To manual therapy or not manual therapy as a Physio

In the physiotherapy profession there is currently a lot of debate regarding the use of manual therapy. It has both its detractors and its supporters. I enjoy a good debate but this is one debate that in particular has perplexed me. I have personally used manual therapy on a regular basis in combination with exercise prescription. However, there is debate within the physiotherapy profession as to the value of the modality and whether physiotherapists should focus solely on providing exercise for patients. This is a divisive issue amongst musculoskeletal physiotherapists.

The key argument against manual therapy is that it promotes patient reliance on the physiotherapist. Performing manual therapy means that the patient involvement in treatment is passive at best. The patient turns up for their session, they receive treatment and then they leave. What part does the patient play in this scenario? Personally, while I am a fan of manual therapy using manual therapy solely on its own can potentially be a fool’s errand. I believe it is important that physiotherapists used multiple treatment modalities to achieve their goals. Unfortunately, I have found some physiotherapists embrace an all or nothing attitude, one approach or another. One is wrong and one is right. However, there is a reasonable middle ground to be found between a hands off and a hands on approach.

The argument that manual therapy creates patient reliance on a physiotherapist is a lazy one. An argument can easily be made when providing a patient solely with home exercise that you are again creating patient reliance. You will provide a patient with one set of exercises but the patient will have to attend again to receive their next exercise progression. This supposed reliance on the physiotherapist is an argument that can be negated with correct and proper communication. If patients are addressed correctly with our language, we make it less about what the therapist is doing and a more about enabling their body to improve. As stated prior, manual therapy is not something that should be used by itself.

Another consideration is that manual therapy can be a time consuming modality to perform and when physiotherapy sessions are finite in number and time it can be harder to justify its use. Is that time spent delivering manual therapy valuable or is it wasted? If you spend an entire session performing manual therapy with no immediate results, then it is arguable the modality is being performed with no real intent/purpose and is being used in the hope it will make an impact. So how do we use manual therapy effectively? From my own experience I have found the following observations/questions to be extremely useful in determining the likely success of manual therapy:

  • Look closely at patient history i.e. times of onset, movements that cause pain, where the symptoms are, time of onset.
  • Look for intermittent symptoms.
  • Look for restrictive movements and painful movements i.e. at what degree does the patient get symptoms and on which movement does the patient get the pain?
  • Look for symptoms that are reproducible.
  • Always assess and reassess, if you are not getting an immediate/sustained change in patient symptoms you probably are not on the right track and need to reconsider your options.

These are not hard and fast rules but I have personally found them to be effective. I would argue that any modality (as long as used safely) that achieves the key goal of patient improvement is the right modality. You cannot argue with clinical results. The right treatment for the right patient at the right time. It is important to bear in mind that if a change is not achieved in session you are unlikely to achieve a change between sessions. There is no right or wrong when treating a patient and our minds should not be closed to that fact.

What do you practise?

Alex Curran


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