Spinal manipulative therapy: a slow death by data?

I am a recovering manual therapist. In my physio career I have moved from freshly qualified apprentice, eager to learn the secrets of what was sold as a powerful tool, particularly for spinal pain, via what might be classed as a skilled practitioner, certainly in terms of courses attended and assessment hoops jumped through, to someone who now would rarely, if ever use it, and if he did would feel somewhat sheepish about it.  That has been based partly on a slow realisation that it did not, anecdotally, reliably achieve its goals, that the theoretical foundation on which the various manual therapy approaches were devised seem to possess little or shaky validity, and partly as emergent evidence from trials and systematic reviews has been less than compelling.

One of the problems of evidence based practice is that in areas where nothing works as well as we would hope, where nothing seems clearly superior and where outcomes are very prone to non-specific effects so that everything seems to help a bit, (and back pain is the exemplar here), it is hard to genuinely inform clinical decision making. Ambiguity and statistically positive but small or unreliable effects are seen by the faithful as hopeful glimmers and by the sceptics as damning.

A new synthesis of the trial evidence for spinal manual therapies (SMT), by Professor J Michael Menke has just been published in Spine. Prof Menke uses the technique of comparative effectiveness meta-analysis (CEM) to ask deeper questions of the data. Unlike standard meta-analysis, where direct comparisons are pooled in trials that compared similar conditions to similar controls, in CEM data from individual treatment arms are extracted from original trials and pooled together and compared with data from other types of intervention or control. So I could take data from all the spinal manual therapy arms, all of the exercise therapy arms or all of the usual care arms and make comparisons based on these, even if those comparisons were not made in the individual trials. It affords the analysis greater power and gives the researcher the ability to make more novel comparisons.  He also uses nested model comparisons which estimate the individual contributions of various factors to clinical outcomes in treatment arms. The analyses include some 265 study arms with over 8000 short term observations and over 11,000 observations in the longer term, a sample size large enough to detect the smallest of effects.

The findings are striking. In acute low back pain only 3% of the variance seen in clinical outcome could be ascribed to treatment. That’s 3%. In chronic low back pain this figure was 32%.  No specific provider group (physio, chiro, osteo, bonesetter) demonstrated superior effects to the others.  A common criticism is that trials often reduce clinician freedom to choose and direct a holistic treatment approach and this is why effect sizes are small or null. But an analysis of arms of “whole systems” chiropractic interventions that afforded the clinician greater judgement and control to deliver multimodal targeted care found them to be no better than arms of plain old manual therapy. Non-specific factors ruled the day and a comparison of observed effectiveness compared with that which would be expected by chance alone suggests equivalence across the board. Notably, compared to sham SMT, unsupervised self-care and waiting list controls did poorly for both acute and chronic pain. Doing something seems better than doing nothing. It is worth remembering that the spectre of “resentful demoralisation” hangs over no treatment and usual care comparisons in trials and can exaggerate those differences.

In a remarkably strident discussion Prof Menke concludes that more research is clearly NOT needed.  Now you don’t hear that every day in therapy research. “That which is already known about SMT for back pain is quantifiably all that is worth knowing” is his message.  Over decades of MT research, effect sizes are stable and not compelling and further research is unlikely to change this conclusion. He further argues that “the difference between sham arms and the usual care effect size is the difference between attention and neglect”, As a result he recommends cautious observation, exercise and “authoritative encouragement”.

There are some grounds for critique here. As a reader I would have appreciated more detail with regards some of the statistical approaches used, exactly how these data were sliced and diced and whether the full analysis plan was established a priori. Data mining can after all be a dangerous game with a risk of manufacturing results, so full reporting is essential. Also the reviews used to source the trials stopped at 2010 and we have more recent Cochrane updates, though the bulk of the available data could be expected to be included. Nonetheless as an example of how everything can appear a little effective, even where there remains a strong chance that treatments have little meaningful impact, this analysis tells a tale.

Perhaps, given the origins of manual therapy, we should not be surprised. The genesis of a manual therapy sect classically starts with an individual making observations that a specific type of poking and prodding seems to work. Observations that themselves are steeped in unreliability. From there a slow-building mass of belief emerges, fed, at least in part, by expectation, confirmation biases, misattributed natural recovery, placebo and the moulding of a structural spinal model to explain the success. This is then enthusiastically disseminated to a clinical community keen for something new, something that “works”. A kind of fallacy-driven snowball effect.  The arguably naïve ideas as to what can be reliably palpated and notions regarding the adaptability of tissues to short lived small forces were all warning signs, as was the rapid roll out of these therapies to everyday practice in advance of robust mechanistic or clinical evidence. Much of the modern reconceptualising of the mechanisms of manual therapy (with a strong emphasis on neurophysiological effects) can appear a little like retrofitting new explanations to defend a trivial, short lived and possibly spurious effect. Taking this path manual therapy risks joining acupuncture in the “unfalsifiable hypothesis” bin. Many will argue that the true benefit of manual therapy for back pain just isn’t reflected in these trials and analyses. If so it seems to be doing a rather good job of hiding.

Neil O’Connell

Neil O'Connell 2As well as writing for Body in Mind, Dr Neil O’Connell, (PhD, not MD) is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist.
He also tweets! @NeilOConnell
Neil’s main research interests are chronic low back pain and chronic pain more broadly with a focus on evidence based practice. He has conducted numerous systematic reviews including some for the Cochrane Collaboration. He also makes a mean Yorkshire pudding despite being a child of Essex.
Link to Neil’s published research here. Downloadable PDFs here.


Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, & van Tulder MW (2013). Spinal manipulative therapy for acute low back pain: an update of the cochrane review. Spine, 38 (3) PMID: 23169072

Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW (2011). Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review Spine, 36 (13)

Menke JM (2014). Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis. Spine PMID: 24480940


  1. Andrew Cook says:

    That raises a lot of questions for me. First, just on the basis of patient management, when do you decide to tell someone that they now have chronic (rather than acute) back ache, and so it’s worthwhile treating them? And, since patients are pretty good at telling whether you are kidding or not (i.e. most are aware when they are receiving placebo), at what point do you tell yourself that there is some point to starting to treat seriously because you now have, according to public health statistics, a better than 30% chance of helping? The answer to both of these is that we treat assuming that we can make a difference because that is a necessary part of being a professional. Even if the success rate is a measly 3%, which I doubt, why treat all the acute patients as basket cases when at least 1 in 30 will receive help- which they would presumably not have otherwise received?

