Disentangling the Truth about Manual Therapy

by Chad E Cook PT, PhD, FAPTA

The “Facts” Please

Perhaps you’ve heard the following “facts”? The Great Wall of China is visible from space. If you touch a baby bird that is in its nest, the mother will abandon it. If you flush a toilet in the Southern Hemisphere, water rotates in the opposite direction through a process known as the Coriolis Effect. I’m uncertain when and where I’ve heard these, but I was surprised to have learned recently that each of these “facts” is actually false [1]. The Great Wall is not visible at low earth orbit without magnification and baby birds are not abandoned once touched. In fact, most birds have a poor sense of smell and won’t even detect that a human has been there. Lastly, toilet construction dictates how water rotates once flushed, not its position on the earth [1]. Each of these statements, which I’m certain you and I have heard numerous times, is an example of the “illusory truth effect” [2].

The illusory truth effect is a cognitive bias in which people tend to believe that a statement or claim is true if they have encountered it repeatedly, even if it is false or lacks evidence to support it [2]. This effect demonstrates the power of repetition and familiarity in shaping beliefs and perceptions. This form of cognitive bias is commonly employed by politicians, marketers, and left- and right-wing journalists to manipulate the truth. Unfortunately, in situations where the “truth” is complicated, the illusory truth effect is a very effective strategy that leads to unwarranted changes in thoughts and beliefs [3].

Manual Therapy doesn’t Work…..Right?

Perhaps you’ve heard the following “facts”? Manual therapy has no clinical effect. Manual therapy is a placebo. Manual therapy which is provided similarly to what is performed in a clinical environment is no better than a sham. Manual therapy has no specific mechanisms. There are no studies that support that manual therapy has a physiological effect on the body. Using manual therapy leads to “addiction” from the patient. Manual therapy is passive and is low-value care. Active treatments lead to substantially better outcomes than passive treatments like manual therapy. Manual therapists have poor pain science understanding and skills, which is why they only adopt a biomedical model of treatment [4].

Chances are you have heard these “facts” on social media by influencers, which is parroted by many of their followers, or have heard someone discuss something at a conference, or through dialogue with selected clinicians who advocate a different approach to treatment. It is likely that you’ve heard these “facts” so many times you’ve begun to question the value of manual therapy as a treatment option. Each of these statements about manual therapy is an example of the “illusory truth effect.”

Simply stated, none of these comments is true.

What is the Truth about Manual Therapy?

In reality, there are numerous (hundreds) clinical trials that show that the average treatment effects of individuals who receive manual therapy are similar or superior to comparison interventions [5-7; and many more]. There are multiple observational and clinical trials that have shown the superiority of manual therapy for cost-effectiveness [8-10; and many more], which is likely why manual therapy is recommended in numerous clinical practice guidelines [11,12; and many more]. Manual therapy is a treatment approach that is preferred by numerous patients, is expected by many, and has been associated with good patient satisfaction, experience, and therapeutic alliance [13,14; and many more]. To date, no studies have shown that using manual therapy interventions judiciously as part of a multimodal treatment (which is recommended in clinical practice guidelines), leads to addiction, low self-efficacy, or other negative psychological traits. Further, well over a 1,000 research studies have explored the mechanisms associated with manual therapy (i.e., how a treatment unfolds physiologically) [15,16; and many more].

In contrast, there are also a lot of outdated philosophical constructs associated with manual therapy, erroneous statements about how it works, and unnecessary barriers to learning/training that are driven by educational profit more so than patient interests [4]. Specific nuances of manual therapy approaches are sometimes conflated as the reason we see outcomes with our patients when in reality, it is likely a combination of features, sometimes unrelated to the nuances. Some philosophical constructs were created over 100 years ago before science could test theory. Now that science has caught up with theory, changes in how we use, understand, and define manual therapy are inevitable. Understanding which changes are needed is critical to advancing practice in this area. It’s the same approach to the use of any intervention. We change as we learn.

As with most situations in which the “truth” is complicated (aka, all forms of patient treatment), adopting extreme “pro” (manual therapy works for everyone) and “con” (manual therapy works for no one) positions is a foolish, naive strategy. Whereas this is useful to know that there are no interventions with a superiority of treatment effect across all potential patients with musculoskeletal conditions, this “middle of the road” (centrist) result is often unacceptable for many. Centrist views are often attacked and if a paper publishes a contrary finding to one’s emotional truth, it is denigrated as a bogus study. Instead of an open debate, and the recognition that nearly all interventions have similar treatment effects, discussion of treatments such as manual therapy has been met with hostility and discourse.

