Manual therapy is under fire. The research continues to show that we as clinicians are not great at palpation, our interventions are not targeting the specific joints that we think they are, and we are not getting any long term benefits from this type of treatment. So it is settled: no more manual therapy . . . Yeah, I’m not too sure this is a great idea.
Most seasoned PTs know at this point that there are many benefits to manual therapy that cannot necessarily be proven with the current body of research on the topic. We know that there is a huge psychological benefit to manual therapy. It helps our patients to gain trust in us and it helps them feel better physically. What else do we need? Now, I am not saying we should be doing the most basic forms of manual therapy for every patient we encounter. It is great to use advanced techniques because it shows the patients we care enough to learn highly skilled manual techniques in an effort to improve joint mechanics and help relax tissues.
If there is one thing the research has shown numerous times it is that manual therapy combined with corrective exercise is more effective for short and long term outcomes for many musculoskeletal conditions than corrective exercise or manual therapy alone. Yes, the psychological benefit and the short term physical benefit does make a difference down the road. Why is this? One part of this equation that we haven’t discussed above is neuroplasticity.
Neuroplasticity and range of motion
Let’s consider a patient encounter: 45 year old patient with chronic “frozen shoulder” decides it is time to come to PT after spending 2 years complaining about how they cannot get their arm above their head or cannot tuck their shirt in the back of their pants in the morning. What do you think their neural map looks like at this point? I’d say their “homunculus” would look a bit more awkward than it already does.
Consider the fact that this person has not had the ability to move through normal range of motion for 2 years. This will lead to changes in the cortical mapping of the primary motor cortex that represent the arm and hand. We would expect this representation to decrease since there is no need for the brain to hold this information any longer. According to the nervous system, this “frozen shoulder” is the patient’s new range of motion.
By performing our manual techniques on these patients, we are temporarily improving range of motion, therefore allowing the patient to move through a larger range of motion with their corrective exercise program. Over time, this will lead to improved cortical representation of this motion. This is why we should be using the best manual techniques we have available to us on these patients.
Some clinicians who consistently turn to the research for answers may begin to believe that manual therapy is not worth their time and that they shouldn’t be wasting precious minutes on it.
I agree to a certain degree that if we have patients who have full range of motion, have no associated anxiety or stress toward their recovery, and are self-motivated that this would be the best option for us. How many patients like this do you currently have on your caseload? I would assume the answer is “not many.”
My hope in writing this article is that you keep up with the research, but you are more careful in how you interpret the results. Just because the research consistently reports that there are no long term benefits of manual therapy alone does not mean that it is a useless tool. It is okay to use anecdote and personal experience to make clinical decisions. We have the research so that we can use this as a piece of the treatment puzzle in combination with our experiences and what we’ve learned from other clinicians.
Spinal Manipulation/Grade 5 Joint Mobilization
Now that we’ve got all that out of the way, I would like to spend the rest of the article discussing spinal manipulations. One interesting observation I’ve made about manipulations is that people either fear them or crave them. I, myself crave a good thoracic manip after a long day of treating patients.
Manipulations tend to give people a sense of instant gratification after feeling like they are “stuck” or “stiff” in certain areas of the spine. Others fear these manipulations because they don’t like the idea of getting their joints “cracked” or have had a bad experience with a chiropractor in which they had pain following a manipulation. This is why education and proper execution are key.
Manipulations, or grade 5 mobilizations as physical therapists may call them, are meant to be performed at low amplitudes using quick, high velocity thrusts. The low amplitude is the part that inexperienced therapists tend to forget. There have been many studies on the safety of using manipulations that have found little to no adverse effects from manipulation to cervical, thoracic, or lumbar regions. An estimated injury rate ranges from 1 in 200,000 to 1 in several million cases according to Thiel, et al.
Performing spinal manipulations requires a fairly high degree of skill and many hours of practice to earn proficiency. The real question here should be “is it worth learning how to perform these manipulations if the research tells us they only provide temporary relief?”. I’ll leave that question for you to answer at the end of this article.
