Physio Network

[Physio Discussed] Hands-on or hands-off? Rethinking manual therapy with Johnny Smith and Darren Collin

• Physio Network

Share episode

In this episode, we discuss manual therapy. We explore: 

  • Patient expectations of manual therapy
  • How does manual therapy work? 
  • Current evidence for manual therapy
  • Is manual therapy an important part of our Physiotherapy toolkit? 
  • How is the current teaching of manual therapy? 
  • What is the future of manual therapy in Physiotherapy? 
  • How manual therapy differs between the public and private settings

Johnny Smith is the Director of Thorpes Physiotherapy and has worked in private practice for the last 11 years. Prior to that, he was an Extended Scope Physiotherapist in the NHS. He qualified in 2003 and completed his MSc in Musculoskeletal Medicine in 2008.  He have been teaching with SOMM since 2008 and is currently the Chair of Education for the Society and Module Coordinator for the Foundation courses. He is also an injection therapist.

Darren currently works as an Advanced Clinical Physiotherapist in Cumbria. He qualified from Manchester Metropolitan University in 2009 and has worked in a variety of settings in the NHS over the past 16 years. He completed his MSc in Musculoskeletal medicine in 2017 and following this completed my Teaching Fellowship with SOMM and have been lecturing on SOMM courses since then. He is now a module co-ordinator on the foundation diploma. He is an injection therapist and a non-medical prescriber. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

SPEAKER_01:

Welcome to the Physio Discuss podcast. In today's episode, we're diving into one of the most debated topics in MSK practice: manual therapy. And we're joined by two highly experienced clinicians and educators, Johnny Smith and Darren Collin. Johnny is the director of Thorpe's Physiotherapy with over a decade in private practice and a background as an extended scope physiotherapist in the NHS. He's been teaching with Som since 2008 and is currently chair of education for the Society and brings a deep interest in both the application and evolution of manual therapy. Darren is an advanced clinical physiotherapist in Cumbria with 16 years of NHS experience, including running his own practice as well. He completed his MSc in musculoskeletal medicine and is a non-medical prescriber, injection therapist, and teaches on Som's Foundation Diploma. Like Johnny, he's passionate about the role manual therapy and also the clinical reasoning behind it for our best patient care. Together, we discuss and explore the key questions. How does manual therapy differ between private and public settings? What does the evidence really say? How does manual therapy work? And are some parts of the body more responsive than others? We also talk about whether manual therapy is still relevant and is it taught well enough in today's physiolandscape? And crucially, what does the future hold for manual therapy? So whether you're using manual therapy daily or if you're questioning its place in modern practice, this is a thought-provoking conversation that you really don't want to miss. I'm James Armstrong and this is Physiodisgust. Johnny Darren, welcome to the Physio Disgust podcast. It's great to see you both. Thank you so much for coming on. Thank you very much for the invite.

SPEAKER_00:

Yeah, we're looking forward to being here.

SPEAKER_01:

I'm looking forward to this conversation as well. It's going to be a good one. Listeners are, I'm sure their ears pricked as soon as they saw the topic. It's always one that grabs attention, and I think for a good reason. So we're talking about manual therapy today. As I said in the intro, we both are involved with the Som and teaching and heavily involved in that education element to it. So it's going to be really interested in getting your viewpoints all around manual therapy, basically. And we're going to kickstart with a really, I think, interesting viewpoint in terms of the difference in settings and how manual therapy is applied. So let's kick start this with how does manual therapy differ between the private and public settings? Johnny, do you want to get us started on this one?

SPEAKER_00:

I've worked in both settings. 12 years I've been purely in private practice, but before then I had many years in the NHS as a physio going up towards an extended scope physio. Personally, I think things have changed a bit over the years. When I started out as a physio in the NHS, I did a lot of manual therapy. I had my mentors, my seniors. I remember being in the room where we wrote our notes, and you'd have a Maitland specialist, a SOM specialist, a McKenzie specialist. So I did a lot of manual therapy as a junior physio, but that's 20 odd years ago. My experience now in private practice, I do like manual therapy, and I do like my team to use manual therapy when it's appropriate. So something we focus quite a bit on. We do a lot of training on, and our patients often appreciate it. So I think from my experience and experience with my team, we use it a lot now in private practice in combination with lots of other things. From what I'm observing, because I've not been in NHS for 12 years, through what I hear from students who do come on the courses, they seem to be doing a lot less manual therapy, particularly the ones who would have probably graduated during the pandemic. I think that may have influenced things because, of course, things were all virtual. I don't imagine they were taught as much during that time. So the feedback I'm getting is manual therapy is not being used as much in the NHS, but used a fair bit in private practice.

SPEAKER_01:

Okay.

