MANUAL THERAPY By Robin Angus, PT, MS, Cert. MDT Manual therapy, also known as orthopedic manual therapy, is a clinical approach used by physical therapists that incorporates skilled hands-on techniques to evaluate and treat spinal and extremity joints, muscles, tendons, and ligaments. During the first visit, a patient’s history is thoroughly reviewed and a comprehensive physical exam is completed. A treatment plan of care is then designed and commenced that incorporates specific techniques to help modulate and reduce pain, decrease inflammation, facilitate tissue repair, and increase mobility.

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The ultimate goal is to improve function via improved pain free mobility. How is manual therapy used in treatment? Patients generally have better functional outcomes when their physical therapy treatment includes a combination of procedures such as therapeutic exercise, neuromuscular control and movement training, and manual therapy as compared to those receiving manual therapy techniques as their only form of treatment. Who is a Manual Therapist? Physical therapy students receive basic training in manual therapy techniques in PT school. Experienced manual therapists, on the other hand, demonstrate a keen interest in manual therapy evaluation and treatment techniques and take many post-graduate training courses offered 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.

After approximately 3-4 years of intensive study with a particular institute, therapists become eligible to be certified in that institute’s approach to manual therapy. The process usually entails successful completion of comprehensive written and practical exams, presentation of case studies, and documented clinical experience using the institute’s assessment and treatment techniques. Certification is not a requirement to use manual therapy techniques. Some therapists study with multiple institutes throughout their career. Manual Therapy Procedures: Joint Mobilization / Manipulation is an evaluation and treatment system that utilizes skilled passive movement of spinal and extremity joints, including the jaw (TMJ), using various grades, speeds, and amplitudes of therapist applied pressure. These advanced techniques allow the bones of a joint to move in ways that patients cannot move or control themselves. Smaller grades of pressure aim to reduce pain in the joint and surrounding tissue and help to relax the tissue, allowing for greater ease of movement.

Higher grades of pressure move the joint into its restrictive barrier, allowing the joint tissues to stretch, thereby improving pain free mobility and alignment. Manual Traction evaluation and treatment techniques are performed via direct therapist hand contact on the two bones of an extremity, TMJ, or spinal joint. A very specific and controlled distractive force is performed to decrease compression and pain, relax surrounding soft tissue, and help restore pain free mobility. In the spine, manual traction is often used with disc disorders, including sciatica and degenerative disc disease, as well as with arthritic conditions. In the extremities, traction helps to “unload” a painful joint, including those with arthritis, thereby relaxing the surrounding soft tissues, and improving joint health and pain free mobility. Traction is often performed in conjunction with joint mobilization and manipulation techniques and is also used with PNF therapeutic exercises. Your therapist may recommend a home traction unit or brace if you respond favorably to manual traction treatment.

Muscle Energy Techniques (MET) incorporate an active isometric muscle contraction by the patient in a specific direction and position against controlled counter resistance provided by the therapist. MET techniques are beneficial to help relax hypertonic muscles and to lengthen and strengthen them. They also indirectly mobilize spinal and extremity joints, improve joint and muscle function, mobility, and alignment. Soft Tissue Mobilization and Myofascial Release are hands-on techniques using varying pressures to muscles, tendons, ligaments and fascia throughout the body. The goal is to decrease abnormal tone (i.e., hypertonicity and spasms), adhesions, scar tissue, and fascial restrictions in the myofascial system, thereby improving pain free movement. Other benefits include improved circulation and healing, decreased inflammation and edema, and relaxation of the muscles.

Some techniques are combined with active movements to help improve myofascial extensibility and mobility. Trigger Point Release techniques are highly effective in resolving the pain from trigger points as well as eliminating the underlying neurophysiological mechanism causing them. Trigger points are tight, painful bands (“knots”) within muscles that have a characteristic referred pain pattern to other parts of the body. Treatment for trigger points includes direct manual pressure to the taught band and specific stretching of the muscle. Once released, referred pain from the trigger point is resolved and pain free movement in the muscle and surrounding region improves. Deep Friction Massage improves pain free mobility in muscles, tendons, and ligaments by breaking down the build up of scar tissue. It utilizes deep manual pressure that is applied transversely 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 goal is to reduce scarring, improve circulation and healing, and restore normal pain free mobility of the targeted tissue and surrounding region. Active Release Techniques (ART®) are movement based soft tissue massage techniques that assess and treat muscle, tendons, ligaments, fascia, and nerve problems.

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It uses a combination of manual pressure by the therapist with active or passive patient movement through a specific range of motion to release soft tissue adhesions and restrictions. Treatment goals include decreasing pain and scar tissue, and improving muscle length, extensibility and pain free movement. ASTYM ® and Graston Techniques ® utilize Instrument Assisted Soft Tissue Mobilization to reduce scar tissue formation that causes pain, stiffness, and altered movement. The therapist uses special ergonomically designed tools to assess, treat, and ultimately heel soft tissue that is scarred, fibrotic, and / or chronic inflamed. Clinicians must be trained and certified in ASTYM ® or the Graston Technique ® in order to use the tools.

Visceral Manipulation involves manual techniques that help the body release restrictions of the viscera, such as the intestines and kidneys, which cause dysfunction, non-optimal alignment and movement, and pain. It incorporates a full body approach, as the therapist feels for decreased motion in the viscera as well as restricted patterns throughout one’s body before applying specific manual corrective techniques.

Lymphatic Drainage Massage is a gentle massage technique used to move and drain the waste fluids caused by lymphedema, which can be a side effect following the surgical removal of lymph nodes. Besides in-clinic treatment intervention, patients are usually taught a self-maintenance home program that involves performing their own massage techniques for clearing fluids and aiding in their reabsorption. Compression sleeves are often recommended with this patient population. If you have questions regarding manual therapy or feel that this approach or one of the above procedures would be appropriate for you, please speak with your physical therapist.