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Practitioner Seed #10: Master Your Manual Skills?

I just feel like it needs to be cracked back into place

My hips are out and need to be re-aligned

My muscles are knotted and need to be released

The common patient vernacular that you might encounter at your clinic on a weekly basis!

Unfortunately, this disturbing narrative about how the human body functions, is rife in mainstream society. As an industry of rehab professionals, in search of the evidence based truth, we are doing our mightiest to change this mindset. However, with the inherent time lag in research translating into practice, this is no easy feat. Counterproductive to this crusade are the professionals who still advocate this type of reasoning to their patients for performing a specific manual therapy technique.

With the evidence now stacking up,  refuting the reliability of localised motion palpation (Landel et al, 2008) and the unnecessary application of specific segmental treatments (De Oliveira et al, 2013), we must seek to understand the benefit that patients receive from us laying our hands on them.

The experiences that inhabit our life as an early clinician, provide the impetus for growth and maturation into a balanced and well reasoned clinician. Speaking from personal experience, I had the opportunity in the early years to work under a model that was heavily driven toward the pelvic alignment, osteopathic approach.

Pelvic up-slips and sacral torsions were endemic throughout the playing list of this elite football team. Muscle energy techniques were localised toward the SIJ with the intention to correct mm’s of misalignment and unlock fixations. You were loathed to send a player out to training until you corrected these ‘dyfunctions’!

 

This mystical world of jedi-like techniques is intriguing to the young player!

In one course we were shown a ‘reiki‘ technique where the instructor ‘felt’  the energy emanating with their hands 30cm from the patients skin surface!  After months pretending to feel things that other people feel, you begin to doubt yourself! However take a trip though the modern literature and it dawns upon you. While there are no magical effects of manual therapy, it certainly does have it’s place!

 

Neurophysiological response or biomechanical changes? Or a bit of both?

The mechanical forces associated with a manual therapy technique, regardless of the technique, affect the neurophysiology peripherally & centrally. Bialosky et al (2018) have eloquently summarised the current literature, highlighting:
  • Peripheral effects-  reductions in peripheral nerve inflammatory mediators.
  • Spinal effects –  Reduction in temporal summation in the dorsal horn of the spinal cord.
  • Supra-spinal  effects – Hypoalgesia mediated by the periacquaductal grey matter (Sympathetic centre) (Bialosky et al, 2009), Pain gating theory (Melzack & Wall, as cited in Jam, 2016), Placebo induced response.
  • Psychological changes – Reductions in fear and catastrophisation associated with pain modulation.

 

A systematic review in 2013 concluded a positive effect of muscle biased treatments on short term pain modulation (Gay et al, 2013). Interestingly, this study also highlighted that it was the intensity, not the duration of the technique, that was most conducive to pain modulation. This aligns with what we see clinically – get in deep with the elbows – increase the intensity! –  and you’re more likely to see a positive response, compared to that of a light skin effleurage technique.

Spinal manipulative therapy has been shown to provide increases in pain pressure threshold at the remote site. This might indicate the effect of a centrally mediated mechanism (Coronado et al, 2012). Although the the presence of an audible sound during manipulation has shown to have no bearing on the outcome from a neurophysiological standpoint, patient expectations might confound this? There are certainly a sub- set of patients who equate the ‘pop’ with feeling better.

 

It’s not working like we think, but manual therapy certainly causes physical changes……

 

Although we are not recreating structure, breaking down tissues or unlocking joints, the neurophysiological response that occurs with manual therapy, can result in detectable changes in the periphery. Increased joint ROM & reduced muscle tone are common resulting effects from manual therapy, and give plausibility to the ‘mini treatment’ and assess / treat/ reassess models.

Although many joint, muscle or nerve biased treatments are taught to be directed toward the specific tissue at fault, De Oliviera et al (2013) has refuted this in their study, concluding that manual therapy does not need to be localised to a specific segment, to achieve a positive response.  In practice, it’s common to see changes in local physical impairments with treatment to a remote region:

 

  • Joint mobilisation toward thoracic extension can have a great effect on improving cervical rotation.
  • Iliacus muscle release can alleviate lumbar extension based pain.
  • Posterior cuff release can relieve anterior shoulder pain.