    I don’t particularly agree with either the 3% or 30%, but that’s another issue entirely. It’s useful to be able to tell people who have been given basket case prognoses based on public health statistics (of which meta-analyses are a great example) – there is no such thing as Mr Average, and for all they know, they could well be one of the % who do OK. When we can tell who is going to benefit vs who is not in advance before treatment, then these stats will be of use outside a public health framework. I’m not convinced that they are appropriate in a public health framework either, but someone has to decide how much money is spent on what. If you had a boat with capacity 3 and there were 100 people drowning, would you not bother because 3 is so close to zero that it makes no difference? I think not.

  2. A brave and somewhat refreshing conclusion that no more research is required. I don’t necessarily see it as another nail in the coffin but rather more support for Butler’s blog implying that the therapist is the main variable in outcomes – not the technique! And so we move forward…….

  3. Roderick Henderson, PT, ScD, OCS says:

    It’s hard to add anything to what you just wrote so I will just say thank you for writing this piece Neil. The recent article by Menke makes me excited for the future of manual therapy. This article should make orthodox manual therapist stir uncomfortably in their chairs. It will be interesting to see whether this results in a renewed enthusiasm for exploring more plausible mechanisms and interventions or professional version of remorseful demoralization. I’m hopeful for the forner.

  4. Thank you Neil for a concise summary of a rather weighty paper.

    If so with back pain that exemplar of treatment targets what about neck pain, shoulder pain et cetera. What implications might this have?


  5. Nice piece Neil. We, the therapist, are simply another “noise” joining the “affarent band” and our intervention is simply just a string on the clinical banjo. If the patients nervous system digs our sound, we may have some impact.

  6. Thank you for writing this piece Neil and helping dislodge the current theoretical hegemony in outpatient PT. I agree with Roderick and I am excited about the future of PT because of the uncertainty that this type of research brings. I firmly believe that there is a conceptualization of manual therapy that as of yet has not been well articulated by clinicians or researchers. This includes abandoning the paradigm of treatment. Treatment itself is an antiquated notion from back when we practiced all sorts of bottom-up nonsense and tried to compare ourselves to physicians treating physiology. I think we need to realize that most of the time we as therapists are helping our patients build capacity (the potential for function) and maximize coping.

    As a practicing PT I use my hands on a session-to-session basis but I do so without hype. I try to blend my hands seamlessly with my words and think nothing of trying to figure out how to leverage the expectation of my touch. My hands are the physical embodiment of my words. They help guide my patients’ awareness and shape their sensory environment as my words shape its meaning. I call this hands without hype. It is consistent with building locus of control, somatic awareness, and capacity in my patients.

    This for me is the future of PT, one that accepts the reality of chronic pain and the limits of the physical manipulation of symptoms but begins to realize that hands + words + movement = the power create a new meaning for those physical symptoms.

  7. The problem with taking a research methodology/philosophy best used for determining whether Drug A is better than Drug B and applying it to a therapeutic intervention with multiple factors over time is you are bound to only get a reductive argument like the quote below.

    “Observations that themselves are steeped in unreliability. From there a slow-building mass of belief emerges, fed, at least in part, by expectation, confirmation biases, misattributed natural recovery, placebo and the moulding of a structural spinal model to explain the success. This is then enthusiastically disseminated to a clinical community keen for something new, something that “works”. A kind of fallacy-driven snowball effect.”

  8. Doug Scown says:

    Kudos to anyone contributing to research however the problem has always been right before us. Change ‘Back pain’ to ‘abdominal pain’ and you instantly see the error and the answer. Exactly what condition/s are generating the symptoms and therefore what exactly does condition x respond to? Pain is not a condition therefore most back research is at best of limited value. The question is wrong. It may be a reflection of the perceived inconsequence of ‘just back pain’. Its not sexy just an economic burden. It can’t kill you, etc. It it it. That’s the problem. We don’t say ‘He has heart pain’ or ‘bowel pain’. We diagnose a problem, apply a considerable body of evidence across fields and manage as effectively as possible. We are not SMT therapists. We are clinicians and the information provided by ‘back pain’ research is unfortunately still mostly a waste. We do not dispense SMT. Its like saying that a surgeon is a knife therapist. Does this make sense? If it does you get it, you understand the problem. If not you’re still a therapist dispensing the same treatment for the next patient who presents with chest pain. Good research is driven by good questions and those come from a mind which understands clinical matters, what diagnosis is, what the latest evidence is for eg chronic facet effusion, what MRI sequence to order, when its appropriate to treat conservatively or refer and how to communicate with pts and other health providers ie how to MANAGE this specific problem because the reality is that MOST neuromusculoskeletal problems are best managed by professions like ours. But It takes alot of work. Cheers.

  9. Andrew Cook says:

    More on the 3/30%

    OK- although back pain is helpable, that doesn’t mean all people can be helped easily or even at all. But with that proviso, based on the throughput in my clinic, the following three factors account for maybe 40% of backpain and are correctable in less than 4 sessions… If you have a different demographic basis, then there might be some substantial difference in that number

    a) dehydration – caffeine, tannin, lack of water, excess salt & sugar – the typical wired diet weakens the lower back muscles – improve hydration, and we immediately have some improvement for quite a few office workers

    b) TMJ – if the jaw has been displaced (especially by wisdom tooth extractions) then the lower back muscles have to be in chronic tension on one side to prevent the whole body twisting. Sort out the jaw, and the lower back is better. Often knees too.

    c) adhesions in the viscera – from IBS-type symptoms or abdominal surgery or childbirth. These account for most lumbar “back” pain, and if it’s just a simple adhesion or an op site, then in most cases one treatment is enough. Think several grams force applied 24/7 for years on a non-rigid structure.

    And in general, most interventions on back pain and sciatica address the same side and the same place that the pain is reported – whereas in fact in most cases the causal factors are somewhere else and/or on the opposite side.

    If someone does research on ANY of the above and finds 5% or better recovery in a random sample, then if you think that can then be applied intelligently by identifying the specific case, we have a set of adaptive techniques that are cumulative in their effect on a general population. But in my estimate there is not one specific technique that will give any better than 20-30% improvement in non-selected cases. So I am not particularly impressed by a meta-analysis of all treatments for all back problems. The maths might be wizzy, but the conceptual understanding is not so hot.

  10. Neil O'Connell says:

    Thanks all for commenting.

