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“Modality empire” is my own term1 for a proprietary method of manual therapy — a sub-discipline — championed and promoted by a single entrepreneur who is likely to suffer from a serious case of healer syndrome. It’s important to know this if you have a chronic pain problem, because so many of the therapies that will be offered to you are the dubious products of modality empires. If you are a manual therapist, especially a massage therapist or chiropractor, you need to understand it too: continuing education should mainly be about acquiring knowledge — with an emphasis on “how to think, not just what to think” (Jason Erickson, HealthArtes.com) — and not just on buying the right to say that you use a trademarked technique.
While there are many taxonomies of alternative medicines, one thing almost all alternative therapies have in common is they are originally the de novo “discovery” of one lone individual.
Most modality empires make big promises of healing powers, and usually make their money by selling expensive therapy and workshops. Even if the brand isn’t strong enough to command high fees, they are inevitable if the business succeeds. Professionals are usually sold on the opportunity to purchase credibility in the form of increasing “levels” of certification, but the quality of these certifications is completely unregulated, and it’s debatable how much demand there really is for such dubious “credentials.”
Modality empires often revolve around an overly simplistic notion of how the body works and how it might be fixed. In particular, modality empires tend to be based on “structuralism,” which is the emotionally compelling idea that our problems are caused by being “crooked” in some way, and that all our problems will be solved when we are “straightened” by therapy. Unfortunately, there is a great deal of evidence that this view of chronic pain is not fruitful.2 Some classic examples of modality empires include:
And here’s a couple good modern examples, brands that have been “hot” in the last decade or so. Again, not necessarily saying these are bad, just very clearly branded:
There are many more, and some certainly are bad. (There are examples that I am unwilling to mention by name because they are infamous for legal bullying of their critics.)
A lack of originality is another major characteristic. There isn’t much in the world of manual therapy that’s new under the sun, and many modalities are really just minor variations on generic old therapeutic concepts that no one should be trying to put a new name on. Some modality empires are particularly unoriginal in my opinion, blatantly re-packaging old ideas for a new generation of workshop consumers, like Paul St. John’s take on trigger point therapy (St. John Neuromuscular Therapy™). And to the extent that they are original, they almost always rely on untested treatment ideas based solely on the experiences and pet theories of the founder, and probably wouldn’t stand up to science-fair level critical analysis.
A lasting guru culture exists in physical therapy, promulgating an ugly self righteousness: “follow me first and then maybe the science.”
Dr. David Butler, “What is the difference between cancer & whiplash?”
When you’re selling a method, you want customers to believe it’s ahead of the science — that it will be validated by science someday. Anyone is entitled to make this bet, but for everyone who actually turns out to be an ahead-of-her-time genius, there are a thousand, or ten thousand, who were just kidding themselves.
Almost all theories turn out to be wrong. Scientists know this. Understanding how things really work is really hard.
Modality emperors usually want to seem science-y, but when challenged they quickly turn on science: “Science doesn’t know everything.” No, it doesn’t. But what a terrible, shallow attitude!3
A modality empire is as much a business model as a method of helping people, and perhaps much more. There is a great deal of overlap between modality empires and quackery. Please note that “overlap” is not a blanket condemnation: I am not saying that everything about modality empires is wrong, or that every modality empire is equally bad. Many modality emperors are also genuinely formidable innovators and experts, and much of value can be found in their methods and teachings.
However, as old joke about lawyers goes, “Only 90% of them are making the rest look bad.”
History has shown us time and again that what drives the popularity of a modality empire is not how well it works, but simply how well it is promoted. Once in a while, a well-promoted modality empires hits the big time and become full-fledged profession. Chiropractic is the most obvious example: it began as the modality empire of master marketer DD Palmer, and then his son BJ, and they spent decades pushing it to the status of a regulated profession. The Palmers were certainly entrepreneurial geniuses, but they also promoted many ideas that have been long since been abandoned as useless … even by some chiropractors.4
What puzzles me most about the promotion of modality empires is how effective they are at fooling people who are cynical about other kinds of businesses — both professionals and patients. Modality empires actually attract customers who hate The Man, corporate greed, and especially Big Pharma. Yet these “sensitive” consumers turn off their cynicism and give a free pass to most modality empires, even though they are — by definition — corrupted by ego (at least) and by massive profits in some cases. Why the double standard?
It’s just marketing 101. Modality empires are able to successfully cast themselves in the role of the underdog just by emphasizing how they are an alternative to everything the customer is cynical about Modality empires primarily exist to give people the health care they want, and not the health care that works — two surprisingly different things.— the target market is super cynical about “mainstream medicine,” and so it’s very easy for a modality empire to make itself look appealing by taking shots at mainstream medicine.
Also, the marketing of most modality empires is usually finely honed by market forces. That is, they primarily exist to give people the health care they want, and not the health care that works — two surprisingly different things, and history is packed with hair-raising examples.5 It really is the industry of emotionally appealing treatment ideas. The successful ones are successful precisely because they have found the right psychological buttons to push. Basically all modality empires are sold on the strength of an emotionally appealing idea or theme.
For instance, many of them are based on the idea of “alignment” — that if you are straighter, you will be healthier. As mentioned above, this “structural” view of pain is simplistic and generally false. The classic specific example is chiropractic, which, despite all of its pretensions, would never be able to survive as a profession without the simple, emotionally appealing idea that spinal alignment is vital to your general health. Clearly that is false, or every person with scoliosis or a simple spondylolisthesis (a scary-looking but generally asymptomatic condition) would be riddled with disease.6
Here’s an oblique indictment of the modality empires: in 2017, the journal Manual Therapy will change its name to Musculoskeletal Science & Practice. Their under-stated explanation:
The new title will better reflect current practice, education and research in the field of musculoskeletal physiotherapy worldwide and ensure that the journal continues to be a leading publication in the field
In other words, “manual therapy” is too narrow, too much about fixing people with techniques and magic hands, and neglects other perspectives and approaches. The change signals a general retreat from the belief that flesh and structure need to be changed… or even can be. It’s writing on the wall that says that manual therapy needs to get beyond being “manual.”
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
Four updates have been logged for this article since publication (2009). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.
I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
— Added an excellent expert quote.
— New section: “Manual therapy needs to get beyond being ‘manual’.”
— Minor but fun: added Adam Meakin’s very amusing and apt random modality name generator.
— Many unlogged updates.
A well-written analysis of the significance of an important paper written by three chiropractors and a PhD (Mirtz et al) about the scientific bankruptcy of subluxation theory.BACK TO TEXT