COVID-19 wash your hands but don’t erase them from our profession – considerations on manual therapy past and present

Our profession faces a developing professional trend against manual therapy [1,2]. a sudden shift restricting the delivery of manual interventions due to the coronavirus pandemic (COVID-19) [3,4], further questions the future role of manual therapy. This two-fold movement away from manual therapy, one slow, one fast, requires that we review the foundations and benefits of a hands-on approach within patient management.

With this movement away from manual therapy, a focus is needed to maintain our ability to provide an alternative to medical management in times of repeated opioid crises [5], and critically looking ahead at a preeminent need to help individuals affected by COVID-19 [6–8].

In the slow transition away from manual therapy [9] we are seeing a shift in the practice of our profession, where the abandonment of hands on approaches in patient care is being applauded by some, with such puerile trending terms as ‘manual therapy sucks’[10], and some of our educational institutions are debating if we should even educate physical therapy students to mobilize and manipulate [11].

This may be a debate for a maturing profession, but as society faces a serious pandemic [12] and an ongoing opioid crisis [5], it is concerning that our practice has started to embrace a neuro-essentialist type approach [13] for a progressively inactive population [14]. Our duty of service to society as a primary musculoskeletal care profession compels us to do more than debate [15]. If we understood our history, we may pause on moving away from our hands-on approach and seek to embrace again the approach that made us so valuable when ‘Modern Medicine’ was failing in the second half of the 19^th century [16].

During the 19^th Century in Northern Europe, a progressively mobile society, with large city industrialization and a growing middle class [17] sought alternatives to medical practice, which focused on strong medications and rest/immobilization for physical impairment [18,19]. Mechanotherapists and especially bone setters provided a hands-on approach in health care [20]. In the United States, a rapid expansion in industry and population saw a multitude of individuals needing management for sprain, strains and mobility losses who did not find a solution in opioids, alcohol and narcotics [21,22].

Both sides of the Atlantic saw professions born that drew on the past successes of those who used their hands [16]; and trusted to feel in assisting human movement and restoring function [23,24]. The focus was not on eccentric overload training or seeking roles as pseudo-psychologists in times of need; but adapting and using knowledge tied to their hands to get people back to moving without pain [25].

These approaches, traditional bone setting, movement cures, mechanotherapy and medical gymnastics provided a foundation for physiotherapy in Europe, and Osteopathy and Chiropractic in the United States [16,26]. Success and profound impact was made through the use of hands as a therapeutic approach to return people to mobility [27]. a cogent example within the early history of Osteopathy, was the dramatic reported success of Osteopathic Hospitals in reducing fatality rates during the Spanish flu pandemic in 1918 from the national rate of 30–45% to just 0.25%[28]. Today we need to consider how we use our hands as we debate our role in the management of the COVID-19 pandemic [29,30].

Northern Europe saw specific manipulative approaches for spinal and thoracic cage impairments developed by individuals including Ling and Branting from 1813 to 1865 in Sweden [19]. These approaches spread rapidly through Europe, including via Edgar Cyriax who completed his PhD on Mechanotherapy in 1899 [31]. Knowledge transfer to the United States saw many publications on mechanotherapy and movement cures produced on both sides of the Atlantic [32–35]. When the Great War (WWI) struck, a group of individuals was ready to use their hands, their knowledge and their desire to help people return back to purposeful movement [36,37]. The recreational aides, who quickly became the physiotherapists in the USA under the tutelage of Mary McMillan and others, restored to function tens of thousands of maimed soldiers through tissue and joint massage and manipulation and exercise [38]. The trained masseuses in the United Kingdom integrated hands on manual interventions from Scandinavian instructors to physically return function to soldiers; and promote active rehabilitation [37]. Modalities were developed to augment approaches, not to replace them [39].

In the United states, hands on approaches successfully integrated into patient care started to diminish once the 1935 Code of Ethics was adopted, which saw all physical therapy practices placed under referral authority from physicians [40]. Modalities and more passive approaches started to take hold. By the 1950’s physical therapists were mastering highly valuable approaches for the management of neurological impairments with the polio crisis, demonstrating a tremendous ability of our profession to rise to the challenge [41], but a vacuum in the use of hands on approaches had developed. Into this void came the Australians, New Zealanders, Brits and Scandinavians who had continued to use a joint based hands-on based approach to ongoing acclaim in their home countries [42]. International physiotherapists such Maitland, Kaltenborn and Paris seeded specific manual therapy back into practice in the United States with great success, leading eventually to thrust manipulation being required in DPT education in 2004 [43].

In 2020, the USA has an ongoing opioid crisis [44] claiming 35,000 lives annually and over 46,000 COVID-19 fatalities to date [45]. Pain and physical disability though persist, calling on over 500 k physiotherapists worldwide, and 250 k in the USA to stay engaged [46]. a danger exists of abandoning the heritage or our past, our hands, and focusing to specific exercises and the best motor control strategy for spinal pain [47,48] and a reliance on technology in our diagnostic processes. Whilst it is a necessary current response to COVID-19, telehealth [49] is also moving us further from our foundation in the use of our hands [50].

