Some clinicians have a strong opinion that manual therapy is not a useful intervention. Some label manual therapy as a purely passive intervention succumbing to the priority of increasing patient activity level. Perhaps these perceptions are unfounded biases (which they are), and maybe these considerations are somewhat legitimate.
Nevertheless, current management strategies for numerous conditions are demonstrated to be ineffective for a high enough percentage of individuals that additional research and intervention strategies MUST be explored. For example, in some cases, upwards of 50% of individuals with tendinopathy report a suboptimal outcome.
The simplicity of a “just load it” approach from less than a decade ago has now been replaced with “it’s a difficult condition with unknown outcomes” over the past couple of years.
What is Manual Therapy?
But before I get too far into the discord and difference of opinions, we must first ask ourselves, what is manual therapy?
- Is it thrust joint manipulation?
- Is it oscillatory mobilization?
- Soft tissue work to muscles and connective tissues?
- Is it Dry Needling?
- Is it MWM’s?
The current answer is that research has categorized all of these things as “manual therapy”. This creates confusion, to begin with. Rarely does any argument specifically state what manual therapy they are talking about. And many controversies are still based on the bias of the presenter as both sides pro and con can be easily referenced.
So is manual therapy the technique? Is it the clinician approach? Or something else?
Perhaps I should take a different approach with this short blog?!?
3 Considerations for "Why Manual Therapy?"
Pain Modulation
The application of manual therapy to address pain is one of the most common uses by clinicians. While contemporary evidence suggests a specific biomechanical approach to manual therapy is limited and unreliable, the use of manual therapy has been associated with improved range of motion and clinical outcomes. Through improved mobility, an individual may be able to more appropriately load tissue, improve ROM, eliminate pain, and restore function with the applications of manual therapy.
Manual Therapy in combination with education and exercise is also recommended for management of chronic low back pain. We also know that forms of manual therapy contribute to the restoration of tactile acuity through the stimulation of the somatosensory cortex. Systematic Reviews have reported in general terms, manual therapy is considered better than a placebo treatment or no treatment at all for LBP.
Patient Expectations
Evidence supports the positive influence of meeting a patient’s expectation to enhance treatment satisfaction. Patients often request manual therapy, or even demand it, from their healthcare professional. According to Hidaglo, 2016, the expectations of the patient may matter most. Expectations were formed by an individual’s social environment and previous experience. A treatment technique is perceived as positive if its characteristics are aligned with the individual's understanding of pain and if care is delivered in an informative and reassuring manner.
Instant Change to Patient Impairments are Possible
This is perhaps the most significant reason! I know of no other Concept that allows me to break down psychological barriers like MWM’s and the Mulligan Concept do. If clinicians were more willing to change their mindset to fitting the treatment to the patient, rather than fitting the patient to the treatment, would this change their expectations for treatments?
How would this work? A comprehensive understanding of the patient’s neurophysiological, psychological, and sociological perspectives may assist in selecting the most appropriate technique.
Perhaps clinicians should be looking more for responders than appropriate diagnoses? After all, participants knowledge and awareness of back pain were shaped by prior experience with health care practitioners including physiotherapists and general practitioners according to a study by Plank. This was reinforced by a preferred technique that was selected if a positive change in pain and function was felt. This selection is likely much more significant to improvement rather than the specific technique performed. This conclusion by Plank reinforces the Concepts of MWM’s in the application as an evaluation tool to determine if patients would be a responder to forces applied across different tissues to result in a symptom-free re-test of a comparable sign they present with. Patients tended to immediately reassess their pain after the treatment to observe and sense any form of change in movement or pain. This happens immediately during MWM’s as the comparable sign is affected in real-time for most techniques. The expectation from the clinician applying the technique needs to be open-minded. Not pre-determined of A will only happen if B occurs.
Conclusion
Consider a different angle to the same question. If clinicians are not expecting to get an immediate change in the presentation of their patients, why would we expect the patient to have different expectations? Are these expectations grounded in scientific fact? Or rather artificial biases that we have created in our minds to substitute our failure to attempt to create these changes quickly? I don’t think these are rhetorical questions.
For another example, clinicians have classically also been known to blame patients for not improving because of compliance with their HEP. However, how do we know that the HEP is going to actually be helpful if nothing changes during a visit? We don’t. Plain and simple. Let’s stop fooling ourselves, and more importantly, let’s stop blaming our patients for our unwillingness to have better expectations for improvement.
Perhaps we should start keeping an open mind for all of our treatments. As a profession, skilled therapy has an opportunity to stop assuming that all rehabilitation and recovery take time. Start investigating what can change during your visit and expect more from your treatments.
For me, the PILL response (Pain-free, Instantaneous, & Long-Lasting) of the Mulligan Concept flows through all of my treatments. I’m more interested in finding responders than I am about how I apply any technique or concept to a patient. Let the patient’s brain guide you to achieving goals.
As a recent attending at one of my Upper Quadrant classes in Ohio eloquently stated.
“find things the body likes….and do those”.
Eric M. Dinkins, PT, MSPT, DPT, OCS, MCTA