The Hidden Utility of Manual Therapy

If you’re on #PTTwitter, you know that there is a growing population of people who are NOT fans of manual therapy. Then again, maybe it’s just in my feed. I can never tell. It’s so echoey in there.

Either way, in this episode, I’m not going to talk about the relative efficacy of manual therapy & the literature surrounding that question. It’s been done. & quite well at that.

I want to talk about manual therapy from a slightly different perspective. I want to talk about a utility of manual therapy that rarely gets talked about, but which can be a tremendous asset in our practice.

I’ll start by talking about my journey with manual therapy, how my beliefs and approach have evolved over time, and finally how & why I choose to use manual therapy at this point in time.

My Manual Therapy Story

I was taught manual therapy from a very biomechanical perspective in PT school. At that point in time, my ‘why’—the reason that I chose to use manual therapy—was to correct biomechanical faults.

Then I started residency and shifted drastically away from a biomechanical model. The neurophysiological effects of manual therapy became more of my focus. My ‘why’ at that point was to provide input into the system, essentially to change people’s symptoms.

After residency, I went through a phase where I slowed way down on my use of manual therapy due to fears of lowering patients’ self-efficacy. My ‘why’ when I did choose to use it was to provide hope. To show that symptoms can be changed.

But I found that I had to shift gears a lot, vacillating between a very hands-off approach with some people and a very hands-on approach with others. It felt disjointed.

Then I went through fellowship training and was guided toward a new perspective, which is where I’m resting these days.

I want to lead you through my current reasoning process surrounding manual therapy, asking what & why at every phase of what we do.

The Person

People come to us for a wide variety of reasons. Not everyone who comes to us wants a thorough examination followed by a specific plan of action that includes exercises and lifestyle modifications.

• Some people just want advice

• Some people just want to be listened to

• Some people want to know that they’re safe doing what they’re doing

But… many people do want (& expect) the thorough exam & specific plan.

The Examination

For the people who want the specific plan, one of the key purposes of the examination involves getting a sense of what might help their symptoms to improve.

The process essentially looks like this:

During the history-taking,

• We ask them what they’ve noticed about the symptoms,

• Any patterns they’ve discovered in the symptoms,

• How the symptoms are interfering with their life,

• What their hopes/expectations are for working with us.

During the physical exam,

• We look at how they move & position themselves functionally & assess their response,

• We look at how they move in specific ways & assess their response,

• We might then move parts of their body passively, assess how it feels to us, & assess their response

• We might also do some performance testing, assessing their performance as well as their response to the testing

But what are we really getting from all of this testing?

One of the main things we’re getting is an understanding of how their body is responding to load.

The more we understand how their body is responding to load, the more we can determine whether they need to rest (reduce load) or reload (increase load) in order to reach their goals.

This could look like a wide variety of things:

• Resting could be…

• Movement modification

• Offloading areas with the use of an assistive device

• Improving mobility of adjacent areas

• Activity modification

• Reducing sympathetic activity

• More

• Reloading could be…

• Movement modification

• Strengthening/endurance exercises

• Manual therapy

• Mobility interventions

• Exposure to feared movements

• More

Determining Symptom Irritability

Our answer to the question: Do they need to rest or do they need to reload? is heavily predicated on our assessment of the person’s symptom irritability.

Symptom irritability is essentially how the person responds to load.

• When symptom irritability is on the high-end, the person generally benefits from resting (reducing load)

• When symptom irritability is on the low-end, the person generally benefits from reloading (increasing load)

If you read Law IV of the Four Laws of Quality Care, you’ll know that irritability has to do with 3 main components:

1. The vigor of activity required to provoke the symptoms

2. The severity of the symptoms, once provoked

3. The time it takes for the symptoms to subside once aggravated

But how exactly do we come to determine symptom irritability?

During the examination—whether you know it or not—you are developing what’s called an irritability hypothesis, a guess about the dosage of intervention that's appropriate, based on what you’re gathering about the three irritability components.

You develop your irritability hypothesis by paying attention to how the person responds to your examination, which is essentially controlled & specific ways of loading.

