In the first article of this blog series, I talked about what I aim to accomplish during a client's first visit. I also described my education which enables me to practice physical therapy, with or without a prescription from a physician. I am now going to lay the groundwork to then build the rest of this blog series, detailing common treatment techniques I use and why.
Yes, I do utilize the Redcord suspension system in my client treatment sessions, but rather than talking about Redcord, I am going to explain manual therapy and some other skilled techniques many people may refer to as “exercises.”
Each manual technique I apply and each exercise I supervise, instruct or facilitate is for a specific purpose: to decrease pain, to improve mobility, and finally to re-educate, restore, and reinforce a movement. I spend each hour individually with each person so they can achieve their goals in the best way I know how and in the most efficient manner possible.
What is manual therapy?
So let's start with manual therapy. There are many schools of thought on this and I wouldn't say any one is always right or always wrong. Different techniques work for different people and for different reasons. There are numerous factors that play into why one person is hurting versus another person, even if it’s the exact same body part.
If we break down the words manual and therapy, the “therapy” part means a technique aimed at being therapeutic (e.g., decreasing pain, relieving tension, improving movement, helping achieve some desired effect, etc.). Meanwhile the “manual” part refers to something that you are not performing on your own. In other words, someone is doing something to you to get better. This is the bread and butter of physical therapy.
After all, why would you go see a physical therapist if it was only to exercise? You could probably get a much better deal seeing a personal trainer, taking an exercise class, or subscribing to some app with a daily exercise routine.
Facilitating or resisting a movement as well as providing a massage like technique to soft tissue are common manual therapy techniques employed by many therapists. I can utilize both of these techniques while also setting my client up in an appropriate redcord exercise to target what is needed. The support of the ropes allows me to have two hands free to guide my client through the movement and help facilitate muscle activation. Here's a video of how I apply a combination of manual resistance and myofascial release during an ankle stabilization exercise:
Word of advice: if you walk into physical therapy and the PT tells you to go through exercises that you’ve already learned, but never actually puts their hands on you — you may want to reconsider where you're receiving physical therapy services.
When I treat clients and they’re performing an exercise — it’s not just to get a bunch of reps in, make them sweat, and give them a good workout. If that’s what they want, I tell them what they’re looking for is a personal trainer, not a physical therapist. The “manual” in manual therapy is what you came here for. Everything you tried on your own didn’t work to get you better and now you need someone to help get you there.
Why manual therapy?
Manual therapy is defined as a technique not performed on your own volition, but rather by the physical therapist to elicit a positive outcome and have a novel effect on the central nervous system to lead to decreased pain and/or optimized movement. So what are the options, and what technique should be used?
As I stated in my previous blog article, I prioritize mobility before stability. This means my first goal when treating someone is to maximize the movement, excursion, or range of motion through which the joints move. If I tried stability or strengthening before mobility, then it’s almost like going bungee jumping with a bungee cord that has a bunch of knots in it, or trying to squeeze fifty people into a mini cooper. Why even bother?
A joint is anywhere in the body that two or more bones meet. This includes the joints of the spine. Each vertebrae has synovial joints that articulate with the vertebra above and below it. Every joint in your body is a synovial joint which means that both ends of the bones that come together have cartilage on them. For instance, in the knee joint, the femur (thigh bone) connects to the tibia (leg bone) by way of the ACL (anterior cruciate ligament), PCL (posterior cruciate ligament), MCL (medial collateral ligament) and LCL (lateral collateral ligament) as well as the lateral and medial meniscus which help make the knee more congruent so that forces are distributed equally.
The whole joint is surrounded by a capsule. This cartilage on the ends of each bone acts like a sponge that squeezes synovial fluid which lubricates the joint and keeps it healthy. So what happens when joints don’t move? The sponge mechanism doesn't pump and the joint becomes stiff.
What makes joints move? The brain telling muscles to contract or relax. What has to stretch, relax, or bend so that muscles and joints can move? The joint capsules, tendons, ligaments, skin and fascia.
What happens when people have surgeries? They acquire scars. What happens if scars don’t heal well? They tend to form adhesions in any and all of the soft tissue where the incision travels.
What do adhesions (or the presence of inflammation at one point or chronically) do? They keep joint capsules, tendons, ligaments, skin, fascia and muscles from being able to be moved by muscles controlled by the central nervous system (brain and spinal cord). Then we all know what happens when muscles can’t move joints. The joints get stiff, muscles get tense, the body tries to figure out what other joints it can move instead; and overuse, compensation and the potential for this cycle begins again.