This leads to escalation, division of thought, and unnecessary polarization within our professions. The current debate of “hand’s on/hand’s off” is an example of this derision, even though most datasets suggest that very few clinicians use only manual therapy or only exercise. Sometimes the truth is less interesting and people push for extremes. Nietzsche once wrote: “Extreme positions are not succeeded by moderate ones but by extreme positions of the opposite kind.” None of these debates are helpful for clinicians, as they just drive people further from the truth.

References

1. Goldschein E, Johnson G. 17 Everyday Facts You Know Are Correct — That Are Totally Wrong. Available at: https://www.businessinsider.com/15-everyday-facts-that-are-totally-wrong-2011-8
2. Udry J, Barber SJ. The illusory truth effect requires semantic coherence across repetitions. Cognition. 2023 Sep 22;241:105607.
3. Should you trust media bias charts? https://www.poynter.org/fact-checking/media-literacy/2021/should-you-trust-media-bias-charts/
4. Cook CE. The Demonization of … MSK – Muskuloskelettale Physiotherapie 2021; 25: 125–132.
5. Wilhelm M, Cleland J, Carroll A, Marinch M, Imhoff M, Severini N, Donaldson M. The combined effects of manual therapy and exercise on pain and related disability for individuals with nonspecific neck pain: A systematic review with meta-analysis. J Man Manip Ther. 2023 Apr 24:1-15.
6. Tsegay GS, Gebregergs GB, Weleslassie GG, Hailemariam TT. Effectiveness of Thoracic Spine Manipulation on the Management of Neck Pain: A Systematic Review and Meta-Analysis of Randomized Control Trials. J Pain Res. 2023 Feb 27;16:597-609.
7. Jenks A, de Zoete A, van Tulder M, Rubinstein SM; International IPD-SMT group. Spinal manipulative therapy in older adults with chronic low back pain: an individual participant data meta-analysis. Eur Spine J. 2022 Jul;31(7):1821-1845.
8. Lilje S, van Tulder M, Wykman A, Aboagye E, Persson U. Cost-effectiveness of specialised manual therapy versusorthopaedic care for musculoskeletal disorders: long-term follow-up and health economic model. Ther Adv Musculoskelet Dis. 2023 Jan 31;15:1759720X221147751.
9. Leininger B, McDonough C, Evans R, Tosteson T, Tosteson AN, Bronfort G. Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain. Spine J. 2016 Nov;16(11):1292-1304.
10. Tsertsvadze A, Clar C, Court R, Clarke A, Mistry H, Sutcliffe P. Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials. J Manipulative Physiol Ther. 2014 Jul-Aug;37(6):343-62.
11. Bier JD, Scholten-Peeters WGM, Staal JB, Pool J, van Tulder MW, Beekman E, Knoop J, Meerhoff G, Verhagen AP. Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain. Phys Ther. 2018 Mar 1;98(3):162-171.
12. George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021 Nov;51(11):CPG1-CPG60.
13. Gross A, Langevin P, Burnie SJ, Bédard-Brochu MS, Empey B, Dugas E, Faber-Dobrescu M, Andres C, Graham N, Goldsmith CH, Brønfort G, Hoving JL, LeBlanc F. Manipulation and mobilization for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015 Sep 23;(9):CD004249.
14. Thomas M, Thomson OP, Kolubinski DC, Stewart-Lord A. The attitudes and beliefs about manual therapy held by patients experiencing low back pain: a scoping review. Musculoskelet Sci Pract. 2023 Jun;65:102752.
15. Lima CR, Martins DF, Reed WR. Physiological Responses Induced by Manual Therapy in Animal Models: A Scoping Review. Front Neurosci. 2020 May 8;14:430. doi: 10.3389/fnins.2020.00430.
16. Navarro-Santana MJ, Gómez-Chiguano GF, Somkereki MD, Fernández-de-Las-Peñas C, Cleland JA, Plaza-Manzano G. Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis. Physiotherapy. 2020 Jun;107:118-132.