The Importance of Combining Manual Therapy with Exercise

The use of manual therapy in some form is common practice in physical therapy and occupational therapy and has been for decades. Common examples of manual therapy (MT) include, but are not limited to:

• soft-tissue mobilization
• massage
• instrument-assisted soft-tissue mobilization
• myofascial release
• muscle energy techniques
• joint mobilizations/manipulations

Historically, MT has often been performed with the assumption that the resulting outcomes are almost always biomechanically-driven. Common clinical explanations used to justify the use of MT often include:

• “put x back in place”
• “re-align vertebrae”
• “correct SI alignment or dysfunction”
• “break up scar tissue”
• “release fascia”
• “break up trigger points”

In reality, though, these statements are not well-supported by the volumes of research that has been conducted in an attempt to understand what happens when MT is performed. There is simply no substantial evidence to support many of the biomechanical claims that we make with regard to MT outcomes.

Despite this, patients often still respond well to MT. But if the biomechanical benefits are not the major driving factor, what other reasons could there be for the positive response? The answer probably lies in two other elements that contribute to MT outcomes: neurophysiological and psychophysiological responses.

Neurophysiological responses refer to changes that occur in the nervous system. The force generated upon tissue during MT stimulates a response in structures of both the peripheral and central nervous systems, which generates some of the outcomes we observe with MT. These can include pain inhibition, varying effects on mechanoreceptors, adjustment of the nociceptor receptor pattern, improved strength/motor control, and reduced overall central sensitization, among others. Evidence suggests that probably the greatest effects from MT occur through these nervous system responses.

Psychophysiological responses encompass mental and emotional processes and changes that are stimulated by MT. This can be seen when a patient has a certain expectation or belief about a treatment process and outcome. The more a patient believes a treatment will help them, the more likely it is to help them. For instance, if a patient believes that a joint “popping” will bring relief, that expectation being met will more likely lead to a positive response. If a patient responded well to a particular treatment in the past, they likely believe that a similar treatment now when they are in pain again would be helpful. However, this could also have the opposite effect; if a patient believes that a treatment is not helpful, or they have had a previous poor experience with that treatment, their negative beliefs about the specific treatment could limit its benefit.

With these ideas in mind, what role does exercise play in treatment alongside MT? An important point to remember is that oftentimes the effects that occur with MT are often temporary and short-lived. As we work to help our clients operate with decreased pain and improved activity tolerance, one of our focuses should be on fostering patient independence and resilience. MT does not really do a good job at either of these things, as the patient can start to view the therapist as the sole source of relief if we’re not careful.

Rather than reinforcing this belief, we should view the use of MT as a chance to temporarily decrease a patient’s symptoms, and use this “window of opportunity” to re-introduce movement or activities that have been troublesome or limited. If a movement or exercise has previously provoked a pain response, the decreased pain after MT gives a chance to attempt that activity again, with pain being less of a limiting factor. If a motion was previously restricted but is now available after MT, that is a great time to introduce movement into that range that was previously limited and instruct the patient on how to maintain that progress. Our goal after performing MT should be to re-introduce load – resistance, motion, stretch, etc. – that will help the patient to return to their prior level of function, and ultimately self-manage their impairments.

Beyond pain or tightness though, there is one other significant limitation or impairment that often hinders a patient from operating normally: fear/apprehension. Painful experiences not only take a physical toll but a mental toll as well. Eventually, the patient may learn to avoid certain movements and therefore avoid pain. The problem is that often these movements are necessary to perform daily tasks and activities. But when faced with the option of hurting more or avoiding an activity, the choice is often made to avoid the painful activity. The original pain stimulus may even subside at some point, but the nervous system continues to overprotect, and now simple movements become challenging.

This is where we have a great opportunity to use MT to provide a “reset,” and allow the re-introduction of movement that has been limited or avoided. One can even think of MT as being similar to a ‘Control-Alt-Delete’ function on your poorly-operating computer: interrupt the faulty programming, and then re-load the programming to perform its intended function. The change in sensory processing from MT gives a window into the nervous system, and a chance to alter motor control with the ultimate goal of a better expression of movement. It tells the nervous system that movement is ok, and should be explored. The goal of exercise then becomes to re-establish and maintain “normal” movement patterns, whatever that may be for the individual patient.

A classic example of this is a patient who had low back pain, along with radicular pain down her leg, that was provoked by forward bending. The patient went to physical therapy and based on her exam findings, she was told to avoid forward bending, and instead use extension-based movements to help calm down her symptoms. This worked well for the patient, her symptoms centralized to her lower back, and she got relief. Unfortunately, the patient moved across the country and didn’t get to the part of rehab where she was supposed to re-introduce flexion. She held the belief that forward bending was problematic, and should be avoided so that she didn’t exacerbate her familiar pain. She found this to be difficult, as lumbar flexion is an essential activity for humans, and pretty soon she began experiencing back pain again, though different than her prior presentation.

She made her way to another physical therapist, and when she was asked to bend forward, she hesitated because of her past experience and what she had been told by another professional. The therapist completed his exam, was unable to provoke any radicular symptoms, and found that pain was only associated with flexion. Explaining the assessment to the patient and getting permission, he performed a lumbar manipulation. After the technique, he had the patient stand up, and encouraged her to try bending forward. The patient reluctantly tried and found that she did not have the pain she expected to have, and furthermore could bend forward more than she thought. Observing this, the patient’s home exercise prescription was simple: find ways to introduce lumbar flexion that are non-threatening and non-painful. Knees-to-chest and cat-camel (quadruped lumbar flexion and extension) were easy options that were tolerated well by the patient, and when she returned a week later after doing these movements at home, her forward bending was improved significantly and her pain reduced. From there, gradually more aggressive flexion movements were introduced, and the patient developed confidence in her ability to bend forward. Eventually, her symptoms were resolved and her function was fully restored.

If the movement had not been attempted after the manual therapy, the patient would not have been able to see the potential she had. If she had not performed daily flexion-based movements after that session, she would not have maintained her gains from the MT performed during the session, and would have returned no better. She would have continued to be limited by pain, and even more, fear of pain.

Manual therapy is a powerful tool at our disposal that can be used to bring relief to our patients. But our manual therapy is only as good as the movement we get the patient to do afterward.

Interested in getting a more up-to-date understanding of the value of manual therapy, and the role that it should play in rehab? Attend my upcoming Live Stream, Evidence-Based Manual Therapy Techniques, on March 10th virtually or in Franklin, TN. This course will review what the evidence currently shows with regard to manual therapy, and the importance of including exercise and movement in any treatment plan to achieve optimal results.

Visit summit-education.com for more information.