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Original Clinical Research
Journal of Chinese Integrative Medicine: Volume 9, 2011   Issue 7
Perception of patients, physiotherapists and traditional Chinese medicine practitioners towards manual physiotherapy and Tuina (Chinese manipulative therapy) in Australia: a qualitative research
Edwin Yong Miao (M. Modern Traditional Chinese Medical Clinic, Ringwood, Victoria 3134, Australia E-mail: edwinmiao2@optusnet.com.au)

Objective: The aim of this study is to gain insight and understanding of the perception of Australian patients toward manual therapies. The study also tries to increase our understanding of manual techniques used by manual therapists.
Methods: This is qualitative field research emphasising the sociological perspective, to interpret health services recipients’ meanings in specific social settings. An unstructured interview is the major study design. The interview study method was conducted jointly with clinical observational techniques. A total of 30 subjects who met the selection criteria were selected. Finally 19 patient participants and 5 practitioner participants entered the study.
Results: Most participants in the research got to know physiotherapy through media and referral from general practitioners. After having gained some experience of manual physiotherapy, patients were expecting a fresh approach from Tuina (Chinese manipulative therapy). Although 94% of patient participants were satisfied with Tuina treatment, most of them could not distinguish differences in technique between Tuina and manual physiotherapy. Some patients consider Tuina as a more costly choice. Most practitioners preferred to use stronger pressure-based methods on trigger points while those who had received formal training in Tuina were in favour of much gentler techniques.
Conclusion: Manual physiotherapy is the first-line choice for many Australian patients. Tuina, as a relatively new method, is often considered as the last-resort treatment due to lack of proper private health insurance coverage. However, most patient participants preferred gentler manual methods, such as Tuina, compared with strong force-based approaches. This study stressed patients’ feelings and needs, which may have an impact on clinical outcomes. This study asserts some possible ways to enhance patient care that would include providing relevant education as part of manual therapy courses, encouraging continual development of the therapists and encouraging patient participation in the treatment process.

Received January 10, 2011; accepted April 2, 2011; published online July 15, 2011.
Full-text LinkOut at PubMed. Journal title in PubMed: Zhong Xi Yi Jie He Xue Bao.
Correspondence: Edwin Yong Miao, MB; Tel: +61-0425723637; E-mail: edwinmiao2@optusnet.com.au


     Manual therapy refers to all hands-on techniques used in treating patients. In Australia, some well-defined manual therapies such as manual physiotherapy, osteopathy and chiropractic, requiring higher education training are regulated. However, less defined hands-on therapies or practices, namely, Tuina or Chinese manipulative therapy, in traditional Chinese medicine (TCM) are facing a challenge. Despite the fact that more and more private health funds are recognising traditional manual therapies, such as massage therapies that normally do not require tertiary training, patients as health service recipients often raise concerns about the quality and efficacy of such health services, especially manual physiotherapy, a dominant therapy, and Tuina, a new manual therapy.
     Manual therapy and soft tissue massage are dominant techniques among physiotherapists in Australia and are used to offer pain relief and improve muscle strength and mobility1. Apparently, the description of the image of Australian physiotherapists by Toomey, an Australian journalist, reflected not only the image presented by Medibank Private, the Federal Government-owned, largest health insurer in Australia, but also that of the Australian public in general1.
     The development of manual therapy by physiotherapists in Australia is closely linked to the feminism movement and the behaviour status of health care and public policy, in which the politics, rules and laws made by bureaucrats played an important role. The trends in the world also contributed to this development. A brief introduction would create a broader picture of this background.
     Traditionally, allied health professionals like physiotherapists were the “allied health professionals” in medicine. Medical practitioners made treatment decisions and the “paramedical” professions, including physiotherapists, carried them out2, 3. Physiotherapy developed in ancillary supportive role to medicine3. The traditional relationship with medicine explains in part why physiotherapists had been reluctant to sever the bond4. However, when most physiotherapists moved out of hospitals, they realised that it was no longer necessary to rely on medicine for continued legitimacy4. The history of physiotherapy is one of the middle-class “feminine” professions5. Physiotherapy is “feminine” to the extent that the occupational culture was shaped by what are traditionally regarded as female attributes such as passivity, subservience and selfless devotion2. Thus, the right to practise without being under medical control and close medical supervision becomes the fundamental practice principle in the Australian physiotherapy field today4.
     Meanwhile, the world trends in physiotherapy are stated by Farrell and Jensen as interest in manual therapy appearing to continue to grow among physical therapy clinicians and educators throughout the world6. In response to calls by physiotherapists, Australian bureaucrats released a discussion paper relating to the regulation of physiotherapy, and consequently, the contents of the discussion paper became the Australian Act7. The paper emphasised manual therapy as a dominant and legitimate technique distinct from other health professions.
     In contrast, Tuina used by TCM practitioners has been excluded from future possible regulations by Australian bureaucrats, due to the fact that, in the physiotherapists’ Act, legitimacy is based on those manual therapies clearly defined in the Act itself7. Although TCM has been regulated in Victoria and the Victorian model will be adopted in all states in Australia8, Tuina, one of the common modalities in TCM, has been excluded9. This was based on Bensoussan and Myers’ report10. Furthermore, due to the national registration scheme, there will be some restriction placed on the practice of TCM practitioners who use manual techniques11.
     Demand for and use of TCM including Tuina have been growing steadily in Australia12. More and more patients raise doubts, questions and confusions about manual techniques that clinicians including TCM practitioners used in practice. The aim of this study is to gain insight and understanding of the patients’ perceptions in relation to these two manual therapies. The study also tries to increase understanding about the manual techniques used by manual therapists. Patients’ perception about health services is linked to not only the quality of the services but also clinical outcomes as stated by a medical sociologist, Talcott Parsons. He asserts that people who are sick are obligated to “cooperate with his or her doctor in the process of trying to get well”13; patients’ understanding of the treatment is therefore central to this cooperation.


