Stay Calm…focus on your reasoning…


By: Brett Windsor PT, PhDc, MPA, OCS, FAAOMPT

For the last twelve years, manipulation has enjoyed the best of seats in the physical therapy house. Careers have been made, Medici-like empires constructed, all on the back of a technique once considered little more than a party trick for a handful of grizzled old romantics apparently intent on destroying the scientific method. Once regularly dismissed in higher circles, reduced to a bargaining chip for direct access in the state-house, manipulation has since driven its own agenda. It’s now taught in all pre-professional physical therapy schools in the US. No serious manual therapy program would consider anything other than the earliest of introductions as they groom their new progenies.

Still, many would have us regard manual therapy (manipulation particularly) as a rambunctious toddler at high tea; tolerated best when seen little seen and heard even less. From their lofty perches atop the mountain of wisdom, they proclaim that there is simply no evidence to support manual therapy. Any published statistics, of course, cannot be trusted; only their sophisticated post-hoc analyses can be trusted to affirm that manual therapy is, well – utterly useless. One should not allow facts to impede any biased pre-suppositions. To a hammer, all appears as nails….right?

Context anyone? None but the slickest of operators would consider wise the unyielding application of any treatment method to every patient that crosses their path a wise course.  Such attitudes toward manipulation do nothing to raise OMPT above the bone-setters and lay-manipulators that, even today peddle their wares to anyone with a credit card. However, it would now seem fair to say that physical therapy as a whole has reached a reasonable balance between manual therapy and other interventions to arrive at a generally well-rounded management approach.

Manipulation is a tool. And as such, it is best suited to a specific purpose. More now than ever before, its effect appears to be largely neurophysiological, causative of changes in local muscle control initiated by the central nervous system. This explains the patient who falls on ice, manipulation at once producing the profound changes in function and pain. What was that almighty ‘clunk’? How did the patient go from the appearance of an acute disc to almost completely normal…in one technique? Skeptical? Don’t tell me it didn’t happen, help me explain why.

Physical therapy is an educational profession. Our highest charter is to know, and to explain, why. Then, physical therapists can facilitate optimal movement patterns in patients. This means postural education, movement retraining, individually dosed exercise and yes, manual therapy. Manual technique plays a key role, but the return to a pain free movement state will only be sustained through education and a long-term commitment to developing optimal postural and movement patterns. And we all know, there are a myriad of methods suited to each purpose. Use all the tools in the box. They all have a role to play.

Focus should move away from the latest treatment fads. The darling of the moment is dry-needling, now the magic remedy for seemingly any problem. What about evaluation? Where has that gone? Does anybody value a thorough, thoughtful evaluation anymore? Evaluation is now an endless procession of ‘special tests’, each statistically more useless than the one before. The dirty little secret is that superior understanding of anatomy, pathology and biomechanics, combined with a critical mind, good questions and a good memory renders special tests quite unnecessary. Diagnosis is made before the touch.

Would you like to have these skills? Would you like to be able to think though problems? Make decisions and understand the true nature of that which impedes movement? Would you like to be able to select any tool from a virtually unlimited box, applying each to the job for which it is designed?

You can. Top left. Click on courses. Join us.

6 thoughts on “Stay Calm…focus on your reasoning…

    1. Hi Evan, Brett Windsor writes most of these posts…in fact unless specified otherwise, this can be taken for granted. You’re right, there are no references for these ‘claims’. That is in fact quite deliberate…this is a blog…a conversation intended to stimulate dialogue…something akin to sitting in a pub over an ale or three…no references needed there. Thanks for taking the time to write. Brett W.


      1. Thank you Brett. So I take it that no references exist for “This explains the patient who falls on ice, manipulation at once producing the profound changes in function and pain. ”

        I disagree that these blogs are “something akin to sitting in a pub “. False information presented here or elsewhere can be terribly misleading to a large audience. IMO we all have the responsibility to share references or clarify that what we are saying is just our opinion. Thank you for your time.



      2. Hi Evan…thanks for your comments. No, I can’t offer references for the patient in question…but I can offer evidence…in the form of clinical evidence and patient experience (2/3 EBP criteria)…It’s a patient that I’ve seen maybe 10-15 times in my 20 years in practice. We don’t yet know why, but manipulation can sometimes have immediate and profound effects. Perhaps we’ll agree to disagree on the pub – I think we’ve got be careful to allow opinions to exist without the seemingly incessant pressure to cite everything that is said. I know I don’t expect references when I read a blog. At any rate, I’m happy to let readers decide what they do and don’t agree with; hopefully it will stimulate a deeper look into peoples own philosophies and preferences. Anything that is not referenced? Well, I think it’s fair to consider that subjective and opinion-based. It’s a good discussion. Thanks for your respectful participation. Best regards. Brett


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