Manual Therapy – Friend or Foe?

What is Manual Therapy?

Manual therapy is a commonly utilized intervention by physical therapists. As defined by the American Physical Therapy Association, manual therapy techniques are skilled hand movements and skilled passive movements of joints and soft tissue. Manual therapy techniques include passive range of motion, mobilization, manipulation, massage, manual traction, and manual lymphatic drainage. These techniques are used with the intent to improve soft tissue extensibility, increase range of motion, induce relaxation, mobilize or manipulate soft tissues and joints, modulate pain, and reduce soft tissue swelling, inflammation, or retraction. Accomplishing these things facilitates the restoration of impairments in body functions and structures, activity limitations, and/or participation restrictions in order to improve overall physical function.

Is Manual Therapy Effective? 

There is a great deal of research supporting the effectiveness of manual therapy. The intervention remains under scrutiny, however, as the mechanisms by which they work are not well understood. Accordingly, it is common for practitioners as well as patients to shy away from what they do not fully understand. Current research suggests that the application of a mechanical stimulus during manual therapy intervention alters the neuromusculoskeletal system through various neurophysiological mechanisms and reflexes. In other words, when manual therapy (“the stimulus”) is performed to a body part (“the tissue”), a cascade of events occurs starting with the nervous system that results in pain relief, reduced inflammation, less muscle guarding, and improved tissue/joint mobility—who wouldn’t want that? Even though the mechanisms are not fully understood, a key takeaway is that positive outcomes have been and continue to be achieved through manual intervention.

 

Current evidence supports that a multimodal approach to treatment of pain is best. When used in combination, manual therapy, exercise, and education seems to provide better outcomes than manual therapy alone. Studies have shown that the application of manual physical therapy can help to optimize conditions for performing strengthening exercises through its ability to improve impairments in mobility, pain, and motor recruitment. For many conditions, manual physical therapy combined with supervised exercise is better than exercise alone for decreasing pain, increasing strength, and improving function. Some of these conditions include all acuities of low back pain, neck pain, cervicogenic headache and dizziness, and several extremity joint conditions including osteoarthritis.

 

Is Manual Therapy Harmful?

Most medical interventions possess some level of inherent risk. Heck, every medication commercial you see on TV is filled with lists of precautions, contraindications, and potential adverse side effects—effects that most are willing to risk for the intended medicinal benefits. When it comes to manual therapy, adverse events are not uncommon, however, the severity and duration of such events have been found to be mild and transient. The most commonly reported adverse effect is soreness in muscles—an effect which is not to be unexpected and could actually be considered a normal reaction to treatment. It is important to note that most often patients also participate in therapeutic exercises in addition to manual therapy during a session making it difficult to discern the which intervention is the culprit. Other minor effects may include stiffness, bruising, or increased pain. While the risk for a more serious adverse event is always present, physical therapists are responsible for utilizing clinical reasoning skills to produce a cumulative risk profile for each individual patient. This is accomplished through their knowledge and understanding of risk factors, disease states, stages of tissue healing, tissue feel, irritability, contraindications to treatment, safe and effective application of interventions, and an ongoing assessment of a patient’s response to treatment. Furthermore, it is important that therapists communicate to the patient all of the all known risks and benefits of a recommended intervention so that shared decision making can occur and informed consent obtained.

 

Does Manual Therapy Create Dependence on Passive Treatment?

There appears to be a stigma that delivering passive treatment through manual therapy creates a dependence on the practitioner and the need for continued, recurrent care. While the pain relief experienced from manual therapy may result in patients wanting to come back for more, the aim is to progress to more active based interventions to further facilitate improved function and performance. As previously stated, current practice guidelines support the use manual therapy in conjunction with other interventions. It is important that patients are educated on the therapeutic process and intent of each intervention so that realistic expectations are established. The ultimate goal is to empower patients and provide them with the knowledge and confidence required to foster as much independence as possible in the management of their respective condition.

Summing It Up

Physical therapists possess a set of core values that they abide by when delivering their services. Some of those values include the integrity to adhere to high ethical principles including “do no harm” and the professional duty to provide effective physical therapy services. If manual therapy were harmful, ineffective, and not backed by evidence you can guarantee it would not be such a highly regarded treatment methodology. Research supports the use of manual therapy is an effective treatment for many conditions by contributing to the recovery of functional capabilities, but it should be included within a multimodal approach tar­geting the functional recovery of the patient. Assuming that the therapist does their due diligence in appropriately screening a patient prior to applying a manual intervention, the benefits appear to far outweigh the risks for most.

 

References

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