1  Methods and study subjects
1.1  Study design 
The fundamental design of qualitative field research is to position the investigator close to the participants, focusing on direct and face-to-face knowledge of patients coping with their conditions and treatments and to interpret their meanings in special social settings[14]. The interview study method was conducted jointly with clinical observational techniques, which are classical methods used in qualitative studies. The major study design employed in-depth interviewing techniques, which were carried out in natural clinical settings where the patient participants or respondents were receiving treatments. The supplementary techniques were clinical physical examinations with observations for patient participants, and face-to-face or telephone interviews for practitioner participants. See Figure 1 for the method chart of this qualitative study.


Figure 1  A flow chart of methods used in this qualitative study

1.2  The selection of participants  The selection criteria for patient participants were restricted to the following: all the patients had complaints of neck pain or upper back pain or lower back pain; all the patients had these conditions for more than three months and intended to have acupuncture and Tuina treatments; all the patients were able to walk through to the consulting room without crutches or other help.
     All the selected participants were treated with manual physiotherapy prior to attending the M. Modern Traditional Chinese Medicine Clinic for TCM treatments for the same condition. The selection period was August 2009 to February 2010. The easiest and low-cost way to gather participants is by using incidental samples because incidents happen every day in clinical practice[15]. Unlike random sampling, incidental sampling may give a biased sample that is not representative of the population. However, random sampling is used infrequently in qualitative research. Moreover, for the study, a subjective method in contrast to quantitative studies is used, with the interviewer selecting those people who are most likely to provide the required insights into the issue under study, called “key informants”[15].
     Among the 19 selected participants: 11 were female, 8 were male; 7 participants’ ages were in the range of 20 to 40 years, 12 participants’ ages were in the range of 41 to 50 years. Participants’ occupations were diverse: 8 worked in offices, 7 were labourers, 2 were students and 2 were housewives. Three patients were Asian, 14 were Caucasians and another 2 were mixed ethnicity. Thirteen patients were religious and 6 were not religious.
     The second selection step was to select the second key informants/TCM practitioner as interviewees. TCM practitioners who met the selection criteria for practitioner participants were selected. The eligibility criteria for the recruitment of the TCM practitioner interviewees were divided into two selection criteria: (1) practitioners who do not have a formal qualification in Tuina; (2) practitioners who have a qualification in Tuina; (3) all practitioners were Victorian residents and came from different private practices.
     Among the 5 selected practitioner participants: all 5 TCM practitioners were Chinese males; 4 practitioners’ ages were in the range of 35 to 45 years; 4 had a bachelor degree in TCM, while one was over 55 with a diploma in TCM. Two practitioners had more than 10 years of practice experience and 3 had over 15 years clinical experience; only one practitioner belonged to a religion.
1.3  Methods of conducting interviews and clinical observations
1.3.1  The design of the contents of the interview 
Unstructured interviews, using participants’ own words[15], were more appropriate for this study than structured interviews because this study tried to gain understanding about patient participants’ conceptualisation and interpretation of their illness as well as to find out practitioner participants’ technique characteristics.
     Examples of the open-ended prompts given to patient participants are as follows:
     How did you learn about physiotherapy? How did you learn about manual physiotherapy and classical physiotherapy? How did you learn about Tuina/Chinese manipulative therapy? How do you feel about Tuina and manual physiotherapy?
     Examples of the open-ended prompts given to TCM practitioner participants are as follows:
     Please talk about Tuina. Please talk about manual physiotherapy.
1.3.2  The method of recording interview information  Case notes are the major record method. It is a free form of notes/recording that is used extensively by clinicians[15]. Open-ended prompts related to the purpose of the study were also used during the interview to direct the interviewees. To have the interview recorded more accurately and precisely, the interviewer spent 30 min immediately after the interview taking notes. To ensure accuracy of recall, the interview was conducted no more than twice a week. Thus, this ensured a more accurate transcript of the original conversation.
1.3.3  Observations and the method of recording clinical observations  The advantages of direct observation are clear: the researcher witnesses the events firsthand as they occur[16]. Case notes in the form of standard medical physical examinations plus additional descriptions of details of the examination procedure and observations were recorded along with the interview notes.
1.3.4  The record of clinical observations from patient participants  All participants involved were asked to feel the differences in pain levels or feelings of tension in the clinical examinations. These patients were asked to mark a Visual Analogue Scale (VAS, divided as 0-10 cm scale) in pain and the area of the pain was verified. This procedure was used in all the 4 consultations. Standard acupuncture treatments (distal acupoint treatments only) were used in the management of pain after the clinical examination in the first consultation[17]. Three standard Tuina techniques (Yi Zhi Chan pushing method, gun method and rou method) were used in the subsequent consultations[18]. Patient participants were asked to provide their feelings or feedbacks regarding these Tuina methods at the third or fourth consultations. All the consultations were conducted on a weekly basis.
1.3.5  The supplementary method: the observer participant and the record of clinical observations from the view of the observer participant  Participant observation is one of two chief types of observation that is used in qualitative studies. The observer participant is a form of regular participant in the activities being observed[16].
1.4  The process of sorting data  Refer to Figure 2 for a summary of the coding tree. When 19 patient participants entered the study, they were coded from B(1)1 to B(1)19 before the first in-depth personal interview and the first observational data were collected as shown in Box 1 of Figure 2. The 19 pieces of coded individual data became raw category C(1) data after the first consultation (interviews and collection of observational data). These raw categorised data were divided further into C(1)1 to C(1)4. After participants’ feedback, follow-up interviews and the collection of subsequent observational data, 4 CR(1) data were refined from raw category C(1). After collecting information from observer participants, CR(1) data were finalised as 4 pieces of CF(1) data. Practitioner participants were coded from B(2)1 to B(2)5 before the interview and became raw category C(2) data (further divided into C(2)1, C(2)2 and C(2)3) after the interview. After further information was collected as shown in Box 3 of Figure 2, CR(2) data were refined from C(2) data. When new data were or information was not found to contribute to further understanding, CR(2) was finalised as CF(2) .


