Hands on Physiotherapy- A Touchy Subject
From it’s inception physiotherapy has always contained some element of ‘hands on” assessment and treatment, and it’s likely most people associate these things closely. Recently however there has been a growing debate within physiotherapy about whether this is a valuable part of our profession and worth keeping. From the inside it can almost appear that there are 2 strongly opposed camps battling it out with little middle ground- almost a civil war…..
Okay…. maybe not all physiotherapists are that attractive… or have as many superpowers…
The hands of time in Physiotherapy
The forerunner of Physiotherapy was established in 1894 as the Society of Trained Masseuses by a group of nurses with a specialist interest in massage and rehabilitation. In 1920 the four pillars of physiotherapy granted by royal charter were (and still are):
Massage
Exercise and Movement
Electrotherapy
Kindred Methods of Treatment
The hands on element of physiotherapy has evolved since then to include not only different forms of massage but also various other mobilisation and manipulation techniques, and in 1970 the International Federation of Orthopaedic Manual Physical Therapists was created. They have defined manual therapy within physiotherapy as:
“…a specialised area of physiotherapy/physical therapy for the management of neuro-musculoskeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercises. Orthopaedic Manual Physical Therapy also encompasses, and is driven by, the available scientific and clinical evidence and the biopsychosocial framework of each individual patient”.
Is it all that handy?
So how does “manual therapy” work? That’s easy right? Surely a therapist feels whats wrong with your body and then uses their hands to rub or stretch it out? Well actually no…. Historically claims have been made that physios could feel specific joints or layers of tissue and and that therapists could fix, realign or release these faulty joints and tissue, increase blood flow, remove toxins, and cause lasting changes.
More recently and as our understanding has improved it has become clear that our hands are not sensitive enough to pick up such small changes, and even if they were most of these tissue changes are either fairly irrelevant to the persons outcome or may not even exist. So does that mean the hands on treatment is worthless? We’ll no actually. Let’s explore this further…
The evidence shows that although hands on treatment likely only has small and short lived affects on the tissue directly it does help to improve patient’s pain and movement in the short-term. How can this be if it doesn’t affect the tissue??? Well it is proposed that it helps to create a host of other responses within our nervous system and brain. Changes in the nervous system and brain are a not an easy thing to measure unfortunately. What the evidence suggests is that with hands on treatment:
the nerves that respond at an area of inflammation can become less sensitive to this stimulus
we can help to prevent these nerves sending information on to the brain
we can affect the way the brain deals with these messages once they get there
we can affect the way we think about pain, our body, normal touch movement and activity.
So what the evidence supports is that with hands on treatment we can have short-term improvements in pain and movement by affecting the nervous system.
With massage and foam rolling/self massage specifically (no, not that kind of self massage you weirdo!) there is also little good evidence that these have a dramatic effect on tissue. The evidence actually suggests that it can help us feel less stiff generally (keep it clean)- not just at the area massaged but throughout the body, to relax and to sleep better. Interestingly a “deeper” massage does not appear to affect these results. Again this suggests an affect on the nervous system rather than the tissue.
For these reasons the most recently published physiotherapy guidelines for treating low back pain continue to support its use as a part of a comprehensive treatment package.
One of the biggest criticisms I hear clinically from clients regarding other therapists is that “they never even touched me”. Research shows (see the graph further down) this belief regarding the benefit of hands on treatment amongst patients is commonly held. Now although hands on treatment is not essential to improve, the evidence suggests it is helpful if used as part of a bigger package and may actually help to create/strengthen the relationship between the patient and therapist. This in turn has been shown to improve adherence to treatment and outcomes.
It has been known in physiotherapy now for quite a long time that some of the best predictors for how long it will take a patient to get better is the patient’s thought and beliefs- about their pain, problem, their outlook, normal movement and activity. Anything that can affect this positively is likely to mean a quicker and more successful recovery. Like any other treatment- hands on treatment, or more importantly the message given with it, has the power to affect these things positively or negatively. The message and intent with hands on treatment appears to be more important than the specific treatment given.
Hands on treatment should be used to reassure the patient about the robustness of their body, and it’s capacity to heal; to show empathy through touch; to reassure regarding normal touch and movement; and to help to decrease the nervous systems sensitivity. It should not be used as a stand alone treatment with the message that it will fix faults or have a lasting effect.
