Manual Therapy is a Physical Therapy approach that utilizes hands-on techniques to treat orthopedic and neurological impairments. The certified manual therapist will apply specific tissue and joint mobilizations to achieve targeted responses and improve your condition. Expected outcomes include pain management, increased range of motion, reduced soft tissue inflammation, improved contractile and non contractile tissue healing, and improved mobility or stability, and the restoration of movement and function. Certified orthopedic manual therapists complete a two to four year formal curriculum and residency program in addition to earning their aster or doctoral Degree in Physical Therapy. (Pacific Therx, 2006)
The manual therapy was associated with lower direct and indirect costs because manual therapy is often more expensive than other treatments in the Netherlands. But the major cost-saving factor was that the patients in this group recovered quicker and were happy with the results.(Warner, 2003)
Manual therapy is not painful, studies done in Texas show; in fact, manual therapy is more effective in relieving pain than non-steroidal anti-inflammatory (NSAID), muscle relaxants, or painkillers. Additional studies show that manual therapy is faster and more effective than physical therapy alone.
This paper will explore on how the manual therapy used technique to improve mobility and optimal healing joint dysfunction. The passive procedures which the therapist assesses the biomechanics of the joint systems to identify any alterations and restore normal joint motion. It will also introduce the therapeutic exercise for pain and injury recovery which is different than a general exercise program. Each program is designed with controlled dosage and progression tailored specifically to the condition of the patient. Lastly, the therapist will help the patient understand the diagnosis and educate the preventive care and the safe progression of the activities.
Goal of Manual Therapy
One of the the goal of the manual therapy is the evaluation and identification of the existing problem, not an anticipated problem. Second, the evaluation of the potential level of function actually achievable .Third, the restoration up to the level reasonably possible and functions which have been lost due to accident or illness. Fourth, the establishment, to the level reasonably possible, of functions which are lacking due to defects of birth .Fifth, the eventual termination or transfer of the responsibility for identified procedures to family, guardians, or other care-givers.(Physical Therapist Services, 2006)
Another, the decrease in pain and improve range of motion in stiff joints and muscles. Once pain has been reduced and joint mobility improved it is much easier for you, the patient, to regain optimal movement patterns. In short, to do what you love with less restrictions and much less pain (Spine-health Online, 2006)
The ultimate goal of therapy is to return the patient to the full functional and pain free activities of daily living and works as well as participation in the sports and hobbies. to increase the functioning ability of a client with a temporary or permanent disability. (Soma Institute, 2006)
The Effects of Manual Therapy
COPYRIGHT 1992 American Physical Therapy Association, Inc.
Manual therapy encompasses a broad range of techniques that are used to treat neuromusculo skeletal dysfunctions. Manual therapeutic techniques are used to relieve pain and to increase the mobility of joints. The techniques that are specifically utilized to affect connective tissues (CTs) could be generally categorized as either stretching or compression and include massage, facial/tendon stretching, traction, and articulation/thrust (i.e., small-amplitude movements of a joint) techniques. In most cases, patients with joint dysfunction have both pain and loss of motion. Therapeutic intervention is usually designed to treat both problems.
One of the aims of manual therapy is to permanently elongate soft tissues that are restraining joint mobility through the application of specific external forces.
According to Holt in the Sport Supplement (2006) the manual therapy gives positive effects to their athletes’ injury especially in rehabilitation. It benefits them because the therapies included under this rubric are massage, myofascial release, strain-counter strain, joint mobilization, and muscle energy. Each of these has its own uses as a modality, although there is a high degree of mutual utility among them. Here, the focus is on the therapeutic benefits of manual therapies as a group. Specific modalities are appropriately designated as they relate to the beneficial effects of therapy delivered on a manual basis.
The athletic trainers apply a large number of techniques with the ultimate objective of returning athletes to full activity and competition. These techniques, therefore, carry therapeutic benefits when applied to the injured athletes. Manual therapy techniques are no different. When employed as therapeutic modalities, they are useful in terms of the forward end of the treatment-rehabilitation spectrum. That is, manual therapies as modality treatment are generally designed to relieve pain and restore normal range of motion (Denegar, 2000). When used as rehabilitation techniques, the objectives are the restoration of strength and muscular endurance, then the restoration of proprioception and coordination (Houglum, 2000), all directed toward full return to activity. These concepts (modalities and rehabilitation activities) are not mutually exclusive, and are often used together in the treatment of athletes. However, modality application is generally used in the first stages after injury in order to allow maximum benefit from rehabilitative exercise and other activities (Denegar, 2000).