    Andrew, the 3 or 30% do not refer to the chance of recovery, simply that variance in outcome attributable to treatment. That observed effectiveness was no better than that which might be expected by chance is troubling. I sense you are not sold on the trial model of testing interventions. I would suggest that to paraphrase statistician Stephen Senn, “he who does not randomise is condemned to draw conclusions at random”. You clearly have some views on causal factors in MSK pain. Should those views be evidenced you may be on to something. However given the total lack of consensus on what is driving pain in most cases of LBP perhaps not. It will take research to clarify things, certainty just won’t do it.

    RS1 I disagree with your characterisation of trials. Trials can be rigid or pragmatic depending on the question and the signs are that allowing clinicians the freedom to address this perceived complexity by tailoring their treatment doesn’t seem to have an impact on the effectiveness of MT. Even with drugs the therapy needs to generate a signal over the noise of complex everyday life. MT is not a unique case against trials. Here is a suggestion with regards reductive arguments: The implication that you might confidently attribute a change in symptoms to your treatment given all the other factors in the way seems truly reductive.

    Doug – not all trials deliver a one size fits all approach. See my response to RS1. Also we really have no reliable way of characterising the pain generator in most low back pain. Sure lots of clinical models claim they do but mostly in the absence of meaningful evidence. Kent and colleagues found no consensus among clinicians on how to classify low back pain. As a neat example For example for facet joint pain, one of the commonest diagnostic subgroups that clinicians identified, they found less than 10% agreement between clinicians on the 3 most common combinations of signs and symptoms. http://www.ncbi.nlm.nih.gov/pubmed/18793868 So who is right? We can all feel confident but perhaps our successes are a trick of the light?

    Deano, Joe, Andy, Erik, Roderick- thanks for your positive comments. As I have done less and less manual therapy what has struck me is how little I have missed it. Occasional patients have needed some convincing but that to me is the challenge of being a progressive evidence base clinician. Though I only worked clinically as a state provider, with no impetus on giving people what they want or what sells, which may have made it easier.

    The bulk of available evidence suggests that back pain follows its course, whether acute or chronic and we don’t have a big influence on that course, though we may help, a little. So excellent assessment, good advice, encouraging movement, letting the patient know what to expect and, as Lorimer said to me recently, trying to give them courage for the journey, sounds like good care to me. No prodding required.

  11. Andrew Cook says:

    Thanks for the article and the feedback, Neil – very clear;y thought out and much appreciated.

    I think we have very different views on statistics 🙂 and maybe also the usefulness of treatment

    Classical statistics is based on the principle of the infinite set and an enumerable number of factors. I think you’d have to sample 10% of the entire population of the UK to get a truly even spread, and to cover all the possible factors. So “randomisable” as a concept for these kind of trials is self-deception, and is inherently biased according to the statistician’s preconceptions. Clinical judgement may also be biased and is a small sample, but at its best I think is capable of offering some insight.

    e.g. I had an interesting conversation with a colleague a few months ago who had noticed a specific set of problems associated with a posteriorly placed sacrum, plus a protocol he’d found to correct it. Then someone walks in my room with a sacrum that’s very posterior and the same set of symptoms – it’s an ocurrence of way less than 1% of the population but for that one person it’s a huge difference. The whole idea of “back pain” being an illness is a mirage, rather like the idea of “cancer” – it’s actually several tens or even hundreds of (sometimes very) different situations that have a generically similar symptomology. Differential diagnosis.

  12. Excellent article with which I agree completely. I published very recently a review article in a Dutch medical journal and concluded that MT is quackery as it was 100 years ago.

  13. As a director delivering chronic pain services in Durham, England. I must admit I breathed a sigh of relief internally on reading the content of this article. The research into manual therapy is a never ending worm hole with a yet unknown destination for our clients in chronic pain. Recent explorations into “giving the handle back” to the client and applying the use of stories, metaphorical language, expert linguistics and enabling safe self-responsibility far outweighs the ever decreasing circle approach of research into ” lower back pain “. I will be the first to say that the fusion of manual therapies with the mind work literally bends me out of shape. However, for the first time, we are seeing a huge shift in our patients as they take their first steps on an often rocky road to recovery that they own themselves and is guided by a team who are comfortable to embrace the challenge with them. Thank you Neil for such an excellent summary of a complex article.

  14. Neil-
    Thank you for your very thoughtful post. I could not agree with your comments more. I have watched all of this research for the past 20 years and scratched my head in confusion. As a profession, we have had this treatment that we really like to use and we swear that it “has to work”. We have done everything in our power to bend the research in our favor. We have searched for mechanisms and failed. We have searched for outcomes and failed (when compared to noise). We have searched for responders and failed. But for some reason, we do everything we can to justify its continued use. Now we say, “Use it for its non-specific effects.” Hey, here’s a novel idea: Stop using it at all. As you pointed out, these “hopeful glimmers” of effectiveness are fed by confirmation bias. We are so critical of treatments provided by others as ineffective beyond placebo (alternative medicine) but give SMT a free pass. We need to just stop with this.
    As a PT student 20 years ago, I remember being dissatisfied by the evidence for SMT. Back then I asked a very business minded PT why we should use these hands on treatments at all. His reply, “I want my patients to believe that I was the key to their recovery. If they have any return of pain they return to me because they believe that they need my hands.” Yikes! Talk about fostering an external locus of control!
    Like you, I stopped using my hands years ago. My current “hands on” techniques include the portions of my exam seeking evidence of more serious pathology (e.g. cancerous mass) or reasons for surgical consult (e.g. serious neurological compromise). My favorite “hands on” technique is what most people call a “handshake”. A firm handshake, a compassionate ear with good eye contact, a solid screen for more serious pathology, and reassuring education on pain behavior (thanks BIM!!!) goes a really long way. Just reassuring someone that they don’t need surgery usually results in “I feel better already”. SMT is not at all required for that interaction.

  15. Richard Bartley says:

    Note to Andy. You specifically came up with the diagnosis of a posteriorly placed sacrum and a treatment protocol for this. I wonder how much evidence is available to support this diagnosis (and said treatment protocol)? This comes right back full circle to the evidence for SMT being unimpressive. If clinicians are using SMT on the basis of empirical untested diagnoses with poor inter-rater agreement then that hardly seems to shore up the concept of SMT.

  16. Very interesting article.

    There seemed to be an interchange between the terms manual therapy and spinal manipulative therapy through the article above. Isn’t SMT a manual therapy?

    Looking at the conclusion in the abstract, i think it suggests that there was no superior treatment from a range of treatment options i.e. spinal manipulation therapies (SMT), medical management, physical therapies, and exercise (“The probability of treatment superiority between treatment arms was equivalent to that expected by random selection.”)