SPEAKER_02:

Darren, what are your thoughts? Yeah, so I'm predominantly more NHS-based and have been for the last 16, 17 years now. And since Johnny, I think as a junior physio, I think I did a fair amount of manual therapy and was around. And the departmental culture was quite different back then in terms of how much manual therapy was promoted within the in the department. As Johnny mentioned, certain figureheads maybe within the department who were quite pro-manual therapy. And obviously that sort of filters down to you as a junior therapist, doesn't it? Now there are potentially more barriers in place, such as perceived time constraints in terms of maybe follow-up times and not being able to see patients maybe as often as you'd like, potentially a barrier there as well. And I think also maybe things around sort of waiting times, patient cohorts, the type of patients maybe we're seeing, maybe more complex patients, maybe patients with more commodities, more sort of persistent symptoms. I was in the clinic today with the guys, and so I've coming on here and asked them what their thoughts from manual therapy were, and it was interesting to get the thoughts. A couple of things that sprung to mind. One chap was, oh, we can't see patients more than five, six weeks' follow-ups. And my understanding of manual therapy that we need to be seeing them three times a week to be effective. You know, another one was around the perception of maybe doing manual therapy, somehow you'll never get rid of your patient. They'll want to keep coming back for more and more. You know, it was an interesting comment. If someone comes in saying they've had manipulative therapy before, I definitely don't go that down that route because I think I'll never be able to get rid of the patient. So some of these maybe sort of myths or or perceptions, I think, have maybe filtered into certain departments. That's maybe one of the reasons why we got away from manual therapy, maybe a little bit more on NHS compared to maybe a private setting.

SPEAKER_01:

Do you think patient expectations have changed or are different in settings across private and NHS?

SPEAKER_00:

I think that's a great question, I think. So and it's something which I strongly teach my team is you've got to find out what the expectations of that patient are, particularly which we may want to come on to later on, because spinal manual therapy may work many different ways. And certainly if a patient has an expectation, a belief that manual therapy, maybe they've had it before, and maybe that's what they're expecting. I think as long as it is clinically indicated, it's safe, it's appropriate. I think exploitations play a big part, certainly in private practice.

SPEAKER_01:

So, following on from that, obviously we can see, and I I think listeners may well agree with the observations. I know I've certainly seen the similar side of the NHS, maybe lesser manual therapy going on, private potentially sticking to it a little bit more. I'm sure there's variations across the country, but it leads on to the question, which is a loaded one for the rest of the podcast, really, is how it works. How does manual therapy work?

SPEAKER_02:

I don't think anyone's ever hit the nail on the head completely, have they, really, about how manual therapy works. And maybe that's potentially a bit of a downfall of manual therapy. We can't be absolutely certain on how it works from a research perspective. I mean, there's lots of different thoughts, and we've definitely sort of moved beyond the traditional sort of model of trying to realign joints and displacement, for example, that certain professions may still hold on to. But I think physiotherapy is part of that evidence-based paradigm, hope would sort of move beyond that, really, to more research-based, you sort of more modern way of thinking about things, really. So I think as Johnny mentioned there, I think the patient experience, past experience, patient expectation plays a big role definitely in picking that sort of cohort of patients manual therapy will work on. And definitely there's sort of new physiological effects and effects on pain perception. And potentially, I think it may work slightly differently on those patients with you know acute back pain, for example, compared to more sort of current patients, which I think then plays a big role in patient selection on who you may do manual therapy on, for example. You go back sort of 16 years now to Bielowski's article in 2009, wasn't it? It was quite a seminal piece about the sort of neurophysiological effects and of summation of what manual therapy does and how it works, how it affects the body. And it was completely multifaceted. So I think for anyone to say definitely this is how it works, I don't think you can do that. And then I think the flipping that round on the other side, I think it's then creates complexity in terms of how you relay that to the patient, in terms of, okay, I'm gonna do this technique on you. What's he gonna do? You know, how does it actually work? And I think that's maybe where people feel a little bit less comfortable and confident, that you know, explaining in layman's terms to the patient, actually, how what am I gonna do and how is this gonna affect your body?

SPEAKER_00:

I think the reasons we choose manual therapy or manipulation, particularly for the spine, is to reduce pain and to improve movement. And I think those who do manual therapy would agree that if you pick the patient right, that is the case. Now, how does it reduce pain? How does it improve movement? We know there is some evidence for the physical, the actual physiological anatomical effects. As Darren said, I think thoughts have changed a lot over the years. I mean, there was a recent systematic review in 2024, which looked at the anatomical and physiological effects. And the current thinking is it's uh possibly more related on this aspect to maybe uh fasc joints and reducing spinal stiffness. So whether or not subtle changes in fascist joint gapping or reducing spinal stiffness are probably more neurophysiological, is maybe the more physical anatomical thoughts at the moment, but we certainly know that there will be lots of other non-logical contextual effects, non-specific effects that will influence uh the response and effectiveness of manipulation. And I think this is a topic that seems to create an awful lot of strong opinion and debate by people saying, I've just realigned your spine, I've released that whatever it was blocking it. We can't say that. We can't say that for sure. There is some evidence for some physiological effects, but there's some evidence for non-physiological contextual effects.