Furthermore, Hutchinson (2004) states that manual therapy, particularly joint mobilization, has been shown to be effective as part of an overall program aimed at increasing range of motion (ROM) in hypomobile joints.18-21 Range limitations may result from trauma, 22, 23 impingement, 18 surgery/cardiac procedures, 24 and pain.25, 26 It is clear, however, that immobility plays a significant role in the development of a hypomobile joint.27-30.
Hutchison added decreased ROM occurs in the HP shoulder poststroke (particularly external rotation),31,32 and a correlation exists between decreased passive and active external rotation motion and the incidence of shoulder pain.32 Rotator cuff tears, impingement, bursitis, and subluxation have all been identified as possible causes of HP shoulder pain which may further limit shoulder motion.27,33-35 However, regardless of the cause of immobility, lack of motion simply contributes to hypomobility in joints, which may lead to capsular restrictions and soft tissue tightening. Such ROM restrictions may be amenable to manual therapy procedures.
Joint mobilization is a hands-on manual therapy designed to restore normal joint play and subsequently normal range of motion. The therapist performs specific passive movement to a stiff joint within or to the limit of a joint’s normal range of motion. (Physiotherapy Works, LLC, 2006)
In treating soft tissues the manual therapy is a good alternative. The specific treatment application of an ache, pain, or injury will be solely reliant on the conclusions reached by the assessments. Any number of treatment techniques may be used to achieve optimal treatment results. Trigger Point techniques provide relief from Myofascial Trigger Points.
Myofascial Therapy, that targets the muscle and fascial systems, promotes flexibility and mobility of the body’s connective tissues. Likewise, it mobilises fibrous adhesions and reduces the severity and sensitivity of scarring caused by injury or surgery. Massage techniques, traditionally known as Swedish Massage, may be used as part of a treatment application. Referred to, in Soft Tissue Therapy, as broad-handed techniques, this mode of treatment aims to reduce swelling and / or inflammation.
Frictions create heat, which in turn provides the impetus for the mobilisation of adhesions between fascial layers, muscles, compartments and other soft tissues. Frictions are also thought to create an inflammatory response that instigates a focus to an injured area, thereby, promoting healing, especially in tendon pathologies. (Makofsky,1985)
Sustained Pressure (ischaemic / digital pressure) alleviates hypertonic (tight) areas within muscle and fascia. Other Techniques such as Active Release Therapy, Myofascial Release and / or Deep Tissue Massage are all combinations of the techniques listed above. These are not unique techniques that have unique or exceptional results.
Generally, any one of these techniques alone, or in combination, may provide the solution to an ache, pain, or an injury. However, claims that any particular soft tissue technique will alleviate a specific condition, predictably, every time, are deceptive.
Joint mobilization can have the following effects:
It gives stretches adhesions in the soft tissue in and around restricted joints. It creates a warming effect in the joint tissue Creates relaxation in surrounding musculature. The decreases pain signals to the brain and stimulates lubrication within the joint and better cartilage nutrition. Stimulates pain relief, increases pro prioception (joint motion sense).Restoration of normal joint motion can result in increased muscular strength. (Physiotherapy Works, LLC, 2006)
Case Studies to Support the Effects of Manual Therapy
This section summarizes two case studies in which some form of manual therapy was used as a therapeutic modality. Obviously, there are many studies that could be cited and reviewed. However, these two provide examples of the use of manual therapy techniques in the healing process of physically active persons.
As reported by Ryterband (2000), a male 50-year old was injured while playing recreational volleyball. The player inverted his right foot when he landed on another player’s foot after a jump. The injury was evaluated as sprains of the anterior talofibular and calcaneofibular ligaments, as well as damage to the distal fibula. There was ecchymosed, swelling, and limited range of motion in dorsiflexion, plantar flexion, inversion, and aversion. Initial treatment included RICE and self-medication with an NSAID. The therapist, a physician, used lymphatic drainage (a compressive massage technique) to reduce swelling and three-planar facial fulcrum release (a combination of myofascial release and joint mobilization) for range of motion. These therapies resulted in significant increase in range of motion for all four restrictions, as well as ambulation without pain. A primary concern of the physician was bruising of the bones (talus and lateral malleolus), which she treated with techniques other than manual therapy. In terms of manual therapy, however, the physician concluded that manual therapy techniques are directly applicable, and should be used with typical ankle injuries.
