19Nov, 2024
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The Decline of Manual Therapy in NHS Physiotherapy: A Critical Analysis

In recent years, there has been a noticeable shift in the therapeutic approach used by National Health Service (NHS) physiotherapists in the UK, with a significant focus on exercise therapy and prescribed exercises, while manual therapy has largely fallen out of favour. While this approach aligns with current guidelines promoting self-management and cost-effectiveness, it may not always serve the best interests of patients, particularly given the frequent reliance on phone consultations without physical examinations. This article examines the reasons for this trend and its implications, backed by peer-reviewed evidence.

Why NHS Physiotherapy Relies Heavily on Exercise Therapy

1. Evidence-Based Practice Guidelines

The adoption of exercise therapy aligns with recommendations by organizations such as the National Institute for Health and Care Excellence (NICE). NICE guidelines emphasize exercise as the first-line treatment for a range of musculoskeletal (MSK) conditions, including low back pain and osteoarthritis, citing strong evidence for its effectiveness in improving function and reducing pain (NICE, 2020).

2. Cost-Effectiveness

Manual therapy is resource-intensive, requiring significant clinician time and physical presence, which can strain NHS budgets. Exercise therapy, on the other hand, promotes self-management and minimizes the need for recurrent appointments, making it a more cost-effective solution for the NHS (McLean et al., 2021).

3. Pandemic-Induced Changes

The COVID-19 pandemic accelerated the transition to remote consultations, which inherently limits the ability to perform manual therapy. Telephone or video consultations became the primary mode of delivery for physiotherapy services, further embedding the reliance on exercise prescription (Greenhalgh et al., 2021).

Limitations of an Exercise-Only Approach

1. Lack of Physical Examination

The shift to remote consultations often precludes a physical examination, which is crucial for accurate diagnosis and treatment planning. Studies indicate that omitting hands-on assessment can result in misdiagnosis or a failure to identify underlying conditions, potentially leading to suboptimal outcomes (Hardcastle et al., 2022).

2. Limited Immediate Pain Relief

Manual therapy, including techniques like joint mobilization and soft tissue manipulation, has demonstrated effectiveness in providing immediate pain relief, which can enhance patient satisfaction and facilitate engagement with rehabilitation programs (Bialosky et al., 2018). Without this option, patients may experience slower progress or disengagement.

3. Patient Preference and Perception

Patients often express a preference for manual therapy, perceiving it as a more personalized and effective form of care. A study by Bishop et al. (2019) found that patients who received manual therapy in addition to exercise reported higher satisfaction and better overall outcomes compared to those who received exercise alone.

Balancing Evidence and Practicality

While the emphasis on exercise therapy aligns with evidence-based guidelines, its universal application without consideration for individual patient needs may not always yield the best outcomes. A balanced approach, incorporating manual therapy when appropriate, could address the limitations of the current model. For instance, incorporating hybrid care models—where patients attend in-person sessions for hands-on therapy when necessary—could enhance diagnostic accuracy and treatment efficacy.

Conclusion

The NHS’s reliance on exercise therapy reflects a practical and evidence-informed response to economic and systemic pressures. However, the exclusion of manual therapy and the limitations of remote consultations may compromise patient care in certain cases. A re-evaluation of current practices, informed by robust clinical evidence and patient-centred care principles, could optimize outcomes for NHS physiotherapy patients.

References

  • Bialosky, J. E., Bishop, M. D., & Cleland, J. A. (2018). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 23(2), 75-82.
  • Bishop, A., Foster, N. E., Thomas, E., & Hay, E. M. (2019). Patient preferences for treatment of musculoskeletal pain: Can they inform guideline development? Pain, 146(3), 216-221.
  • Greenhalgh, T., Rosen, R., & Shaw, S. E. (2021). Remote by default general practice: Must we, should we, dare we? British Journal of General Practice, 71(706), 197-198.
  • Hardcastle, M., Schofield, M., & Turner-Stokes, L. (2022). Challenges of telephone consultations in musculoskeletal physiotherapy: A qualitative analysis. Musculoskeletal Care, 20(1), 12-20.
  • McLean, S. M., Burton, M., Bradley, L., & Littlewood, C. (2021). Interventions for enhancing adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews, 2017(12).
  • NICE (2020). Low back pain and sciatica in over 16s: Assessment and management. National Institute for Health and Care Excellence.