SPEAKER_01:

And this to say, in terms of just having your hands on a patient, okay, the effect of physical touch and how our palpation alone might have some of those effects as well. Definitely.

SPEAKER_00:

Again, it comes back to that patient and the environment they're in and have expectations. I think we don't have that definitive answer, but I think we can be confident if we pick the patient correctly and we implement it correctly. I picture to the patient, I see you've got a bit of stiffness here, we're not moving too well. We can do this technique which will hopefully reduce your pain and get you moving freer, to then enable us then to progress with your exercise and education. So for me, we never do manipulation in isolation, and I think the effectiveness is multifaceted.

SPEAKER_01:

And that leads us nicely onto the current evidence. You mentioned a recent systematic review, Darren, you mentioned some work a fair while ago, and there's a lot in between. Where do we currently sit with the evidence around manual therapy when we're looking at it from a balanced point of view, which I feel this is quite hard to find these days, especially if we look on social media. But yeah, where do we sit really truly unbiasedly? It's interesting, isn't it?

SPEAKER_02:

Because you look at the sort of clinical guidelines, and you look in the UK, obviously, we've got our nice guidelines for thinking about spine ontology, you know, low back pain with and without ridiculous symptoms. And obviously, manual therapy is in there, and obviously, you know, a lot alongside a holistic approach, which I'd hope that most therapists would follow in terms of combining manual therapy with education, with sort of an exercise-based approach. And I think it'd be pushed to find many therapists who would just take a purely manual therapy approach and disregard any patient education or exercise-based therapy. But there's definitely evidence to show that manual therapy can enhance the outcome and potentially speed up the rate of improvement as well. But it's interesting with those guidelines, isn't it? Because we look around the world and you look at Australia, for example, and their clinical care standard, and manual therapy is not included in that at all. There's no mention of it. And fundamentally, that's based on pretty much a similar body of evidence that those reviewers are reviewing and coming up with those guidelines. So even at that sort of that level, there's still difference of opinion, isn't there, at the end of the day, about the place for manual therapy as part of that sort of treatment approach, which is interesting. And I think you look at a lot of the systematic reviews that have been done in the last decade, and you actually look into nitty-grid of how many studies are actually included in those systematic reviews. It's not many. A lot of them have got 10, 12, 15 sort of articles in there. So I just think it shows that, yeah, obviously there is some evidence out there of a moderate level, but again, we're lacking, as we are as a profession in many areas, that really high quality, large-scale multi-centre RCT trial, really, looking at specifics. And I think with manual therapy, it's very difficult because that manual therapy umbrella encompasses a great deal, doesn't it? Really? And to make that sort of applicable, and you know, as mentioned before, people coming from different backgrounds, different techniques. How do you package that in terms of a pragmatic trial to really get that high-level mindset? So I think it's quite a hard thing to do. So yeah, I think that the research from that perspective may always be slightly limited.

SPEAKER_00:

I like the way you initially asked the question, James, because it's an unbiased view. There's the course there's such research out there, and I think one thing we talk about in our courses is critical thinking and thinking about do we have, we will all have some inherent cognitive biases and logical fallacies. And it's just trying to step back as to as I maybe started this podcast today, thinking about well, my undergraduate training, I had quite a lot of manual therapy. We had a maitland physiotor, and when I became a physio, there was a lot of manual therapy. I went into private practice quite early on, and I've always adapted that approach. So your first clinical supervisor you really liked, or your first senior, the way they taught you was probably subconsciously influenced your thoughts. And I think it's quite good as an experienced clinician to step back and go, right, what kind of advisors do I have? Because if you are pro-manual therapy, you may well only try to search out research that is in support of manual therapy. If you are very much exercise-based, and we're talking, say, about spinal methodology, you may well just try to research uh evidence for exercise for spinal pain, find something that ticks your box. Maybe there's a publication bias who wrote it or flaws in the methodology. So we try find something from an unbiased point of view if we can. And I think evidence over the last decade, as Darren said, with the systematic reviews of RCTs, probably moderate evidence. There is moderate evidence out there for manual therapy. But is that sometimes the flaws of the way some RCTs are done? Because we've all said in clinical practice, we won't just do manual therapy, we will combine manual therapy with education, with advice. And therefore, is that a flaw in just the way to analyze things?

SPEAKER_01:

You said there, Darren, you said as well, when we look at the systematic reviews, obviously they're underpinned by the RCTs that go before them. And do you think there's just too much noise in what's going on in clinic to truly pick out some of the big or significant effects?

SPEAKER_02:

Yeah, and as we said before, it's that individualised approach as well, isn't it? So it's just very difficult, isn't it, to sort of design a trial that's that big and yeah, there's a lot going on there. And whether we'll ever get beyond that with the paradigm of RCTs, I'm not too sure. Because I think if we're gonna do that, I'm sure that that probably would have been done. You know, they've been recommending greater, bigger trials for these systemic reviews for the last 15, 20 years and it hasn't happened yet, has it? So when is that gonna happen and will it happen? You know, got it moving forwards. Um, I'm not too sure. And the danger is obviously if it doesn't happen and if we're doing less manual therapy, there's less centers doing manual therapy, is it's probably less likely to happen, isn't it, moving forwards, really? It's a tricky one, yeah.

