Acknowledging the elephant in the room

Manual therapy is not effective in the long term in treating chronic pain1,2.  It’s the elephant in the room that is harder for some practitioners to acknowledge than others.  Is it the fear that this science might make manual practitioners obsolete in managing these patients, that makes it easier to ignore or dismiss than engage with?


Some manual practitioners might have difficulty engaging with pain science because they are quietly thinking “but what I do works – I make people feel better”.  And there is a reason that they think this – a lot of the time, patients will get a level of pain relief from manual therapy.  Practitioners will hear it day in and day out – “it feels a lot easier/more free/less painful” after a treatment.  It affirms that what we do is hitting the spot and having an effect…….. but the problem is, if we continue with this model of care in the chronic pain setting, we will be having this conversation over and over and over because the relief that people feel in this situation is overwhelmingly going to be temporary.

The temptation for manual practitioners delving into pain science might be to disengage with the material all together – “you can’t measure what we do,” “I am confident that I am making a difference,” “my patients tell me it helps them,” or “perhaps what you do doesn’t work, but I practice this particular stream of manual therapy techniques and I fix people with chronic pain.


In order for us to get good acceptance of pain science in manual therapies, we need to make sure that our approaches don’t throw the baby out with the bath water – manual therapy can still have a place in the chronic pain setting, it just has to be used in a very defined context that is understood by both the practitioner and the patient.  We also need to offer manual therapists some really good options for how to incorporate an understanding of pain physiology into their practice.  There are plenty of “non hands on” evidence based approaches that demonstrate good clinical outcomes,  that can be used in private practices such as osteopathic, physiotherapy, myotherapy or massage practices. These might include exercise, mindfulness, pain education and cognitive behavioural therapy (CBT) approaches.  Up-skilling manual therapists in these approaches makes a lot of sense – who else has good palpation and assessment skills, an opportunity to create good rapport with patients due to the nature of our longer consultations and a solid health sciences background?


I firmly believe that active approaches are the way forward in both the acute and chronic setting.  However I still use my hands on skills every day in practice.


  • Being able to reproduce a patient’s pain in an initial consultation during the examination process demonstrates to the patient that you have listened to their story and that you believe that their pain is real.  This is very important if you are including, or the patient has been exposed to pain education material that tells a story of central sensitisation.  One of goals of pain education is to help the patient to separate out the sensation of pain and the idea that the pain is representative of tissue damage.  We teach that the mechanisms perpetuating the pain are located not so much in the original tissue, but in the central nervous system, and if we are not careful, we can convey the idea that the pain is not real.


  • Having a good idea of where and how the pain can be reproduced gives us a “yard stick”.  We can get the patient to engage in active approaches and demonstrate to them how these can improve the level of pain provoked on palpation or with other examination techniques, thereby reinforcing that these approaches are effective.


  • When you are starting movement based approaches or starting a chronic pain management program that removes or reduces some of the “crutches” that people have been using, (including the reduction of opioids), patients are likely to experience times of increased pain, often for several weeks before the introduced approaches start to have an effect.  This can reduce the patient’s acceptance of the outlined management and they can potentially fall off the wagon.  If manual therapy had worked for them in the past in temporarily reducing their pain, then using it in the short term as the program is getting started is probably justified, as long as both practitioner and patient know that that is the context it is being used in and that the expectation is that over a period of time it will be reduced or stopped.


  • No matter how well we try to educate our patients, reframe our management approaches and attempt to get the patient to embrace active approaches, there are some that are going to be resentful in coming to see a manual therapist without receiving manual therapy.  This is particularly prominent in patients who have attended other practitioners of  your particular profession or even other practitioners in the clinic and long held that  expectation. There is probably a case to be argued that refusing to treat these patients with any manual therapy will result in them leaving the clinic and searching for the next practitioner/therapy/intervention that is going “cure” their pain.  In these cases perhaps a softly softly approach might work better- a combination of gradually introducing pain concepts and active approaches  whilst gradually reducing their reliance on manual therapy.  We know that these patients are particularly vulnerable to anyone who offers them a quick fix – it could be argued that even though it doesn’t fall strictly within the bounds of an evidence based approach at the outset, if you are moving them in the right direction, it is a better outcome than losing them to the expensive miracle healer around the corner.


What do you think?  Should we interpret evidence in a black and white manner or is there room to read between the lines?  Is any form of manual therapy in the chronic setting to be avoided altogether because it sends the wrong message to the patient?   Are there other aspects of using manual therapy in chronic settings that might be considered helpful?  Discussion and comments welcome.



  1. Rubinstein, S., van Middelkoop, M., Assendelft, W., de Boer, M.,& van Tulder, M. 2011. Spinal Manipulative Therapy for Chronic Low-Back Pain: An Update of a Cochrane Review. Spine 36,13
  1. Loeser, J. & Turk, D. (2001). Multidiciplinary pain management.  In Loeser J (3rd ed., pp2069-2080).  Philadelphia:Lippincott.  Bonica’s Management of Pain.       Williams and  Wilkins.