Figure 2  A flow chart of the progress of sorting data


2  Results
     As a qualitative study, the most appropriate way to summarise the study results is using the method of data categorising and reduction.
2.1  Data categorising of patient participants
2.1.1  In relation to the reason for the treatment 
There are a number of factors in relation to patients’ decision for seeking manual treatments. Nine or 47% of patients of the participants visited their family general practitioners (GPs) for pain-related conditions such as back pain. Consequently, they were referred by GPs to physiotherapists for manual treatments. Seven or 36% of patients learnt of physiotherapy through newspapers and the media. Three patients thought physiotherapy is a part of orthodox medicine. In contrast, 9 or 47% of patients visited Tuina practitioners because they wished to try Tuina as the last resolution. Two patients found the clinic through the yellow pages or local newspaper business listings. Five patients visited the clinic because they got this clinic’s information from friends who were existing patients of the clinic. Three participants thought that manual treatments should be better provided by TCM practitioners who also use Tuina. Eleven or 57% of patients were not willing to take non-steroidal anti-inflammatory drugs (NSAIDs) or analgesic medicines.
2.1.2  In relation to the expectations of the treatment  Ten or 52% of the participants thought that the manual treatments were going to resolve their painful condition. Before the start of treatment, almost all the participants thought manual therapy would help for the relief of pain, at least to some degree. However, after experiencing manual physiotherapy first, then seeking TCM manual treatment for the same condition, 15 or 78% of patients visited Tuina clinic as there was a lack of progress after long periods of manual treatments offered by physiotherapists. These participants were expecting a fresh approach from Tuina, which turned out to be another manipulation technique. Two patients thought manual physiotherapy was not very helpful because their conditions were too severe. Another 2 patients thought manual physiotherapy did give them some relief of pain. However, they were running out of patience because the progress of treatment was too slow.
     I hurt my lower back one year ago. I felt severe pain at that time. My GP suggested to me to take Panadeine. I did not like painkillers. GP also referred me to a physiotherapist. The physiotherapist offered me massage, passive stretch and taught me to do stretch exercises. I felt much better after the physiotherapy. My severity of pain is nearly 50% better. I can sleep now without waking up because of the pain. My pain was much better after two months of the treatments. However, the pain is still there. I have been to the physio once a week for the last twelve months. I could not see much progress except during the first two months. The physio told me this situation is called a “plateau”, which is very common. My quality of life has been affected. I cannot keep going on like this forever. I want to make a change, maybe Tuina can help me.
—Patient 1

     I have had neck pain for more than 10 years. I cannot recall any accidents or injuries in the past which may have contributed to my neck symptoms. I used to go physiotherapists for the relief of my neck pain. I like physiotherapy. It is orthodox medicine. Five years ago I wanted to go to university to study physiotherapy. However, my VCE (Victorian Certificate of Education, high school marks) marks were too low to meet the entry requirements. I have never heard of Tuina before. It is new for me. I would like to make changes. Basically, I would like to try new therapies.
—Patient 2
