Modality Empires

“Modality empire” is my own term1 for a proprietary method of therapy — a sub-discipline — championed and promoted by a single entrepreneur who is likely to suffer from a serious case of healer syndrome. There are many kinds of modality empire, but they dominate manual therapy. 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.

Dr. Mark Crislip, “The Marshall Protocol” on Science-Based Medicine

Big promises and hard selling

Most modality empires make big promises of healing powers and high success rates, 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:

• Ida Rolf’s ROLFING®
• John Upledger’s craniosacral therapy
• David Graston’s Graston Technique® (although he no longer owns the brand)

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:

• Sue Hitzmann’s MELT Method®, which has aggressively made a brand from hype about the alleged clinical relevance of fascia.
• Lee Burton’s Functional Movement Screen (an interesting example in many ways).

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 handy chart from snarky physiotherapist blogger Adam Meakins: “Business a bit slow? Want to stand out from the competition? Looking for that marketing edge? Here’s the answer! Develop your own therapy … ”

Ahead of the science

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

You can’t patent “nice”

Compassionate contact will always be by far the most important part of massage, no matter what alleged technical innovations anyone tries to sell.

Modality empires are businesses

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 the 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 empire 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 long since been abandoned as useless … even by some chiropractors.4

“Success rates” are meaningless

Advertising a high "success rate" is a classic modality empire marketing ploy. Most people know better than to believe a highly inflated number, but we need to be skeptical even of more modest claims, like, “I find about 70% of people get better with this approach.”

That is not something individual clinicians can actually know. Clinical outcomes are subject to a dazzling number of confounding factors — so many that estimates are basically meaningless. Most importantly, clinicians have a badly skewed sample: patients tell them about perceived successes much more than failures.

Claiming a high success rate always strongly implies that the idea of the modality is sound. However, even an actually high success rate doesn’t actually constitute validation of method. Again, the confounding factors: there are many ways that people can actually get better that have nothing to do with the alleged “active ingredient” in the therapy.

Why aren’t customers cynical about modality empires? A double standard

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 — 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

Manual therapy needs to get beyond being “manual”

“Manual therapy” refers mainly to massage, spinal manipulation, and acupuncture for common musculoskeletal problems and injuries, services that are mostly provided by physical therapists, massage therapists, and chiropractors. It is a pseudoscientific dumpster fire, and what little good research exists shows little benefit.7 Modality empires have thrived on the on the idea of “magic” hands. They are all about “fixing flesh.”

Here’s an oblique indictment of the modality empires: in 2017, the journal Manual Therapy changed 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 the writing on the wall that says that manual therapy needs to get beyond being “manual.”

The sketchiest methods will always be promoted the most aggressively.

The Salamander’s Law of Bad Therapy

What are the alternatives? Academic continuing education

The alternative is continuing education that is actually educational, focused on increasing general academic knowledge rather than skills, techniques, and methods. Learn from good teachers, writers, and subject matter dorks (also known as “experts”), rather than “gurus” and “masters” and course publishers that are too much about a “brand.” Some folks who are setting good examples:

• The Massage Therapist Development Centre, which offers good articles as well as courses like “Clinical Applications Of Pain Science: Manual Therapy, Exercise And Rehabilitation Principles For RMTs.” See also Eric Purves Professional Education (Eric is also involved in The MTDC).
• Greg Lehman does intimidatingly smart work, and teaches a pitch perfect course called “Reconciling Biomechanics With Pain Science” — which I think is exactly what the field most needs (and you can see why I think so in this article). He’s also particularly prolific and informative on Twitter.)
• Neuroscientific painmodulation is two days of pure education about pain and rehabilitation science, with a strong research focus, taught by physiotherapist and writer Lars Avemarie, well-known for his relentless science advocacy and debunking of nonsense. Of all the options here, this is the closest to being a seminar version of PainScience.com itself… and Lars might even have a bigger bibliography.
• Walt Fritz was once deeply involved in one of the most notorious guru-centric modality empires (John Barnes’ Myofascial Release Approach®), and chose to leave it behind to create something better. Cool! And cool for a long time now.
• Diane “Dermoneuromodulation” Jacobs. Diane’s thing can seem like just another modality to the uninitiated, but she’s dedicated to academic excellence rather than dogmatic methodology. She is a true expert.
• Laura Allen has been teaching and writing about massage therapy for as long as anyone I know of, and with a steadily increasing passion for science over the years. She earned a spot on this list the day she published Excuse Me, Exactly How Does That Work?
• The San Diego Pain Summit, an annual conference about the science of pain — where all the cool educators go to learn from each other. (I wouldn’t be surprised if literally everyone on this list has been. I haven’t myself, but that’s only because I’m a weird recluse with health issues that make travel hellish for me.)
• Adam Meakins, the sweary physio, does a terrific shoulder course: “The Shoulder: Complex doesn’t have to be complicated.”

PainScience.com is too small a shop to maintain an active, comprehensive directory of good providers of continuing education, especially as their numbers increase. But please let me know if you think I’ve neglected a particularly excellent example.

The price of honesty and humility

Many ethical healthcare pros refuse to jump on any the modality bandwagons. They cautiously, compassionately dare to educate patients that pain is too complex for any one treatment to be highly effective. In doing so, they routinely face disbelief, disapproval … even contempt. One massage therapist told me that her humility is not always well received:

“Some definitely think I just must not be good enough at my job.”

Awful! 😞

She can thank modality empires for that tragic attitude. They have been gushing too-good-to-be-true promises for decades. The crank, quacks, and snake oil salesmen pushing their branded methods have constantly and aggressively inflated consumer expectations, effectively training most of the people of Earth to believe that there must be easy answers to these hard problems. Even the cynics who assume that most of it is bullshit still think you just have to be savvy enough to buy the right therapy/gadget/supplement.

Be more cynical! And — please — appreciate humility in healthcare when you see it. There are legitimate, effective treatments in pain medicine… but not many, and they tend to be either modest or specialized or both. See What Works for Chronic Pain?

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About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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Notes

1. Charmingly, I have now seen it used “in the wild” a few times. It’s catching on!
2. Ingraham. Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. PainScience.com. 21878 words.
3. “Science doesn’t know everything” is a classic, common non-sequitur from people defending quackery. It’s true but obvious, and irrelevant to their point … which is that their kooky treatment beliefs are so exotic that they are immune to investigation and criticism, beyond the reach of science. Nope! Not even close! It’s like declaring a leaky old canoe to be seaworthy because we don’t yet know everything about the ocean depths.
4. ScienceBasedMedicine.org [Internet]. Hall H. The End of Chiropractic; 2009 Dec 11 [cited 13 Nov 28]. PainSci Bibliography 55780 ❐

   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.

5. The colorful history of medicine and quackery is overflowing with people who “swore by” treatments that were bizarre and perilous. Even the worst had fans. People believe what they want to believe. For more information, see Popular but Weird & Dangerous Cures: The most dangerous, strange, and yet popular snake oils and “treatments” in history (and why anecdotes and testimonials cannot be trusted).
6. Ingraham. Organ Health Does Not Depend on Spinal Nerves! One of the key selling points for chiropractic care is the anatomically impossible premise that your spinal nerve roots are important to your general health. PainScience.com. 4736 words.
7. Ingraham. Manual Therapy: What is it, and does it work? The science of hands-on treatments like massage and spinal manipulation to “fix” tissue. PainScience.com. 3183 words.