Manual therapy has long been a staple in the treatment of musculoskeletal conditions, offering hands-on techniques designed to alleviate pain, improve mobility, and enhance function. While widely practised by physiotherapists, osteopaths, and other healthcare professionals, the value and long-term effectiveness of manual therapy have been the subject of ongoing debate within the medical community.
This blog aims to provide an in-depth exploration of manual therapy, outlining its various techniques, the physiological mechanisms behind its effects, and a critical evaluation of its role in musculoskeletal rehabilitation. By examining both the benefits and limitations, we will assess whether manual therapy should stand as a primary treatment method or serve as a complement to other therapeutic interventions like exercise and education. Additionally, we’ll explore alternative approaches, emphasising the importance of a holistic, patient-centred strategy for managing injuries and pain.
What is Manual Therapy?
Manual therapy is “the use of hands… or a hands-on technique with therapeutic intent”. It involves applying skilled movements to joints and soft tissues such as muscles, ligaments, and fascia. It is frequently used by various healthcare professionals, such as physiotherapists, occupational therapists, osteopaths, chiropractors, and massage therapists. Techniques commonly include joint mobilisations, manipulations, soft tissue massage, stretching or similar. These methods improve blood flow, relieve muscle tightness, and enhance the range of motion. The goal is to reduce pain, improve mobility, and restore function by addressing issues such as joint stiffness, muscle tension, or movement imbalances. Manual therapy is often integrated with other treatments, like exercise therapy, to enhance effectiveness and achieve longer-lasting outcomes.
Types of Manual Therapy
Manual therapy encompasses a variety of hands-on techniques, each designed to address specific issues such as joint stiffness, muscle tension, or soft tissue restrictions. These approaches range from gentle mobilisations to more forceful manipulations, depending on the condition being treated. In this section, we’ll introduce some common manual therapy techniques, explaining how each one works and when it might be used to help improve movement, reduce pain, and restore function.
Joint Mobilisation
Joint mobilisation involves the passive movement of joints to improve mobility, reduce pain, and restore function. This technique is often graded in intensity, from gentle oscillations to more forceful mobilisations. It helps restore the natural movement of a stiff joint and is commonly used for conditions like arthritis, joint injuries, or after surgery.
Joint Manipulation
Also known as “high-velocity, low-amplitude thrust,” joint manipulation is a more forceful, quick movement applied to a joint. The aim is to improve movement and reduce pain. You may hear a “pop” or “click” during the procedure, similar to cracking knuckles. It’s often used in treating neck or back pain.
Soft Tissue Mobilisation
This technique involves applying pressure to the soft tissues, including muscles, tendons, and fascia. It is used to reduce tension, increase circulation, and improve mobility and range of motion. Techniques can range from gentle pressure to more intensive, targeted movements. Soft tissue mobilisation is often used to relieve muscle spasms, or adhesions after injury.
Myofascial Release
Myofascial release focuses on relieving tension in the fascia, the connective tissue surrounding muscles and organs. This hands-on technique involves applying sustained pressure to areas of restriction to improve movement and reduce pain. It is often used to treat chronic pain conditions such as fibromyalgia or postural imbalances.
Trigger Point Therapy
Trigger points are tight bands of muscle fibres that can cause pain and restrict movement. Trigger point therapy involves applying direct pressure to these points to release muscle tension and reduce pain. It is often used for conditions like tension headaches, back pain, or repetitive strain injuries.
Massage Therapy
Massage therapy involves the manipulation of soft tissues to reduce muscle tension, improve circulation, and enhance relaxation. Different types of massage include deep tissue, Swedish, and sports massage, each varying in pressure and technique. It’s commonly used for general muscle stiffness, stress relief, and recovery from injuries.
Muscle Energy Techniques (MET)
In this technique, the patient actively contracts specific muscles while the therapist applies resistance. The goal is to improve the range of motion. MET is often used for joint dysfunction, muscle imbalances, or postural issues.
Passive Stretching
Passive stretching involves the therapist gently moving a patient’s limbs into a stretched position to improve flexibility and reduce stiffness. This technique is often used for people recovering from injuries or surgeries where the normal range of motion is compromised.
Lymphatic Drainage
Lymphatic drainage is a gentle massage technique aimed at stimulating the lymphatic system to remove waste and toxins from the body. It is used for reducing swelling, fluid retention, and conditions like lymphedema.