SPEAKER_01:

And then when we talk about manual therapy, obviously listeners will be using it or not using it, but certainly be aware of its use across the body. And we're we're talking more sort of spinal manual therapy, but in certain areas of the body, just touching on this, are there certain areas of the body where you would say that manual therapy is more effective or has been shown to be more effective, or in your experience more effective? Johnny, we'll go to you on that.

SPEAKER_00:

We'll probably focus a little more on with the spinal manual therapy. However, thinking about my own clinical practice, I've got to be aware of my own cognitive biases because I am quite pro-manual therapy. But I was thinking sometimes in the periphery, if you've got that stiff angle that hasn't, you know, it's been in it, an inversion injury which hasn't been mobilised adequately, some of the mobilization movements work a treat, or sometimes in other peripheral joints. I like manual therapy throughout the body, but I think there's probably been more focused from an evidence point of view on the spine. And I think that's probably where there has been more research and possibly more support.

SPEAKER_02:

I think there's quite strong evidence around sort of written about some sort of arthrotig knees, for example, manual therapy. I think I think that's fairly well supported in terms of a specific sort of region of the body or specific sort of pathology that that could benefit from manual therapies. And I think that's something that it is to be fair still done quite widely, or more widely than other joints, for example, or the classic, you know, you stiff ankle, chronic ankle, yeah, definitely. But yeah, the predominantly UCL folks, more spinal, yeah.

SPEAKER_01:

So then it leads on to is is manual therapy an important part of a physical toolkit? I think probably we can guess relatively well what your answer's gonna be here, but let's just touch on that a bit in terms of, and I think the important bit is part of the physio toolkit. I think we use that term an awful lot. But what are your thoughts around that in terms of it being still an important part of a toolkit? Can we get away without having it or do we need it?

SPEAKER_02:

Yeah, as you probably expect, I think it is a vital part of our toolkit. I think as a profession, really, it's a dangerous log. Our manual handling skills, even from thinking about assessment approach, you know, you touched on before, that power of touch and taking that time to assess people, appreciate end fields, ranges, and that then feeds through to your treatment, doesn't it, really? And for a manual therapy technique to be effective, and I think this is maybe where it falls down as well, is that if people lose confidence or don't ever get confidence in these techniques and they're not really doing a good technique or an effective technique, then obviously it's not gonna be it's not gonna work, is it? It's not gonna be as effective potentially. I think it is a vital part, but yeah, as I mentioned before, I don't think there's many therapists out there that would just purely do manual therapy. I think it's just part of that sort of holistic approach. And I'd flip around saying if you've had the education approach, had that sort of exercise-based approach, you've been through your full repertoire of sort of exercises of progressions, and that patient's still coming back and not progressing or getting better, where do you go with that patient? And is manual therapy something that there's another tool in the kit bag you can try, and maybe something that you've missed in that sort of shared decision-making process earlier on in your assessment and overlook that because you know the the whole sort of rationale, I suppose, that shared decision making is getting that patient expectation, that patient perspective, what their past experience has been to guide your treatment approach. And if you if you're gonna go down and ask all those questions and get that information and then maybe completely disregard a treatment they've had previously that's been successful, then for me that's probably not doesn't make much sense really, you know, to just just disregard that because I'm not a manual therapist, I don't really believe in that. I'm just gonna go off a completely different tangent and hope I get as good a result as maybe what they've had in the past. So, yeah, I definitely think it's still a vital cog in that wheel, yeah, definitely.

SPEAKER_00:

I would completely agree. It concerns me a little bit when I'm teaching on courses and we will put out we'll will say, Can you put your hand up if you are using manual therapy? And there's quite a lot of newer physios who aren't. And from a personal experience of you know 20 plus years of using manual therapy, well, it is such a useful tool, but it's got to be used in the right context. But I think also, whilst I think you can have a direct reduction of pain improvement in movement, it helps with that therapeutic relationship as well. Like it can help to build trust. If you can do something and you can reduce someone's pain and get them freelanced easier, and it builds that trust, which then when you explain, look, you really need to improve on these lifestyle factors, we've got to get you more active, we've got to work on the exercises. But if someone trusts you and you've been able to modulate those symptoms, that therapeutic relationship can be really important. And certainly when I'm doing manual therapy, I'm giving advice as I'm doing it. I think personally it's a really important tool. And I think if you're a newer qualified physio and you're thinking, I've not been taught much undergraduate, I wasn't taught much, because I guess the thing is now we may well have some senior physios, some band six physios who maybe came through the pandemic and maybe if they've not done any manual therapy and they're now the senior, thinking back to my old seniors who did quite a lot of manual therapy, are the newer physios coming through just not going to be taught this. And I think that'd be a huge shame and a huge concern for the profession. So I think as always, it needs to be balanced. But for me, it's an essential part. And for the physios I employ, that's an essential skill, and we do lots of training. And if someone, I don't want this to sound wrong, but if someone came and was extremely anti-manual therapy and didn't want to even consider that, I don't think they get a job working for me.

