Current Stance on Manual Therapy

Manual Therapy seems to always be a hot topic among rehab clinicians and sport clinicians.

We have clinicians who feel that they are "Manual Therapists" and that they have the ability to fix many issues with solely their hands. On the other end of the fence we have people who claim that any type of manual therapy intervention is a load of placebo, makes patients dependent on the therapist, and that everyone performing any type of manual therapy is foolish and should be banned from the profession.

SRE's stance is somewhere in the middle. This is not a copout answer, as I will provide you with my complete thought process. I just personally find there are very few things that merit an extremist answer as there is generally many things to consider in any given scenario.

Manual therapy is clearly a skill that many clinicians seek out. This is obvious by the number of continuing education classes available, who all teach their own methods. A couple beefs that many people have with manual therapy is that: #1 it is a passive treatment so the patient becomes reliant on a clinician to treat them and "fix" them. And #2 is that many manual therapy techniques, people describe the treatment as if they are changing physical structure within the human body.

To answer this I will preface with saying that if your patient believes the statement above that "you" as a clinician is fixing them, then you as a clinician have framed the rehab process wrong!

As clinicians we are facilitating the individual's healing process, which ultimately it is up to them to put in the work and do the right things to get better.

The importance of framing treatment and therapy plan of cares in such a way that shows and teaches the client they are in control of their pain and that healing is an active process is paramount. If the client is able to feel in control then threat, anxiety, fear, etc all start to diminish which is a huge benefit and often a barrier to some rehab programs. However, to the point at hand, isn't there many forms of "manual therapy" that are active as well?

Let's say providing a spot assist for the patient to get an extra rep with the weight they are using a form of manual therapy? Isn't an assist with transfer a form of manual therapy? You are placing your hands on the patient and helping them complete a task. To me that is still manual therapy. We will get into hands on treatments in a moment, but let's cover issue #2 from above first.

"Manual Therapy"

It is pretty clear that we cannot change the physiology of tissue with our hands. There has been plenty of research to show this, we will cover more of this with article reviews on SRE in the future. But if you need one now, look up "Three Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy" by Chaundry et al. 

Lucky for us the human body is not made of clay and we cannot mold the tissues in such fashion, if we could the force necessary for running, jumping, back squat, etc would crumble us. But who's to say that human's emotions and psyche is built in the same fashion? Certainly it would be beneficial to develop a resilient mindset, but that may not be the patient currently sitting in front of you. Manual therapy may be an entry point to start this discussion if carefully done so with this intent (more on this later).

Our ability to be specific with palpation, trigger points (if they even exist) is very poor at best. Again much research is out there to show this. Take a systematic review for example: "A Critical Review of Manual Palpation for Identifying Myofascial Trigger Points: Evidence and Clinical Significance." by Myburgh et al.

Also if we are looking at palpation to discuss alignment of bony landmarks, the same thought process would apply. The logic of alignment I feel is misunderstood as well. Laying on the table statically tells us very little. Why would we measure something static? Static and immobile is not the goal of treatment. The goal of treatment is to facilitate movement and activity. When during activity does "alignment" remain still?

Never!

Wouldn't an approach that looked more at movements and if the body was capable of achieving positions necessary for movement be more meaningful to look at?

In my opinion, yes!

So what are we doing with hands on soft tissue techniques that many people refer to as manual therapy?

Well I can't say we definitely know yet. There is a lot of factors that make a controlled research article difficult to perform for an issue that is this complex. However, currently I think we can surmise that some type of neurological phenomenon is taking place causing momentary changes.

Providing a sensation to change perception can temporarily alter movement capabilities. Descending inhibition is very real and has the ability to change pain in the short term, which can be advantageous to facilitate some type of active movement that will ultimately provide longer term relief and resolution. Going back to how this is framed, it is important to let your patient know about what is happening so dependency is not created (just be sure to talk in terms and analogies that are relevant to the patient that they can understand, many patients do not care about the physiology happening).

Furthermore I would question if you would need to even use a soft tissue technique to always accomplish this?