Selective published research, which shows a small benefit for exercise alone over manual therapy alone, rather than the complimentary approach practiced clinically, is now the vehicle to represent that a hands-on approach is inferior [51]. Systematic reviews, which show a smaller effect size for a hands-on approach versus exercise are being used to change educational approaches and to downplay the benefits of therapeutic touch [52]. We have shifted in many ways to telling people what to do versus helping them to move [53]. We are finding ways to use motivation for patient populations to complete home exercises [54] but making the potential error of correlating this to an inferiority in our hands-on approaches. a likely culprit is the modern medicine approach of the 21^st century, which is a more nuanced version of the one from the 19^th century (opium, alcohol and cocaine). Today it is narcotics, muscle relaxants, anti-inflammatories and surgery [5].

Exercise is the new medicine is being touted [55], but we forget that movement is rooted at the tissue, joint and neural level. Our forebearers in the 19^th century used their hands to provide skilled interventions to address sprained ankles, ‘wrenched’ spines and twisted knees to restore movement into joints and tissues and to restore function [20]. Emerging professions at times claimed well beyond what they were doing [56]; and theorized whole systems of healing based purely on subtly adjusting articular structures or energy flows and whole-body systems of wellness [57], but many simply helped people through skilled touch. These health care practitioners enabled individuals to trust in their bodies, and to engage in movement again [58]. It was not all ideal, but manual therapy won a very important place in modern medicine for North America, Europe and the world alike [59].

Before us now is a great opportunity and two great challenges: COVID-19 and opioids. The opportunity is that society has in front of it two modern medical crises and we have a tremendous skill set to offer. The challenge is that we may not trust ourselves, and this can be evidenced by an ongoing transition to remove our profession from the hands-on patient encounters [60], and we lack guidance specific to our hands-on approach to inform our care delivery in the time of an infectious pandemic.

Competing ideologies have existed before in the immobilization vs. movement debates of the 1700/1800’s [61]; and now a new debate on ‘hands-on or hands-off’ exists [11]. Our existence as a profession relies heavily on the success of the bone setters and manual therapists of the 1700–1900’s who we borrowed heavily from to develop our skill set [16]. We are dealing with the same human body, and with people with similar needs and complaints. There are still great access challenges, and in the USA physical therapists only interact with approximately 10% of individuals with primary musculoskeletal impairments [62]. If we narrow our approach to be predominantly hands-off, we may end up being proficient at managing even a lower percent of the population with a reduction in the quality of outcome for each individual.

Research on the manipulative management of low back pain has informed our profession to be selective in the use of manual therapy as not all need it [63]. Those that do need it though are potentially disadvantaged if we chose not to use manual therapy [64]. If we move to a predominant exercise and advice only approach, to a predominant telehealth approach, how many people will we harm who will receive less than what they need, and track back into more pharmaceutically based medical management?

Our profession tends to be fad based and attracted to the newest and most ‘innovative’ approaches, undertaking novel professional development courses to use in the Monday morning clinic. Dry needling, cupping and blood flow restriction training are growing rapidly with developing research support [65,66]; however, they should not replace a hands-on approach at the joint level because they are newer. We host manual therapy conferences yet at times predominantly speak of pain sciences. We chase the latest innovations to constantly improve upon ourselves, without asking the important question ‘is change needed’?, though at times change is forced upon us [30].

In the 1960–90’s manual therapy was recaptured in the United States into physical therapy practice and the profession expanded rapidly. The benefits of the use of our hands has been integrated into skilled patient management that optimally returns people into movement-based interventions; and load based retraining to improve movement [67]. The tremendous interest in these approaches is seen in the fact that over half of all Fellowships in the USA are the 32 specific orthopedic manual therapy-based Fellowships [68].

Today in the United Kingdom, Australasia and other areas manual therapy-based approaches apparently are being pushed aside [10,11]. Will the COVID-19 pandemic result in additional hands-on care reduction for a period of time; or will this persist? There is and will be an ongoing need for manual therapies. Have our peers in osteopathy (who have in large parts moved onto allopathic medical practice) or chiropractors filled this need? Have exercise based approaches solved the medical crisis as exercise is the new medicine? If we are honest, we know the answer is ‘no’ as functional impairments continue and the drive to opioids from primary musculoskeletal impairments persists [69].

Manual therapy is at a tipping point. Charismatic presenters [70] can capture the new generation of physical therapists, who have a limited short-term exposure to the benefits of manual therapy. Pain science matters as a component of comprehensive patient management and clinical reasoning, but not to replace hands-on approaches [71]. Further, the rapid impact of COVID-19 has the potential to change how our profession provides interventions, as social distancing creates a wedge between our hands and our patients. We need to recognize where our value comes from – both originally and now, so as not to be changed forever [38].

Our genesis and shared foundations of manual therapy across professions inform us that a hands-on approach remains critical within our overall approach to health care in the 21^st century. Though it is tempting to embrace what is newest as what is best, to embrace social media and develop followers online, how will we meet the needs of the COVID-19 crisis and the ongoing opioid epidemic? Who will fill that void if we de-skill our profession?

What is clear is that we need answers now.

This issue of the Journal of Manual and Manipulative Therapy will provide an invited response to address both the future of manual therapy practice and education in manual therapy, informed by international perspectives.

Disclosure statement

No potential conflict of interest was reported by the authors.