SPEAKER_01:

Brilliant. It makes a lot of sense, given what we've talked about so far. And then we talked about biases, we talked about the influence of seniors in in our early stages in career, and and all the way through people we look up to and people who we we build respect for during our career have an influence on what we do. Do you think that's had an influence on, and I suppose my next question is on your techniques? Do you have preferred techniques? Do you have techniques that you think work better than others or you feel more comfortable with, or not?

SPEAKER_00:

Well, all of our personal preferences based on our experience. Darren and I both teach with some. I've been teaching with some since 2007. So I utilize the SOM techniques a lot. But the first thing we say on our courses is look, combine this with other techniques, other approaches. This is not uh you're gonna need more than this. But I certainly find that the SOM techniques can be very helpful. They will be, from a spy-up point of view, probably classified more as non-targeted manipulation. But there was a systematic review from Solventon a couple of years ago, which compared targeted to non-targeted manipulation. Both were effective, both were effective very similar. So I do combine things. So I will I'll have a certain approach I will use, but from a some perspective, we have a very pragmatic approach, and that's what I think is brilliant. You know, say if you if you're treating the neck or something, you've got so many options we can do. Like there's the some techniques, there's I like the mateline and stuff, I like mobilization with boobin techniques. So we've got so many things we can try. And I think if you didn't do any of those, I just think your patient's basic and person.

SPEAKER_02:

Yeah, and I'd I'd sort of echo uh Johnny's thoughts there at the end on the sort of non-specific nature of stunt techniques. And those are tend to what I tend to use, especially thinking about spinal pathology. It's interesting that, you know, the sort of manual traction for the spinal neck pain, very, very effective technique, I feel, and one I use pretty much every day in clinical practice. But teaching that and getting sort of younger, new grads and and sort of people who are less experienced coming on to try that for the first time. You can see them very, very nervous because going near the neck, and obviously the amount of you know, the tension or whatever that they feel that they're putting on the neck. And it takes a long time, you know, over the course of the course and then coming back, doing exams and stuff, you can see them becoming more proficient in that technique. But the first time they do it is very nerve-wracking for them, but it's it's a fantastic technique and it's really, really beautiful technique to do. So I think that's where that experiential learning from each physio, going away and trying it, what you're comfortable with, how your body works. And again, it's that patient co-ax. I suppose you know, if you're seeing six foot eight, 20-storm rugby players, that what you're gonna be doing on those patients is gonna be completely different to maybe what you're doing on a in a five foot three, seven-stone gymnast. So I suppose it's what type of patients you see in data in your clinical practice is is guiding what sort of techniques you may end up sort of becoming more proficient at in your own sort of clinical practice, really.

SPEAKER_01:

So, with that in mind, we've touched on again on this already in in terms of the current teaching. Johnny, you mentioned it a little bit. Where are we at, do you think, at the moment, with the current teaching of manual therapy on the undergraduate course? Is it good enough? Is it enough? What could be improved?

SPEAKER_00:

Tricky to answer in as far as I haven't seen the actual syllabus nowadays of what is being taught. All I can go on is what feedback I get from students on our courses and when I interview people who come to will love me what their past train has been. The last course I taught on, I was speaking to probably four or five people who were between one to four years qualified. They all came through different universities, and from Torkinson, it concerned me as to what they were taught because they seem to be taught very little, whether or not, as I've said, the pandemic influenced some of that. But the one who qualified a year ago. So now it would concern me as to potentially what is being taught from a manual therapy perspective, but I imagine it might be different in different universities.

SPEAKER_02:

I think we can only go on on you know, the start of every course. We have maybe 20, 30 physios there, and we asked them why you're here, why have you come on the course? And invariably in recent years, it's because of maybe a lack of confidence, or as Johnny says, maybe a lack of uh manual therapy being taught on some grad or in sort of departments around the country. It was a study, wasn't it, a few years ago, 2021, looking at new grad experiences and did it preparedness basically for clinical practice. And I think it did show that they felt they were uh prepared for the standards of proficiency, however, like lacking maybe in like clinical skills. And I think that is definitely what we see having a lot of maybe year one to year four post-qualification physios coming on our course. It's the thing with our course that they're nationwide, so it's not just Northwest, these are physios from you know across the UK all saying the same thing. We have two or three hundred physios coming on our course every year and saying the same thing. So there must be something in that really across the UK. Yeah, it's concern, isn't it? Because that's you know, those handling skills I said before, that they're fundamentals potentially of physiotherapy practice and assessment, aren't they? So, and if that's not a big part of undergraduate syllabuses, then it's concerning, isn't it?

