Manual Therapy: What is it, and what do you need to know about it?

Despite our differences, physical therapists, chiropractors, massage therapist, and osteopaths have a few important similarities. The most obvious of which is the use of manual therapy.  Manual therapy takes many forms.  Static stretching, joint mobilization/manipulation, trigger point release, myofascial release, deep tissue massage and much, much more all fall under the blanket term of “manual therapy.”  In short, manual therapy can be defined as the use of skilled practitioner’s hands to elicit a favorable response in their patient/client. 

With the growing popularity of Instagram and Facebook, manual therapists now possess a whole new avenue of self-promotion.  A quick glance at my Instagram feed reveals folks being poked, prodded, scraped, and manipulated in all manners of ways.   Why the sudden obsession with manual therapy?  What does the run of the mill weekend warrior or headstrong fitness enthusiast have to gain from receiving these therapies?

Well, this blog post will hopefully enlighten you to what manual therapy actually is, what it does, and why you may or may not be a candidate for it!

What does manual therapy actually do?  Years ago, the widely accepted theory was that a therapist’s hands could make structural changes to the soft tissue (ie muscle, fascia, tendon) of a patient.  The patient has tight quads? Stretch them.  A painful tendon? Use cross-friction and “realign the fibers.”  This certainly seemed to make sense, after a few minutes of stretching; a patient’s quads would actually be less tight!  Unfortunately, the truth is a little more nuanced than that…

Research shows that before and after manual therapy to a muscle or tendon, there are no observable structural changes1.  In fact, it takes 925kg of force to stretch the iliotibial tract (or “IT band”) just 1% of its length2. So unless your therapist is the Incredible Hulk, I highly doubt his 10 minutes of soft tissue work are creating much of a structural change. However, time and time again patients report their symptoms have significantly improved after a bout of manual therapy.  Also, the research supports the use of manual therapy for the treatment of many conditions, including low back pain, carpal tunnel, knee and hip arthritis, and more 1. So what is really going on here?

Here’s where we need to take a quick diversion into basic neuroscience.

Think of our bodies as mere puppets, and our nervous system as the puppet master.  Every section of every muscle in the body is innervated by nerve endings that originate in the brain. Our muscles and joints are really quite useless without the nervous system.  It is the input from the nervous system that allows us to move our bodies, as well as perceive painful stimuli.  So if manual therapy has no effect on the structural components of one’s body (muscle, bone, and ligament) maybe it has its effect on the nervous system! (Ah, the plot thickens…)

Gate Theory: What is the very first thing that you do after you stub your toe on the coffee table (aside from shouting obscenities)? Most people will grab that toe and/or rub it as the pain subsides.  Now this is important.  The pain sensation from ramming that toe into the table travels to the brain via what are called Aδ fibers.  However, the touch sensation that you provide to the toe by rubbing it travels to the brain on Aβ fibers.  These Aβ fibers (aka nerves) send their signals faster than the pain fibers (Aδ) send theirs. 

We can liken this situation to sitting in a quiet room.  In the room you hear an annoying clock ticking (your toe pain).  So you decide to turn on some music (rub your toe) in order to drown out the noise of the annoying clock (pain).  And viola!  Your perception of the pain has been modulated by giving your brain something else to focus on.

Now this is an over-simplified explanation of gate theory, but will have to suffice. By creating novel stimuli through manual therapy, we therapist are able to “dampen” the pain signal sent to the patient’s brain.

Trigger Point Theory:  Another possible explanation for the effectiveness of manual therapy is also based in neuroscience.  The term “trigger point” can be loosely defined as a tiny muscle cramp.  Those who subscribe to the trigger point theory will explain it as a small bundle of muscle fibers held in a constant contraction.  Imagine that you could flex just a tiny, one centimeter portion of your biceps muscle.  Then imagine that you had no control over this contraction, and it stuck around for days, weeks, even months.  That, in theory, is a trigger point.  Subscribers to this theory will say that when this tiny portion of muscle is contracted, there is no blood flow to the tiny region of muscle, therefore nutrients can’t be brought in and waste products cannot leave.  This small patch of muscle fibers becomes a toxic waste dump of metabolic byproducts, and over time, may become painful or inflamed. 