Proprioceptive Neuromuscular Facilitation (PNF) Stretching
PNF stretching combines passive stretching and isometric contractions. The patient stretches a muscle group, then contracts it against resistance, and finally relaxes the muscle for a deeper stretch. It can improve flexibility and is often used in athletic and rehabilitation settings.
Graston Technique
This technique involves the use of specialised instruments to address scar tissue and fascial restrictions. The tools allow for deeper manipulation of the tissues, which can help to improve movement. It's commonly used in treating chronic conditions like tendonitis or post-surgical scarring.
Each of these manual therapy techniques is tailored to specific conditions and needs and is often used in combination with other treatments like guided exercises to achieve the best possible outcomes for the patient.
Now that we've covered the various manual therapy techniques and how they are applied, it’s important to understand the broader effects these techniques can have on the body. Each method, whether targeting joints or soft tissues, aims to address specific issues like pain, limited mobility, or muscle tension. In the following section, we’ll explore how these techniques contribute to pain relief, improved flexibility, enhanced circulation, and overall relaxation, providing a clearer picture of what manual therapy is used for.
What manual therapy is used for?
Manual therapy involves a range of hands-on techniques that can help address common issues such as pain, restricted movement, and muscle tension. By focusing on specific areas of the body, manual therapy aims to improve function and mobility in a targeted way. In this section, we will explore what manual therapy is used for.
Pain Relief
Manual therapy can reduce pain by targeting specific areas of discomfort. This effect occurs through several mechanisms, including reducing muscle tension, decreasing nociceptive input, pain gate theory (don’t freak out about the scientific words, we will explain their meaning later) and stimulating the nervous system to release endorphins (natural pain relievers). Techniques like joint mobilisation, soft tissue work, and trigger point therapy can help alleviate pain.
Improve Joint Mobility
Joint mobilisation and manipulation restore movement in stiff or restricted joints. By manually moving the joints through a controlled range, manual therapy helps improve the range of movement and stretch the surrounding tissues. This is particularly useful in conditions like arthritis or after injury, where joints become stiff and limited in motion.
Increase Range of Motion
Manual therapy techniques such as joint mobilisation, manipulation, passive stretching and muscle energy techniques help improve flexibility and increase the range of motion in both muscles and joints. By loosening tight muscles and mobilising stiff joints, patients can achieve greater movement, which is crucial for everyday activities and sports performance.
Reduce Muscle Tension
Manual therapy techniques, including soft tissue mobilisation and myofascial release, help relax tense muscles by directly manipulating muscle fibres and connective tissues. This helps relieve tightness and improves muscle function, often leading to a reduction in pain and discomfort caused by muscle spasms or overuse.
Enhance Circulation
Pressure to soft tissues promotes better blood flow to the treated areas. Improved circulation enhances the delivery of oxygen and nutrients to tissues while helping to remove waste products such as lactic acid. This is especially beneficial for healing and recovery from injuries or surgeries.
Reduction of Swelling
Manual lymphatic drainage and other soft tissue techniques help reduce swelling by encouraging the movement of lymphatic fluid. This can alleviate fluid buildup in areas affected by lymphedema, injury or after surgery, reducing discomfort.
Relaxation and Stress Reduction
Manual therapy induces relaxation by activating the parasympathetic nervous system, which helps to lower stress hormones like cortisol. Techniques like massage therapy and myofascial release promote a sense of well-being, reduce anxiety, and help patients feel more relaxed. This may be beneficial for patients dealing with stress-related conditions.
Reduction of Nerve Compression
Manual therapy can relieve nerve compression by reducing pressure on the nerves, particularly in conditions like sciatica. Joint mobilisations and soft tissue work around the affected area help to decompress the nerve, reducing pain, numbness, and tingling sensations.
As we’ve seen, manual therapy involves a variety of techniques aimed at addressing pain, improving movement, and reducing muscle tension. They also produce specific physiological effects that contribute to the relief and improvements patients experience. Now, let’s explore the scientific mechanisms behind these effects to better understand how manual therapy works on a deeper, physiological level.
Physiological Effects of Manual Therapy
A physiological effect refers to the changes or responses that happen in the body as a result of a specific treatment, activity, or condition. These effects are related to how different systems in the body—like muscles, nerves, or blood circulation—respond and function. For example, when you perform exercise, a physiological effect would be an increase in heart rate or muscle strength. In therapy, a physiological effect might be pain relief, improved movement, or better blood flow, all of which are direct responses to the treatment applied.
Manual therapy techniques, whether it is joint mobilisations, massage, myofascial release, or stretching, often share core physiological outcomes. Now, let’s dive a little deeper into the science behind these effects to give you a clearer understanding of how they work.