Patients who are candidates for manipulations may also find relief from other manual therapy techniques such as joint mobilizations, PROM, active release, and muscle energy techniques, however this feeling of relief may come much sooner with a manipulation in certain cases. In my experience, people who present with a facet joint dysfunction and are feeling “stuck” in one position will tend to feel relief sooner from a manipulation versus performing active range of motion or receiving manual joint mobilization. It’s up to you to be the judge here.
Patients who exhibit yellow flags (high anxiety levels, fear avoidance behavior) may not be the greatest candidate since they may feel anxious about the technique or be upset about potentially feeling soreness afterward. For these patients, I prefer to use muscle energy techniques. If these techniques are unsuccessful, I will use other therapeutic techniques such as education on proper diaphragmatic breathing (can realistically be used for anybody exhibiting poor breathing patterns and muscle tension), active range of motion, mobilization, and PROM.
Some things to consider…
We are the movement experts of the healthcare field. Corrective exercise should always be the most important tool in our toolbox. If we have patients who come see us and only want a manipulation or any other form of manual therapy, we must be cautious of them becoming dependent on these techniques for pain relief. Patients should be weaned off of manipulations and manual therapy in general. We should be empowering our patients to take as active a role in their therapy as possible. We are giving them the tools they need to manage their symptoms and improve upon their condition.
Let’s consider this from a business perspective. You own a small clinic and would like to retain the patients you evaluate who seem skeptical of your new business or physical therapy in general. What would convince the patient to return to the clinic for subsequent sessions more than significant relief from symptoms after one session? While there are many other ways to help your patients feel relief during the first session, a manipulation may be your best option for patients who are good candidates.
In the beginning of this article, I spoke about neuroplasticity and rewriting the maps in the primary motor cortex. Using this ideology, the ideal use of manipulation should be for addressing restrictions in AROM. The patient should then follow this technique with AROM or self-mobilization techniques, and then stabilization exercises. This order will ensure that the patient is providing their central nervous system with enough input to achieve a more permanent effect on range of motion with repetition over time.
- Manipulation can be a useful tool for physical therapists in conjunction with corrective exercise despite the poor research on long-term outcomes when performed as the sole treatment
- Manual therapy should be used as a supplement to corrective exercise to help get patients better and make them more responsible in their care
- Understanding and actively seeking out the research is important but making patients feel better is a top priority in our plan of care
- If you aren’t proficient or confident in performing manipulations, do not use them
- There are many alternative ways to mobilize a joint besides using manipulations
- Be aware of yellow flags when performing these techniques
- Consider the concept of neuroplasticity while creating a treatment plan
- There can be a strong psychological benefit to manual therapy
- Manipulation may provide quick relief of stiffness and pain for patients with facet dysfunction
- We are in the business of helping people function better, but also feel better
A brief summary of the current research…
Dorron et al. found that one session of spinal manipulation to the lumbar region using the L5-S1 side-lying technique led to significant improvements in pressure pain threshold and pin prick sensitivity locally and even peripherally for up to 30 minutes post session. Why should PTs find this useful? Well, this would be a great time to use corrective exercise to address the patient’s impairments now that they feel less pain. We should use this temporary state of hypoalgesia to our advantage.
Jull et al. compared the effects of manipulative therapy, exercise therapy, and a combination of both therapies on the duration, frequency, and intensity of cervicogenic headaches. They found that all therapies significantly reduced symptoms as compared to the control group, however at the 7 and 12-month follow-ups, the combined therapies group proved to be superior to all other groups. One interesting finding was that the exercise therapy group was no better than the manipulative therapy group for improving headache duration. We as PTs understand that corrective exercise is king, but don’t these results speak to the effects of manual therapy on some level?
Schiller compared the effects of thoracic manipulation and placebo ultrasound treatment on subjective pain measures and range of motion. She found that there were significant differences in percentage of pain directly after the session in favor of manipulative therapy, however there was no difference in perceived pain at the one-month follow-up assessment. Interestingly enough, she found that the manipulative therapy group had improved in their lateral flexion measurements compared to the placebo group. There was no difference in flexion, extension, or rotation ranges of motion. I would have liked to see a group who performed corrective exercise… Unfortunately, the research is truly lacking on the category of thoracic manipulations in general.
