By December 30, 2014 7 Comments Read More →

The Role of Manual Therapy

Now the most obvious key role of manual therapy is that it provides pain relief in some patients (for those interested in the research relating to the mechanisms of manual therapy this topic please see this previous post and this recent systematic review by Voogt et al (2014)). Pain reduction in patients is great, but there is something else that the patients response to manual therapy can assist us with.

Some of the Research:

Results support the use of within-session changes in ROM, centralisation, and possibly pain intensity as predictors of between-session changes for musculoskeletal disorders of the cervical spine. Tuttle (2005)

A methodical approach that considers change in parameters such as patient impairments is likely to be a useful guide for decision making during ongoing patient management but only when the change being reassessed can be directly linked to functional goals. Changes in active range of movement or centralization of pain appear to be better indicators of treatment effectiveness than changes in either pain intensity or assessment of joint position. There is limited evidence to support the use of changes in segmental stiffness to guide ongoing management. Tuttle (2009).

The results suggest there is a significant association between a within/between-session change after the second physiotherapy visit and discharge outcomes for pain and Oswestry Disability Index in this sample of patients who received a manual therapy intervention. A 2-point change or greater on an 11-point scale is associated with functional recovery at discharge and accurately described the outcome in 67% of the cases. This is the first study that has shown an association of within/between-session changes with disability scores at discharge and is the first to define the extent of change necessary for prognosis of an outcome. A within/between-session change should be considered as a complimentary artifact along with other examination findings during clinical decision making. Cook et al (2012)

Our results showed that manual therapy for neck pain involves a “two-steps forward, one-step back” recovery pattern. Whilst minor adverse events are undesirable, they do not seem to be significantly associated with long-term recovery………Whilst a progressive improvement in symptoms during a course of treatment does not predict the rate of recovery independent of the duration of pain, general health or absence of headache, it can still be a useful guide for clinicians about expected progress………..There is an intuitive link between short-term and longer- term improvement, which can be incorporated into discussions with patients about their expected course of recovery……..There is a relationship between immediate improvements in pain during manual therapy treatment and speed of recovery, as well as longer-term perceived benefits of treatment. Trott et al (2014)

My Thoughts?

Based on the above, and my clinical experience, I think we can be confident that patients who respond well to our manual techniques should have a positive recovery/outcome.  I also strongly believe that a positive response to treatment is something that we can use to re-assure our patients that:

  1. They should also be positive about a recovery from their injury/pain:
    • If we can make their pain improve significantly or completely, even for a short period of time, then why should we not be able to achieve this permanently, or at the very least for significantly sustained periods?
  2. The likelihood of them having something structurally wrong with their painful area is very unlikely:
    • Research on manual therapy suggests that it does not appear to impact on structure. I know this is a contenscious topic, but the research, at this point of time, does not support a structural effect. Without getting off track, if heavy duty stretching does not create permanent change in muscle structure (see here and here) then how are our hands possibly changing structure? We are most likely not pushing “discs back in”, or “realigning the spine”, thus if the patient responds well to treatment I am thinking that their “disc bulge” on MRI is probably not the issue.

Communicating the above two points being, in my opinion, very important as patients will often come to us with a view that they have a structural problem (disc bulge, worn facet joints etc) that is stopping them from getting better and/or is a reason to not use their painful area normally. This belief itself can be a significant impediment to recovery!

So a positive response to manual therapy is great, but what about the patient who DOES respond well to treatment but DOES NOT sustain or continually gain improvements? I often think there are some common factors/reasons that can explain this situation. For example, the patient:

  1. Is non compliant with other management aspects (not doing their rehab exercises etc).
  2. May have other factors impeding their recovery e.g. poor sleep, elevated stress levels, pacing issues etc that keeps sending them back to the start (two steps forwards, two steps backwards). See these posts for more information regarding negative prognostic indicators that may need to be addressed (Fear and Fear Avoidance, Psychosocial Factors, Co-morbidities, Sleep, Sleep and Chronic Pain, Negative Prognostic Indicators).
  3. Has other people/practitioners providing conflicting views about what the patient needs to do to get better. As many of you would know it is common that health practitioners are not on the same page regarding treatment of conditions, hence the poor patient gets stuck in the middle. This might also then impact on both of the above points.

