Finding Your Place Between Manual Therapy and Pain Science

By Laura Rathbone

There's a quiet crisis happening in physiotherapy and it seems to be internationally shared and across generations and experience-levels.

Clinicians trained in pain science are feeling professionally isolated, caught between worlds that seem increasingly polarised. Struggling to find a narrative that includes touch-based therapies and clinical assessments with talking-based therapies and whole-person approaches.

Rachel, a rural Australian physiotherapist recently shared on our monthly Coffee Club discussion: "I've had to really change my identity as a physio...I actually feel quite isolated, not just as a discipline, but from other physios sometimes."

The emergence of the term 'WiFi Physio' an updated version of the 'hands-off phsyo' I was branded with many years ago when I began teaching talking-based therapies to physiotherapists and valuaing communication over protocolised manual therapy systems. Ironically, around the time I was completing my MSc in Advanced NMSK Physiotherapy to become a UK member of the MACP - previously the Manual Therapy Association of Physiotherapy.

The function of these labels is very clear: Othering physiotherapists that acknowledge the value of their words over their hands and the patients' own intrinsic capacity for recovery and change.

AI generated image of a "WiFi Physio" using Gemini

The False Dichotomy

Over decades, the Phsyiotherapy community has created an unhelpful binary in our profession.

On one side, the "manual therapy physio" who uses their hands under a patho-anatomical framework.

On the other, the "non-manual therapy physio" who works purely through education and exercise, potentially deliverable via screen.

The problem which such simplistic labelling is it leaves some of us feeling outside of our profession and wondering: "What am I becoming? Exercise physiologist? Occupational Therapist? Psychotherapist? What am I now?" Meanwhile, those who continue hands-on work face judgment for not being sufficiently "pain science informed."

The truth? Both extremes miss the point.

Context is Everything

Evidence-informed practice means making therapeutic decisions based on context, not ideology. Someone may genuinely benefit from manual therapy as part of their rehabilitation. Someone who's had fifty failed manual therapy attempts probably doesn't need a fifty-first. Physiotherapy practice shouldn't overly identify with specific styles or systems of practice.

The nuance lies in evidence-informed therapeutic decisions. When a Physiotherapist is flexible enough and broadly trained enough to respond to individual contexts rather than applying standardised protocols or rigid theoretical positions.

Touch as Communication

What if we stopped thinking about manual therapy as a structural intervention and reconceptualised touch as a kind of body-body communication?

Consider this scenario: You see someone with complex chronic pain. They need you to perform a physical assessment, not because you'll find anything new, but because it's a ritual that honours them. "It's almost like they need me to fulfill that role in order for us to meet each other halfway," Christine, our co-founder, shared when reflecting pn her practice this morning.

When you place confident, experienced hands on someone's body and they say "yes, that's the spot," you're not necessarily finding a structural defacit, but you might be establishing that the pain exists, it's real and you're listening without doubt. For someone whose pain has been dismissed or disbelieved, this validation can be transformative in your therapeutic alliance.

Of course, this might not be relevant or applicable to all people's pain. I can think of many patients for whom touch - would be untinkable with. Especially in the beginning.

Wouldn't it be great if we were a profession that celebrated knowing this in a way that didn't devalue it or role in supporting people in those situations?

This is why moving towards "touch-based therapies" might serve us better than traditional systems of "manual therapy". It acknowledges that we're not 'always' looking for structures or biomechanical dysfunction. We're having a human-human conversation about pain that transcends words and medical systems.

The Death of Standardisation

To clarify, I'm not advocating for a touch-based approach to all Phyiotherapy encounters. that would be a regression to stadardisation.

I'm advocating for us as a person-body-world focused profession of therapists, to be able to weave meaningfully around the person's need for compassion, validation and collaboration within their pain care.

Traditional manual therapy protocols insisted everyone should receive the same assessment, the same techniques. We relied on this standardisation for our research, our credibility and our identity.

"The decision to use touch or not should not undermine our professional identity. That leaves us fragile as a profession and diminishes our role in caring for our patients and supporting people to live well alongside the challenges of life" LR

But our measurements have evolved. We use quality of life measures now. We understand that clinical assessment tools have confusing sensitivity and specificity. We don't need standardisation of approaches anymore. We need an agreed set of principles to work from and an evidence-informed apporach to how we make decisions together with the person.

This is actually liberating: we can rebuild our practice identity around principles and ethics rather than standardised systems of practice. You might use touch-based approaches with one person but avoid them completely with the next. Both decisions can be equally valid, evidence-informed, and professional.

Finding Your Place

If you're feeling caught between worlds, you're not alone.

I think we will recover our sense of shared identity as a profession when we recognise that skilled physiotherapy means having multiple tools and the wisdom to know when each is appropriate for the person you have the privilege of working with.

You can be excellent at touch-based therapy and skilled in pain education. You can honour the ritual and validation that touch provides while understanding it's not "fixing" structures. You can work differently with different people and still maintain professional integrity.

The goal is to become and build a healthcare profession that is thoughtful, principled and able to meet each person where they are, and do our best to co-create the optimal environemt for beneficial change.

Because good therapy, across all of our rich allied professions, can change lives.

Isn't that the point?