Why I am not a Manual Therapist

Photo Credit: Myxi

Read that title! Here comes Erik again, with all his manual therapy hate and negativity! *Sigh* This is not an attack on manual therapists, it is a defense of NOT being a manual therapist. In other words, it’s not all about YOU and what YOU ARE. It’s about ME and what I’M NOT. Quick disclaimer: This is going to be long format. You are a busy person and might have already made up your mind, so you probably shouldn’t read it. This is more about me just pulling back the curtain a little bit.

I’m late. I’m always late first thing in the morning. Who the hell put the morning people in charge of the world anyway? 7am workout with my older brother. It was my freshman year and I wasn’t going to the brand new SW Rec Center at the University of Florida with it’s sea of cardio and machines. I was going to the old school weight room in the basement of the O’Connell Center (O-Dome). I liked this weight room. Just free weights. Small. No windows. Perfect.

The other thing I liked about that weight room was the environment. A lot of the university athletic department offices were there. I was never a huge sports fan (go team), but I love the sports environment. I love playing sports, supporting sports, working with athletes, etc. I love the SMELL of an arena/stadium when it’s empty. For that reason, I loved working out at the O-Dome.

I ride my bike as fast as I can, throw it into the bike-rack, and run down the stairs and into the weight room. My brother has already warmed up and is in the squat rack. 225 pounds all set up. “Sorry I’m late! I’m already warm. I got this.” I jump in and start my reps. When I’m done, my back feels “wrong”. I finish the work out but I’m starting to have a lot of pain. By lunch, I find myself in the free student health center.

I have always been a skeptical person. My parents are Cuban exiles. My father was 19 when he emigrated to the United States and my mother was 12 – they both came alone (my mom went into a foster home for a year). Not to get into it, but it should be apparent that this was not the most laid-back, easy world for my parents as kids. For obvious reasons, I was taught not to believe something just because an authority says so. My mother (school teacher) and my father (engineer) instilled in me a love of the scientific process as the antidote to all the dogma. I understood the concept of placebo at a young age. Alternative medicine was an easy target in my home, especially “hands-on” treatments. When I went off to college, I majored in philosophy but still took chemistry and physics because I’m a huge nerd. Understanding knowledge itself is something I have always geeked out on.

The physician comes in and examines me. “Probably just a strain. I’ll send you to PT.” I wasn’t very familiar with PT. I knew what an athletic trainer was and assumed it was similar. The PT for the free student health center was in the basement of the exercise physiology building. Back then PTs were always in the bowels of buildings, devoid of any natural light. He had a student with him and did a quick screen. I listened to him describe to the student all of the reasons that I did not have anything serious and give his confidence in those reasons citing research studies. I was in love! All of that science! All of that elegant simplicity! He encouraged me to get moving again, gave me some stretches, taught me how to use an ice pack, and told me to come back in two weeks if I wanted to. Of course, since I had acute low back pain, he could have handed me magic beans and been just as effective. I never saw him again – couldn’t even tell you what he looked like. That was 20 years ago. Who knows? Maybe he is a Reiki/craniosacral master today.

I switched majors. I was now a physical therapy major (Back then it was a Bachelor’s and we didn’t have fancy smartphones and PDF articles you lucky bastards!) and started volunteering at the big teaching hospital on campus. I loved it so much that I got a job as a PT aide cleaning whirlpool tanks in the wound care unit (anything to be part of the team) and covering 8 hours a week in the outpatient ortho office. These PTs had science oozing out of them. They were considering the non-specific effects of their care, being careful to foster an internal locus of control, and empower the patients to help themselves. Their outcomes were great but they were always skeptical of their outcomes. Some were PhD researchers and would invite me into their labs. I was in heaven!

