (context) only helps the effects seen (when they are seen) and is the only realistically modifiable part (as opposed to rigid traditional beliefs around manual techniques) that can bring it all closer to patient-centered care.
Does that mean manual therapy by itself doesn’t work?
That depends, on your understanding of what ‘work’ is. If ‘it works’ for you is a subjective betterment of symptoms for a brief period, for other active and enabling modalities to take over? Then YES, it works.
If ‘it works’ for you is a total impact on patients’ well-being holistically, a positive outcome, favourable prognosis, better self-efficacy, self-management, and independence (even with some pain in some cases). Then Manual therapy could just be a small (facilitating) part of it, for some people with specific preferences, beliefs, and experiences.
In all cases, it isn’t a magic-delivering technique for you to master and apply to all for instantaneous miracles.
In the end a short note for students and new grad physios:
Don’t fall for the ‘master of X’ trap.
Be careful of the gatekeeping, it is quite common and apparent in the Manual Therapy sphere.
Don’t succumb to the elitism and pressure of not being able to deliver ‘magic’ cures.
It doesn’t make any difference if you have less experience or know a lesser number of these specialized manual techniques than someone who holds a specialization certificate.
Always consider 'your patients’ well-being.
And- never question a manual therapist! It’s not about becoming submissive. Rather, the rigidness and incredible ability of MTs to resist new information (especially opposing info,) to summarise this point here’s a quote from Diane Jacobs (from ‘The Battle Continueth’, her take on Chad Cook’s paper ‘The Demonization of Manual Therapy’:
“Most of the defenders of any fortress are those who would feel very psychosocially uncomfortable living outside it. I think in the manual therapy world fortress defenders still entertain delusions of grandeur, the possibility that one day, manual therapy will gain the respect they feel deep inside themselves that it deserves.”