Webinar Dr. Toby Hall: Reconceptualising Manual Therapy

Reconceptualising Manual Therapy: Which Patients Actually Benefit?

Webinar content

The webinar covers: the formal definition and historical development of manual therapy; the Lancet low back pain series and the crisis in physiotherapy; the evidence for manual therapy in back and neck pain; the evidence for education, exercise, walking and group therapy; three worked case examples; occult tissue injury and Taylor's autopsy findings; the classification and decision model; subgroups and the washout effect; red and yellow flags, the Örebro questionnaire and the STarT Back tool; central sensitisation; clinical prediction rules and the problem of replication; mechanisms of manual therapy; and an extended question-and-answer session on the reliability of manual examination, the role of imaging and the place of exercise.

Does manual therapy work? The real question is: for whom

In this webinar, Dr Toby Hall (PT, PhD, FACP, Curtin University, Perth) takes you through the full body of evidence for manual therapy in low back pain, neck pain and nerve-related arm and leg pain — including the studies that found no effect. The systematic reviews by Hidalgo, Coulter and Rubinstein show modest average group effects. In Hall's view that is not evidence that manual therapy fails, but a sign that we are asking the wrong question: not does it work, but for whom, at what dose, and in what combination.

The decision model: who should not receive manual therapy

Hall sets out an explicit, multi-layered indication model. First, exclude serious pathology — including in referred patients. Then identify yellow flags and overt central sensitisation using the short-form Örebro questionnaire and the clinical indicators described by Smart. Only then subclassify into movement impairment, control or load impairment, and neural pain disorder, each leading to a different intervention. Three worked case examples from his paper Reconceptualising manual therapy skills in contemporary practice show how the same movement problem leads to three entirely different management plans.

Reading research without being misled

A substantial part of the webinar is about methodology. You will learn to recognise the washout effect — why a trial giving one technique to an undifferentiated population averages away a real subgroup effect. You will learn why a replication study using a different protocol does not refute the original finding, using the Flynn prediction rule, the Childs validation and the Hancock replication. And you will see how a study's title and abstract can diverge from its actual results.

Imaging, red flags and overdiagnosis

In an Australian primary care cohort of more than a thousand patients with back pain, 80% had at least one red flag, while fewer than 1% turned out to have genuine serious pathology. Hall discusses what that means for your referral policy, why imaging harms rather than helps most patients, and which combination of red flags should prompt action — with reference to the international framework by Finucane et al.

Who is this webinar for?

This webinar is designed for physiotherapists, manual therapists and human movement scientists treating patients with low back pain, neck pain or nerve-related limb pain, and for anyone wishing to sharpen their indication-setting for manual therapy and read research more critically. It is relevant to general physiotherapy practice and to the manual therapy specialism.

Scientific faculty: Dr Toby Hall

Toby Hall is Adjunct Associate Professor at the School of Physiotherapy and Exercise Science, Curtin University, Perth, and Director of Manual Concepts. He published Reconceptualising manual therapy skills in contemporary practice and co-authored Mobilisation with Movement: The Art and the Science. He has taught internationally on manual therapy, neurodynamics and clinical reasoning for decades.

Learning Objectives

Upon completion of the webinar and the accompanying online assignments, the participant is able to:

1. Clinical reasoning and indication-setting

Critically apply the decision model presented to a given patient case in order to justify the possible role of manual therapy, taking account of indicators of serious pathology, psychosocial factors, movement-related findings and the limitations of the model itself.

2. Research evidence and applicability to the individual patient

Appraise the results of a trial or systematic review for their meaning for a specific patient or subgroup, using the conflicting findings on clinical prediction rules for spinal manipulation as the worked example, weighing study design, patient selection, intervention protocol and outcome measures against one another, and explicitly distinguishing what has been demonstrated from what is assumed.

3. Fidelity of intervention delivery

Judge whether a manual therapy intervention — whether in a research protocol or in one's own episode of care — has actually been delivered as intended, on the basis of targeting to the individual patient, dosage and progression guided by response, and on that basis argue which conclusions about efficacy are and are not justified.

4. Pain processing and treatment choice

Critically weigh, in a given patient case, features that may indicate altered pain processing against alternative explanations, and justify the possible role of manual therapy within a person-centred, multimodal treatment plan, including an explanation of the residual uncertainty that the patient can understand.

5. Imaging and referral

Justify a decision on further investigation, referral or re-assessment in a given low back pain case, interpreting the diagnostic value of red flags in the light of their high prevalence set against the low prevalence of genuine serious pathology in primary care, and weighing the potential benefits and iatrogenic harms of imaging in the management plan.