     I know about Chinese remedial massage and I thought Tuina is Chinese remedial massage. When I was sitting in the waiting area, I have read through some of the display pamphlets. It seems therapists doing Tuina have to have tertiary degree while massage does not have to have a higher-level training. Last month I went to a TCM practitioner who does Tuina massage. I felt very painful when he used his finger to press my upper back. The reason I went to him was because the physiotherapist who is not the physio I usually go to, did the same thing to me, and I was in pain even for the next seven days. I used to go to the same physio. She used the finger to press my back. However, the pressure was not as hard as the last two therapists. I usually apply ice to the massaged area when I get back home as told by physio. The next day I usually feel slight pain, and the pain usually eases by the end of the next day. I have just finished a workplace first aid course. I have learned that ice should be used within 24 hour of an acute injury. I thought that I might have done the wrong thing to place the ice to my back all the time because the back pain, obviously, is not an acute injury. I think that Tuina must be different and I expect this technique to help me.
—Patient 3
     I have just heard about Tuina because my son goes to RMIT University, there is a new tertiary course called acupuncture and Tuina (Chinese manipulative therapy) in the same campus of the university. I used to go to a physiotherapist for my low back pain. The therapist used to use very hard pressure on my lower back by using elbow or fingers. I felt great. I felt pain and tense at the time of the treatment, but I did not mind it, as the harder you got, the better you would feel. I usually get some relief from the treatment. Two weeks ago I suffered from upper back pain. The physio did the same treatment for me by using these strong force-based techniques, I felt some relief immediately after the treatment, however, I could not move my neck and felt severe pain around my upper back for the next a few days. I thought this was not right and I would like to seek a second opinion. I got some information about Tuina from the internet. Tuina is a part of TCM with a history of two thousand years and it is a gentle form of manual therapy. I would like to try this ancient form of manual technique.
—Patient 4
2.1.3  In relation to the experiences in therapeutic process  Ten or 52% of patients experienced more severe symptoms after manual physiotherapy for the few days following the treatment. Seven or 36% of participants experienced more relaxed feelings immediately after the manual physiotherapy treatment. Two of the participants commented positively about manual physiotherapy because their symptoms had improved. Eighteen or 94% of patients were satisfied with Tuina treatment. They experienced no discomfort during and after the treatments and felt relaxed after the treatments; their pain improved remarkably (improvement in VAS score averaged 5 scales). However, when the two manual therapies, manual physiotherapy and Tuina were compared in terms of patients’ feelings about treatments, 15 or 78% of the participants thought they were 80% similar, 1 thought they were the same, 3 gave the 50% similar answer. Seventeen or 89% of participants had similar feelings regarding the symptomatic areas, including trigger point areas, as a result of manual physiotherapy and Tuina. All participants could not identify any differences between classical physiotherapy and manual physiotherapy.
     I have tried Tuina in another place before and I have also tried manual physiotherapy a few times. Sometimes they are great and the treatments gave me some relief. Sometimes they don’t and these treatments increased my pain. I cannot distinguish any difference between Tuina that I experienced before and manual physiotherapy. They both use fingers on the pressure points or trigger points and they both press these points very hard.
—Patient 5
     Tuina is so gentle. I feel great relief. I have been to another TCM practitioner before and he did a similar technique on my back. I do not feel any pain or sour during the treatments. I feel warmer and warmer on the back. I feel a completely different sensation on the back. This is quite a different form of manual therapy that I have never experienced before.    