Lunn (2001) reported the case of an 18-year old male who had reconstructive surgery of the right anterior cruciate ligament following a skiing accident and subsequent re-injury. The patient therefore had considerable restriction in range of motion and muscle strength, as well as concomitant pain. The patient used crutches, toe touch weight bearing only, and no brace. Medication was prescribed for pain. The physical therapist used integrative manual therapy, or a variety of manual therapy techniques used in combination, for initial rehabilitative treatment. The specific techniques used were Jones strain-counter strain, lymph node advanced strain-counter strain, advanced strain-counter strain, myofacial release, bone bruise therapy, disruption of membrane, and neural tissue tension. Home exercises were also performed as directed by the therapist. After two days, there was significant improvement in quadriceps strength, ambulation, and range of motion in hip, knee, and ankle joints, as well as sensory improvement in the affected thigh. Ad additional manual therapy technique, immune deficiency motility, was used to increase quadriceps strength, which had not progressed to the extent as other elements of recovery at 15 days post-surgery. Overall, the integrated manual therapy techniques were successful in rehabilitating the ACL reconstruction.
Another study finds out that Manual Therapy is effective for shoulder Dysfunction/Pain. A study published recently in the Annals of Internal Medicine has found “manual therapy” in conjunction with “usual medical care” to be much more effective for shoulder dysfunction and pain than usual medical care alone. (Bergman GJD, Winters JC, Groenier KH, et al, 2004). Researchers in The Netherlands noted significant improvements in recovery, severity of complaint, shoulder pain and shoulder disability with the addition of a 12-week course of manual therapy.
Below is the comparison of two groups the control group which were given information about the nature and course of shoulder symptoms, along with advice on daily use of the affected shoulder” with prescriptions for “oral analgesics or no steroidal anti-inflammatory drugs (NSAIDs) if necessary.” Control group patients who did improve could receive another two weeks of analgesics or NSAIDs; if this approach was ineffective, they could be given “up to 3 corticosteroid injections.” If improvement remained insufficient two weeks after injections were administered, the injections could be repeated, or patients could be referred for physiotherapy consisting of shoulder exercises, massage, and physical applications. (Bergman GJD, Winters JC, Groenier KH, et al, 2004).
The Patients in the intervention group received usual care and manipulative therapy that included specific manipulations (low-amplitude, high-velocity thrust techniques) and specific mobilizations (high-amplitude, low-velocity thrust techniques) “to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine and upper thoracic spine and adjacent ribs.” (emphasis added) This is an important point, as this study provides evidence that by utilizing spinal manipulation to address shoulder pain and dysfunction, problems in the shoulder (and other extremities) can be addressed through manipulation of the spine. (Barclay and Vega, 2004)
A maximum of six treatment sessions could be given over a 12-week period. While physiotherapists provided the manual therapy, the manipulative techniques used were similar to those commonly performed by doctors of chiropractic. Almost all of the control patients (92%) “were treated with a wait-and-see policy, 28% were treated with corticosteroid injections, and 27% were referred to a physical therapist for a maximum of 9 treatment sessions.” Patients in the manipulative therapy group received similar care, but in addition, they received an average of 3.8 “treatment sessions from a manual therapist.” (Bergman GJD, Winters JC, Groenier KH, et al, 2004).
The differences in results showed substantial improvement for those patients receiving manipulative therapy. (See graphs below.) by Bergman GJD, Winters JC, Groenier KH, et al., 2004
The above figures demonstrated that manipulative therapy for the shoulder girdle in addition to usual medical care by a general practitioner accelerated recovery of shoulder symptoms and reduced their severity. These effects were sustained at 52 weeks of follow-up.
Further case of Dicke, in Belgium he was diagnosed with thromboangiitis obliterans. As a result of this right leg condition, she was bed ridden. She tried to relieve her pain by applying one finger-pressure patterns on the very tense area located just above her sacrum and her right iliac crest. After a while the tension in this tissue decreased significantly. E. Dicke began feeling pins and needles as well as warmth in this lower extremity. She extended her maneuvers to the trochanteric region as well as to the lateral aspect of the thigh. After three months, she observed a disappearance of her symptoms.
In the neurological point of view Dicke said , any organic dysfunction generates an “irritative field” located at the level of the posterior or dorsal horn of the spinal chord. This triggers reactions in the corresponding muscular and cutaneous tissues by way of reflexes and by autonomic system involvement. This “irritable field” permanently sends pathogenic influx to the corresponding organ (Assandri,1965). This is the viscero-musculo-cutaneous reflex. Using manual techniques on the dermal area corresponding to the affected organ, it is possible to have an effect on this organ and to correct the imbalance. This is the cutaneous-musculo-visceral reflex.
