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Manual therapy won’t save you.

Part 2: People are not cars.

In our previous post, we discussed why manual therapy might not be as specific or effective as you think. If you missed it, take a look here. Now let’s shine a light on the ways manual therapy can positively impact progress in a course of PT rehabilitation.

A lot of people who show up to physical therapy think the purpose of manual therapy is to fix something mechanical: Reposition a joint that’s out of place. Correct asymmetries by moving body parts into optimal alignment. Break up adhesions between layers of soft tissue. Like dropping the car off at the mechanic, there’s a notion that we can drop off our bodies at the PT’s or chiropractor’s office to get all fixed up. Good as new, right? But people aren’t cars. If manual therapy has worked for you in the past, the reasons why it works might surprise you. 

While some level of mechanical adjustment is possible, there is little evidence that interventions like joint manipulations and soft tissue mobilization are consistently reproducible, or as precise or effective as many people believe.

At best, manual corrections provide temporary pain relief. Unfortunately, in most cases, manual therapy alone offers little to no long-term benefits. Its application upholds a system of ongoing reliance on a healthcare provider, as opposed to active treatment tools that champion patient education and empowerment. A piece by Chad Cook, The Demonization of Manual Therapy, does a good job of examining the potential gains and pitfalls of manual therapy. Bottom line: If manual therapy is applied for early management of pain, progression to more active interventions should become the focus of treatment after the first 2-4 visits. Get pain under control and move on to exercise programs that patients can do on their own. Physio Greg Lehman said it best: “Calm sh*t down. Build sh*t up.”

So what if we shifted our mindset around manual therapy? What changes in the how and why if we view it as an entry point into more robust long-term solutions? 

Here are two reasons for applying manual therapy that aren’t about mechanics: 

1. Analgesic: Touch is a powerful tool for immediate pain relief. Ever banged your elbow on a table and immediately rubbed it for relief? Or found some comfort in massaging your neck and shoulders to ease the feeling of tightness after a long flight? Novel sensory input, such as that experienced by self-touch or touch from another person, introduces a non-painful stimulus that competes with familiar pain symptoms for your attention. Further, skilled therapeutic touch can decrease feelings of anxiety and hypervigilance that typically accompany pain symptoms. 

When we’re able to tolerate a new sensation that’s different from our pain, it can make other unfamiliar sensations—such as exercise that promotes long-term positive adaptation—feel less scary and less painful to perform.  Pain modulation through touch opens up a window of opportunity for transitioning into active movement that’s less fearful and guarded, and therefore, more comfortable and easy to perform.

2. Somatoperceptual: Manual therapy can help improve brain-body mapping for decreased pain and more coordinated movement. “Soma” means body. “Somatoperceptual” simply refers to one’s perception of their own body—bodily sensations, feelings of stretch, tightness, effort, release, how it feels to move. In an article by Geri et al. (2019) somatoperceptual touch is supported as a means for helping people reorganize mental representation of the body in the brain, discriminate between threatening and safe stimuli, and improve their sense of agency over the body. 

Sensory feedback is a powerful tool for enhanced awareness of body condition and position. This is especially true for regions of the body like the back, spine, or shoulder blades; Areas we can’t visualize with our eyes. Through soft tissue mobilization and passive joint movement, the patient can develop a clearer understanding of the involved body region—its size, shape, muscle tone, sensation of tissues shortening and lengthening, pain-free range of motion—as preparation for active movement and exercise. Think of it as a “warm-up” for your brain-body connection.

The key is to use manual therapy as a way in. A starting point.

At Gotham PT we believe in applying the minimum amount of passive treatment necessary to achieve the benefits outlined above. To “prime the canvas,” so to speak. Introduce sensory information that makes the experience of robust exercise interventions feel less like a threat, and more like good medicine. Most importantly, instead of relying on endless appointments for short lived results, our intention is to help people help themselves for the long haul.
Got a painful physical condition that’s been concerning you for a while? Come by for a check-up. Click here to get started.

Manual therapy won’t save you.

Part 1: Manual therapists are not car mechanics.

Manual therapy can’t fix your joints and tissues. At least not in the direct, mechanical ways you might expect. A lot of people who show up to physical therapy think the purpose of manual therapy is to fix something structural: Reposition a joint that’s out of place. Correct asymmetries by moving body parts into optimal alignment. Break up adhesions between layers of soft tissue. Like dropping the car off at the mechanic, there’s a notion that we can drop off our bodies at a manual therapist’s office to get all fixed up.

When it comes to treating joints and soft tissues at a structural level, here are two common assumptions about hands-on therapy:

1. Joints that have become misaligned can be realigned. 

Let’s look at the low back as an example. It is, after all, the most common site of pain in the human body. Word on the street (from many people who’ve landed in a manual therapist’s office) is that a lumbar vertebra has become misaligned, a disc has slipped, or the sacroiliac joint is rotated, tilted, or stuck. “I just need somebody to push it back in place.” Sound familiar?