1. Pain Gate Theory
Joint mobilisation can reduce pain through the Gate Control Theory of Pain. This theory suggests that the spinal cord has a “gate” mechanism that can inhibit or allow the transmission of pain signals to the brain. By stimulating mechanoreceptors (sensory receptors in the joints and tissues) through manual therapy the input from these receptors can "close" the gate, reducing the perception of pain. This helps explain the immediate pain-relieving effect of joint mobilisations.
2. Creep
Creep is the gradual elongation or deformation of connective tissues (like ligaments, tendons, and joint capsules) under a sustained or repeated load. During joint mobilisations, soft tissue manipulation or stretches, the application of a low-level, sustained force over time leads to stretching and elongation of these tissues. This allows for increased joint mobility and flexibility by reducing stiffness.
3. Hysteresis
Hysteresis describes the energy dissipation in tissues when they are cyclically loaded and unloaded, as occurs during joint mobilisation. When tissues are mobilised, some energy is absorbed, leading to heat generation and tissue relaxation. This reduces tissue stiffness and improves elasticity, allowing the joint to move more freely after the mobilisation is complete. Hysteresis contributes to the softening and relaxation of tight tissues.
4. Reduction of Cortisol (Stress Hormone)
Manual therapy, particularly when it reduces pain and improves mobility, can lead to a reduction in cortisol levels. Cortisol is the body's primary stress hormone, and its levels tend to rise with chronic pain and stress.
5. Oxytocin Release
Oxytocin, often called the "feel-good hormone," can be released during manual therapy. This hormone is linked to feelings of well-being and relaxation.
6. Stretch Reflex Modulation
Joint mobilisations can modulate the stretch reflex, which is responsible for protecting muscles from overstretching by triggering contractions. By gently mobilising the joint, the reflex sensitivity can be decreased, reducing muscle tightness and allowing for greater flexibility and improved movement.
7. Decrease in Nociceptive Input
Nociceptors are sensory receptors that respond to painful stimuli. Joint mobilisation can reduce the input from nociceptors by altering the mechanical environment of the joint and surrounding tissues. This decrease in nociceptive input helps lower the sensation of pain, contributing to the overall analgesic effect of mobilisation.
While the physiological effects of manual therapy offer valuable insights into its potential benefits, it’s important to recognise that these effects may not always lead to lasting results. Techniques like joint mobilisation and soft tissue manipulation can create immediate changes in pain perception, tissue flexibility, and muscle relaxation, but the durability of these changes is often limited. Understanding both the benefits and constraints of manual therapy allows for a more balanced view, especially when considering its long-term effectiveness. The next section will critically evaluate the limitations of manual therapy techniques, emphasising the need for adjunctive approaches like exercise to achieve sustained therapeutic outcomes.
It’s not all roses: Critical Evaluation of the Effectiveness of Manual Therapy
Manual therapy is widely used to address musculoskeletal dysfunctions, offering benefits like pain relief, improved mobility, and flexibility. However, these techniques often yield temporary results and require ongoing intervention for long-term effectiveness. Joint mobilisations and soft tissue mobilisations (STM) are commonly applied to reduce pain and restore function, but both techniques primarily provide short-term relief without inducing lasting structural changes. The physiological response of creep, which refers to the elongation of soft tissues under sustained force, plays a role in the short-term effects of manual therapy. This analysis critically examines the underlying mechanisms and limitations of creep, joint mobilisations, and STM, emphasising the importance of combining these approaches with active therapeutic interventions like exercises for sustained outcomes.
1. Creep in Soft Tissue Elongation
Temporary Effects:
While creep can temporarily increase flexibility, tissues tend to revert to their original state once the load is removed.
Tissue Damage Risk:
The amount of load needed for a significant change in tissue can overstretch and damage ligaments or tendons, risking tissue degeneration.
Neurophysiological Factors:
Flexibility gains may result more from changes in muscle relaxation or pain perception than from permanent tissue elongation.
2. Critical Evaluation of Joint Mobilisations
Short-Term Pain Relief:
Joint mobilisations can provide immediate relief by activating pain-reducing mechanisms (e.g., Pain Gate Control Theory). However, this relief is often temporary, lasting hours to days.
Limited Structural Change:
Mobilisations can temporarily increase joint mobility but are unlikely to produce permanent structural changes in tissues without continuous therapy or exercise.
Patient-Specific Factors: Effectiveness varies based on individual factors such as pain tolerance, chronicity of the condition, and neurophysiological responses.