Any other thoughts????? Please feel free to throw them into the comments section below!

What about the patient who gets worse with treatment?

Again, I think there are a few obvious reasons for this, apart from them having a structural injury like a broken/fractured bone!:

  1. Maybe your are treating too aggressively and creating an acute tissue reaction. I reckon I have caused many an acute local tissue reaction from treating too aggressivley (i.e. forcefully) in the past! Whilst we are not changing structure with manual therapy we can still cause some surface tissue trauma, or move a painful/sensitised area too much.
  2. They may have a presentation that is dominated by heightened tissue sensitivity e.g:
    1. An acute injury/sprain (lots of inflammatory mediators that sensitise the tissue).
    2. A neuropathic/central sensitistation/non-mechanical disorder.

Now the last two points above are different but the clinical history should give you some clues as to what the underlying mechanism might be:

  1. If a patient comes in with a 1 day history of a back strain, with no red flags, constant pain that disturbs sleep and/or is worse upon rising in the morning (e.g. localised nociceptive inflammatory pattern pain) I am often not expecting to change their pain much. I also need to be wary not to make it worse. Sometimes manual therapy won’t even be of any great use at all in these patients. Importantly I will explain all of this to them! Don’t get me wrong, I will try to change their pain but be realistic in my thought processes that I might no because of the tissue strain and presence of inflammatory mediators. For example I wouldn’t expect someone who hobbles into the clinic with an acute ankle sprain to run out pain free after our first consultation!! Think about tissue injury and healing…..we cannot work miracles.
  2. If a patient comes in with a 2 year history of ongoing chronic pain and has findings suggestive of neuropathic pain/central sensitisation (see the following posts for more information here, here, here, and here). Often the clinical picture will present with heightened tissue sensitivity with findings such as allodynia, cold hyperalgesia, wind up and temporal summation. Logic, and clinical experience, tells me that a presentation dominated by these findings will often get worse with even very gentle manual therapy. Out of interest I usually try manual therapy even with these patients as it gives me information regarding:
    • How they respond to treatment, or not, and;
    • If their symptoms might be reducible, or not.
    • Assists with the diagnosis and prognosis.

Once again, please throw some more examples at me, this is not an exhaustive list!

What about the patient who does not have any change in symptoms?

If I have a patient who does not note any change whatsoever to treatment (better or worse) I am often left wondering if:

  1. I am not treating the correct problem/area/factor in their presentation.
  2. They have a non musculoskeletal problem (e.g. a medical issue that is masquerading for an apparent musculoskeletal pain). See my Red Flag post and Masqueraders post for more information.

They might also simply have an acute tissue injury/strain. Whilst I used the acute strain example above in a condition that might worsen with manual therapy, if an acutely strained area is not severely sensitised it might not react much at all to treatment. Once again, time frames/history will give you some key guidance.

Any more examples??? Comments below please.

Final Thoughts:

Now I reckon I could go on and on about this topic. What I hope the above has achieved is that it gets gets you thinking about what the results from your manual therapy treatments are telling you about the patients presentation.  This was something I vary rarely took into account until recent times, and since doing so it has benefited my clinical practice, and patients, immensely.

I also think this approach can be useful to incorporate with our other modalities (motor control exercises, stretches etc). We should use re-assessment of pain and function with all treatments/techniques. This can tell us if, for example, the stretching exercise or motor control change is of benefit, or not. This in turn can tell us whether to persist with the treatment/exercise, or not.

Thanks for reading!

Thankyou!

Thanks to all who have shared, tweeted, commented, subscribed and perused this blog over the past year. I think (hope) I am slowly evolving and improving  my writing style.

I apologise that succinctness and grammar are not my strong points! But, like my clinical practice, I feel they are slowly getting there.