    Therefore it is not really the slow death of SMT but the slow death of manual therapies. Is that correct? Thanks in advance for any advice given.

  17. Andrew Cook says:

    Hi Richard

    I didn’t devise the treatment protocol or the diagnosis, but I have seen one case. And I specifically gave it as an example because there is very little room for ambiguity.

    If you ever come across a posteriorly displaced sacrum, it’s quite noticeable visually. In palpation the iliac edges of the SI joints are so anterior as to be almost inaccessible – and as a result the ASISs are very medial anteriorly. Whereas a normal sacrum presents with the iliac edges prominent and almost level with the medial sacral ridge. Symptom-wise, there is moderate lower back pain, greater pudendal pain, and the digestive tract is unresponsive to the point that a minor dietary change can precipitate abdominal pain on eating plus massive weight loss – which can easily be mistaken for an eating disorder. The guy who told me was also quite touchy about the whole matter because he had seen quite a few of these were also associated with a history of rape. That also was the case in the one instance I saw. Which means that there is also a requirement to be (at the very least) non-invasive in any treatment.

    AFAIK there is no evidence in the way you think of it. When the above symptoms present, then physical correction of the sacral position substantially reduces the physical digestive symptoms and pudendal pain within less than one hour. I think that’s pretty good evidence. Getting the correction to hold – with all the other adaptations that it comes with – is not so easy, and I dislike manipulation (particularly repeated manipulation), to the point that this is virtually the only instance I would consider using it. To be frank, in this case, if doing something that has only anecdotal evidence improves somebody’s digestive function to the point that they are no longer starving to death, I think I am not going to moan about not being auditable to EBM standards.

    Most people I see have had their problems for months, usually years, sometimes decades, and they tried everything to help it and nothing has really worked. Then it reduces (or isn’t there any more at all) after a treatment – there is a certain synchronicity and coincidence that makes me think I did something right. Am I missing something? At what point is it reasonable to infer causality? Has anyone even defined that? If your belief system is that PT of any kind does not really do anything, then causality would never be inferred, and it would just be serendipity – luck. So the definition of what may be causal or not is determined largely by belief system. That’s an uncomfortable edge for a scientific pov. Two careers ago I spent one year in a research job looking at signal-noise ratios for a particular measurement problem, and I think I have quite a balanced sense of where a reasonable line should be drawn.

  18. Richard Bartley says:

    I think if you suggest some physiological/visceral dysfunction combined with musculo-skeletal subluxation/dislocation you should consider the patient as a red flag and refer on to medics.

  19. Andrew Cook says:

    That’s the most underhand accusation of a lack of professional integrity and intelligence that I’ve seen for quite a few years. I’ll assume you didn’t intend it that way and were really trying to be helpful, Richard.

  20. For clarification, what type of medical/professional training do you have Andrew? Are you a Physical Therapist? DO? I don’t think I can appropriately respond to your scenario without understanding your background or scope of practice?

  21. Frédéric Wellens, pht says:

    Thanks Neil, Very interesting blogpost, reflecting a lot of what has gone on in my mind for a while now. Obviously, the usual supporters of the traditional pathoanatomic model of manual therapy will rant over it. There will always be a place for their circular reasonning and all the other errors in logic we are all prone to when emotionnaly and $$$ invested in what we do.

    For my part, all this non sense subluxed, fixated, tilted, compressed, and what else is long gone and forgotten.

  22. i am not an expert with research methodologys – but sent this article to a colleague who know a bit more…. His reaction without knowing about the commentary on this website:
    ‘I always love reading a good study…however, after reading this study, this is not a GOOD study. First, the statistical methods used are incredibly suspect. The data averaging and the use of “arms” within the selected 57 studies were not even utilized in the studies that were in included in the meta-analysis. Without the raw data and the original study materials, there is no way to reanalyze the information. Secondly, they lumped non-cohesive data into groupings that did not belong together. For instance, they talked about SHAM treatment which could be a treatment in itself. This is not the same as controls. They did not note a difference. Finally, they stated that SMT done by PTs is the best, yet they say nothing worked in SMT. How can one be better than another yet there not be any difference?’ Very poorly done.

  23. The conclusion of the meta-analysis from Menke is what every self-reflecting therapist already should know through experience. The question is what will be done in todays and tomorrows education. Will the curriculum in colleges that teaches osteopaths, chiropractors and physiotherapist change?

  24. Neil O'Connell says:

    David – you are correct it refers to manual therapies more broadly, for back pain.
    Erik, Paula, Fred, Cees, many thanks for your kind comments.
    Ina (I have seen your comment but it seems to have disappeared – not sure why). Your friend has legitimate concerns regarding the lack of clarity. There needs to be a much clearer paper trail. That said I could easily have written the same blog-post based solely on the Cochrane reviews, which do have a clear trail.
    In terms of sham we shouldn’t regard sham as a potential treatment as shams should be devised so as not to achieve the mechanistic goal of the active therapy. That doesn’t mean that touching folk in non-specific ways might have some benefit – but that in the context of these trials and the questions they are asking we shouldn’t consider that benefit important. If anything , credibility and therapist blinding issues with most sham manual therapies are likely to exaggerate any effect of the true therapy.

  25. Mike Caruso says:

    Thanks Neil for you very helpful presentation of this article and your thoughtful comments.
    I am also a recovering manual therapist.

    Terrific discussion all ! I am aware the we live in challenging healthcare times and I need this science to think anew about the patent before me, the mindset I bring into the examination room, what I want this patent to leave with, and the message to the public about what physical therapists can do.

    The mindset of any practitioner as the one you described (“I want my patients to believe that I was the key to their recovery. If they have any return of pain they return to me because they believe that they need my hands.”) points to the larger problem facing all of healthcare described by Prof. Nortin Hadler in Worried Sick…. the problem of the medicalization of life’s challenges that lead us to focus on a back ache. Dr. Hadler studied manual therapy and found the evidence lacking years ago. The results of the Prof. Menke study are not surprising.

    Perhaps a better model for our patient encounter is from an education model… as patient educators we are most effective when we are ‘A Guide by the Side, not the Sage on the Stage’ by Harold Burrows.

    Perhaps we should be studying the mindset of the patent coming into the encounter and the mindset they leave with.
    I have observed that some measures associated with work disability (FFQ-K Fear, CIEQ-C catastrophic thinking, CIEQ-I perceived injustice, GPDI disability index , Mick Sullivan, PDP 2010), can be changed positively in one visit when a patient problem is attentively heard, and a functional loss can be reduced to a manageable movement problem with a corrective exercises successful taught.