Adjunctive Role:
Joint mobilisations work best when combined with active interventions like exercises, which help maintain mobility and address underlying musculoskeletal issues.
3. Critical Evaluation of Soft Tissue Mobilisations (STM)
Short-Term Relief:
STM provides temporary relief from pain and muscle tension by manipulating muscles and fascia, improving circulation and flexibility.
Lack of Long-Term Changes:
the effects of STM are often temporary without ongoing active interventions like stretching and strengthening exercises.
Psychological and Neurological Benefits:
STM can trigger psychological benefits (e.g., relaxation, sense of well-being) and neurophysiological changes (e.g., pain reduction), but these are usually short-lived.
Inconsistent Results for Chronic Conditions:
STM may not provide lasting relief for chronic musculoskeletal issues, where central sensitisation and neurophysiological factors play a larger role.
Each technique has its strengths in providing temporary relief, but long-term improvements generally require combining manual therapy with active therapeutic interventions like exercises and patient education.
As we delve into the critical evaluation of manual therapy's effectiveness, it's essential to recognise the broader context in which these techniques operate. While manual therapy may offer immediate relief through mechanisms such as pain gate control, creep, and hysteresis, these effects are often transient, necessitating further exploration of alternative or complementary treatment modalities. Understanding the physiological responses involved in manual therapy lays the groundwork for assessing its role in injury management. This prompts a vital question: Is manual therapy truly necessary for treating musculoskeletal injuries, or can other strategies such as education, reassurance, exercise, and lifestyle modifications provide a more sustainable path to recovery? As we examine the appropriateness of manual therapy as a treatment approach, it is crucial to consider individual patient factors and the dynamic nature of musculoskeletal conditions.
Do I need Manual Therapy to Treat my Injury?
Manual therapy is often considered a go-to intervention for treating musculoskeletal injuries, given its widespread popularity among clinicians and patients alike. However, a critical evaluation of its effectiveness raises important questions about its appropriateness as a standalone treatment.
While manual therapy techniques such as joint mobilisations and soft tissue mobilisations can provide immediate pain relief and enhance mobility, their benefits tend to be short-lived. Evidence suggests that while these techniques may alleviate symptoms temporarily, they do not produce lasting structural changes in tissues without ongoing interventions, such as exercise or rehabilitation. This transient nature of relief raises the question: should manual therapy be the primary or sole treatment approach for musculoskeletal injuries?
One significant consideration is the variability in patient responses to manual therapy. Individual factors such as pain tolerance, the chronicity of the condition, and underlying psychological aspects can influence the effectiveness of these techniques. For instance, patients with chronic pain conditions may experience limited benefits from manual therapy alone, as their pain may be more influenced by neurophysiological factors rather than just physical tissue damage.
Moreover, reliance on manual therapy can risk creating a dependency among patients, where they may expect immediate relief without engaging in active self-management strategies. This dependency can hinder long-term recovery and rehabilitation, as effective treatment of musculoskeletal injuries often necessitates a multifaceted approach that includes patient education, exercise, and lifestyle modifications.
Furthermore, there are potential risks associated with manual therapy, such as tissue damage from excessive force or inappropriate techniques. Clinicians must exercise clinical reasoning to determine when manual therapy is appropriate and when it may be contraindicated. Clinical reasoning is the cognitive process that healthcare professionals use to assess, diagnose, and manage patient problems. It involves gathering information from patient history, physical examination, and diagnostic tests, interpreting this data, and applying relevant clinical knowledge to make informed decisions about patient care. Clinical reasoning is both analytical and intuitive, requiring the clinician to integrate evidence-based knowledge, experience, and patient preferences to provide optimal treatment. It is a dynamic process that involves continuous reflection and adaptation based on patient outcomes. Not all musculoskeletal injuries respond favourably to manual techniques, and sometimes other modalities, such as modalities for pain control, strengthening programs, or functional training, may be more suitable.
In conclusion, while manual therapy can be a valuable component in the treatment of musculoskeletal injuries, it should not be viewed as a one-size-fits-all solution. A comprehensive approach that integrates manual therapy with active interventions, patient education, and self-management strategies is crucial for optimal outcomes. Clinicians must engage in thoughtful clinical reasoning to tailor treatment plans to each individual's needs, ensuring that manual therapy is employed sensibly and effectively within the broader context of musculoskeletal rehabilitation.
How can Physiotherapy without Manual Therapy work?