—Patient 6
     I am surprised. Tuina is an amazing technique. I feel very warm on my back and I feel an indescribable but very comfortable feeling on my back during the treatments. Is it so-called energy flow? I noticed that you used the shower towel to cover my back. Does the towel avoid the escape of the human energy? I like the idea of towels. Most manual therapists use essential oils, and I have to have a shower after the treatment. With Tuina, I can go to the work straight away after the treatment.
—Patient 7
2.1.4  In relation to the expenses of the treatments  Sixteen out of 19 patients raised costs issue during the interview. For 14 participants with health insurance, their preference for seeking manual physiotherapy first was made while on their current status of private health insurance coverage. That is that low premiums are paid for the high coverage of manual physiotherapy, which cover up to 40 visits a year. In contrast, around only 5 to 12 TCM services a year are covered, with higher premiums required by some private insurance companies. For instance, Medibank Private covers 12 to 14 acupuncture visits a year, and does not cover full TCM services.
     I like Tuina because it is so relaxing. However, it is a little bit expensive. I do not have private insurance cover. I cannot afford to come here often. When I desperately need the treatment, then I have to come.
—Patient 8
2.2  Data categorising of practitioner participants
2.2.1  In relation to the rationale for treatment 
All the practitioners outlined the importance of the rational aspect of the treatment. The rationale was based on diagnosis and TCM assessments. However, there were different opinions relating to neck pain and back pain diagnoses and assessments. Three participants expressed their views that in the absence of neurological deficits, neck or back pain should be based on TCM pattern assessments, which are distinct from the concepts of non-specific pain commonly used by physiotherapists. Two participants pointed out the importance of biomedicine diagnoses regardless of whether patients have a status of neurological deficits.
2.2.2  In relation to the belief in and knowledge of the treatment  All the practitioners stressed the importance of trigger point treatments. However, opinions were divided with regards to the time and methods of the trigger point treatments. Two participants (without Tuina training) would prefer to use single finger or elbow pressure methods for the treatments in the hope that it can deliver strong pain-relief effects while the three who had received formal Tuina qualifications would prefer to use much gentler methods such as whole hand pressure methods for the aim of promoting blood flow.
2.2.3  In relation to the training skills required for treatment  For those with formal training in Tuina, the treatment methods commonly used are the gun method, Yi Zhi Chan method and rou method. Two with general training in TCM often tell their patients “no pain no gain” when they perform finger pressure methods by using strong force.
     There are two different Tuina approaches that you have seen in Australia. One is the ancient method or pressure force-based manual technique; another one is Yi Zhi Chan method and rou method-dominated technique. There are not much differences between manual physiotherapy and the first form of Tuina. However, you have to have a much specialised training for the techniques of Yi Zhi Chan and rou method.
—Practitioner 1
     Pressure force-based method is called sports injury massage in TCM. In Australia, it is called TCM remedial massage. A lot of people called it Tuina. Actually Tuina is quite different. Tuina has a relatively short history. Although it is based on TCM, the formation of its dominating techniques is about two to three hundred years.
—Practitioner 2
2.3  Data categorising of the observer participant  The observer participant became a patient to undergo treatments. The observer experienced more severe upper back pain, which lasted up to three days after the treatments, because of strong force pressure treatments administered by manual physiotherapists and TCM practitioners. In contrast, the participant did not experience any discomfort from Tuina. The methods used were the Yi Zhi Chan method and rou method.