As a manual therapist, one might perform deep pressure or “trigger point release” to this area of muscle tissue.  The “treatment” allows the nervous system to relax its hold on the muscle fibers, and restores normal blood flow to the area.  I think it is important to mention at this point, that this is all theoretical. The science behind trigger point identification and treatment is dubious at best and non-existent at worst3.  Nonetheless, the above scenario is easy for a patient to wrap their head around.  So if it helps clarify why they felt better after manual therapy, then I’m all for using this theory as an explanation.

A Word on Joint Manipulation:

Joint manipulation also falls under the umbrella of manual therapy.  We’ve all seen it, maybe we’ve experienced it, and there remains a lot of confusion about what joint manipulation is and isn’t.  So let me clear it up the best that I can.

Certain practitioners will claim that the joints of your spine can become “out of alignment” and that they need regular adjusting in order to remain pain free and prevent chronic disease (even things like kidney stones). These fear mongering tactics seem to be fairly effective, because hundreds of thousands of Americans appear to be sold on the idea that their spine is frail, vulnerable, and constantly shifting around like the Earth’s tectonic plates.  So let’s set that topic straight right now.  Spines don’t “get out of alignment” willy-nilly. Major fractures to the vertebrae and conditions such as spondylolisthesis can cause changes in vertebral alignment, but these are the exceptions not the rule.  Consider that there are competitive powerlifters out there deadlifting upwards of 1000 pounds and not causing their spines to go “out of alignment.”  We are robust creatures.  Back pain is almost always caused by minor sprains, strains, or disc herniations, and rarely by a structural deformity that can be corrected with a quick manipulation.

So what is manipulation?  Grab your finger, give it a tug (no, this is not a crude jest).  Did you hear a pop?  Awesome, you just “manipulated your joint.”  MRI images have discerned that the noise we hear during joint manipulation is not the joint surfaces clicking back into place, but rather the gas exchange that is caused when two joint surfaces are pulled far enough apart.

So what am I saying? Is joint manipulation a complete hoax?  Well, no.  Joint manipulation can effectively restore mobility to a stiff joint, as well as relax a local muscle spasm through unknown mechanisms1.  Wait, are we talking about the nervous system again?  You bet we are.  So for those of you who have experienced a reduction of your symptoms after joint manipulation, fret not.  You were not simply placebo-ed, but the explanation that you received for the reduction of your pain might not have been entirely correct.

Instrument Assisted Soft Tissue Manipulation (IASTM):  We have all seen the shiny, medieval looking tools that have become so popular in the past few years.  These are instruments used for treating the myofascial system while simultaneously saving the practitioner’s hands.  Proponents of IASTM will claim that the tool is effective at identifying fascial adhesions or trigger points, increasing blood flow locally, and decreasing nervous system “tone” in a muscle.  Sounds familiar right? These are all the same reasons that manual therapy may be effective. 

(P.S. the above paragraph holds true for dry cupping, theraguns, dry needling, etc… etc…)  These are just different modalities with the same aim.  The use of these different strategies will vary with practitioner comfort and preference.

Conclusion: Manual therapy is an excellent way to break the cycle of pain early in the healing process.  When pain restricts function, it will affect your ability to rehab your injured tissues. Motion is lotion, as we PT’s like to say, and the best way to heal your body is through volitional movement (aka exercise), but that is a conversation for another day….

References:

1. Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 14(5), 531-538. doi:10.1016/j.math.2008.09.001

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/?_escaped_fragment_=po=21.8750

2. Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M., & Findley, T. (2008). Three-dimensional mathematical model for deformation of human fasciae in manual therapy. The Journal of the American Osteopathic Association, 108(8), 379-390.

https://www.ncbi.nlm.nih.gov/pubmed/18723456

3. Quintner, J. L., Bove, G. M., & Cohen, M. L. (2015). A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford, England), 54(3), 392-399. doi:10.1093/rheumatology/keu471

https://www.ncbi.nlm.nih.gov/pubmed/25477053


  • February 2, 2018

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