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The Demonization of Manual Therapy

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

Physical therapist Chad Cook thinks perhaps his profession’s methods have been “inappropriately demonized over the last decade.” He could be right, and he makes some good arguments in a new article, “The Demonization of Manual Therapy.”

I would presumably be one of the chief demonizers — a notorious skeptic about treatment techniques like joint manipulation, massage therapy, dry needling, and so on — anything done to patients by a therapist with the intention of making their tissues better. And indeed, I am cited — twice! But not as a culprit, not really “called out.” Phew! Close call!

First, Cook points to my take on a study of rates of adverse effects in physical therapy — and then he goes on to cite the same paper in the same way, without dispute: there are indeed adverse effects! Poop does occur. He adds only that serious side effects are rare. Not that anyone has ever said otherwise. Okay, good talk.

Cook also points to my work in support of his view on the fourth (of eight) demonizations, which he concedes is “mostly true” — namely that “manual therapy techniques are based on outdated, inappropriate philosophies that were derived to support a guru’s theories.” He references my work on more extreme subluxation bullshit as an example.

But I still am a dirty rotten demonizer in spirit, whether I am called out for it or not. Cook highlights several things that I have griped about over the years:

  • no unique specific effects
  • no lasting effects, patient dependence
  • poor bedside manner
  • poor “value-based care”
  • inability to personalize treatment (identify responders)

I have made all of these points over the years, and I stand by all of them to some degree. The truth is in the nuanced middle, as ever — and Cook has some good thoughts about it. It’s all good food for thought, and required reading for professionals. See also:

  • A detailed rebuttal from Adam Meakins, another dirty demonizer. Adam characterizes Cook’s piece as knocking over a bunch of straw-men (criticizing opinions he doesn’t actually hold).
  • Diane Jacobs weighs in with, “The battle continueth.” She writes: “I think in the manual therapy world fortress defenders still entertain delusions of grandeur, the possibility that one day, manual therapy will gain the respect they feel deep inside themselves that it deserves. But he took the bait and fought back in the literature, instead of just grumbling and trying to take Meakins out politically. And for that, I applaud Cook.” (And that, in a nutshell, is why I didn’t wade in myself with any kind of rebuttal. Yet. Perhaps another day.)

Anything here for patients?

If it’s not too late, if your eyes haven’t glazed over, I think Cook has a key point worth highlighting for patients: good manual therapy can be a fine pain-killer. Even if it isn’t lasting, even if it’s not “curative,” the benefit can be significant and valuable — especially because, ideally, it’s also packaged with a lot of other useful education and coaching.