    This is an exciting time and we have much to do !

    Mike Caruso PT FAAOMPT

  26. JW Matheson says:

    Thanks Neil for a thoughtful post:

    I wanted to respond after reading Ina’s comments:

    I foresee this will be the norm (questioning the methodology of Prof Menke’s work) as the method for people to attack the conclusion. I agree, more clarity and transparency seems like it could only help. What I hope is that the meta-analysis is repeated again. I often say, “I never meta-analysis that I liked.” Often garbage in = garbage out. Clinical heterogeneity in manual therapy reviews is often confuddled.

    Regardless, my take home from this analysis is that it’s refreshing to see it become more mainstream to hear the voice of science (e.g. “SMT has a small effect, may not work, I am doubtful that it works, prove it does”) versus the usual physiotherapist/PT mantra of (e.g. “Hey SMT worked for me, I think it works, this shows it probably works, prove it doesn’t.”)

    I wish I personally could understand the statistical analysis better. But as you have said above, this study really doesn’t tell us what we didn’t know from the Cochrane reviews. I do hope we see more high quality reviews in the future. I would challenge those who say the methodology is suspect, to give us a solution to correct it, then let’s repeat the analysis, etc. That’s science.

    The manual therapy issue, to me, is very similar to the acupuncture debate. Confirmation-bias driven believers confusing non-specific effects with specific effects. Despite a plethora of high quality studies consistently showing very small trivial specific effects when therapeutic alliance and equipoise are factored into the research.

    I don’t want a world without manual therapy, I am just tired of listening to manual therapy proponents who, like the weavers in the Hans Christian Anderson story, promote pluralistic ignorance and indoctrinate young minds in faulty reasoning. So it’s nice to be reminded that it’s okay to be the child yelling the “Emperor Has No Clothes.” Our profession needs more science and we need more discussions like this. Thanks again.

  27. Andrew Claus says:

    Perhaps our mission is to extract the good things.
    That would mean that the glass is 3-32% full, with a selection of top-shelf drinks within reach ; )

    Keep well,

  28. Neil O'Connell says:

    What a discussion – thanks to all who have contributed. When the blog post went live I braced myself to hide under a table with a hard hat on for a couple of days I have have been proven roundly wrong. I see constructive discussion and genuine critique. So thanks and thanks.

  29. Evanthis Raftopoulos says:

    Thank you for writing this Neil. According to the evidence that we have today, I think that your critique is spot-on.

    This also invites us to re-examine the purpose of ‘advanced’ manual therapy training programs.



    relevant discussion at SS here http://www.somasimple.com/forums/showthread.php?t=16824

    The postings on this site are my own and do not represent the views or policies of my employer, or any other organization with which I may be affiliated.

  30. Thank you for the article, Neil! I have a question: If my recollection is correct, you have summarized acupuncture research and essentially called it an elaborate placebo. Would you say manual therapy is essentially same?

    My next question, secondary to the first question, is if manual therapy causes very small amounts of positive, non-specific effects that border on placebo, is it ethical to use it as an adjunct to other elements of good treatment, as you and Erik above have described? My hunch is that even though you may cause small additional improvements, you also risk decreasing internal locus of control, and creating negative back beliefs (someone needs to fix me, something’s out of place, etc) that aren’t worth the small benefits, but I’d love to hear your thoughts. Thanks again!

  31. Richard Bartley says:

    A note to Wyatt. May I make a comment in reply to your post?

    The positive effects of manual therapy may be non-specific, but whether one uses these techniques may depend in part on whether you are in private practice or not.

    It is easier for clinicians in state salaried posts to discourage dependency in patients by avoiding SMT but what about those who’s businesses depend on it? Patients have high expectations of ‘hands-on’ treatment (which undoubtedly helps the placebo effect) and private practitioners depend on SMT in some form to maintain their salaries.

    I don’t the answer. Just food for thought.

  32. Neil O'Connell says:

    Thanks Wyatt,

    I think manual therapy is very similar in that respect, yes. I think there are issues with knowingly delivering placebos. I share your concerns totally. Small short term gains possibly at the expense of tough to measure harms. I’ve touched on that before here: http://www.bodyinmind.org/ethics-and-placebo-in-physiotherapy/

    Richard, i take your point. But ultimately I have always found the patient choice argument weak. Patients want it because they have been sold a story about it. Continuing to do it re-markets the story. When clinicians invoke PT choice it makes me uneasy since they drove the market demand. Patient choice becomes a tidy business model that has nothing to do with EBP. Hucksterish. We need to be careful that what we sell is expertise and evidence led best practice. When we simply become sellers of modalities we are no longer clinicians. But I get the tension.

  33. Wyatt- Yes, that was exactly my point. If I can enhance non-specific effects through other means (compassionate listener, honest education, patient advocacy/alliance/validation, etc) while at the same time empower the patient to take control and get active, I would prefer not to add a hands on component that might undermine locus of control in this population.

    Richard- Sadly, as a private practice owner myself, I totally understand your point. First, I really HATE discussing healthcare as a money driven, for profit business enterprise, but at the same time we all need to pay for rent, lights, not to mention a reasonable compensation for the providers themselves! We looked at it this way to make the business side look more “profitable”: We collect more money for an evaluation than we do for a follow up visit. The less “lower reimbursement” follow up visits we have, the more slots we have for “higher reimbursement” new evals. In my experience, for what it’s worth, by being open and honest with our patients, we find that they come back to us later for all of their other musculoskeletal problems (“My shoulder is killing me lately. What can you teach me about that?”). They become more trusting of me as a provider and feel that their previous PT was just happy to take their money and string them along for 20 unnecessary visits. As Neil said, PTs get caught acting like hucksters. This becomes a bad PR problem for the profession.

    For those looking for manual therapy, I provide education on their diagnosis, pain science (if appropriate), and placebo. Maybe I attract a certain kind of patient, but they usually shrug it off and ask, “What do you recommend instead?” I have found that even though patients might have some preconceived ideas of what they need, they are happy to concede that we are the experts – it is the real reason they are seeking our care in the first place.

    I will say we stay plenty busy.