People often visualize the low back region as being fragile, vulnerable, or overly sensitive. While there is a real and meaningful psychological component to these attributes—long story, deserves another post—from a purely structural standpoint, these representations couldn’t be farther from the truth. Lumbar vertebral bodies and the discs between them are tough stuff. The sacroiliac joint is an incredibly robust and rigid joint that transfers heavy loads between the legs and trunk with every step we take. These structures are not easily moved out of place. If they do shift, it requires massive forces or years of repeated stress to move them. Consider an activity like running. Running requires repeated hopping from one foot to the other. The impact of one’s entire body weight on a single leg delivers a magnitude of force to the SI joint and lumbar spine far greater than any therapist could reproduce with their hands in the clinic. So how could small, low force, hands-on adjustments could jiggle things back into place? And if there is some temporary change, how would that change last beyond standing up and taking a few steps?   

Several research studies have examined the use of specific vs. nonspecific mobilizations for the lumbar spine, revealing no significant difference between groups. Meaning, the manual therapy techniques that applied a precise direction of force to a specific spinal segment were no better at changing a patient’s symptoms than a randomly applied treatment in any direction to any region of the spine. Another study looked at mobilizations applied by experienced therapists with advanced training and certification in manual therapy vs. treatment applied by therapists with little experience or training, and no advanced certifications. Results demonstrated slightly better outcomes from the treatment by less experienced therapists. Shocking? Maybe. But only if we’re expecting a therapist’s treatments to operate on a mechanical level.

So if the precision or quality of the manual treatment doesn’t correlate with better patient outcomes, why is it that patients experienced decreased pain at rest and improved tolerance for previously painful movement after receiving any of the treatments in any of these studies? 

Could it be that the positive outcomes are due to broader, secondary effects on the whole brain-body-movement system, as opposed to a small mechanical correction at the joint level? I mean, there happens to be a whole person attached to the lumbosacral joint, amiright?

2. Sensations of tissue tightness correlate with mechanical tissue tightness, and tissue changes can be reliably felt and interpreted by a trained practitioner.

When most people think of tightness in the body’s tissues, they’re probably associating it with an uncomfortable sensation. You know the feeling. Getting out of bed in the morning, the first few creaky steps after sitting through a long movie, or the discomfort in the legs and shoulders standing still at a concert. Many people seek out treatment by manual therapists with the expectation that tissue tightness can be released.

What we’re learning about sensations of stiffness is much like the latest research on pain—that it’s highly subjective. In the same way pain can exist without actual tissue damage, sensations of stiffness can exist without actual tissue tightness. Dense, ropy, tight textures in tissues don’t necessarily correlate with discomfort. Achy, stiff, uncomfortable sensations don’t reliably produce objective measures of tightness by hands-on palpation or other means quantified in the research lab. Further, there is little evidence of manual therapists’ ability to identify regions of a patients’ perceived “tightness” by feel. 

Perception. Our bodies and brains are pretty good at telling us when something is wrong. Think of it as an internal alarm bell. If we remain inactive, in a static position for long enough the “alarm bell” will remind us to move. The brain sends out a signal in the form of pain, tightness, or both. All the body really wants is a change in position, some dynamic movement, or exercise to create contraction and lengthening of tissues. These strategies for relief aren’t as much about creating mechanical change in tissues as they are about the secondary effects: Increased blood flow to tissues, and novel sensory input to compete with, and in a way, override the alarm bell. 

Can manual therapies like soft tissue mobilization help promote these secondary effects? Yep, they sure can. Is it any better than movement or exercise? According to the available research, no. 

Stay tuned for another post on these secondary effects. We’ll cover how and why manual therapy plays an important role in managing pain, improving load tolerance, and reducing fear of movement.

In the meantime, if you’ve got a painful physical condition that’s been concerning you for a while, come see us for a check-up. Click here to get started.

The MOST effective treatments for musculoskeletal pain: The (latest) research is IN!

A very interesting article came out just recently: “Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence.”1 (Check it out if you like. It’s free.) It attempts to give an overview of the effectiveness of all the various current treatments for neck, back, shoulder, knee, and multi-site pain. The conclusions may be surprising to you

What you don’t know about pain could be making you worse!

What do you know about pain?

It’s quite likely that your understanding of pain is based on the model first proposed by Rene Descartes over 300 years ago. In it a painful stimulus is detected by a special pain receptor and the stimulus is carried upon a nerve to the brain where you feel pain. Descartes described them as tubes that carried the “animal spirit.” We’ve come a long way, but we still have a lot to learn.