 

The issue we face as clinicians is the longevity of our manual therapy efforts. You might be able to make a significant change to the patients pain within a session, only for them to come back 3 days later, seemingly back to square one from a pain perspective. Hegedus et al (2011) studied the effect of a single manipulative thrust to the lumbar spine, concluding that the neurophysiological effects last only 5min. Although they did highlight that one study provided 24 hrs of hypoalgesia.

 

Setting the scene……… What not to do!

Imagine walking in to a clinic.  Reception greets you with a barely audible “hello, take a seat”. You sit on a crickety old chair and reach for a magazine from a skewed pile. You are made to wait 30min past your appointment time. When the clinician greets you , they don’t use you name, you sit in the cubicle in silence…….. Then the questions come and all of a sudden its time to jump up onto the plinth.

Far from an awe-inspiring start in your journey back to full health!

The assessment concludes and the clinician begins to speak jargon, with some familiar words scattered throughout. You pick up on a few ….’degenerative” , “Unstable”, “Joint is wearing”. 

Then the treatment starts…. it all feels a bit awkward and there has been no explanation as to what is happening.

You get off the plinth and the pain has increased!

 

Set the expectation, create a positive environment &  build rapport!

Not many positives to take from the horrendous experience above! In this instance, the scene has been set for failure!

So we just do the opposite?

Building a strong patient experience, which is denoted by a friendly therapist who connects with their patient is the first step to achieving a positive outcome. Non-threatening easy to digest language that has meaning to the patient is the next step. Build rapport!

& finally the manual therapy technique – One that is explained simply, in a positive light, executed with confidence & mastery – will provide your patient with an internal environment that is conducive to a hypo-algesic response & a favourable outcome.

Bialosky et al, (2008) highlighted the effect of a verbal explanation prior to spinal manipulative therapy (SMT), on pain response. They found a hypo-algesic response from SMT generally, however when coupled with a Negative verbal explanation of the technique, Pain worsened.

The ‘Enthusiastic therapist effect” is a phenomenon that is at play, behind the scenes with every patient interaction.

Here are some tips:

  • Build a strong & collaborative relationship
  • Remain positive at all times, while maintaining realistic expectations
  • Explain your manual handling in simple terms  – “Loosening up a tissue”
  • Master your handling and manual techniques – Ooze confidence!

Exercise v Manual therapy

This polarising debate that occurs predominantly on social media, has always fascinated me. Within the body of evidence we find support for both approaches. As a holistic clinician, why aren’t we advocating a balanced approach? Manual therapy is a just a tool in our belt, that when used appropriately, can be tremendously powerful . I don’t think we have to discuss the benefits and effectiveness of exercise!

The bottom line  – Don’t throw the baby out with the bathwater!

Master & Maintain your Manual Therapy Skills!

 

Reference:
1. Landel R, Kulig K, Fredericson M, Li B, Powers CM. Intertester reliability and validity of motion assessments during lumbar spine accessory motion testing. Phys Ther. 2008 Jan;88(1):43-9.
2. De Oliveira RF, Liebano RE, Costa Lda C, Rissato LL, Costa LO. Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther. 2013 Jun;93(6):748-56.
3. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18.
4. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8.
5. Jam, Bahram. (2016). A new Paradigm in Manual Therapy: Abandoning Segmental Motion Palpation.
6. Gay CW, Alappattu MJ, Coronado RA, Horn ME, Bishop MD. Effect of a single session of muscle-biased therapy on pain sensitivity: a systematic review and meta-analysis of randomized controlled trials. J Pain Res. 2013;6:7-22.
7. Coronado RA, Gay CW, Bialosky JE, Carnaby GD, Bishop MD, George SZ. Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis. J Electromyogr Kinesiol. 2012 Oct;22(5):752-67.
8. Hegedus EJ, Goode A, Butler RJ, Slaven E. The neurophysiological effects of a single session of spinal joint mobilization: does the effect last? J Man Manip Ther. 2011 Aug;19(3):143-51.
9.Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskelet Disord. 2008 Feb 11;9:19.

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