Simplifying the manual therapy process

Before getting this week’s article started I have a couple announcements

1) I’m currently halfway through Charlie Weingroff’s DVD T=R3 and am loving it so far. I hope to do a review of it for the blog.

2) As next Monday is a long weekend I will not be posting a new article that week. Tune in in 2 weeks for my next piece -3 applications of Interval Training for Health.

Now getting to the point of my story…

            I understand that I’ll get a ton of flack for saying this but it needs to be said anyways – manual therapy is not this complex, high skilled task that many therapists like to think it is. It’s not so simple that just anyone can do it, it requires you to apply force safely & to know contraindications, but it isn’t this fancy skill that requires tens of thousands of dollars in training to get results with.

            It’s important for me to write about this as I see many new therapists that are underconfident and feel like their manual therapy skills aren’t up to par with their colleagues. Plus many therapists, myself included, feel (or have felt) very frustrated when they can’t “find” these pseudobiomechanical faults that other, more experienced therapists can.

            In this article I will go over why manual therapy is not the high skill activity that it’s portrayed to be and how to simplify it …..

Disclaimer: this isn’t going to be a debate about whether or not to use manual therapy. I see enough bickering about it on Facebook and quite frankly I have better things to do with my time than get into an endless debate on the topic.

Disclaimer 2: to keep this article short & not bogged down in references this is not a systematic review by any stretch.

With that out of the way – here is why and how manual therapy should be simplified.

Part 1: Assessment

In spinal/SI joint pain cases many therapists will assess each spinal segment to determine which ones are hyper or hypomobile. However – these assessments are shown to be unreliable^1–4..

“Well you just haven’t developed the magic hands yet”

That’s the most common argument I see when this evidence gets presented. However, these assessments are unreliable even amongst experienced therapists – debunking the skill argument.

Realistically – vertebral segments move a few degrees each and the SI joint only moves a maximum of 4-8 mm.

In SI joint pain therapists sometimes try to palpate pelvic position to detect “upslips,” “downslips,” and “rotated innominates.” These positional assessments are also unreliable^4,5.

Part 2: Treatment

Back in PT school I always remember my instructors telling me “you just want to isolate that one segment” and “you only want to move that segment.” However – research has shown that spinal manual therapy directed to one segment actually affects multiple segments and in one study increased ROM at a different segment than the one being mobilized⁶!!!!!

A small body of research has also questioned the concave-convex rule of joint arthrokinematics. For instance, in people with frozen shoulder, a posterior glide was more effective in increasing shoulder external rotation than an anterior glide⁷.

Lastly, some studies have compared different manual therapy techniques for the same condition and shown that they provide equal effects on pain & disability^8,9.

Now before you’re all ready to lynch me…

I’m not saying that manual therapy needs to be dumped – it just needs to be reconceptualised within a scientific framework. Manual therapy techniques provide non-specific effects on muscle tension, pain, and other variables through neurological mechanisms¹⁰.

Side note – please read this free open access paper on the mechanisms of manual therapy if you haven’t https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/.

The best way of approaching manual therapy is to keep your approach simple. Some research in spinal pain suggests that the best techniques are the ones you’re most comfortable & confident performing¹¹. So pick a few techniques for each area that you’re comfortable with, make sure there are no contraindications or precautions, use a reasonable amount of force and don’t aggressively crank on the patient (when in doubt gentler is better) and keep it simple.

Anyways if you’ve made it this far and haven’t clicked out of the article I just want to say thank you and congratulations on reading and reconceptualising your view of manual therapy in a way that’s in line with the scientific literature.

Take home points

-          Many manual therapy assessment tests (e.g. spinal segmental hyper/hypomobility, SI jt positioning) lack reliability even amongst experienced therapists

-          Spinal manual therapy affects multiple joints not just the one you are targeting

-          Some studies have shown different manual therapy techniques produce the same results for the same condition

-          Manual therapy has non-specific neurological effects

-          Some research suggests that the best techniques are the ones you are comfortable performing

References

1.           Herzog W, Read LJ, Conway PJ, Shaw LD, McEwen MC. Reliability of motion palpation procedures to detect sacroiliac joint fixations. J Manipulative Physiol Ther. 1989;12(2):86-92. http://www.ncbi.nlm.nih.gov/pubmed/2715742. Accessed July 21, 2017.

2.           Walker BF, Koppenhaver SL, Stomski NJ, Hebert JJ. Interrater Reliability of Motion Palpation in the Thoracic Spine. Evid Based Complement Alternat Med. 2015;2015:815407. doi:10.1155/2015/815407.

3.           Kilby J, Heneghan NR, Maybury M. Manual palpation of lumbo-pelvic landmarks: A validity study. Man Ther. 2012;17(3):259-262. doi:10.1016/j.math.2011.08.008.

4.           Huijbregts PA. Spinal Motion Palpation: A Review of Reliability Studies. J Man Manip Ther. 2002;10(1):24-39. doi:10.1179/106698102792209585.

5.           Cooperstein R, Hickey M. The reliability of palpating the posterior superior iliac spine: a systematic review. J Can Chiropr Assoc. 2016;60(1):36-46. http://www.ncbi.nlm.nih.gov/pubmed/27069265. Accessed July 21, 2017.

6.           Branney J, Breen AC. Does inter-vertebral range of motion increase after spinal manipulation? A prospective cohort study. Chiropr Man Therap. 2014;22(1):24. doi:10.1186/s12998-014-0024-9.

7.           Neumann DA. The Convex-Concave Rules of Arthrokinematics: Flawed or Perhaps Just Misinterpreted? J Orthop Sport Phys Ther. 2012;42(2):53-55. doi:10.2519/jospt.2012.0103.

8.           Langevin P, Desmeules F, Lamothe M, Robitaille S, Roy J-S. Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short-Term Effects. J Orthop Sport Phys Ther. 2015;45(1):4-17. doi:10.2519/jospt.2015.5211.

9.           Aquino RL, Caires PM, Furtado FC, Loureiro A V., Ferreira PH, Ferreira ML. Applying Joint Mobilization at Different Cervical Vertebral Levels does not Influence Immediate Pain Reduction in Patients with Chronic Neck Pain: A Randomized Clinical Trial. J Man Manip Ther. 2009;17(2):95-100. doi:10.1179/106698109790824686.

10.         Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531-538. doi:10.1016/j.math.2008.09.001.

11.         Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of “therapist-selected” versus “randomly selected” mobilisation techniques for the treatment of low back pain: A randomised controlled trial. Aust J Physiother. 2003;49(4):233-241. doi:10.1016/S0004-9514(14)60139-2.