What is Manual Therapy?
Manual therapy is a complicated topic in the online rehabilitation world. Most physical therapists are black-or-white all-or-nothing supporters or haters of manual therapy. Before we get too deep into things, a quick definition of manual therapy. It simply refers to any hands-on physical therapy including massage, stretching, joint mobilizations, and a bunch of other techniques. Some people argue that it is useless and a waste of time, others will say all you need is an experienced pair of hands to fix everyone’s aches and pains. Unsurprisingly, my answers are somewhere in the middle. I change my mind each day with every client that I see, so this is where I sit right now. I may revisit this again one day in the future as my opinions change, but this is my best shot at my understanding of manual therapy.
The first idea that we need to discuss is that manual therapy probably does not do what it is supposed to. Here is what I mean by that. If you get a massage, the massage therapist may talk about “breaking up trigger points” or “releasing your tight muscles”. This is not happening. Our bodies are really strong. It takes thousands of pounds of force to deform fascia by even 1% (I talked more about fascia in my plantar fasciitis blog here). If a massage therapist pushing on a muscle caused it to “release” then we would have died out a long time ago. Stepping on a Lego would actually kill you.
The same thoughts go into adjustments and manipulations. If your spine could be moved with a gentle push then we would have a lot of other problems. The crack you feel from a manipulation is probably a gas bubble that is popping. The rapid movement probably causes your muscles around the joint to relax. The truth is, we do not totally understand everything about the body and you should be wary of people who claim to know everything.
So, what does manual therapy actually do? I want to go over some benefits that it can have along with the probable reasons that they occur. As I mentioned before, this is simply where my thoughts are now and they could change tomorrow or next year.
Pain Relief
Pain is an important variable when it comes to physical therapy. It is not the only metric that we should use, as research shows that exercising with some pain may be necessary in certain cases. However, getting rid of pain can be helpful for everyone. Movements can be changed by pain and muscles can get stronger simply from pain being eliminated. It can be easy to focus on the source of pain and miss other contributing factors. For example, if a baseball pitcher has elbow pain because of weakness in his shoulder, then the shoulder is the root cause of pain. However, no client has ever complained about their pain decreasing during physical therapy.
The actual cause of pain relief depends on the type of manual therapy used, but often it is due to increased blood flow in the area. Healing factors are transported through our blood, so stimulating blood flow can hasten their arrival. Also, trigger points can cause decreased oxygen in a muscle as shown by Bubnov and Golubnitschaja. Trigger points are simply dense areas of muscle that can generate pain. You can think of them as “knots”. Treatment of trigger points through soft tissue mobilization or trigger point dry needling can improve oxygen and tissue quality, leading to a decrease in pain.
Comfort
Client comfort is an often overlooked part of physical therapy. Touch has many powerful effects that we do not fully understand. Simple physical contact can decrease your sympathetic (fight or flight) nervous system, which can go a long way towards feeling better. Manual therapy inherently involves one-on-one contact between the patient and the therapist. I have been in clinics where the physical therapists see 6 patients per hour. There was no time or ability for manual therapy and exercises were the only option. You would be surprised how many patients you can supervise with exercises at a time. However, manual therapy requires you to be focused solely on one patient.
Our healthcare system devalues individual time and accessibility with providers. Average office visit duration continues to decrease mostly for financial reasons. Efficiency is an admirable goal for many jobs, but I am not sure that healthcare is one of them. If we sacrifice patient satisfaction for efficiency, is it really worth it?
A comfortable environment can lead to relaxation mentally but also physically. There is a reason that spas have calm music or white noise. It creates an environment where you can let your guard down and relax your muscles. A busy physical therapy clinic with 20 other patients is not very relaxing, but the comfort of manual therapy can allow for improved muscle relaxation.
Novel Stimulus
Our bodies are not stupid, they remember pain. This Ted Talk by Lorimer Moseley does a fantastic job of explaining the rationale behind pain. Basically, we have pain as a protective mechanism and our bodies are wired not to forget it. If you touch a stove and are burned as a child, you remember that pain. If we forgot each time we touched the stove, we would have died off a long time ago.
Part of the benefit of manual therapy is that your body receives what I call a novel stimulus. Novel stimulus means a new sensation that is out of the norm. Cupping is a perfect example. You have probably had a bunch of people poke and prod your skin, but a cup actually sucks up your tissue with negative pressure. This is a new and weird feeling and your body forgets about the pain temporarily.
The gate control theory states that our sensory nerves compete to send messages to our brain. If you have pain, then your pain nerve is winning the race to your brain. However, if you utilize cupping, scraping, or other techniques then your body feels that sensation and the pain loses the race. Think about how you instinctively rub your arm after you get hit, that is probably the reason.
In the simplest terms, we are providing a new concept to the brain. If you get punched in the arm, your brain thinks arm = pain. If your arm keeps hurting, this becomes the dominant thought process for your brain when it comes to your arm. Now if you reach to grab something, your brain’s instinct is to think of pain. This leads to pain with movement. However, if you put a couple of cups on your arm, your brain gets distracted. Now if you move your arm your brain is thinking “what the heck are these cups doing?” Your body is now moving without pain which causes the brain to reconsider all arm movements leading to pain. It is all about giving your body positive movement experiences.
Improve Mobility
I see many clients who lack mobility and want to improve their range of motion. Manual therapy can be a valuable tool to achieve this. A study by Bailey, et al. looked at baseball players with limited range of motion in their shoulders. One group of players received instructions on how to stretch themselves. The other group received the same instructions and one session of manual therapy. Guess which group improved mobility more? It was the one who received manual therapy in addition to stretching. Research that I have discussed before shows that limited shoulder range of motion puts baseball players at greater risk of elbow injuries. You could say that manual therapy in this case could help prevent future injuries.
Part of the benefit of manual therapy is for athletes to understand how they should move. Hands-on cueing can allow clients to understand where their body should move in space. Following this up with exercise is the best strategy to make long-term improvements in my experience. The mistake that many providers make is to isolate manual therapy or exercises, when they should be used to empower each other.
Conclusion
In conclusion, manual therapy does provide some benefits for pain and mobility. It should not be the only intervention for any injury, but it should be part of a larger solution. I like to view manual therapy as creating a window to benefit from exercises. If an exercise is too painful to do, but manual therapy gives a pain-free window to accomplish the movement, then it was successful. Repetition of that movement will allow your body to relax and prove beneficial in the long run.
Exercise is much more important when it comes to injury prevention, as strength is probably the most important factor. However, manual therapy gives the opportunity to progress exercise and allows for an individual to increase their confidence in movement. To me that is worth taking the time to perform it. Other practitioners may disagree, but this is how I use manual therapy at Eclipse Wellness.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about how and why I utilize manual therapy. It provides tremendous benefits when used appropriately. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you want to subscribe so that you don’t miss any other posts, click the sign in button on the top right of this page. Once you have created an account, click the drop-down menu in the top right next to your name and go to your settings page. Click the subscribe button next to “Blog Subscription” and you won’t miss any future posts! If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at danny@eclipsewellnessnova.com or follow me on Instagram or Twitter @drdannydpt.