The debate rages amongst clinicians and students alike. Which is better - manual therapy (in all of its myriad of forms) or mechanical therapy (otherwise known as MDT, or the McKenzie Method)? For some reason, clinicians seem to be very polarized when it comes to their approach to orthopaedics. This makes for some rather entertaining dialogue between the factions involved.

At the entry-level of education and beyond,  students continually ask faculty which is "better". I have had physical therapy students sit in a classroom and debate, with great passion I might add (given their lack of experience), that one approach is better than the other. This extends to practicing clinicians that are also struggling with where to spend their continuing education dollars. It seems like it has evolved into an "us versus them" mentality. At best, it is an entertaining dialogue; at worst, a fine example of ignorance amongst well-educated clinicians.

One must be better, yes? Isn't that the way it has to be? Someone has to lose, no?

Is the great debate – manual therapy or mechanical therapy – just a great perceptual divide?

If we look at the underlying elements between the two approaches to care, we find some rather amazing similarities. Manual therapists move patients - as do mechanical therapists. Manual therapists assess the symptomatic and mechanical responses to movement - as do mechanical therapists.

Beyond these factors, the differences are elemental.

Manual therapists use their own therapist-generated forces, first and foremost, to move the patient. The "laying on of hands" is the first solution provided to the patient. The patient then associates improvement (or regression) to what the therapist has done to them. Manual therapists utilize palpation skills as a basis for assessment.

Mechanical therapists, those trained in MDT, use the patient's own self-generated forces as their primary tool. The first solution provided to the patient, if possible, is to implement strategies that foster "competent self care". The McKenzie-trained mechanical therapist then uses therapist-generated forces if and only if the patient-generated forces are deemed appropriate but insufficient. McKenzie therapists do not utilize palpation skills as a basis for assessment.

There is good evidence to support the use of manual therapy in the first 2 to 4 weeks post-injury. There is good evidence to support the concept that there is oftentimes a directional preference of movement (per the mechanical therapist’s assessment) that may in fact guide the prescription of exercises for the patient.

Beyond this, it's really quite simple. Our perception of our role in the care of the patient is the driving force behind the selection of assessment and treatment interventions. Nothing more, nothing less. Clinicians select their assessment and treatment approaches based on their belief systems - much like we do with anything else in life. Our perception is our reality. If you feel a need to be the "fixer", the "guru", the "healer", then I can guarantee which approaches to care you will select. If you feel a need to be a "mentor", a "coach", an "educator", then, again, I can guarantee which approaches to care you will select.

It then becomes an emotional issue. Many clinicians have their own personal belief systems and self image built around the "I am the fixer" mentality. Whether we realize it or not, our perceptual mechanisms drive our comfort zone - and for many therapists and clinicians alike, relinquishing control over the patient is a difficult (and emotionally challenging) task.

Perhaps that sounds almost too simple to be true - but it is the foundation upon which the debate rages on.

The evidence, should anyone care to debate it logically and respectfully, is quite clear. If you take a critical review of the current scientific literature on back pain (as but one example), you'd find that much of it simply supports a gradual resumption of normal activities after an episode of back pain. Many peer-reviewed guidelines have established that many commonly-used palpation-based treatment approaches are no better (if not worse) than nature itself. And one thing that has been well-researched in the literature (and that provides a primary difference between manual and mechanical therapies) is that palpation is a poor assessment tool. It displays poor inter-rater reliability and questionable validity. Simple.

But let's remove ourselves from the equation. From the patient side of the equation, it all boils down to the old adage - "Give a man some fish and you feed him today ... teach a man to fish and you feed him for a lifetime". The concept of long-term "health" is directly related to the ability of the patient to be an informed consumer of their own health care. In an era in which we struggle to finance our health care and in which chronic illness and disease (of which 'back pain' would be included) are draining the system, “competent self care" is critical to our long term success. Treatment approaches that foster these long-term benefits – for patient and for health care system alike – should be advocated.

The clinician's perceived role in the care and independence of the patient has a cost associated with it. There is a long-term impact on patient self-responsibility and on creating a system of effective "health" (care). Unfortunately, it is the self-perception of the clinician's role that will prove to be the biggest battle that we face. And until that is resolved, the other issues will be slow to follow - evidence or no evidence.

Photo credits: Al_HikesAZ