Isometric contractions have been found to be an analgesic, and we know we can drive sensation of muscle activity to a particular site based on the exercise or task you ask the client to perform. Because this is a form of active treatment, then isn't this a much better way to establish a locus of control for your clients? Plus you as a clinician can still be "hands on" by giving occasional and appropriate touches for where they should feel the muscle working to provide feedback and more sensory input. We know that touching your client in a professional way has a way to build repore and buy-in with clients so this is a way to still accomplish that.

If I can accomplish this with my patients and get the desired effect (which would be improving a movement pattern or test) then I will always go to this first!

However, sometimes utilizing a hands on soft tissue technique is necessary due to constraints the client may have. Such as extreme levels of pain, central sensitization, fear of movement, or even personal preference.

For those who believe that hands on soft tissue treatments are loads of placebo, which there is some evidence that this very well could be a potential mechanism. I would offer this analogy: Any patient who comes seeking your service and treatment is going to want to know how and if you are going to make them feel better. The majority of the time (baring any red flags) you are going to say "yes, if we do x, y, z I feel that this will indeed start making progress and get you to feel better or move better." That statement right there is very much placebo based. Placebo is not necessarily a bad thing if used properly and with good intentions.

If we feel the changes are probably neurological, then the technique utilized does not have to take a very long time. Furthermore, during this time you can still be trying to utilize active movement with your technique (whatever that may be, hands, IASTM, Cupping, etc). Also you can be starting to educate the client and changing their false beliefs during this time. Often time's clients will have preconceived notions about things so you will have to soft sell them and probably be in the education game for the long haul to really change their opinions. But others may quickly start to understand and trust your opinion on the matter and change perceptions quickly.

I'm not so sure that manual therapy isn't capable of creating some type of long term physiological change though....

Maybe not tissue length or quality, but what about somatosensory and 2pt discrimination?

I am not familiar with any research (if you are, please fill me in!) on the possibility of some type of hands on treatment improving 2pt discrimination in the short or long term. We know that cortical smudging does take place in chronic pain as well as after surgery and nerve blocks potentially. This discussion is better fit for another day, but I feel it's one worth looking into!

Back to actually treating human beings and not controlled research articles....

It would be great if everyone was bought into doing some type of daily maintenance routine in the morning or some type of meditative/mindfulness routine on occasion for the psyche. However, it is unrealistic to assume that everyone is going to have the mindset to prioritize these things, and very well could have other priorities that occupy their time that THEY feel is more important to THEM. As such they choose to currently use their time to search out some type of manual therapy to keep them going. Is that really such a bad thing?

I grew up on a farm and have worked in rural areas, the video above was true for so many of the patients that walked through the door. A fishing pole in one hand, case of PBR in the other, Red Man in his pocket (and a love for bacon)... Simply put, I had to start with whatever intervention I could get some buy in from them and go from there. As a clinician you need to be able to read your clients based upon the conversations you are having.

My approach does not change for an athlete either. We need to remember that athletes love to play their sport. They don't necessarily all love to train or the weight room aspect of things. Sometimes after a game they need strategies to down regulate. There are low level exercise options for this, but an athlete may also prefer some sort of hands on treatment. My thought process does not change for this individual and the same rules apply.

Always have the long term in mind, and if the short term does not help both you and them get there, then consider changing your approach slightly so that it starts heading in that direction.

I'm going to end this discussion stating that touching your clients (obviously always in a professional way) is very important.

For example a study showed that when servers touch patrons lightly on the arm or shoulder, diners leave larger tips ("The Midas Touch: The Effects of Interpersonal Touch on Restaurant Tipping" April H et al). In other research, when used car salesmen lightly touched prospective buyers. Those buyers rated them far more positively than they rated salespeople who didn't touch (Tactile Contact and Evaluation of the Toucher" Erceau et al.).

Part of your success with clients is going to be developing professional relationships and trust with them to get them to buy into a treatment plan. Physical contact is a very positive way to influence this. However, there are many forms of treatment that clinicians can utilize touch other than soft tissue manual therapy treatments. Start with whichever provides the client with the most control and elicits the desired effect. Realizing fully that for some patients this may be a passive soft tissue application technique. Jst don't forget the end goal and spend the least amount of time necessary with the passive treatment to create the desired response then move on.