3  Discussion
     The central concern of phenomenology is the meaning and understanding given to everyday actions and phenomenology asks how the individual’s interpretations are shared by others19. Using phenomenology is likely to help clinicians who provide physical treatment for neck pain and back pain, for them to understand the social context associated with these pain conditions and their treatments.
     The aim of this study is neither to generate a general result nor make a comparison in terms of the differences in effectiveness between manual physiotherapy and Tuina. Rather, this study tries to generate understanding about how our patients feel about the manual therapies. Because this study used a perspective of analysing language as a method of interpretation, which means that our language shapes and gives meaning to events, and is the way by which the individual constructs their world19. The study also tries to outline the technique differences between manual physiotherapy and Tuina. One TCM practitioner sent documents to the investigator after their interview, which outlined the very similar hands-on techniques used by TCM practitioners and manual physiotherapists, thus, the need for interviews with manual physiotherapists was unnecessary.
     The unique design of this study lies in using the observer participant to supplement the main method. By placing the observer in the same situation as the participants, he or she will be able to have an increased degree of understanding about the natural realistic environment that patients have. By chance, the observer suffered from upper back pain and low back pain, which is also well fitted to the selection criteria, and the observer participant paid visits to two different TCM practitioners for Tuina consultations and two physiotherapists for manual therapy. Face-to-face interviews and observations were conducted in a real-world practice environment.
     Most of the patients visited manual physiotherapists as their first choice. This behaviour is understandable because the Australian Physiotherapists Association attempts to raise an awareness of physiotherapy within the community and among medical practitioners and has increased the dissemination of literature to GPs and the media4. Gardner and McCoppin4 described a status, being the merit of claiming the independence of physiotherapy from medicine on the one hand while fighting for inclusion into medicine on the other, which tacitly suggests that physiotherapy still saw its legitimacy as stemming from medicine, a status which can be questioned.
     When patients seek manual treatments, they become a passive subject, a receiver of the treatment. The importance of patients’ participation in the treatment plan is neither well documented nor in application for clinical practice. This study may remind clinicians who practice manual techniques to look for a second opinion from their patients, not their peers, about feeling and insight regarding manual therapies. The study also raises an issue, that being whether, the practitioner-centred approach in manual therapy is truly a better model than the patient-centred approach in the current clinical guidelines, in the interest of achieving better practice outcomes.
     The interest of Australian health services regulators is to provide a legislative framework for the protection of the public. Placing a restriction on TCM practitioners who use Tuina11 is inappropriate as this demonstrates favour of professions such as manual physiotherapy rather than interest in patient protection, since some manual techniques in Tuina are very similar to manual physiotherapy. A better way to enhance patient care should be to give potential therapists further education and encourage patient participation in the treatment process. To minimise the risks or side effects of manual therapies, education is the key. The Royal Melbourne Institute of Technology (Melbourne, Australia) has introduced Chinese manual therapy education. A comparison of the similarities and differences between Tuina and manual physiotherapy outlined in the curriculum would be able to enhance future health services in this area. In addition, none of the patient participants knew about classical   physiotherapy, which is based on the application of physical devices. Thus, this brings into question the loss of identity of current physiotherapy: although originally a physical therapy (without use of hands), physiotherapy is now considered as a manual therapy, yet should remain identified as a physical therapy due to its nature.


4  Conclusion
     Generally speaking, Australian patients seeking manual treatment are receptive to that with which they are most familiar, an attitude influenced by the referral of GPs as well as the media. Manual physiotherapy is the first-line choice for many. Tuina, as a relatively new method, is often considered as the last-resort treatment or an expensive option for the rich due to a lack of proper private health insurance coverage. A number of patients cannot identify the technique differences between manual physiotherapy and Tuina. However, most patient participants prefer gentler manual methods, such as Tuina, compared with strong force-based approaches. This study stresses patients’ feelings and needs, which may have an impact on clinical outcomes. This study expresses that possible ways to enhance patient care would be to include relevant education as part of manual therapy courses, encourage continual development for therapists, and encourage patient participation in the treatment process. This study may be referred to by health services educators and public health policy makers.


5  Disclosure statement
     There are no competing financial interests existing.

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