In the world of physical medicine and rehabilitation, there are countless approaches and dogmas within the realm of manual therapy. There are gurus upon gurus who are portrayed to have almost magical hands that can palpate, assess, feel, and wiggle out all of the dysfunctions that we mere mortals can’t seem to find.
Each of these gurus claims that their own special treatment focus and skill set is superior to all the rest. They claim that theirs is “the tool you have to add to your belt” to be a truly successful clinician.
You NEED their technique in order to help all of those patients you weren’t able to help before. Just think about all of those people you’ve failed who you can now help!
Does practice actually make perfect?
“Growing up” through school, we are taught that when we truly achieve manual prowess, we will be able to “feel” all those “things” our proud instructors said we should feel.
We can “bend the wings of a fly” with our mobilizations, palpate a hair through a sheet of paper, PPIVM down to the most minute difference in vertebral motion, zero in on a 1mm x 1mm trigger point, feel cerebrospinal fluid flow (through skin, bones, muscles, ligaments), assess 1mm sacral torsions, assess subdermal adhesions through a metal scraping rod, etc., etc., etc.
And when we are frustrated by our lack of skill we are told, “Don’t’ worry if you don’t feel it at first, it takes years of practice to become an expert!” or “One study showed that it takes at least 10,000 hours to become a master at a craft!”
Diving into the research
Ok, so maybe we can’t refine our palpatory skills to the point of being able to feel all of these assumed dysfunctions we once thought. Certainly, becoming proficient in a variety of techniques is still important in order to focus treatment at different dysfunctional tissues, right?
To address the question of whether these specific manual therapy interventions provide different treatment effects, we can look to the research of Joel Bialosky and Andrew Vigotsky. I’ve already done an in-depth review of this research with my article, The Mechanisms of Manual Therapy.
This topic has been further evaluated in an article in Science-Based Medicine with regards to the specific Graston technique.
With regards to massage and soft tissue work, Paul Ingram has already done an excellent job reviewing the literature in his article, Massage: Does it Work?
Long story short
It would appear that manual therapy “works” via various neural and endocrine processes at the systemic and central levels rather than via specific effects at the sight of the local “target tissue.”
As Diane Jacobs would say, “When you are touching someone’s skin, you are actually touching their brain.”
This highlights the importance of a variety of other contextual factors that are constantly at play during the course of any patient-provider interaction, such as the environment, language used, the provider’s confidence, therapeutic alliance, patient beliefs, etc. It emphasizes the need to “make pain science the air we breathe, not the thing we do.”
So is manual therapy a skilled intervention at all?
It can be frustrating to recognize that manual therapy may not be as technically skilled as we previously thought. Most of us have spent years learning and perfecting their “skills,” in addition to a small fortune on continuing education hours.
There were entire classes devoted to manual therapy in school and there are entire fellowships and certifications devoted to manual therapy. How can it not be a highly skilled and specialized intervention?
Interestingly, at the most recent AAOMPT conference, rumor has it that the curriculum and discussion were far removed from manual therapy and heavily focused on the topics of pain, biopsychosocial factors, and more “soft skills” of patient management.
Despite all of this, I would argue that yes, there is in fact skill in manual therapy. The skill in manual therapy comes less from proficiency in performing a specific technique and more from being able to skillfully HEAR what your patient is telling you. You must be able to adjust your treatment under an umbrella of the evidence, rational thought, and skilled setting of the environment.
I would propose that the majority of the skill in manual therapy comes from confident handling skills, using touch to increase therapeutic alliance, and persistent questioning of how an intervention feels to the patient. For best results, we should pair these techniques with consistent test-retest evaluations for objective findings. This comprehensive approach is the best way to create patient buy-in to the ENTIRE treatment program.
The key to being a skilled manual therapist
The skill in manual therapy lies in the ability to seamlessly build the power of novel, familiar, and/or purposeful human touch into a well-rounded treatment approach. This approach must have the patients and their values at the center, standing on a foundation of the evidence.
Abbott JH, Flynn TW, Fritz JM, Hing WA, Reid D, Whitman JM. Manual physical assessment of spinal segmental motion: intent and validity. Man Ther. 2009 Feb;14(1):36-44
Haneline MT, Young M. A review of intraexaminer and interexaminer reliability of static spinal palpation: a literature synthesis. J Manipulative Physiol Ther. 2009 Jun;32(5):379-86
Stovall BA, Kumar S. Anatomical landmark asymmetry assessment in the lumbar spine and pelvis: a review of reliability. J Am Osteopath Assoc. 2010 Nov;110(11):667-74
Hestbaek L, Leboeuf-Yde C. Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. J Manipulative Physiol Ther. 2000 May;23(4):258-75.
Maher C, Adams R. Reliability of pain and stiffness assessments in clinical manual lumbar spine examination. Phys Ther. 1994 Sep;74(9):801–809; discussion 809–811.
Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 1998 May 15;23(10):1124-8
Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531-8.