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Manual Therapy from a Clinicians Perspective

This article is inspired by a recent PhysioEdge podcast interview with Prof. Chad Cooke of Duke University on the topic of manual therapy in clinical practice.

As a physiotherapist with 20 years experience who regularly uses manual therapy as a treatment technique, here are some of my comments and insights on manual therapy from a clinicians perspective.

Manual therapy can be considered a range of hands-on techniques which may include joint mobilisations, manipulations as well as techniques targeting the soft tissues. Mostly, manual therapy is applied to the client, but some manual therapy, such as the very effective mobilisation with movement technique, is performed with the clients' active participation. Clinically I find techniques which combine passive and active techniques most effective, when applied correctly and at the right time, in restoring movement and function to an affected joint or joints.

manual therapy 2Research would suggest that which technique is used makes little difference in longer-term health outcome measures. That may be so; however, I find the more immediate post-treatment effects, in particular, how much pain relief occurs, very dependent on which techniques I use and how I apply them.

Research would also suggest that the direction in which the force is applied, to a joint, for example, does not affect pain and health outcomes. That may apply when overall averages are considered, again at long term follow up; however, I am interested in the more immediate effects of my manual therapy. When using manual mobilisation techniques to ease pain, if I apply a gentle force to a joint, in a specific direction of ease, the result is better when compared to a direction which provokes unpleasant pain. Clinically I find techniques which 'open the joint' most effective for this purpose.

The concept of dose in manual therapy is essential but does not seem to be well emphasised in clinical research. Simply speaking, pain creates more pain. Some manageable discomfort, experienced by the client, when receiving manual therapy is acceptable and may even be beneficial. However, if I hurt my client and cause aversive pain by being too forceful, it is likely I will aggravate my clients' pain, and then he or she will cancel their next appointment! So I prefer to be gentle, at the start at least and get the dose right.

Manual therapy triggers certain physiological effects, both specific and non-specific, which, if the body is able, helps reduce pain. These effects have an all-over body effect as well as a more local effect which may, in some clients, be more dependent on where the techniques are applied. Clients who respond well to manual therapy are referred to as being 'pain adaptive' which means their nervous system can respond positively to the manual therapy stimulus applied. Some clients, may for specific reasons, may not be pain adaptive. I would certainly agree that clients who are not pain adaptive i.e. who do not achieve pain relief after a reasonable number of treatments should not continue to receive manual therapy. In this case, other techniques should be used.

I think of manual therapy as simply another tool in my physiotherapy toolbox. Like the many other techniques, medical acupuncture including dry needling, for example, its function is to help alleviate pain, restore movement as well as facilitating exercise and behaviour changes as required. My treatments are, along with many other experienced clinicians, always a combination of techniques. For example, I use therapeutic exercises to prolong the effects of manual therapy and also to improve confidence in movement and self-efficacy. Other more counselling type techniques may also be used to address the psychosocial aspects of pain if relevant for the client. For this reason, I would love to see some research studies which don't just compare one or two types of treatment but instead are more pragmatic studies which compare a range of physiotherapy techniques used together and compared with drug therapy, surgery or no treatment for example. Given how effective integrated physiotherapy can be, the results could be quite interesting.

Finally, there seems to be much emphasis placed on the expectations and preferences of the client when deciding which techniques to use. But what about the experience of the therapist? Some argue this does not matter that much, but I would disagree. Knowing what techniques to use, as well as when and how to use it for best and quickest results, takes time to learn. I can undoubtedly recall occasions early in my career when, despite my best efforts, I got it wrong. Thankfully this happens very rarely nowadays, but it has taken time and experience. Which techniques will work best requires becoming somewhat attuned to the client's body, and a multifaceted decision-making process which I am sure would be very difficult to replicate in large research studies.

If you have got this far, you may well be interested in manual therapy, and if looking for a good manual therapist, I can certainly recommend any member of the team here at the clinic.

In good health,

Simon Coghlan MSc, BSc Physio, DipMedAc
Chartered Physiotherapist

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