If numerous authors have discovered a therapy based on the reflex nature of the relationship between skin and organ, a few of them have understood that such a therapy requires an understanding of neurology. To be effective and not to generate side effects, the reflex manual techniques must obey neurological principles. (Assandri,1965).
Therefore, I can say that manual therapy is an important component of a comprehensive treatment plan that typically integrates hands-on techniques, exercise, and education. Some patients benefit from more manual therapy and less exercise, while others require more exercise than hands-on work. It’s very individualized, depending on the person, the injury, and his or her goals. And while the manual therapist guides and facilitates the healing process, the patient must be willing to enter into an interactive relationship and put forth the effort needed to heal.
Although manual therapies are more extensively used in later stages of rehabilitation, they have definite uses as modalities to reduce pain and increase range of motion in injured tissues. Especially, the use of therapeutic massage, myofascial release, joint mobilization, muscle energy, and strain-counter strain are important for modality application. These therapies are usually used in conjunction with other modalities such as TENS or other non-mechanical techniques (American Academy of Orthopedic Surgeons, 1991), but are often used by themselves in the early rehabilitation of injuries (Denegar, 2000; Lunn, 2001). However they may be used, it is certainly the case that the athletic therapist’s hands have become much more widely employed modality tools in recent years.
“Benefits of Therapy”.(2006). The Soma Institute. December 13, 2006, from http://www.soma.edu/prospective-students-clinical-massage-therapy-main-page.html?source_id=google
“Manual physical Therapy for Pain relief” (2006). Spine-health Online December 13, 2006,from http://www.spine-health.com/topics/conserv/manual/manualtherapy01.html
“Physical Therapy Services.(2006). Independent Physical Therapists. December 13, 2006, from http://health.utah.gov/medicaid/pdfs/PT.pdf
American Academy of Orthopaedic Surgeons. (1991). Athletic training and sports medicine (2nd ed.). Rosemont, IL: American Academy of Orthopaedic Surgeons.
Assandri , Alain (1965). De Sambussy School of Physical Therapy. Paris France. December 13, 2006
Barclay, L. ; Vega, C. (2004). Manipulative Therapy helpful for Shoulder Dysfunction and Pain. December 13, 2006, from http://www.medscape.com/viewarticle/490007?rss
Bergman GJD, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain. Ann Intern Med 2004;141:4320439.
Denegar, C.R. (2000). Therapeutic modalities for athletic injuries. Champaign, IL: Human Kinetics.
Dicke E. (1929). Cutaneous Reflex Manual Therapy. December 13, 2006, from http://www.pacifictherapy.com/cutaneous.asp
Houglum, P.A. (2000). Therapeutic exercise for athletic injuries. Champaign, IL: Human Kinetics.
Hutcjinson, Karen. (2004). Manual Therapy Applied to the Hemiparetic Upper Extremity of a Chronic Poststroke Individual. December 13, 2006, from http://www.findarticles.com/p/articles/mi_qa4108/is_200409/ai_n9434811
Joint Manipulation(2006). Physiotherapy Works, LLC. December 13, 2006, from http://www.physicaltherapyorlando.com/jointmobilization.html
Lunn, L. (2001). Anterior cruciate ligament reconstruction: A clinical profile. December 13, 2006, from
Makofsky, Howard, (1985). Spinal manual Therapy. Decembre 13, 2006, from http://www.slackbooks.com/view.asp?slackCode=45694
Manual Therapy. (2006). Pacific Therx. December 13, 2006, from http://www.pacifictherx.com/what_is_manual_therapy.htm
Rosenberg, Michael. .(2006).The Use of Upper Extremity Joint mobilization . December 13, 2006, from http://www.rehabedge.com/TNS_article1.asp
Ryterband, S. (2000). Case study: Treating an ankle sprain with integrative manual therapy techniques: The role of bone bruise and disruption of membrane techniques. December 13, 2006, from http://www.centerimt.com/e-journal/sarah_r.html
The effects of manual therapy on connective tissue. 1992 American Physical Therapy Association, Inc. December 13,2006 http://www.accessmylibrary.com/comsite5/bin/pdinventory.pl?pdlanding=1;referid=2930;purchase_type=ITM;item_id=0286-137245
Warner, Jennifer. (2003). Hands-On approach effective, and More Cost-effective, than traditional treatment. December 13, 2006, from http://www.webmd.com/content/article/64/72233.htm