SPEAKER_01:

I feel I mean I would agree. I think where I am, we're definitely seeing a huge reduction in that teaching or what's coming out. I can't say what's taught, but sort of what's coming out and the confidence that we see. Why are we seeing that? What do you think's led to us seeing such a reduction or a an observed reduction in those skills that are coming out from undergraduates?

SPEAKER_02:

I'm not sure. There's got to be the number of competing factors, isn't it, for syllabus? Whether the syllabus is expanding, whether the move as a physiotherapy profession towards the enhanced practice ACP pathway, and that sort of I suppose it's move to more diagnostics, isn't it? Really? Whether that's filtering through to higher education, potentially, and they're taking that off the ball in terms of the more traditional sort of assessment manual handing techniques, as I said, potentially, whether it is a little bit of an inherent bias that's there in terms of our perception of the evidence, maybe, or maybe a bit of academic snobbery, maybe, if there isn't that the evidence potentially, or perceived evidence around manual therapy, and potentially that diminishes it its value in being taught to undergrads, potentially. A few thoughts, really. Johnny, what do you think?

SPEAKER_00:

I really am not quite sure. I mean, I assume I don't have any evidence for this, but I assume still the majority of student placements are in the NHS. I know private practices do that, but I guess it becomes back to the start of the podcast. And again, I don't want to speak out of turn, it's been 12 years since I was in the NHS. But I guess if there is potentially less manual therapy happening in the NHS for various reasons. If they're the majority of the supervisors, may they think, well, actually, it's not as much of a priority to do that. I'm not sure.

SPEAKER_01:

Interesting, isn't it? I'm thinking now out loud, we probably need to get some other people on and find out and see. I think it'd be really, really interesting to find out. If it's not why, because there might be some really good reasons as to why we're seeing less of it that we haven't thought of. So there you are. Listeners, keep watching. We'll get that on at some point, I'm sure. So, in terms of that, do you think physios coming through or I suppose just working in general, whether they're newly graduates or whether they're been qualified for a fair few years, do you think there's a reduction in confidence or change in confidence in therapy skills? And do we need to upskill a little bit?

SPEAKER_00:

I think it will vary a lot depending on the working environment. I'm just thinking in my own practice, the physios who are 20 years qualified just tend to do a lot more manual therapy and they're quite proficient and very happy with it. Whereas the newer people coming into prior practice, maybe not as much. But that's from a private perspective. I guess in the NHS, maybe if, as Darren said earlier, it's been brilliant for the profession having FCPs and APPs and all of that. But I guess maybe there's if someone's been in those roles for quite a few number of years and then fancy a bit of a change, they may well not have done much manual therapy for a while. So that might influence proficiency in more senior people in NHS if they've not utilised those skills because they've been in those more diagnostic type jobs.

SPEAKER_02:

Yeah, no, I'd agree. And we talk about upskilling, it's difficult, isn't it? Because are we getting more upskilled in exercise, education, looking at that sort of biosychosocial approach, and we're upskilling there, and manual therapy's sort of falling by the wayside because of that? And is that then leading to better outcomes for our patients? Potentially not. But definitely from you know, think about manual therapy. I think as Johnny says, I mean, I think there's been a drain in that sort of senior clinical experience for many physiode departments, and I put myself into that, you know, a bit sort of more removed from the traditional sort of physiotherapy therapy department. And I think it's undoubtedly if you take that level of experience at clinical expertise out of a department, then you're gonna see change value in that in that department, really. And it's frustrating because I've been working as a FCP, APP, and the amount of times you refer patient for therapy, and then they come back and I've just got a sheet of exercise and didn't I'll know better, so I've come back to see you again, the diagnostic role, and it you feel like your hands are tied a little bit there, don't you? So it's it's a it's a strange dynamic now, I think, within the HS, and then I think that's maybe where people are seeking that in in more of a private setting, potentially. So yeah, it's difficult with the upskinny because I think if you ask a lot of departments, that I think physios are more skilled and having more enhanced skills than ever, you know. But in relation to manual therapy, I definitely think it is potentially going the other way. So more of a shift in focus? I think so, yeah. Shifting focus away from maybe manual therapy being a as a part to play, really, yeah, in the in sort of traditional therapy setting, yeah.

SPEAKER_01:

And it's interesting, you said there, Darren, is the focus across onto exercise, education, the psychological approach, and is that better? Are we getting better outcomes for that, or aren't we? And do we know that? And that's a really interesting question, isn't it?

SPEAKER_02:

Yeah, you know, I think there's more patients on long term opioids, you know, paying for next uh are busier than ever. So there definitely needs to be some literature around that in terms of outcomes for well, we're talking about spinal pathology here, but any anti pathology really, and especially from an NHS setting. Johnny, anything to add on to that that we haven't covered?

SPEAKER_01:

I think.

