As an older physical therapist, past academic educator, and manual therapist, I have wondered why the pendulum and interest in “hands-on treatment” seems to be waning. My disappointment in the waning interest in manual therapy (MT) stems from a long professional experience with the positive patient reaction to therapeutic touch.
I suspect many new physical therapists (PTs) and students can attest to the experience of seeing a medical caregiver who never touched them, despite a physical complaint of pain, swelling, or functional limitation in movement - the clinician did no physical examination. As therapists, we have likely heard patients seeking our help state, “the doctor never even touched my back, neck, arm, etc.”
As a PT, I have taken immense pride in trying to gain trust and connection with my patients. I have learned through open and professional communication, eye contact, and body language, that when appropriate, touching can be quite powerful at creating a trusting and positive connection with a patient. As we enter a new era of advanced diagnostic imaging and important clinical lab testing, it is easy to see PTs drifting away from relying on hands-on physical examination as well as treatment.
Looking Back
Over a career of numerous continuing education classes and post-graduate coursework in MT, I have always remained humbled by other clinicians and educators who have what I would say are “better hands” or the ability to feel something that I may not have been able to “feel” at the time. Long ago, I came to appreciate and pass along the words of a past mentor - “practice makes better” - not the usual cliché of “practice makes perfect”. I think it is critical to educate students that MT is an art and a skill development that takes time and practice. Students need to know the limitations in scientific evidence for MT, but neither should they ignore the vast amount of reported empirical evidence for MT.
As a past academic educator in manual examination and therapy, I have also found that there are varied attitudes and abilities in developing manual skills. Today unfortunately there are many academically gifted students and educators who simply do NOT see enough evidence in MT to invest the energy and practice time to improve their ability to perceive tissue asymmetries, pathology, and patient response to touch. There are also numerous students and therapists who let cognitive intellect get in the way of “feeling with their hands” or simply give up saying, “I can’t feel anything”. We should not forget that although we may not feel something as described by an expert, a patient will know whether you touch them or not. At a minimum, we can at least communicate and be able to feel whether a patient responds negatively to touch / palpation. I do believe a large majority of patients want to communicate about their condition, whether it is pain, swelling, lack of sensation, or asymmetry by being touched and physically examined.
Looking at the Present
I will readily admit that manual therapy (MT) lacks a significant degree of scientific evidence. MT has relatively low intertester reliability regarding palpation and the application of manual forces. A placebo effect with MT has been reported in the literature. On my continuing education courses, I have stated that we should accept and embrace the benefits of the placebo effect when using MT. I personally do not feel the need to “throw the baby out with the bathwater”, when considering the lack of scientific evidence for MT. One only needs to look at the literature to see that there is extensive empirical evidence for MT and a wealth of valuable case reports. Those of us who examine and treat with our hands will attest to its value, despite the difficulty in being able to determine MT value by clinically measurable and objective physiologic effects.
Looking Forward
I feel it is critical to the profession of Physical Therapy that at least a portion of us is known to the public as professionals who do place their hands-on for examination and treatment. We only need to look around and see that other professionals are willing to take up more “turf” by the laying on of hands. It is an undeniable human trait that many of us need to be touched and seek professional help through human touch because it is also a means of communication. I think many of us have heard the claim that a particular PT was “so good with their hands”, and other endless clichés such as “I don’t know how they felt my pain without saying anything to them”, “I could not move without pain until they guided me with their hands”, “I finally could relax after hands-on treatment”, and of course, “at least the PT was willing to touch my …..”.
Paraphrasing an old saying that has always meant a lot to me is: “Finding the evidence for MT may be likened to a blind person looking for a black cat in a dark room that may NOT even be there.” As professionals, it is important to keep looking for the evidence and accept that the laying on of hands does have a placebo effect. However, there is scientific evidence and an overwhelming body of empirical and clinical evidence that MT and the laying on of hands diminishes pain and improves movement. I do hope that physical therapists continue to be known as professionals who do use their hands to examine and treat those individuals seeking help for pain and movement restrictions.