Testing Symptom Irritability

So you take the history & perform the exam, you develop your irritability hypothesis, now how do you test that hypothesis?

You test your hypothesis by seeing how the person responds to repetitive or prolonged load: which is one of the main components of treatment (if the examination involves determining how people respond to controlled and specific loading, treatment is just the repeat or prolonged exposure to the type & amount of load that you believe to be helpful, based on your exam).

The way the person responds to the intervention that you provide gives you information about your irritability hypothesis:

• If the intervention increases their symptoms, perhaps the symptom irritability was higher than you suspected

• If the intervention makes no change, perhaps the symptom irritability was lower than you suspected

• If the intervention reduces their symptoms, you may have been right on

So the question becomes, how much control do you want to have over the testing of your irritability hypothesis?

• You could test it out through only active interventions— interventions that the person is performing under your guidance

• Or you could test it out through passive interventions— interventions that you are performing in a controlled manner

The problem that I kept running into when I went through my hands-off phase was that sometimes there were just too many variables.

If I was a little shaky on my irritability hypothesis, it could take me a lot of trial and error to get a good handle on the appropriate dosage.

Think about it like this: when we have someone perform an active intervention, for us to get good data we have to make sure they’re performing it the way we want, and with the vigor that we want. This can be challenging for many people, who come to us after all because they have difficulty managing the problem on their own, and who often can’t find the sweet spot between doing too much & doing too little.

This is my main reason for performing manual therapy these days: it allows me to load the body in a controlled manner to test my irritability hypothesis.

…so that I can laser in on the dosage that will help the person move toward their goals.

Before delving deeper, let’s take a brief pause and review how we got here:

• For people who want a specific plan and action items for their problem, we need to determine if they need to rest or reload

• To determine this, we need to determine their symptom irritability

• In determining symptom irritability, we first develop an irritability hypothesis

• Based on their descriptions of the symptoms & their patterns (history)

• Based on controlled loading of their body (physical exam)

• We then test our irritability hypothesis through repetitive/prolonged loading (treatment)

• We can use active interventions, which come with more variables

• Or we can use passive interventions, which come with fewer variables

Example

So let’s say that I have someone come to me with neck pain and difficulty turning their head left. They’re a cyclist and are having difficulty checking for cars when they’re riding because of the pain and limited motion.

I perform a history and a physical exam and I suspect that their symptom irritability is somewhere between moderate & high because the symptoms came on easily during the exam, were moderate when provoked, then lingered for a while after testing (which is what happens after a ride with a lot of head-turning).

If I want to help this person improve their neck mobility so they can turn to check for cars, I have to make a decision about how to test my irritability hypothesis: Do I want to have the person perform a mobility intervention, or do I want to perform a mobility intervention for them?

If I perform a mobility intervention, I can control exactly how hard I push and get immediate feedback on their response to my pressure.

So I decide to do simple Unilateral PA Mobilizations (UPAs) over the painful area of the person’s neck

• I first explain to the person, “I want to provide some pressure to your neck in the area that hurts, to see how your body responds to that pressure. How your body responds will help us to determine what things you can do about this, and will help me to give you better advice. Does that sound OK?”

• When setting up for the UPAs, I ask the person to say “Now” when the symptoms begin as I gradually apply pressure. They say “Now” and I back off.

• I decide to push right up to the point at which the pain begins, so I let them know, “I’m going to push right up to the point where the pain begins, OK? Pay attention to how it feels and tell me if it gets worse.”

• As I mobilize, I ask a few times over the course of the minute or so, “Is it getting worse?” If it is, I back off a bit and keep going, confirming that it isn’t still worsening.

• Then I have them get up and we retest left rotation

• If it has worsened, the irritability may be higher than I expected

• I can repeat the intervention with less vigor and test again

• If no change was made, the irritability may be lower than I expected

• I can repeat the intervention with more vigor and test again

• If it has improved, my hypothesis was right on

• I can move on, or repeat the intervention

The outcome of this process will heavily inform where I go next and the advice I give.