SPEAKER_00:

It's a really interesting point that Devin said. I think it has been fantastic with FCPs, APPs, but has this shift been more diagnostic, knowledge of masqueraders, knowledge of diagnostic imagery, knowledge of injection therapy, which remains one of our most popular courses, and those things that are those skills that are more critical to an FCP ABP role rather than manual therapy. And if you're uh a physio in say in the NHS and you're becoming a band six, and after a little while, you're going into FCP, you're going into ABP, you're leaving the traditional physio department. And then when a new one comes in there, are there still the same level of physios with, say, manual therapy skills to pass on the training? I'm not sure.

SPEAKER_01:

Do you think there's also a shift in perception of what advanced skills are? Where we once maybe would have thought of manipulative therapy and manual therapy as an advanced skill. Is that now not necessarily seen as one of the advanced skills? Because a lot of people, as you said, there, when you talk about advanced skills, they're thinking of diagnostics, they're thinking of imaging, they're thinking of injection therapy, those more clinical-based skills. Is that happening, do you think?

SPEAKER_02:

Yeah, I'd definitely say so. I mean, I think go back to the point Johnny made before you're coming into a spinal outpatient's department 16, 17 years ago, and seeing the the most senior clinician in that department was the sort of band seven senior clinical lead in spinal physiotherapy. That was as senior as it got clinically. Whereas now that band five coming in new grad student is looking at this department and thinking, well, who is the sort of main person around here? Yeah, there is sort of an APP who does diagnostic clinics five days a week. And they're the sort of main role model you've got in that clinical setting to look to, rather than maybe someone who's more clinical treatment based. Whereas then I think you've flipped around to Johnny's clinic, for example, then a new grad going in there is still seeing someone who's clinic director, who's still clinical, who's still hands-on, still doing treatment, manual therapy, and that's their focus in terms of that's top of the tree for them, and that's their sort of focus in terms of maybe more career development, which is potentially different. I'm not saying that's that right for everyone, but that you know, going into the department that is vastly different to how it was back then, really, and whether that has an effect on focus and priorities of that junior member of the team. That would I would say.

SPEAKER_00:

I think maybe the almost the first question you asked for the difference between in the NHS and private setting, maybe in the private sector, we would think about more clinical schools as a more advanced skill, manual therapy as a more advanced skill. And we want to be putting our physios through those courses or through master's degrees in manual therapy, whereas maybe in the NHS, the drivers and the importance are in a different direction.

SPEAKER_01:

Yeah, so in terms of some of the real positives of the profession in physiotherapy with these extended roles, is these 8A roles, etc., in APBs and FCPs and ESPs, which is great for the profession, is also leading to the role models changing on what was once seen as a role model and as a someone to look up to. Like we started this podcast off that have such an influence on us as we graduate, that's changing a little bit. And as you said there, John, that changes in a different setting. So a nice way to come round back onto what we started with, definitely. The big question is what is the future? The future of manual therapy, what's it looking like now and where would we like it to go?

SPEAKER_02:

I think it's uncertain. The danger is we develop a two-tier system, you know, an NHS physio model that's going in one direction and a private physio model that's going in a completely different tangent. I think that's the danger. I think it does take those role models nationally, really, to stand up and look into that. As I said before, I think if the research was going to be done, I'd thought that would have been done by now. So I don't think we can sit around and wait for that research to come along, you know, to back us up any further in terms of the manual therapy sort of argument. And yeah, with the current pressures in sort of HS setting, it's difficult to see how that changes, really. I think, as we mentioned before, the only way that would change potentially if we had some data on potential outcomes, our overall overall outcomes getting worse and potentially why that is. And I think that maybe would drive people more back to rethinking them their sort of thoughts on my therapy potentially and maybe revisiting it as a potential treatment technique to get back in that tool bag if if it's something they've packed.

SPEAKER_00:

One thing we haven't discussed because it's maybe not relevant to this podcast, but is the influence of AI as well. Because I guess if AI becomes more, that's not going to be manual therapy. It'd be a real shame if there is that kind of two tier. I mean, I absolutely loved working in the NHS for all those years, but I think manual therapy will remain strong in practice. Certainly, as a director of a company, it's an important component. There's lots of other important components. Patients, some expect it, some really like it. So I think it will remain strong in private practice in the NHS. I hope it does. I really hope it does. But as there's financial challenges and as AI becomes more and more prevalent, we might not see as much in the NHS.

SPEAKER_01:

I know one thing I've noticed is whilst not necessarily seeing the skills come out through undergraduates, I'm still seeing a real thirst for wanting to understand it and wanting to be able to do it. It certainly doesn't seem to be a change in the want to do it. It just seems that there isn't the skill set or the confidence there of to do it. That does seem to be quite promising, I suppose, when you were saying there, Darren, it being uncertain.

SPEAKER_02:

Yeah, no, definitely. And I think it is there. I think it just needs that fire stoked a little bit, I think, more really in departments now, really. And yeah, it's how we go about doing that, really, yeah, on a national scale.

