Grounded in evidence, manual therapy improves patient outcomes
There is nothing new about the concept of “hands-on” physical therapy treatments. Various studies show that conditions such as low-back pain and musculoskeletal pain are effectively treated with a combination of manual therapy and other treatments such as exercise and strengthening.
Manual therapy, according to Craig O’Neil, PT, DMT, OCS, COMT, vice president of clinical excellence at Results Physiotherapy, a Tennessee-based network with over 100 locations, is much more than a set of techniques. “Current manual therapy is not only technique, but it is also skilled examination, clinical reasoning and a movement-analysis thought process that integrates the neuromusculoskeletal system at all levels,” he said.
Adam Lever, PT, DPT, ATC, staff physical therapist and member of Drayer Physical Therapy’s orthopedic residency program in Mechanicsburg, Pa., believes that performing manual therapy on his patients “allows for more of a connection with the patient and allows you to physically change something, whether it’s muscle tone, flexibility or joint mobility.” According to Lever, he performs some form of manual therapy on every patient he sees at the clinic.
Though both physical therapists are at different points in their careers, both recognize the broad range of conditions that can be treated with manual therapy.
“The power of touch can cause a number of benefits to occur within the nervous system,” O’Neil said. “There are mechanical, psychological, physiological and biochemical results, and there are very few things that we treat that can’t benefit from that level of influence.”
The influence of hands-on therapy can be achieved through joint mobilization and manipulation, soft-tissue manipulation, hands-on guidance or retraining movement, trigger-point dry needling and instrument-assisted manual therapy.
When treating patients, it is important to remember that manual therapy is not a one-size-fits-all treatment. Certain conditions should be considered before beginning or continuing manual therapy. Aggressive joint mobilization may not be the best option for someone with a healing fracture, rheumatoid arthritis or osteoporosis. Ultimately, if a particular manual therapy technique does not benefit the patient or if the patient has already achieved their desired results, it should not be performed.
Protocol and Techniques Used
While the previously mentioned protocols and techniques are applied in physical therapy clinics and facilities across the country, Lever claims that joint-specific techniques tend to work best for many patients. “When you have a joint stiffness, [physical therapists] can easily get in there and quickly change that condition,” he said.
Protocols and techniques for manual therapy can be learned through schooling, residency programs and continuing education courses, but the patient should be taken into consideration when choosing which technique to use. “What I’ve learned through my residency training are specific mobilization and manual therapy techniques that are very effective,” Lever said, “but a lot of times, you’ll see clinicians that have five different techniques they use on anybody, and they don’t retest a specific movement or function to see if it’s actually making a change.”
O’Neil agrees that there tends to be a “dogmatic approach” to manual therapy. “Hands-on physical therapy works in many different ways, and I think it’s useful for our profession to understand what manual therapy has evolved into from what it was,” he said.
Test, Retest and Test Again
Both O’Neil and Lever noted how using the right interventions at the right time creates positive results in almost all areas to some extent, from the cervical spine to the hand. However, Lever firmly believes that without evaluating and then re-evaluating the affected area, there is no way to see progress.
“We go through specific mobilization and manual therapy techniques, but more than anything, my standard protocol is to test and then retest to see if the techniques have made a difference,” Lever said. “If someone’s having trouble going down steps and it’s causing a lot of ankle pain, I’ll do some type of manual therapy on the ankle to change those symptoms and retest right after I use those manual techniques.”
In addition to the fact that reassessment allows the physical therapist to determine what steps must be taken in real time to help the patient, retesting manual therapy results also helps with patient buy-in. “If the patient can see the improvement, they’re going to understand why exactly they need to be [in the clinic] for physical therapy,” Lever said. “They will be able to see how it helps their symptoms and change their functioning at home.”
By allowing a place for reassessment after manual therapy during a physical therapy session, the therapist and patient are able to take the time to see whether the patient feels better and if the affected area looks different. If the attempt to change the area was ineffective, a new technique can be applied.
The Future of Manual Therapy
The effects that manual therapy can provide seem almost endless, but what will the future of physical therapy look like in regard to manual therapy technique and protocol? O’Neil thinks that therapists should look further into the way our bodies process pain.
“The integration and understanding of pain science and the way that manual therapy works beyond the mechanical effects is the biggest change coming in our future,” he said. “It will definitely maximize the benefit of manual therapy. Historically, we’ve thought of manual therapy as a very mechanical approach to movement, but understanding the effect that it has on patients’ nervous systems, their expectations and ultimately the outcomes. we need to learn how to understand how to integrate that into our treatments to further enhance the effects of manual therapy.”
While some newer and increasingly popular techniques have received media attention, such as trigger-point dry needling, this hands-on approach to change muscle tone is not available in physical therapy clinics in every state. Currently, eight states (California, Florida, Hawaii, Idaho, New York, Pennsylvania, South Dakota and Washington) do not allow physical therapists to perform this type of manual therapy. Lever expects that in the future, patients should see more therapists using instrument-assisted manual therapy and techniques such as dry needling.