Manual Therapy (Part 3/3): Treating Under Contemporary Manual Framework

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In the previous two posts of this series I came out and said it’s time to essentially throw out everything we were taught in school about manual therapy. We aren’t doing many of the things we once thought (*see part one here*) and we also now have a better understanding of what we are actually doing (*see part two here,*) However, up until this post I have minimally touched on what all of this information means for us as practicing clinicians. So, what does practice under this contemporary framework look like?

First, a focus on the macro level rather than the micro level

We know from *part one* that we are not nearly as specific as we would like to be (regardless of experience.) We can’t identify micro dysfunctions or limitations, nor can we target micro regions like specific spinal segments. However, I argue we can still do a lot of the same things – just on the macro level rather than the micro. Can we accurately locate C4? Nah. But I’m confident we can accurately locate the upper, middle and lower cervical spine. Can we accurately identify if a part of the spine is slightly hypomobile? Nah. But I’m confident we can accurately identify on the far end of the spectrum – like if an individual is grossly hypermobile (say someone with Ehlers Danlos) or hypomobile (like an elderly patient or roided out bodybuilder.) Similarly, can we accurately manipulate the right side of C4? Nah. But we can manipulate the mid-cervical spine and try our best to target the right side. (Even then, we know outcomes aren’t affected by whether or not a cavitation occurs.)1,2,3

Second, we look for sensitization with manual assessments, not tissue dysfunction or restriction

If we can’t identify restrictions, regions or dysfunctions then what the in the hell are we assessing right? Well first, I would say we can identify -gross- restrictions or dysfunctions (now whether that perceived limitation is relevant is a whole different thing…) However, the main thing we are looking for is macro level areas and movements that are sensitized. If you are unsure what I mean by sensitized, then I highly recommend reading an older post of mine (*see here*) but essentially think of it as parts of the body or movements the brain perceives as a threat and subsequently produces pain at or during. We can identify this more accurately than motion restrictions or landmark identification by assessing for pain provocation.4,5 These sensitized segments or regions are then what we are typically going to try and target with our interventions.

When applying manual techniques what we are doing is desensitizing an area or a movement. This is assisted in part by the mechanisms described *previously in part 2.* In effect we are showing the brain that the area or movement is okay and not a threat, helping to decrease pain, muscle guarding and subsequently improve range of motion. Not only is this the explanatory model we should be working from, but in a recent study Louw even found that providing this explanation in conjunction with manual techniques resulted in better outcomes than applying manual techniques with a biomechanical-based explanation.6

Why is it important to know all of this?

Because there is a wealth of literature out there in which authors found outcomes were better when manual therapy was applied in conjunction with “typical PT” treatment (exercise) compared to either alone.7,8,9 So, knowing how to apply the techniques in the most effective, evidence-based manner is important. An important thing about these studies too is that the volume of manual therapy applied wasn’t typically high – often just a couple bouts of mobilizations or a manipulation or two. So, we don’t need to be using high volume of manual therapy in the clinic to get a positive effect on outcomes.

 

Adam, stop rambling and talk about how to take and use this in the clinic

I’m unaware of any great literature out there with a specific approach on how to integrate and apply this information in the clinic. So, I sure as heck can’t say I know the best way to apply it all (I’m mostly trying to present the evidence and get you thinking.)

While I make heavy use of manual assessments for diagnostic purposes, manual interventions don’t compose a large percentage of my treatment at this point. Based upon my knowledge I believe there are three primary, worthwhile ways to apply manual therapy in the clinic.

 

First, I believe manual therapy has great diagnostic value

I am a student at Washington University in St. Louis. As a result, I receive heavy education on the Movement System Impairment approach by Sahrmann and so my treatment focuses heavily on identifying the body region and direction(s) of movement/movement patterns to which the individual is sensitized (and, typically temporarily, modifying them to a less sensitized pattern.) In my eyes, manual accessory assessments are incredible for assisting here – It helps me differentiate between if it’s the lower or upper cervical that is sensitized or whether it’s the TL junction or low lumbar. Physiological assessments help me identify which direction is bothersome more accurately than simple active movement. This then helps me hone in on the specific movements and regions to focus my attention on. Further, I believe manual assessments are exceedingly valuable in clearing certain body regions as the source of symptoms – specifically the spine.