Wishing you all a happy and safe 2015! See you next year.

Cheers

Mark

Posted in: Clinical Reasoning, Pain

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

7 Comments on "The Role of Manual Therapy"

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  1. Cameron says:

    Hi Mark,

    I don’t know why physio researchers aren’t onto this, but ‘therapist factors’ are the most potent determinants of outcome. I estimate the contribution to outcome to be in the 95%+ range. The choice of mechanical technique appears to be quite unimportant. So long as there is some sort of stimulation in roughly the right area, then that’s all that’s required. Your research links highlight this nicely.

    Some clients get so much value from the interaction that they will tell us the pain is still there, yet happily book more appointments without prompting. “No change” doesn’t always mean no change.

    I’m in the process of learning to let go of what *I* want to happen in a treatment session. I used to use some very tricky hypnotic patterns to get some quite miraculous changes in pain levels, but there seemed to be something lacking in terms of client satisfaction. Clients want much more than for the physical pain to disappear. They are also naturally disinterested in what I have to gain from getting a good clinical outcome. Being happy with ‘no change’ is part of that, I find.

    Cam

    • Mark Gibson says:

      Hi Cam,

      Well said. Couldn’t agree more with you about the “therapist factors” and “choice of manual therapy technique”. I reckon that my “manual therapy” techniques continue to become less technical and less specific as time goes by. I also now use less techniques i.e. I used to have a a whole bag of techniques to mobilise a lumbar spine for example. My bag of techniques has now reduced to a handful of techniques and continues to reduce further, with no obvious drop off in clinical outcomes. In fact I reckon my clinical outcomes are better now that I am focussing not so much on the techniques but rather on communication, education etc whilst I “push” around the right area!

      Unfortunately I still see it, “manual therapy”, taught so laboriously and specifically that I wonder if the academics/teachers are aware of what you have outlined above.

      Thanks for the comment. Happy New Year to you!

      Cheers
      Mark

      • Cam says:

        Same here. Absolutely no drop off in clinical outcomes.

        If only therapists knew that a simple “back rub” achieves the very same outcome as a “grade 2+ unilateral mob 3*60 sec in combined ipsilateral ROT/LF position”… for example.

        I think there’s a few ways to ‘power up’ a simple pain gating technique (like isometric contractions, Valsalver manoeuver or pain itself(read DNIC)), even if these are performed, the effect is still limited in its duration. The long term outcome will bear no relationship to any of this.

        Mark, you’re a teacher – how do you approach this problem of attachment to fancy unproven physical techniques? So long as such an attachment remains, progress cannot happen. The really powerful aspects of therapy require enormous skill and are fun to learn, but they are all psychological.

        Regards,

        Cam

        • Mark Gibson says:

          Hi Cam,

          My apologies I wan’t notified of this comment! Hence the delayed reply. Happy New Year to you!

          As a teacher i approach the issue you talked about simply by educating the patient/therapist about the research evidence. The problem being that, in my opinion, therapists like you and I are in the minority. Most therapists, and critically the schools of physiotherapy, are still dogmatic and stuck in the past their approach to the teaching of manual therapy. Manual therapy is taught, in my opinion, far to laboriously. Whilst we shouldn’t brush over it I think a happy medium is the way to go with time then able to be allocated to other, more critical and relevant skills/topics.

          Having said that I think there is a gradual shift towards what you and I have spoken about. I am hoping the shift starts to gather steam though, or our profession may remain stuck in the past preaching and teaching skills/theories that do not stand up to the scientific rigour. The alternative option to move forwards and strengthen our position in the health field is far more appealing to me.

          Sorry about the delay again! Time to double check my notification settings!

          Cheers
          Mark

  2. Cam says:

    And Happy New Year to you also. 🙂

    (no need to publish this)

  3. Fabricio Alves says:

    Hi Mark,

    I´m fiding great discussions here and learning a lot from you and the others.

    Thank you very much for that and please keep up the good work.

    Cheers.

    Fab.

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