If the symptoms improve and the irritability turns out to be on the lower end,

• I’m going to give the person mobility interventions with the advice to go ahead and push into it a bit (I’m not so worried about them making the symptoms worse because we just saw that loading helped).

• The advice I give them will be that when they’re riding, it will actually help if they look left as far as they can and that it’s OK to push into it a bit (because we just saw that pushing into it helped).

If, on the other hand, the symptoms worsen and the irritability turns out to be on the higher end,

• I’ll probably give the person gentle movement and maybe muscle activation exercises with the advice to make sure they’re not making the symptoms significantly worse during or after the exercises.

• The advice I give them might be a suggestion that they take a break from riding until the symptoms calm down a bit.

In both cases (symptoms improving & symptoms worsening) my decisions & advice are grounded in the evidence that we just gathered together

If I had this person perform some exercises right off the bat and it made the symptoms worse, it would be much more difficult to determine why that might be. Was it the way they performed the exercise? Was it the vigor in which they performed the exercise? It would be hard to say.

Further Reasoning

Once I have a thorough understanding of their irritability, I have much less reason to use manual therapy.

The next step is to use the data gathered to help them navigate the symptoms and set the conditions to allow healing to occur (in the broadest sense). This may take several visits to get a good handle on, and I also want to find out about the person’s delayed response to my testing & interventions.

And for some people, it’s so cut and dry that I don’t feel the need to use manual therapy to test my irritability hypothesis at all. I’m confident enough just from the history & physical exam to move forward.

Other reasons I use manual therapy

As a regional test.

Some people come in with reports of symptoms that are not reproducible in the clinic. This can be quite challenging because if we can’t reproduce their symptoms, it makes it difficult to determine a direction for treatment.

What I’ll often do with these folks is vigorously treat an area, often with manual therapy, to see if it changes their symptoms (for better or worse). And I tell them, “This might make your symptoms a bit worse over the next few days, but this is actually a good thing because it will be telling us that we’re on the right path.”

If it doesn’t change anything, I’ll keep pushing harder until I feel that I’ve cleared the area. Once I’ve cleared the area, I’ll move on to another area that I suspect might be contributing and repeat.

I’ve treated several challenging patients with this method who have seen many specialists and had symptoms for years without relief. We simply worked through the possible contributing areas systematically until we determined the area that seemed to be related. We then treated it with exercise and lifestyle change.

To give people hope by showing them that their problem is changeable.

This was discussed in detail in Law II of the Four Laws of Quality Care. The concept is that we can use symptom modification procedures (manual therapy being one option) to show people that their symptoms and their body are adaptable.

So often people come to us with beliefs about the fragility of their body and with little hope of improvement. Showing them that things can change can help them to commit to the process of treatment & lifestyle change.

As with everything, it’s all in how you frame what you’re doing.

Manual therapy and dependency

Many people fear their patients becoming dependent on passive interventions, which stops them from performing them.

In my experience, the vast majority of people don’t want to come to PT forever. They don’t want to feel that they need someone else in order to live their life in the way they want to live it. They’d much prefer to be able to live their life on their own terms and be able to take care of themselves

So if I have someone who seems to want to come in just to get manual therapy for the foreseeable future, I get curious about what it is they really want.

In my experience, most of the time, it’s not that they want to come in & receive manual therapy forever, it’s that they think they need to. This is often tied to a belief on some level that they are broken and need to be fixed. And the way we and other healthcare professionals explain what we’re doing can have a lot to do with this.

Once we discover what it is the person truly wants, we can then find out together how they can move toward that— how they can get to the place where they don’t need me.

If what they really want is some sort of passive treatment, I’m happy to refer them to a massage therapist or chiropractor in my network. It’s no problem.

In Summary

Manual therapy is a tool. It’s not good. It’s not bad. It just is. And the way that we choose to use it makes a huge difference in the impact that it has on the context of our relationship with our patients.

The utility of manual therapy, in my opinion, lies in its power to test our irritability hypothesis with precision, so that we can deliver properly dosed interventions and give our patients advice with confidence.

Thanks for reading,

Andrew