How Do Physical Therapists Use Manual Therapy In Treatment?
On a patient's initial visit to a physical therapist, his or her medical history is reviewed and a comprehensive physical exam is then completed. Based on the history and clinical exam findings, a treatment plan of care is designed which may incorporate manual therapy techniques to help modulate and reduce pain, increase mobility, decrease inflammation, and facilitate tissue repair. A typical physical therapy goal of treatment is to achieve optimal clinical and functional outcomes via improved pain free mobility and movement. Research shows this is best achieved when other treatment procedures, such as therapeutic exercise, neuromuscular control, and alignment and movement training are combined with manual therapy to help the patient achieve their functional activity goals.
Who is a Manual Therapist?
Physical therapy students learn basic manual therapy assessment and treatment techniques in PT school. Experienced manual therapists, on the other hand, demonstrate a strong interest in incorporating manual therapy evaluation and treatment techniques into their treatments and choose to take many post-graduate training courses taught by manual therapy continuing education institutes. Sequential coursework includes advanced study of anatomy, physiology, joint and soft tissue biomechanics, clinical reasoning, and medical screening, as well as the application of skilled hands-on evaluation and treatment techniques. Therapists are eligible to be certified in a particular institute’s approach to manual therapy after approximately three to four years of study and practical application with patients. For most institutes, the process usually entails successful completion of comprehensive written and practical exams, presentation of case studies, and documented clinical experience using their assessment and treatment techniques. Certification is not a requirement to use manual therapy techniques, however. Some therapists study with multiple institutes throughout their career and use an eclectic approach in their treatment.
Manual Therapy Procedures
Different types of manual therapy procedures are used by physical therapists in their day to day assessments and treatments with patients. The following explains some of the most common procedures we utilize:
Joint Mobilization / Manipulation:
Joint mobilization uses skilled passive movement on all spinal and extremity joints, including the jaw (TMJ) and sacroiliac joints, to evaluate and treat patients. Various grades (1-5), speeds, and amplitudes of hands-on pressure are applied by the therapist. These passive movements allow the two bones of a joint to move in ways that patients cannot move or control themselves. Smaller grades of pressure and movement aim to reduce pain in the joint and surrounding tissue and to help relax the tissue, allowing for improved pain free movement. Higher grades of pressure move the joint into its end range, allowing the tissues connecting the joint to stretch, which helps to improve pain free mobility and alignment.Manual Traction:
Manual traction uses evaluation and treatment techniques that are performed via hands-on contact on the two bones of an extremity, TMJ, or spinal intervertebral joint. Specific and controlled distraction forces are performed to decrease joint or nerve compression and pain, relax surrounding soft tissue, and help restore pain free mobility. In the spine, manual traction is often used with disc disorders, sciatica, stenosis, and degenerative disc disease, as well as other arthritic conditions. In the extremities, traction helps to “unload” a painful joint, including those with arthritis, which relaxes the surrounding soft tissues and improves joint health and pain free mobility. Traction is also performed with joint mobilization and manipulation techniques as well as with proprioceptive neuromuscular facilitation (PNF) therapeutic exercises. If there is a favorable response to manual traction treatment, the therapist or referring provider often recommends a home traction unit.Soft Tissue Mobilization and Myofascial Release:
These are hands-on techniques that use varying pressures to muscles, tendons, ligaments and fascia throughout the body. The goals of these techniques are to decrease abnormal muscle tone (i.e., hypertonicity and spasms), adhesions, scar tissue, and fascial restrictions to restore pain free movement. Other benefits include improved circulation and healing, decreased inflammation and edema, and relaxation of the muscles. Some soft tissue techniques are combined with the patient's active movements to help improve myofascial extensibility and mobility.Muscle Energy Techniques (MET):
Muscle Energy Techniques use an isometric muscle contraction by the patient in a specific direction and position against counter resistance provided by the therapist. They are used to relax muscles that are stiff, in spasm, or have too much tone, as well as to lengthen and strengthen the dysfunctional muscle(s). Muscle energy techniques indirectly mobilize spinal and extremity joints, improve joint and muscle function, mobility, and alignment.Deep Friction Massage (DFM):
This technique uses a hands-on technique that breaks down the build up of scar tissue in muscles, tendons, and ligaments. Manual pressure is applied perpendicularly to the tissue and is commonly performed on sprained ligaments (such as after spraining an ankle), injured muscles, and conditions causing decreased tendon mobility (tendinitis, for example). The goals are to reduce scarring, improve circulation and healing, and restore normal pain free mobility of the targeted tissue and surrounding region.Trigger Point Release:
Trigger point release is a highly effective manual therapy technique to eliminate pain from trigger points as well as their underlying neurophysiological mechanism. Trigger points are tight, painful bands (“knots”) within muscles. Each muscle has a characteristic referred pain pattern to other parts of the body which have been well- documented. Trigger point manual therapy treatment includes direct hands-on pressure to the taught band and stretching of the muscle. Once the trigger point is released, the referred pain is resolved and pain free movement in the muscle and surrounding region improves.Active Release Techniques (ART®):
These techniques are movement based soft tissue mobilization techniques that assess and treat muscle, tendons, ligaments, fascia, and nerve problems. A combination of therapist applied hands-on pressure along with active or passive movement through a specific range of motion releases soft tissue adhesions and restrictions. ART treatment goals include decreasing pain and scar tissue, and improving muscle length, extensibility and pain free movement.Instrument Assisted Soft Tissue Mobilization:
Graston Techniques® and ASTYM® use Instrument Assisted Soft Tissue Mobilization to reduce scar tissue formation that causes pain, stiffness, and altered movement. The therapist uses special designed tools to assess, treat, and ultimately heel soft tissue that is scarred, fibrotic, and / or chronicly inflamed. Clinicians must be trained and certified in ASTYM® or the Graston Technique® in order to use the tools.Lymphatic Drainage Massage:
This is a gentle massage technique used to move and drain the waste fluids caused by lymphedema, which is common following the surgical removal of lymph nodes. Besides hands-on treatment intervention, patients are educated in self massage techniques which they perform at home to help clear fluids and aid in the fluid's reabsorption. Compression sleeves are often recommended to augment treatment intervention with this patient population.Visceral Manipulation:
Visceral manipulation uses hands-on techniques to help release restrictions of the viscera, such as the intestines and kidneys. These restrictions may cause non-optimal alignment and movement, pain, and dysfunction. A full body approach is utilized, with the therapist feeling and assessing decreased motion in the viscera as well as restricted patterns throughout the body before applying specific manual corrective techniques.If you have questions regarding manual therapy or feel that this approach or one of the procedures would be appropriate for you, please speak to your physical therapist.