SPEAKER_01:

Brilliant. Johnny, Darren, you've this been a really good conversation. I think what I'd love to finish it off with, which isn't on my list of things, is some takeaways. What advice would you have for listeners? And I suppose we're maybe pointing this more at new grads listening to this podcast. What advice would you have, having listened to this podcast and maybe thinking to themselves, oh, I don't have those skills or I don't have the confidence to use those skills? What advice would you have? What pearls of wisdom, reassurance maybe, would you give to those listeners?

SPEAKER_00:

I touched upon that earlier, but I think having the skills of criticality and critical thinking is really important. I think it's amazing nowadays how we can access so much information, but we've got to make sure that cognitive biases don't creep into our clinical practice. So just step back and reflect and think, right, what am I doing? What's made me do this? Are there other things I can try? And certainly from someone who's been doing manual therapy for many, many, many years, I found it extremely helpful. I still do. I would say to someone, go on a course, whether or not it's a SOM course or a different course, go on a course and expose yourself to it and give it a go and try it and then figure out what works for you. Because we have a pragmatic approach, we combine it with lots of things, and there's no way I would just do manual therapy, not at all. And I think it concerns me if I hear some clinicians say, Well, I don't do manual therapy, it creates dependency on the patient. And I like a saying if, well, manual therapy doesn't create dependence, it's manual therapists that create the dependence of how you are pitching it, how you are approaching to your patient. So don't be thinking that if you do manual therapy, your patients are going to be completely reliant upon you. That shouldn't be the case at all. But analyse your thoughts, use a bit of critical thinking and give things a go and try things out and see what works for you. Yeah, absolutely, Johnny. I think that critical thinker is vital.

SPEAKER_02:

And I'd say, yeah, have a go and try things out. Go and find a mentor. If there's no one in your department, is there someone where you can go and visit or locally or online through social media, you can find and spend time with, you know, thinking back to those sort of pioneers in manual therapy, McKenzie, Maitland, they traveled the world spending time at each other's clinics, you know, Syriax, and you know, they'd spend a lot of time each other sharing ideas, techniques, and that's how they developed the skills. So that should be no different at this point, really. So I think, yeah, have a critical mind, try things. Think about that first patient you gave some exercises to for back pain. And hopefully those exercises you gave on that first day as a student are vastly different to how you treat that patient now with exercising education, and it's no different with manual therapy. The first time you do that manual technique, it's probably not going to be that good. But if you develop that and develop your handling over five, 10, 15 years, then hopefully you become a very proficient, safe, efficient practitioner, which is you know, if you read Roger Kerry's article from last year, that's all we're trying to work towards in terms of teaching and manual therapy and becoming that sort of proficient, safe practitioner in that sort of shared decision-making environment. So give it a go and go and get a clinical mentor who can work with you to develop that skill.

SPEAKER_01:

Brilliant. Both of you, thank you so, so much for your time. And and just to finish off, because I think it'd be a lot of listeners are probably intrigued. Where can people learn more about the courses that you both run on manual therapy?

SPEAKER_00:

I think it's SOM, the Society of Musculosurgical Medicine website. On there, we do a whole load of courses. We've got a we've got a new course on spiral manual therapy. So that's a one-day course. So if someone is completely new to SOM, want to dip the toes in, or wants to learn the evidence about manual therapy, we have lectures on critical thinking, we go through some what we think are useful techniques for the whole spine. Someone on that one-day course could dip the toes in and see what they think. But if you go onto the website, there's all the information regarding our foundation course, our advanced courses, and our one-day courses. So that would probably be the best thing. But please, you know, do try and follow us on social media. We do try to be as active as possible and give it a go.

SPEAKER_01:

Brilliant, brilliant. And I think it's probably worth mentioning just around the SOM, it's not just manual therapy, is it? Because I think it's probably quite important to actually for listeners to think until we're talking about biases that SOM isn't just a manual therapy education provider. Just want to just very briefly just cover that for us.

SPEAKER_00:

Yeah, well, SOM has changed so much over the years as well. We continuously open adapt our materials. So with our foundation courses, there's units one, two, and three, but we go through kind of anatomy, we go through clinical examination. We've got really good lectures on the importance of lifestyle skills on clinical masqueraders, on diagnostic imagery. So, one of the key skills, I think, is clinical examination and critical thinking and clinical reasoning. You will get taught some mobilization, some manipulations, you'll get taught when injection therapy can be appropriate. And we really include a lot more exercise-based discussions and rehab into the courses now as well. So it really isn't just a manual therapy course, but it's a component of it.

SPEAKER_01:

Just like that toolkit we talked about. It's having more tools, it's having more things at your disposal so you can utilize it to create the best patient experience for the person in front of you. Johnny, Darren, again, I've said it so many times now. Thank you so much for your time. I'm going to leave it there. I'm sure we'll speak to you again. For those listening, do check out the song, but also check out Johnny and Darren crossed any social media. Thank you very much, both of you. Take care.