Monday, July 26, 2021

The battle continueth

I watch this battle with interest and enthusiasm not because I personally have anything to gain or lose anymore, but because I just enjoy it. I get why people flock to tennis games and things like that. 

Recently a paper by Chad Cook came to my attention on twitter: The Demonization of Manual Therapy,  
in response to a years-long blog siege by Adam Meakins, a physio in England, who argues that manual therapy deserves to be taken down by a few or by many pegs in our world. 

Some disclosure on my personal perspective. 
I am (rather was) a licensed physio in Canada for 50 years. I am no longer licensed but I still consider myself a physio, recently retired. 
I saw a lot in 50 years. I felt the Big Wave of orthopaedic manual therapy hit in the 1980's. I wanted to be a manual therapist but found I was allergic to the frank discomfort of the clunky procedural learning, plus I found the biomedical, biomechanical premise, "pain comes from joints,"  kinda stupid, really. So I plowed on with what was called at the time "soft tissue" techniques. 
A great deal of snobbishness went on - those who became "certified" as orthopaedic manual therapists within the profession looked down their noses at those of us who dropped out. We were considered non-scientific and less qualified. Our bottom-up "soft tissue" propositions were pooh-poohed and scorned, even though theirs were equally suspect. 
The gestalt of it all, the momentum of it was understandable - they wanted to create something, they wanted to scientifically examine manual therapy, which was good, I guess... Cook's paper exemplifies that attitude I think. The flip side of that, though, is that the dubious snobby attitudes of OMT, buttressed by a bit of added 'silk purse from a sow's ear' type of academic prestige, held strong even as good research came along to disconfirm said propositions! We can't afford to lose any ground in our social climb! A fortress has been built and must therefore be defended, dammit! 

For me, the entire purpose of manual therapy was to help people with pain problems they were having, more importantly, that they were worried about, anywhere along a scale of being annoyed by but not really disabled much by their ache or pain, all the way to being terribly anxious and physically impaired by it. 
The central organizing principle around which I revolved for most of my career was pain relief. Period. 
I was happy to embrace:
1. pain science and the growing wave of research dedicated to its relief or at least self-management 
2. research that supported a biopsychosocial attitude toward MSK pain to replace the clunky biomedical biomechanical one we had been saddled with since Descartes 400 years prior

The war rages on. People get upset at Meakins, who is seen to have started the fight. He doesn't care. He's quite ready to be a martyr. His perspective is that it's a righteous fight and that he is a warrior doing Something Good for the profession. He wants to wake people up. He cheerfully lobs his catapults at the fortress, which he knows like the back of his hand. He gets captured, brought to "court," then released because he is as good a science-based arguer as he is at getting under people's skin!  
Waking up is uncomfortable.
I get it. 

I have always lived outside that manual therapy fortress, even though I know a lot of the tunnels into and out of it. My strategy to get through life was to argue for a new version of manual therapy because I decided based on pain science that none the old ways deserved any respect, based as they had been on faulty premises and narratives.  

Cook defends the fortress. Most of the defenders of any fortress are those who would feel very psychosocially uncomfortable living outside it. 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. 

Meakins cheerfully rebutted Cook's paper in this most recent blog post. 😀

To know what these two are like in person, in real-time debate, watch this podcast hosted by Jared Powell. 👍

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