Opinion Piece by Tom Belotti.
I would argue that manual therapy and its prevalence in musculoskeletal physiotherapy settings is the main barrier for high value, cost effective care within the profession.
Clinics are set up for manual therapy delivery, patients come in expecting and asking for manual therapy and physiotherapists provide it. Further to this, physiotherapy employers expect and ask for prospective students and employees to have manual therapy ‘skills’ and thus universities teach it.
So it seems everyone is happy; practice owners, patients and physiotherapists feel comfortable within a familiar clinical environment, patients feel they are receiving optimal treatment and physiotherapists feel they are meeting their patient’s needs. In addition to this, physiotherapists have a clearly laid out path for progression; developing their manual therapy skills via specialist musculoskeletal post-graduate courses, led by experienced physiotherapists who feel they are in a position to impart their specialist ‘knowledge’ and ‘skills’.
Where this state of happiness comes undone is when researchers view manual therapy through a scientific lens. Since physiotherapy aims to be a respected, evidence based profession the initial conflict is found within universities. It is becoming commonplace for university lecturers to explain that yes manual therapy has the potential to decrease pain and improve function in the short term, however this change is non-specific, unreliable and has small, non-superior effect sizes, not to mention being inefficient, costly and can potentially contribute to various detrimental long-term patient outcomes born from the passivity of manual therapy (link) (link) (link) (link) (link) (link).
This means universities, who’s students expect to learn the most up to date, evidence based theory and practical skills available are spending a relatively large amount of time, resources and energy teaching and assessing ‘knowledge’ and ‘skills’ in low value care. This is happening because in order for a physiotherapy course to function it requires students to have access to external practical placements and employment opportunities during and beyond the course respectively. Hence there is the need to equip students with the ability to assess and treat in a typical musculoskeletal setting, which currently equals large doses of manual therapy.
However, this issue runs deeper. Pain science including the biopsychosocial model, pain education, tissue healing, tissue adaption, goal setting and lifestyle changes are all taught in addition to manual therapy in university courses. This addition of valuable information without discarding outdated ideas and modalities leads to confusion, frustration and feelings of moral compromise within the profession on behalf of students and new graduates. Established evidence-based physiotherapists in manual therapy dominated work environments also mirror this experience, as do their patients who may receive conflicting information and treatment. The lack of consistency between the theory and practical components of university courses is the birth place of this disillusionment within the profession and furthermore takes time away from learning and developing practical assessment and treatment skills that are of high value (link)
So manual therapy doesn’t work as well as, or for the reasons our patients and many physiotherapists thinks it does and the mix of evidence based and non-evidence based modalities are having detrimental effects on members of the profession and patients. How then can it’s place in the profession be defended?
Don’t say we should provide manual therapy if patients ask for it, especially if they have had a good experience with it in the past. What you will find is that if you explain why manual therapy may work and why it may have worked for them in the past as well as explain what works better and why that is so, most patients will not be as eager for low value care. If you find the above difficult, that may be a cue to work on your’ rapport building, communication and education skills. Put it this way, there are many techniques that can produce comparable effects to manual therapy, the reason you’re feeling inclined to choose one over the others is due to the context you are in and not because of the utility of the modality, this is not a sound approach. For those few patients, who will still ask for manual therapy despite your education, let them know that you don’t provide or charge for low value care. The action that will prevent this scenario from persisting and fast track the preferred alternative is cultural change in and around physiotherapy and that won’t come from continuing to provide low value care. Instead it will come from universities and post-graduate courses teaching high value care and clinicians practicing high value care.
Don’t say that manual therapy is a useful modality for the experienced clinician. There is plenty of research to show that there is no consistency or potency in terms of identifying anatomical landmarks, assessment of muscular tenderness, joint stiffness or laxity as well as in the delivery of massage, mobilizations or manipulations despite high levels of clinical experience and specialization (link) (link) (link) (link) (link) (link) (link) (link) (link) (link) (link) (link) (link) (link) (link) (link). In light of this, the seeming intrinsic need to validate the physiotherapy profession in relation to the role of other health professionals with the use of what are presented to be ‘specialist skills’ is laughable.
Don’t say that manual therapy is a useful modality for creating a ‘window of opportunity’ for active treatment tools. The evidence suggests high value care includes patient centered education (link), direct exposure to feared and painful tasks (link), graduated active interventions such as mindfulness (link) (link) and movement training (link) along with an emphasis on returning to valued activities and engaging with healthy lifestyle behaviors. Not only can these high value interventions modify short-term symptoms just as well as manual therapy, they also improve patient independence, self-efficacy and long-term outcomes in relation to meaningful goals.
Don’t say that manual therapy does no harm and is therefore an inert but pleasant addition to the patient/therapist interaction. The simplest answer is at best it is a waste of time and attention better spent on education, reassurance and supervising active modalities to maximise exposure and treatment adherence, not to mention the swathe of other associated health and lifestyle benefits.
Don’t misinterpret that no manual therapy equals no touch. Yes of course you should touch your patient during assessment feeling for heat, swelling, sensitivity etc. You should also use touch as a teaching tool, guiding patients whilst moving and engaging in active treatment.
So what is high value physiotherapy care?
It’s person centred, collaborative, goal focussed and evidence based, in that it continually looks to maximise positive effects and minimise negative effects of intervention for the individual as well as for the wider health and wellbeing culture.
The fact is if the physiotherapy profession didn’t exist and we were to initiate it based on best evidence, manual therapy would not get a serious look in; we need to stop treating manual therapy like royalty and update our job description. Lets best fulfil our role as health professionals by being in the business of helping people become more pain (life) tolerant, building their capacity and developing their resilience as well as maximising their long term wellbeing, rather than playing the short term symptom modification game.
As a clinician, be proactive in developing your knowledge of and skills in high value care. Work to change the culture around pain and physiotherapy, you’re meant to be the expert; patients don’t know what they don’t know and therefore often don’t seek what they should seek. Instead teach them what is worth seeking and why, help develop their understanding and equip them to inform others.