When addressing musculoskeletal (MSK) conditions, effective treatment often extends beyond manual therapy. While hands-on interventions can offer temporary relief, long-term recovery and sustainable outcomes are frequently achieved through a more comprehensive, patient-centred approach. In this section, we will explore the critical role that education, exercise, lifestyle modifications, and pain management strategies play in empowering patients to manage their own recovery. By understanding their condition and actively participating in their rehabilitation, patients can not only alleviate their symptoms but also prevent future injuries, fostering lasting health and well-being. Let’s dive into how these elements contribute to successful MSK treatment.
Education and Reassurance:
Understanding the condition can significantly reduce anxiety and fear of movement. Providing education about the nature of the injury, expected recovery time, and self-management strategies can empower patients to take an active role in their recovery.
Exercise:
Tailored exercise programs are foundational in treating MSK conditions. Strengthening, stretching, and functional exercises can improve mobility, enhance strength, and promote healing. Exercise is often essential for long-term recovery and preventing future injuries.
Lifestyle Modifications:
Addressing factors such as ergonomics, posture, and activity levels can play a significant role in managing MSK issues. Encouraging lifestyle changes, such as incorporating regular physical activity and maintaining a healthy weight, can contribute to better outcomes.
Pain Management Strategies:
Techniques like cognitive-behavioural therapy (CBT), mindfulness, and relaxation techniques can help in managing chronic pain conditions by altering the patient's perception of pain and reducing stress.
Self-Management:
Encouraging patients to take responsibility for their own health through self-management techniques can be highly effective. This might include using heat or cold therapy, practising good sleep hygiene, and staying active.
While manual therapy can provide benefits for certain conditions and individuals, a comprehensive, multimodal approach that includes education, exercise, and lifestyle modifications can often lead to successful outcomes without the need for manual interventions. Ultimately, treatment should be individualised based on the patient’s specific needs and preferences.
Conclusion
In conclusion, manual therapy remains a valuable tool in the management of musculoskeletal conditions, providing immediate relief from pain and improving joint mobility. However, its effects are often temporary and should not be viewed as a standalone solution for long-term recovery. The physiological mechanisms behind manual therapy, such as creep and pain gate theory, offer insight into its immediate benefits, but these must be supplemented with active interventions like exercise, education, and lifestyle modifications to achieve lasting outcomes.
While manual therapy can play a role in the initial stages of treatment, particularly in reducing discomfort and restoring movement, the true key to sustainable rehabilitation lies in empowering patients to actively manage their own recovery. A comprehensive approach that integrates manual therapy with patient-centred strategies—focused on self-management, physical conditioning, and behavioural change—offers the best path to preventing recurrence and ensuring long-term health. As such, clinicians must apply manual therapy sensibly combining it with a broader treatment plan tailored to the individual needs of each patient.
References
Bialosky, J. E., Bishop, M. D., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, 14(5), 531-538. https://doi.org/10.1016/j.math.2008.09.001
Cassar, M. P. (1999). Handbook of clinical massage: A complete guide for students and practitioners. Churchill Livingstone.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2021). Advanced health assessment & clinical diagnosis in primary care. Elsevier.
Evidence review for manual therapy for chronic primary pain. Nice, 2021.
Field, T. (2010). Touch for socioemotional and physical well-being: A review. Developmental Review, 30(4), 367-383.
Koes, B. W., van Tulder, M., & Thomas, S. (2006). Diagnosis and treatment of low back pain. BMJ, 332(7555), 1430-1434. https://doi.org/10.1136/bmj.332.7555.1430
Lederman E. (2015). CPDO Online Journal. A process approach in manual and physical therapies: beyond the structural model. 1-18
Lederman E. The Science & Practice of Manual Therapy. 2nd ed. London. Elsevier. 2005
McCracken LM, Turk DC. Behavioural and cognitive-behavioural treatment for chronic pain—Outcome, predictors of outcome, and treatment process. Spine. 2002;27:2564–2573. doi: 10.1097/01.BRS.0000032130.45175.66.
McEwen, B. S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87(3), 873-904.
Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150(3699), 971-979. https://doi.org/10.1126/science.150.3699.971
Sharman, M. J., Cresswell, A. G., & Riek, S. (2006). Proprioceptive neuromuscular facilitation stretching: Mechanisms and clinical implications. Sports Medicine, 36(11), 929-939.
Vicenzino, B., Hing, W., Rivett, D. A., & Hall, T. (2012). Mobilisation with movement: The art and the science. Churchill Livingstone.
Comments