  34. Mike Reiman says:

    Great conversation!
    Neil, very thought provoking post!
    Eric K – nice approach.
    Erik M & JW – you know I am not one of those promoting “pluralistic ignorance” “manual therapy thumpers”. I do understand where you are coming from and share your concern on this part.
    Have you followed the discussions on twitter and blogs recently though? The pendulum has swung strongly in the opposite direction. Manual therapy is now being described as “quackery”, to “stop using it at all” and suggesting it is not “ethical”. How about “pluralistic bending of young minds” here? This influence is a two-way street.
    I am equally concerned of “manual therapy thumping”.
    Isn’t sharing your negative beliefs of manips (to patients at least) as much a nocebo as the placebo you argue against?
    Are we so opposed to manual therapy (by the way includes several tx approaches that I am not in favor of) that we will resort to its collective condemnation? To its classification as dishonesty/deception?
    Perhaps I am not as reformed/recovered as Neil (or likely just slower) but I do see a place for mobs and manips. Yes, they are short-term (in their result and should be in there implementation) and are a small part of an approach that PREDOMINANTLY includes education, lifestyle change, exercise, patient empowerment, CBT…etc.
    Erik M- perhaps I do not understand the scientific argument you assert, but aren’t short-term neurophys changes something? Yes, I understand mechanisms are necessary, but not knowing the exact mechanism- does that qualify as charlatanism and ONLY non-specific effects?
    You state you utilize other means to enhance non-specific effects while at the same time empowering patient. Is there a difference if I use mobs/manips to do the same, as well as what you use? Undermine locus of control? Then the practitioner is doing a crappy job of letting that happen – don’t blame manips, blame the practitioner!
    MT – not the penthouse or the outhouse; likely somewhere in the gray area between???
    I understand validating what we do, etc., but our profession appears to thrive on defending your stance. I do not believe this has ever moved us forward.
    BTW – I love the “gray” in our profession.
    Respectfully, Mike

  35. Richard Bartley says:

    Note to Mike Reiman. Agreed – a fascinating debate of sorts.

    I am inclined to agree with you that even if the effects of SMT are small and don’t last long, used with the right patients and combined with advice, education and authoritative encouragement, it may still have some value. Perhaps avoided in patients with high START scores who are at risk of chronicity and dependency.

    However, I would balk at the idea (which you are not suggesting) that to use it as a deliberate placebo or to pay the rent is unethical. Here is Dr Alain Braillon’s comments on placebo (Dr Braillon’s legitimate claim to fame has been involved in a long running dispute with the Sarkozy’s government and the tobacco industry):

    “The placebo effect is simply belief, a powerful and dangerous tool. It spoils the doctor- patient relationship, which is based on trust; strengthens medical arrogance; and infantilises patients. The first point risks a backlash, the other two have a name; disease mongering.”

    When I have used SMT sparingly I have always warned the patient that the benefits are small, that the techniques do not have a robust evidence-base but may help in the short-term. In other words, I make a contract with the patient that’s based on honesty.

    What startles me is that so many health care professionals are fooled by placebo effects themselves. They often attribute improvement in patient outcomes due to ‘their skills’ or ‘guru-taught techniques’ rather than because of non-specific effects or regression to the mean.

    My road to Damascus conversion was a few years at a specialist orthopaedic hospital where I was mentored by highly sceptical clinicians and specialists. Scepticism is good (although cynicism is not) and improves medical and therapeutic acumen.

    The only downside with scepticism is that it can lead one to become a bit disillusioned when so many physiotherapy treatments turn out to not do what they originally said on the tin. A bit like David Butler’s recent confession!

  36. Ade Wagstaff says:

    This is a brilliant and rather more grown up discussion on SMT than i am used to on twitter! Though I do appreciate Neil’s respectful presumption of a possible need to lay low (duck!). However, I think the article and study are both quite rounded in many ways (well done). It echoes many issues surrounding SMT, yet a common theme I feel emerges……..understanding what we are treating! Although, in critique there is bias on the authors own preconceived opinion (recovering manual therapist!). Irrespective of our problems with manual therapy, we continue to use it. It has an effect, short term, but has an effect nonetheless. Though we over use and over rate its success, perhaps fabricate outcomes even! Furthermore, patient and treatment recommendations are destined for failure – is it ever going to be the same diagnosis?
    The problem with research is that we apply a largely non specific technique to a……….rather non specific problem! -are we really surprised at the result. (As for acupuncture. ………people already think its quackery so no great hill to climb there!). The issue with SMT is the therapist failing to understand whether it has a place or not. I totally support both perspectives. 1 – we are not providing a solution to a problem and thus in making short term gains make the patient totally dependent on us; but, 2 – the short term/or long term (only short term if patient doesnt recover) reduction in pain allows us to progress on with rehab and may even expedite recovery. Not helping a patient when we know small effects are all that is gained……is this ethical? However, I appreciate the dangers. Without adequate education we can reinforce a patient’s belief (and therapists) that SMT is the only way to recover from injury. Indeed, most problems go away a little advice and encouragement. So then we ask why manip? Here comes the research! – we try to find a scientific justification. This falls at the first hurdle. Its a non specific delivery and thus we are not going to access a clean and robust conclusion. I agree, no more research. Enough is enough. Yet I have very little fear in this useful technique being lost. The demand exists. People seek symptom reduction and together with adequate education we have an opportunity for ‘some’ patients to achieve an expedited return to activity. Great! Another research project! But education is key. Understanding pain is key. The health service loves this research. Its nice and cheap to provide a service where advice and education is all that is given…..in practice it doesnt always work like that. But research delivery of this nature, to the masses, is almost and dangerous as patient/therapist dependancy on SMT. Many of my sentiments probably echo that of Mike’s. I feel totally at ease to challenge my practice. But I cant drop a useful technique. I do use it less and sparingly, not because I want to agree with Neil’s comments but because I understand that I am dealing with pain and I can not use one technique to cure a multi-dimensional syndrome. Im not convinced sub group and prediction rules will help determine if SMT is useful. Thus, we are left with the “grey” area of our practice…….

    Thats my bag. I dig the post. I agree with many/most of it. But I dont think abandoning it or blasting it out of PT is the answer. Educate people, therapists and patients. Therapists need to reflect and truthfully evaluate the usefulness of these techniques.

    ……..Thanks for the post and you can delete this if you think it is total rubbish!


  37. Andrew Cook says:

    Well, there are other downsides to scepticism – probably as many as there are downsides to having a mind so open that there are birds nesting in it.

    I find the whole debate on placebo and ethics is mindbogglingly obtuse. It should be simple – no practitioner should practice what they do not believe in. If we practice what we believe in, then we are congruent – that congruency is recognised deep within the patient – body language, mirror neurons, however you wish to explain it – and then regardless of what we do, there is an inevitable placebo effect. It is not necessary to deliberately invoke placebo, it’s just there as an unquantifiable part of the treatment.