 

Second, I utilize manual therapy to improve patient buy-in, satisfaction, and motivation

I can’t imagine there is any practitioner or patient out there who would contest the importance of patient buy-in and satisfaction – even if we ignore the obvious business benefits. I argue that it is going to be much harder to get a patient who is not engaged or satisfied to improve than vice-versa. Maybe this is because it helps shape a positive expectation of treatment (which we know improves outcomes.) Maybe it’s because an engaged, satisfied patient will likely be more adherent, or maybe something else entirely. Regardless, if I can spend 2-3 minutes to cut a patient’s pain in half with a manipulation at the initial evaluation and have them walking out with a positive outlook and ready to come back then I sure as heck will. Similarly, if a patient is flared up at the end of a session and I can spend 2-3 minutes to abolish their pain and prevent them from having pain the next couple days I sure as heck will too. Maybe they’ll even be able to do more of their HEP and move more the following day than they would if they had pain. However, as with anything I argue we need to be calculated and deliberate in our application for this purpose to prevent facilitating patient dependence. For that reason I gradually decrease the use of manual interventions as the plan of care progresses and never allow them to be the primary portion of my treatment.

Third, I utilize manual therapy to improve exercise performance

Essentially what I’m talking about is the “window of opportunity” argument that sometimes gets hate on social media (and that I at one time was on the side of.) *From part 2* we know that manual interventions can decrease pain, improve strength and improve range of motion. If I have a patient walk in with significant pain or subjective “stiffness” that is markedly limiting their ability to move and perform the exercises on our agenda, you can be dang sure I’m taking advantage of those effects. An anecdotal example is a patient performing GHJ IR that came in atypically limited by pain at ~30 degrees who, following CT junction manipulation, more than doubled their ROM and increased resistance. Do I think I made any true change to their shoulder? Heck no! But if I can spend 2-3 minutes to get the patient moving and applying sufficient stimulus to make true tissue change for the next 30-40 minutes of the session why wouldn’t I? Especially if the alternative was to go through the session doing minimal work (exception being if you loaded too much in the prior session or something along those lines.)

Quick Recap:

  • We can palpate, assess passive mobility and apply manual interventions on the macro level, not the micro level
  • We are looking for and treating sensitization, not perceived tissue or mobility restrictions/dysfunctions
  • Patient outcomes are better when we include manual therapy with exercise
  • Manual assessments are great for identifying sensitized regions and movements
  • Manual interventions are great for improving patient buy-in, satisfaction and motivation
  • Manual interventions can be used to enhance exercise performance

 

This post concludes my initial series on manual therapy. Hopefully you enjoyed the information and it sparked some thinking.

Hit the Instagram (where I am most active by far) or other social media icons up top and drop me a follow for updates on future blog posts, research reviews, exercise videos and other content.

 

Thanks for reading,

~Adam

 

References:

  1. Flynn TW, Childs JD, Fritz JM. The audible pop from high-velocity thrust manipulation and outcome in individuals with low back pain. J Manipulative Physiol Ther. 2006;29(1):40-5. (https://www.ncbi.nlm.nih.gov/pubmed/16396728)
  2. Cleland JA, Flynn TW, Childs JD, Eberhart S. The audible pop from thoracic spine thrust manipulation and its relation to short-term outcomes in patients with neck pain. J Man Manip Ther. 2007;15(3):143-54. (https://www.ncbi.nlm.nih.gov/pubmed/19066662)
  3. Bialosky JE, Bishop MD, Robinson ME, George SZ. The relationship of the audible pop to hypoalgesia associated with high-velocity, low-amplitude thrust manipulation: a secondary analysis of an experimental study in pain-free participants. J Manipulative Physiol Ther. 2010;33(2):117-24. (https://www.ncbi.nlm.nih.gov/pubmed/20170777)
  4. Hestœk L, Leboeuf-Yde C. Are chiropractic tests for the lumbo-pelvic spine reliable and valid? A systematic critical literature review. J Manipulative Physiol Ther. Mosby, Inc.; 2000;23:258-275
  5. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Arch Phys Med Rehabil. 2008;89(6):1169-76. (https://www.ncbi.nlm.nih.gov/pubmed/18503816)
  6. Louw A, Farrell K, Landers M, et al. The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. J Man Manip Ther. 2017;25(5):227-234. (https://www.ncbi.nlm.nih.gov/pubmed/29449764)
  7. Celenay ST, Akbayrak T, Kaya DO. A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2016;46(2):44-55. (https://www.ncbi.nlm.nih.gov/pubmed/26755405)
  8. Macaulay J, Cameron M, Vaughan B. The effectiveness of manual therapy for neck pain: a systematic review of the literature. Physical Therapy Reviews 2007; 12(3): 261-267.
  9. Miller J, Gross A, D’sylva J, et al. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010;15(4):334-54. (https://www.ncbi.nlm.nih.gov/pubmed/20593537

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