Why some can’t handle it
This appears to be where some of the criticism within physiotherapy of hands on treatment comes from. The abuse/miss-selling of hands on treatment as a cure or panacea. Some physiotherapists have even described hands on treatment as harmful! Like all treatments, including exercise, there is likely a very small risk of physical harm if it is is applied inappropriately. Some more bogus clinicians may tell you that hands on treatment needs to feel painful or cause bruising to be effective- this is not only untrue but is potentially causing injury to your body. The risk of psychological harm comes when the message delivered with hands on treatment is harmful, as mentioned above, rather than from the treatment itself.
Another criticism that has been made is that it is a low value. It’s not clear how critics have measured this value- although it appears that the value patients themselves put on this treatment, and that fact that it is rarely used alone have not been considered.
Below is a graph illustrating patient’s expectation that their lower back pain will improve in relation to different treatments.
What it shows is that a significant proportion of patient’s have an expectation that treatments such as massage and manipulation, along with exercise based treatments, will improve their pain. This gives us some idea of the value patient’s place on more hands on treatments. As mentioned earlier- we know that when therapists and patient’s share values and have a strong relationship outcomes improve and patient’s are more likely to stick to their treatment plan. Techniques that create a strong relationship involve different forms of communication, empathy, and touch! The clinician-patient relationship has been found to be so important that it is actually a better predictor of outcome than the specific techniques used by the therapist. This means we can harness the value that some patient’s place on these treatment to help get them better. It also means that patient’s who value hands on treatment are the ones who are most likely to benefit from it!!
Other criticisms are that hands on treatments are passive and create dependance. Again this is possible but it depends on the message given with the treatment. If the impression is given that all the patient needs needs to do is lie back while someone fixes the problem for them then yes- this is passive. However if it is explained that hands on treatment may ease pain and improve movement in the short-term; it is used to make the patient more confident in normal touch and movement; while stressing the importance of changing lifestyle, behaviour, beliefs, and increasing exercise/activity levels then this does not seem a particularly valid criticism. Again the important part is the message and priority given with the treatment.
A similar criticism is that by using hands on treatment to reduce a patient’s pain in the short-term physiotherapists are not creating “resilience” in patient’s. I find this argument a bit patronising to patients. It is true that sometimes too much focus is placed on reducing pain by therapists rather than improving tolerance to movement and activity, however that does not mean that helping make someone more comfortable is wrong. Patients come to see therapists commonly because they are not coping and this has come to a head. We can help them to cope better in the long term through education and exercise but also in the short-term with hands on treatment among other things. It does not have to be one or the other! If I was a patient personally I know I would want the benefit of both. If helping someone cope short-term is a bad thing then why are people recommended to use ice/heat and take painkillers? Should we ban patients from doing this because it does not promote “resilience”?
Although the foundations of physiotherapy were built on hands-on treatment the profession is increasingly becoming more research based- which is potentially hugely beneficial, as we can ensure that what we do is based on evidence. All evidence based therapists aim to use treatments that have a clear and measurable action and effect. It would appear that some therapists have a hard time using treatments that are shown to improve outcomes and valued by patients because they cannot easily explain/measure why this is. They are uncomfortable with the uncertainty and because of this claim that hands on treatments are unskilled.
Ironically all physiotherapy treatments come with some uncertainty because physiotherapists treat human beings. This includes hands on treatment, exercise, education etc. The reasons for this are that any treatment used will have a host of effects on the person’s body, brain and how they interact with their environment. It is impossible to account for all of these affects at the same time. I would argue the skill for physiotherapists with hands on treatment is in selecting the right patient, being able to handle them while they are potentially highly sensitive, creating a strong relationship, having them leave feeling better short-term, while giving them a confidence and a plan for the long term.
Keeping you in safe hands
It is my opinion that physiotherapist are well placed to deliver hands on treatment to patients as they are the ones who are likely to do so appropriately, with the right message and as part of a comprehensive treatment package. When used in this way it can be a safe and effective treatment strategy, that patients value. If you have any further questions regarding hands on treatment feel free to contact the clinic at betterphysio@outlook.com.