    “First do no Harm” – that should be simple in that there is care taken to work in such a way that balances any force used (including force of ideology) against the physical or emotional vulnerability of the patient. imo, telling someone that PT is useless is pushing a particular opinion, and is not far off telling them that their particular condition is incurable. A more honest statement would be “I don’t think I can help this using PT” – rather than speaking negatively on behalf of all PT professionals. If we do no direct harm, then the unquantifiableness of placebo is irrelevant – we have acted to our best as professionals – that’s what we are paid to do.

    I don’t see how anyone can separate “non-specific effects” from those achieved as a result of doing something that has a physically beneficial effect. Seeking to know mechanism and saying that mechanism has to be known before treatment is either ethical or effective – is rather putting the cart before the horse. People used gravity (and lots of other things) well before the mechanism was determined. And the mechanistic approach commonly used assumes a) that some ill-defined point is causal (but anything less is not – but why choose that particular point?) and b) once a mechanism has been identified it is THE mechanism – why cannot there be with so complex an organism multiple and parallel (and even apparently contradictory) ways of coming to the same point? If you look at the medical repertoire for psychoactive pharmaceuticals, there are very few well described mechanisms. SSRIs are a case in point a) most serotonin is stored and produced in the gut, so why not treat the gut, and why assume a direct correlation between depression and serotonin? b) there is no clear correlation between depression and serotonin in the general population, c) some antidepressants decrease serotonin levels – but are still antidepressants. Similarly statins – there is NO evidence to link pharmaceutically reduced blood cholesterol with reduced heart attacks. If medical science is so unclear on mechanism for some of the most widely prescribed drugs, surely there is a bit of leeway for hands-on therapies, which by their complex nature are fundamentally less easily to evaluate or attribute mechanism.

    wrt medicalisation – I agree- and some kind of patient empowerment so that they leave believing more in their own capacity to self heal (and at the same time have some increased level of self-awareness so that this is practical and not wishful thinking) is an ideal that we can strive towards. The fact that it bucks the whole current popularised view of health/illness makes for this being a goal that should be secondary to pain relief and rehab – it’s a professional agenda rather than being of immediate benefit in accord with the patients objectives for seeing us in the first place.

    All the above have factors that vary wildly according to the patient population seen, and whether they are seen in a private or public health setting. But putting all of PT into a common boat and then casting it adrift into the sea of failed and disreputable quackery is imo throwing a lot of babies out with the bathwater. Likewise SMT – I don’t use it in over 99.9% of cases. One major current debate in the Osteopathic profession in the UK and in much of the world is that SMT is over-used. And there are versions of Chiropractic (McTimoney, McCauley) that have left the heavy duty manipulations behind. But that doesn’t mean that there is absolutely no place for them. I recommend you have a look at the recent biography of AT Still (Lewis – From the dry bone to the Living man) if you want to see what manual therapy (including “SMT”) is capable of in the right hands.

  38. Evanthis Raftopoulos, PT says:

    My answers to Wyatt’s questions:

    1. IMO manual therapy can operate on a more plausible level than needling in the context of health and functionality: it can assist the patient complete a movement that is understood as limited, usually due to pain. The goal is to help with movement, and I find this valuable for some patients during the first let’s say 1-2 sessions. I cannot claim that it is necessary, and I cannot generalize its usefulness to all patient population. Also, I’m not talking about massage (soft tissue mobilization), although one could argue that the temporary relief some patients experience after massage can provide them with an opportunity to move easier.

    2. Manual therapy is totally ethical in the context of physical therapy. We are licensed to use our hands for the evaluation and treatment of painful conditions. What might not be very ethical is setting wrong expectations, and/or using outdated and implausible explanatory models to justify the use of our hands.

    Evan Raftopoulos, PT

  39. Thank you everyone for great input and discussion of my questions. I feel I lean mostly with Neil’s reply, but I can respect most other’s positions as well.

    One thing I feel is truly needed is for the growing evidence and science of physical therapy, such as this discussion here, to filter through our culture. I find it truly shocking how many orders I get from physicians for outdated, placebo treatments such as ultrasound. I also find it disappointing how many times I hear from patients pseudoscientific things like “something just needs to be popped back into place” or “my core is weak” or “doc said I could end up in a wheelchair”. I spend a big part of my day just discussing common misconceptions, one patient at a time.

    Neil – and others – I would like to pose a question in light of this. How can we best address these misconceptions and get science/evidence-based info to the masses? I apologize for such a vague question, but I feel there is a great need to approach these issues from a community health perspective, and as a PT . Do you have any ideas/recommendations on how best to address these sorts of things from a community level? I’d love to hear your thoughts.

  40. Neil O'Connell says:

    Good question Wyatt. Its not easy. BiM and blogging generally is one approach, but it suffers from the problem of selection bias – you tend to access folk who are already on that wavelength. Rachelles Buchbinders classic trial of a mass media campaign returned really enouraging results for both patients and clinicians, but similar approaches tried elsewhere have had less success.

    I think the professional bodies have a larger role to play, but the barrier is that they generally advocate for physios first. I my view a truly mature professional body recognises that whats good for PTs might not always be whats best for patients. Hopefully it is usually but it is not an assumption one can make without risk. In the UK our professional body, the CSP, recognises special interest groups in acupuncture (no surprise) but also in “energy medicine” and expressed disappointment that the NICE guidelines for managing arthritis did not include recommendations for acupuncture. That seems to me to be a failure to put rational patient care first. Just my opinion.

    Other than that we need to use platforms like this and twitter to keep having conversations like this one.

  41. Dave Nolan says:


    This is a tough one. In an era where we are all pitted against each other for services I think the CSP feels the need to “sell” physio, whatever that physio may be. And what could be better than jabbing a few needles in OA knees, could keep us employed for years.

    However, what is best for the patient and society in general might actually be bad for “selling” Physiotherapy. As I feel we tend to over complicate and over treat many of our patients (whiplash being the most obvious case), when the reality and the evidence might start to suggest that less is more.

  42. Dave Nolan says:

    Neil. I missed off the last line from previous response.

    Do you think the CSP should be the body that takes on the role of a critical eye over the profession or should they be more cheerleaders and a platform for debate?

  43. Nikki Petty says:

    Eric, I really like this conceptualisation, sounds very interesting. Have you published this anywhere?

  44. Neil O'Connell says:

    Hi Dave,

    Good question. I think, to some extent, both. By endorsing things like the ACPEM it is very difficult to maintain a position of credibility and any talk of valuing EBP rings hollow. In that respect the profession needs to look hard at itself and I would suggest the CSP have a role to play there.