So the big question when treating someone is what came first, the chicken or the egg? Did the soft tissue (skin, muscle, ligament, tendon) injury, inflammation or weakness cause the joint stiffness? Or is a bony problem causing the soft tissues to become tense, strained, inflamed, overused, torn and thereby painful? Furthermore, if someone has been dealing with pain associated with movement for a long time, then compensatory strategies have rewired how the brain controls movement. This can further compromise joints and muscles above and/or below the initial location which can repeat the cycle.
The role of manual therapy performed by a physical therapist or another practitioner who is licensed to perform manual techniques is to manipulate the structures discussed above. The objective is to improve movement so that the muscles can then finally move joints in the most optimized range possible. This enables a person to move better, with less or no pain, and get back to the things they want to do like dancing, walking, picking up their kids, playing sports, or even turning over in bed.
Here's another video of me enhancing the way my client moves. I am applying manual facilitation of hip abduction and external rotation to maximize hip stability in lunge stance.
When to apply manual therapy
Do all people in physical therapy require manual therapy? I would argue yes. People may come to see a physical therapist for pain relief and to achieve functional goals like being able to put on socks or raise their arm. These goals more obviously require manual therapy. But people may also utilize services from skilled physical therapists who can help with sports performance goals like running faster, jumping higher, or lifting heavier. Just because the individual isn’t complaining of pain doesn’t mean they wouldn’t benefit from manual therapy to optimize a deficient movement or push them beyond a training plateau. Seeing a physical therapist would more likely help prevent pain from overtraining or performing with suboptimal movement in need of manual therapy.
Okay, I believe I have helped to establish that almost anyone would benefit from manual therapy. But what does that really look like and how do you know if you’re receiving effective manual therapy or physical therapy services? The simple answer is this: you’re getting better. The outcome of effective manual therapy techniques performed by a licensed practitioner should be improvement or optimization of the individual’s condition.
The caveat is this. Manual therapy alone rarely gets anyone 100% better. It must be reinforced with exercise. That means homework. Yes, if the goal is to change a movement and reeducate the brain to abandon a painful or compromised movement and adopt a new way of moving without pain or compensation, it is imperative. Home exercises need to be performed to carry over what was done in the clinic under the direct supervision and with the skilled hands of a physical therapist.
If anyone went to an MD and had a disease that could only be treated with a medication and the individual left the physician’s office and never filled the prescription expecting to be cured, you may be questioning that individual’s sanity. So imagine a painful or deficient movement caused by weakness, tightness, or any of the problems I discussed earlier given the prescription of a manual technique performed by a therapist for a whole hour within a treatment session (that’s being generous) in one twenty-four hour day. If that therapist says you need to come back regularly to have that tissue manipulated and re-educated multiple times to get better, that's because it’s true.
There are twenty-four hours in a day, around thirty days in a month, and twelve months in a year. If someone has been moving with pain or compensation for thirty days or ninety days or five years, it’s going to take some time. If manual therapy was performed for one hour in a twenty-four hour day, it’s likely going to have some effect. But that person still wants to move the way they’ve been moving the other twenty-three hours in that day and seven days in that week.
Homework and changing movement and performing home exercise techniques prescribed by your physical therapist is the only way these changes can really stick. Then, returning to that therapist in the next couple of days or weeks with a little more mobility or a better ability to activate a muscle can then be built on with more manual therapy and prescribed exercises to further optimize your movements and to achieve your goal.
It’s a marathon, not a sprint.
Physical therapy can be like peeling layers of rust and dirt off an antique record player to reveal the original design and the perfect craftsmanship so it can play music without error. It can be a really short marathon or restoration project if someone seeks help before pain becomes a factor; or it can take a long time if those problems have been around for years.
I know I still haven’t gone into detail about any specific manual therapy technique or tool. That wasn't my focus for this article. I will go into that in the next blog. Like I said before, there are so many techniques out there. Some manual techniques have fancy tools and equipment. Some have trademarked names. Some are only able to be used by specific practitioners in specific states.
The most important part of any manual technique used isn’t as much about the technique; rather it's about the skill of the therapist choosing the correct technique or combination thereof for the correct problem. My husband is a contractor and when he paints, he insists on using Benjamin Moore paint. But the real skill is in how that paint is applied and who is applying it. How he prepares the walls underneath the paint. How he tapes and spackles the seams of the drywall.
You can have all the best tools and know all the best techniques. However if they’re not used for the correct job or if the practitioner doesn’t apply those techniques with skill, then it really doesn't matter what you were using, because it’s not going to accomplish the goal.
Disclaimer: The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.