I then spent some time as an intern athletic trainer with the Gator football program (“American” football for you commonwealth folks). I liked the athletes but didn’t like the high stress “do whatever the athlete wants” mentality of the setting and quit when I got into PT school. I liked PT school a lot. We had great research faculty at the University of Florida. I ate up the evidence-based practice course especially, spending time with the professor after hours in his exercise physiology lab. Of course we learned passive electro-modalities but it was from the perspective of, “You need to know this, but the efficacy is questionable at best.” Manual therapy was taught in the same light.

Back in the day, we didn’t have PDFs. Hell, we didn’t even have internet in most places. To do a literature review, you had to physically drag your ass to the medical library, show your ID, then go to an onsite computer to pull up Medline. No handy user interface either, just a blinking cursor on a blue screen. You ran your search and printed the list of citations – no abstracts. You then had to take that list to rack after rack of journals and physically find each and every article. If you found something relevant and wanted a copy, you had to grab a copy card and get in line at the massive, toner-leaking copier (damn oncology resident hogging the thing all freaking night). And that was only for medical articles. Psychology studies were in another library on another database across campus. My final paper for school was on Behavior Modification for Chronic Low Back Pain. I spent a lot of time in that psychology library.

When I graduated, I moved far away from my safe little world of science and got out into the “real world” of physical therapy. I was horrified. Whisky-Tango-Foxtrot (WTF)!?!? When did we become massage therapists and chiropractors (no offense, but not what I signed up for)??? “What about the non-specific effects? What about confirmation bias? Where is your evidence?” I would ask. But I was a new grad, what did I know? Here were the responses I got in 1998:

“They seem to get better with it.”

“The patients seem to like it.”

“What’s the harm?”

*Sigh* Of course you could say that about a lot of other treatments like acupuncture, etc. With no specific effects, I’m skeptical. “Well,” I thought, “evidence-based practice is coming and I am at the forefront of that – the profession just needs to catch up.” So now, in 2014, I ask the same questions. Here are the current answers:

“Outcomes show they kind of get better with it.”

“Patient satisfaction shows that they like it.”

“It is cheaper and safer than surgery.”

Same responses, just with the new and improved evidence-based practice lingo! But, isn’t this science? Not to me. What if I used “medically applied moist hot pack” (HA HA HA! So silly!) as my intervention and showed patients had a little better outcome, good patient satisfaction, and was cheaper and safer than a spinal manipulation? It would mean nothing, wouldn’t it? And what if I showed that being a compassionate listener and educator while administering this “medically applied moist hot pack” made those effects even greater? Again, means nothing. But no such study has been done, you say? Exactly my point. Why would you do those studies? When you look at manual therapy compared to other treatments, it appears to have more to do with attention vs neglect than anything else. It’s not special.

At best we are uncertain. So what does that mean? “Uncertainty” is handled a certain way in science. We can’t prove that acupuncture meridians don’t exist. Does that mean we shrug and say, “Maybe someday we’ll see them? Let’s use it until we prove it false!” No. When the scientist is faced with uncertainty, the default position is to err on the side of doubt, not belief. I know, manual therapy is more plausible. Yeah, that and a bag of chips will get you…what can you get for a bag of chips? Glucosamine was thought to be plausible to help with osteoarthritis – How did that turn out for ya? I need more than plausibility.

“But that systematic review didn’t categorize appropriately!” and “This study didn’t account for a specific technique!” and “They didn’t look for responders!” Why so defensive? Where is the doubt? Why is there always an excuse when reviews are performed? How many more years of barking up this tree do we need to change your mind? When you lack a testable hypothesis with a specific effect, you chase your tail.

“So what is your deal, man!?!? Why so negative on manual therapy!?!?” No, I don’t think manual therapy is any more evil than electrical stim or any other “feel good” thing we can do. What bothers me is how many PTs define themselves as “manual therapists”. And the pretension that if you aren’t using manual therapy, you are somehow inferior or not evidence-based. Hopefully you can understand my agitation. By no means are all manual therapists this way! But the culture is not very accepting.

All I really want to say is that it is okay NOT to be a manual therapist. Reassuring contact is important, it’s just not treatment to me.