  45. Hi Neil another thought provoking post so thanks. I always have a sense though that we are throwing the baby out with the bath water! We have much to learn! That is why we are so rubbish at treating these problems! More research please ! Never using touch as a tool to help, makes the world seem a rather sad place.

  46. Nikki-

    Thanks! Being that it is just my attempt to thoughtfully apply the science, psychology, and ethical considerations to the profession of physical therapy (including business side) I have only published such ideas on my own blog and via lectures. I have presented a similar concept of ethical/professional business models through APTA and often get invited to state PT association chapter meetings here in the US to present science application (next one is at the Texas meeting this April).

    I did write a post on locus of control on my website a couple months ago that in some ways applies to this discussion. http://ptpodcast.com/are-your-patients-out-of-control/

    There is some other crap on there too (that’s our tagline)…


  47. Evan Raftopoulos says:


    I wouldn’t say that we are “rubbish” at treating these problems, but I’ll say instead that we often have the wrong expectations, especially in the context of pain resolution. We expect that the patient will stop experiencing pain in a linear and predictable way and because of our interventions. And when the patient does eventually improve, whatever treatment that the patient was having takes the credit (no matter how nonsensical the treatment was). It seems to me that this misconception is especially popular amongst manual therapists. There is a lot of confirmation bias, and we are all subject to it.

    About touch: there can also be a great deal of touch during manual assessment and active movement.

  48. Characteristically incisive commentary Neil, I like it. I would offer an observation, I’ll preface it by saying that it is independent of my view on the results of the study. I also do so aware that this is a bit of a side-track from the rest of the discussion here, so am happy if you want to let it lie for another day.
    I’ve not heard the term comparative effectiveness meta analysis (wouldn’t this term apply to any intervention-focused meta analysis?), but assume it is something like a network meta analysis. While I really like the idea that this is possible – I do love a meta analysis – it worries me a bit. The usual garden-style meta analysis relies on the contention that the included studies are ‘homogenous enough’ to pool their findings, i.e. that they are all estimating the same effect. As you know this requires a subjective judgement on the part of the researcher and is nearly always open to the argument that homogeneity is insufficient and therefore meta analysis inappropriate (even before we look at statistical heterogeneity).
    My concern is that indirect comparisons compund this heterogeneity issue. Keeping in mind the idea that a pooled estimate only makes sense if all the contributing numbers are estimating the same effect, otherwise the mean we get is well, meaningless…

  49. As the author of the study, I find it gratifying that the findings are being challenged and discussed. Several points I would like to address in the posts. And my background was as a chiropractic student, researcher, and practicing chiropractor from 1984 to 1999. My data analysis career started in the 1970’s and was limited to the frequentist / null hypothesis testing that is predominant in most clinical research and subsequently aggregated for meta-analyses. My methods appear unconventional in the clinical research world, but they are adapted from Bayesian indirect comparison methodology.

    Cochrane and other meta-analyses tend to focus on single treatments compared to a small variety of control groups. Relative or comparative effectiveness remains unaddressed. Prospective comparative effectiveness is prohibitively expensive and resource intensive. If we could extract at least some useful information from the intellectual capital already available, we might do humanity a service. When I embarked on this project, I was prepared to find at least some “rule-outs” – i.e., some clear losers to omit from future consideration and analyses. I still think that is the potential strength of the method – cull out the least promising.

    Across individual study arms selected for the same condition is fraught with heterogeneity as one thoughtful contributor has mentioned. However, that variability (uncertainty) can be tamed by pB (prob of recovery distributed as beta). The practicality though of the procedure was defined for me, when I reasoned that if so much of the outcome is non-specific and natural history, then the superiority of treatment over comparison will appear at the same rate as any random process.

    Non-specific factors were actually just stratified control groups such as sham, as compared to real SMT in a (meta) regression. Roughly, the sham outcome is one estimate of the SMT / MT natural history and non-specific elements. Again, though, the hidden “random” engine was making treatments appear effective at 1/(number of arms).

    Now, I think we should just start there – seeing if 1/(number of arms) is the same as the treatment successes irrespective of statistical significance.

  50. Very interesting blog and comments. And a very important topic.
    I too have progressively reduced use of manual interventions for the spine over the years based on experience and intuition more than awareness of this lack of evidence, and prefer to rely on mind-body interventions, activity/movement reeducation, neuroscience education, time, posture, self-care, stress reduction/central and autonomic self-regulation skills, etc.
    I do feel, however, that the question that has been posed about ethics and placebo needs further attention. I believe a well-crafted treatment can sometimes utilize a modality that is not “evidence-based” per se (actually am simultaneously a supporter of “evidence-based” and completely sick of it masquerading under other motives, especially when it limits good medicine which I define as “anything that gets the patient better” (I’m sure that will draw many comments if the context I’m coming from is not understood, but so be it)) and/or that which yields a short-term result allowing time for successful integration of other factors. After all, placebo is so powerful that drug studies have to rule it OUT. It is truly the elephant in the room. How about assisting providers in learning to skillfully activate it, and to aid patients in learning how to consciously harness it, since it is the most powerful effect we have – when I hear “just placebo”, I cringe. Such a comment lacks an in depth understanding of what it represents at the mind-body level (and the neurophysiological correlates behind it).
    And, when do you meet the patient at their beliefs, if that would support the best outcome? Is this unethical if doing so involved a manipulative technique, or a short-term effect modality, or even many of the exercise techniques that have consensus belief (outside evidence-based circles) yet little actual evidence in their use? Personally I don’t believe so, at least not in all cases. Keep in mind, in my practice, I don’t need to take such a route very often, but I certainly would not rule it out as being “unethical”. In fact, to not skillfully navigate a gap between belief/placebo/nocebo to me would be unethical.

  51. Rico Paras says:

    And there lies the problem…when the efficacy of a treatment modality relies on the skill of the provider rather than the effectiveness of the actual procedure. In my mind, for a treatment to be effective, it has to be reproducible if carried out by anyone with necessary skill set.

  52. Nick Clode says:

    What an excellent, thought provoking debate. Matt, considering your comment with good medicine being ‘anything that gets the patient better’ you will enjoy watching the following presentation by Larry Benz. Larry discusses how physiotherapists may use ‘non-specific effects’ to enhance clinical outcomes. Brings up an ethical debate, but very entertaining nevertheless. https://www.youtube.com/watch?v=PQGF1bBPa0s