The hands on/off dilemma through a philosophical lens

The hands-on vs. hands-off debate continues to rage in social media circles. It’s a fertile field for misrepresentation of others’ views, clinical practice, and logical fallacies in general. Personally, I have found myself being placed into the “hands-off” group. Perhaps this is a reflection on my profession, based on the name alone, Exercise Physiology comes with a “hands off” and exercise first association. And possibly based on past social media posts that lack context. I think that I have a distinct bias towards communication strategies that move people towards more active treatments, and I’ve gradually moved away from my manual therapy training over time. However, I am not anti- touch, nor am I anti-manual therapy – after all, it is a part of evidence-based guidelines for musculoskeletal related pain. Instead, I am an advocate for critical appraisal of our clinical practice. I also have a strong belief that no clinician (or profession) should place themselves above scrutiny.

In my view, this debate seems to be strongly fuelled by the desire to maintain our group memberships – that is, to protect our identity within our chosen clinical circle – rather than for any attempt to learn, reflect, or have meaningful dialogue. It closely resembles the extreme partisanship plaguing some democracies, where politicians refuse to cross the aisle for the benefit of the people. But I digress from the main purpose of this blog, however, I do discuss this idea more in a free webinar HERE.

In this blog, I’d like to start this hands-on/off conversation from a different angle. I want to share some of the philosophies that underpin how I currently view the world in this clinical practice context. In doing so, I hope my assumptions and values become transparent when coming to a clinical decision. You may not resonate with these underpinning philosophies. Still, in such a case, I hope this transparency clarifies why we may diverge on specific topics, providing a basis for further constructive discussions. I also encourage others to do the same to help further any conversations in the future and put our patients in front of our clinical identities and egos.

I always reserve the right to change my views as new knowledge comes to my attention, so I welcome discussion.

To ensure that everyone is starting on the same page, I’ll start with definitions. I’m considering ‘hands on’ to mean specific manual therapies where practitioners aim to manipulate, mobilise, or alter anatomy using their hands or tools. I think that we can all agree that touch is a powerful social tool. In my view, ‘Hands off’ clinical practice would bias other strategies that do not require a physical intervention using manual therapies and tools (this does not include tactile feedback etc.). To be clear, I believe both can have a place in clinical practice, and the following philosophical lenses are how I navigate this situation in partnership with a person seeking my care.

First, my current treatment philosophy is closely aligned to functional contextualism. Simply, how does the approach/intervention being considered serve the function (the desired outcome) for the problem given the individual’s context? For example, suppose a person is seeking help, and the function you are serving is pain relief (function), given that they are in such discomfort and cannot concentrate on their daily tasks (context). In that case, we can consider what strategies may be helpful. May hands-on therapy be on the table? Yes. Can we consider movement prescription? Yes. We have multiple options that we can discuss in a shared decision-making framework to explore the use of an intervention.

Contrast this with a person who is seeking to get back to a valued activity. Their pain is tolerable given their understanding of what is going on. In that case, short term pain relief attempts may not be helpful given their context. This may even create a barrier to recovery at times, especially where the treatment provided is not in line with their treatment goals (function).

This philosophy can be applied to other considerations within the clinical interaction such as patient rebooking. In a shared decision between patient and practitioner, if both parties decide that further support is required (for whatever reason), given the context and the function it is to serve, then it would be deemed appropriate. However, this requires a discussion that elicits the context and function. This may be one way to avoid both under- and over-treating.

In all cases, it’s clear that the only way we can determine the function and context is by listening to the person in front of us. Great communication skills are imperative to elicit the current sense-making that the person is going through and their objectives. Patients sometimes come into the clinic with expectations of a specific treatment. They are also often seeking out knowledge and experience from the healthcare professional. We have a professional duty to consider the function and context in which our strategies are to be applied. Thus, it may be vital that we discuss other options further the patient may not have considered and educate appropriately.

However, there are some issues with relying on Functional Contextualism alone. I will assume that most readers do not believe Reiki to be a valid form of healthcare. However, we hear stories of people experiencing pain relief or benefitting from the practice. So, for the function of pain relief, given the context of being able to partake in daily activities, this sounds valid. So how do we avoid justifying whatever nonsense we can conjure up? This is where a second philosophical lens comes into play.

Second, science-based practice (SBP).  

We often discuss evidence-based practice (EBP), which integrates relevant research, clinical expertise, and patient values and expectations into the clinical interaction. All factors here are essential; however, SBP (a term introduced by Dr Steven Novella) does not replace EBP but rather emphasises the ‘science’ component. The scientific plausibility of an idea or treatment needs to be considered. Thus, in the example of Reiki, we can apply the fundamentals of scientific knowledge to suggest the ‘energy healing’ that is presumed to take place is no more plausible than a unicorn that shits leprechauns.

SBP extends to other treatments that do have science-based evidence for some contexts. For example, many manual therapies have evidence of providing short-term analgesia. If that is the goal, then perfect. However, the same modalities have less evidence for long-term improvement in function, and thus are less supported by science in that context. Further, there may be unforeseen harms when we rely on treatments that lack adequate testing (e.g., negatively altered health beliefs and behaviours). The mechanisms through which manual therapy treatments work are still to be clearly elucidated. Without these mechanistic underpinnings, it is hard to determine if these treatments are necessary, and if they are necessary, when and for whom?

In all, it’s clear there is no such thing as perfect practice. We have some well-established guidelines, science, and our limited experiences to help navigate the complexity of humans. It’s not easy, and I’d like to think that we are all in this for at least one fundamental reason – helping people and providing healthcare. For me, our privilege to practice comes with a responsibility to reflect, read more, have these conversations (with humility and respect), and have empathy for the views of others as we all navigate the unknowns of healthcare. Adopting the above with a coaching mindset (versus a fixing mindset) also fits my biases, and fits well with a biopsychosocial/enactive lens. I call for others to consider their underpinning philosophies, to reflect on their group memberships and how this may be influencing their beliefs and clinical behaviours. Further, we need to encourage and respect those who are critical of current practice (and of our own practice), because, alas, attempted refutation is an important component for the progress of knowledge.

If you’d like to hear more on our values and philosophies at The Knowledge Exchange, please have a listen to our round table catch up on our podcast (wherever you listen to your podcasts), or on our webpage HERE.

The hands on/off dilemma through a philosophical lens
Brendan Mouatt