Manual therapy: how many techniques do you really need?

There are so many advertisements from various companies that offer courses for manual therapy. Whether it’s joint manipulation, soft tissue mobilization (STM), instrument assisted soft tissue mobilization (IASTM), or dry needling (DN), the companies will promote how these skills will improve your results in the clinic. While that may be true, there are a couple points to keep in mind before signing up:

1. Some of these classes are expensive and it is imperative to spend your money wisely. For example, if you have novice skills with cervical manipulation, taking an advanced course might be beneficial for you! If you are already competent with these techniques, I would highly reconsider and reflect on the cost benefit. Do you really need to know 5 different techniques to manipulate the lower cervical spine? All of which reproduce the same effects? In 2013, I had the opportunity to go into a full-time orthopedic residency at the University of Chicago Medical Center (UCMC). It was here where I became proficient with techniques such as advanced joint manipulation (cervical, thoracic, lumbar) and peripheral joint mobilization. I had great teachers (Craig Hensley, DPT, OCS, FAAOMPT and Michael Maninang, DPT, OCS, FAAOMPT) who helped me refine my skills. While it may come as a surprise, manual therapy is like riding a bicycle–once you master a skill, it stays with you forever (ex. the barriers/end-feels, use of multiple levers, positioning of the patient, etc.). Once you become proficient, additional teaching is usually not necessary. Excel at 1-2 techniques that address all the mobility patterns of that specific joint. Master them and they will serve you well. No matter what the instructor tells you, an upglide is an upglide and a downglide is a downglide in the cervical spine. A posterior glide of the talocrural joint is the same regardless of the position the patient is in (albeit, some positions may be more comfortable). No matter how fancy the technique looks, it still produces the same end result. There is more than one way to skin a cat, but paying extra money to learn how seems a little unnecessary.

I have already touched on why I believe DN should not be used as a first line treatment in many situations. In my opinion, the evidence does not substantiate it as a primary intervention (see previous post). Speaking from experience, I paid a significant amount of money to be certified in DN (half of it was reimbursed from the company). While I have found success using DN for certain situations, I do not use it for the large majority of my patients. They simply don’t need it. Looking back, I probably would have invested in another continuing education opportunity. DN courses are simply too expensive and the benefits do not justify the financial cost. Unfortunately, DN is the newest fad, another tool in the toolbox, and it will take some time for the cost of the classes to decrease in price. Its true value will only be realized when the premium for the certification is reduced (if and when that ever happens). The same goes for expensive instruments used for STM. Do you really need a hawksgrip or graston tool? Or could you use something like this Edge mobility tool that is a fraction of the price?

(https://www.edgemobilitysystem.com/products/edge-mobility-tool?variant=815471351)

Sure, the hawksgrip may give you better user feedback for the mobilization, but these nuances ultimately make no difference. In contrast, I recently spent $110 on a CEU course with Kevin Wilk, DPT, where he discussed shoulder rehabilitation in the context of overhead athletes and rotator cuff repair. It was affordable and the information that was provided justified the cost of the course.

2. Keep an open mind when learning new manual therapy skills, but be weary of claims that go beyond up to date evidence. It is a disservice to our profession and our patients when we falsely advertise information. Yes, there will be times that we have to reshape our patients perception of pain, mobility and function, but we still need to be truth-tellers. Test everything. What is the evidence behind these interventions? Research the information and then decide if the class is truly worth it.

3. Lastly, remember that no matter how many manual therapy techniques you learn or courses you take, empowering patients to move is what matters most. The majority of techniques are passive in nature. These tools are a small piece of the puzzle, and while they may “jump start” a patient in the short term, movement is the key to long-term success.

If the course you are looking into is affordable and paid for by your company, by all means, go for it! If it is super expensive, consider seeking out other opportunities that will help you address your weaker areas. You will be a better clinician by continuing your education judiciously.

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