Walker et al. found that a program including manual therapy (manipulation, mobilization, soft tissue work) plus corrective exercise was better at improving pain, disability, and perceived recovery in patients with mechanical neck pain at short and long-term follow-ups versus a group that received advice, one mobility exercise, and subtherapeutic ultrasound. I included this study to backup a claim I made in the introduction paragraph to this article about how numerous studies have shown short and long term improvements from a combined program.
Vieira-Pellenz et al. found that there were short term improvements in pain perception, spinal mobility, SLR test mobility before onset of pain, and recovery of disk height after manipulations to the L5-S1 region in patients with diagnosed lumbar degenerative disk disease. Sounds like an excellent precursor to corrective exercise… but let’s not jump to conclusions. Please note that this study did not include a long term follow-up session.
Hegedus et al. studied the effects of a single session of on skin conductance and skin temperature changes. They found that in asymptomatic subjects, there was a significant change in skin conductance, but not temperature. They also noted that this change in conductance lasted a maximum of 10 minutes. Further studies are needed on this topic, but the researchers were trying to connect manipulation/mobilization with a sympathetic nervous system response by measuring local skin conductance and temperature. They discuss how improvement in these parameters could potentially mean that manipulation stimulates the dorsal peri-aqueductal (dPAG) matter of the midbrain, which typically produces analgesia, sympathoexcitation, and motor facilitation. If manual therapy can stimulate the dPAG directly, then it should produce pain relief. Just some food for thought...
Dorron, S. L., Losco, B. E., Drummond, P. D., & Walker, B. F. (2016). Effect of lumbar spinal manipulation on local and remote pressure pain threshold and pinprick sensitivity in asymptomatic individuals: a randomised trial. Chiropractic & Manual Therapies, 24(1). doi:10.1186/s12998-016-0128-5
Hegedus, E. J., Goode, A., Butler, R. J., & Slaven, E. (2011). The neurophysiological effects of a single session of spinal joint mobilization: does the effect last? Journal of Manual & Manipulative Therapy, 19(3), 143-151. doi:10.1179/2042618611y.000000000
Jull, G., Trott, P., Potter, H., Zito, G., Niere, K., Shirley, D.,Richardson, C. (2002). A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine, 27(17), 1835-1843. doi:10.1097/00007632-200209010-00004
Schiller, L. (2001). Effectiveness of spinal manipulative therapy in the treatment of mechanical thoracic spine pain: A pilot randomized clinical trial. Journal of Manipulative and Physiological Therapeutics, 24(6), 394-401. doi:10.1067/mmt.2001.116420
Thiel, H. W., Bolton, J. E., Docherty, S., & Portlock, J. C. (2007). Safety of Chiropractic Manipulation of the Cervical Spine. Spine, 32(21), 2375-2378. doi:10.1097/brs.0b013e3181557bb1
Vieira-Pellenz, F., Oliva-Pascual-Vaca, Á, Rodriguez-Blanco, C., Heredia-Rizo, A. M., Ricard, F., & Almazán-Campos, G. (2014). Short-Term Effect of Spinal Manipulation on Pain Perception, Spinal Mobility, and Full Height Recovery in Male Subjects With Degenerative Disk Disease: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation, 95(9), 1613-1619. doi:10.1016/j.apmr.2014.05.002
Walker, M. J., Boyles, R. E., Young, B. A., Strunce, J. B., Garber, M. B., Whitman, J. M., Wainner, R. S. (2008). The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain. Spine, 33(22), 2371-2378. doi:10.1097/brs.0b013e318183391e
Xia, T., Long, C. R., Vining, R. D., Gudavalli, M. R., Devocht, J. W., Kawchuk, G. N., . . . Goertz, C. M. (2017). Association of lumbar spine stiffness and flexion-relaxation phenomenon with patient-reported outcomes in adults with chronic low back pain – a single-arm clinical trial investigating the effects of thrust spinal manipulation. BMC Complementary and Alternative Medicine, 17(1). doi:10.1186/s12906-017-1821-1