There’s a civil war raging among outpatient therapists. A classic “us” vs “them” storyline for the ages. . . Manual-based therapists vs exercise-based therapists. Yeah I am being a tad dramatic here, but the arguments on social media between these two groups ARE dramatic.
Not sure when it happened, but using manual therapy in PT practice became controversial and polarizing. Especially if you used it a lot. It also seemed you had to pick a side. If you work in outpatient you are either exercise-based or manual-based. Now I’d say most of us fall somewhere in the middle, but maybe gravitate towards one or the other. Personally I’d say I gravitate more towards exercise based. HOWEVER, that doesn’t mean I never use manual therapy or think therapists that do use these techniques aren’t good at their job.
Let’s settle this manual therapy debate once and for all. Why some PT’s hate it, what it does and doesn’t do, and it’s place in PT practice
How Did Manual Therapy Become the Villain?
You know what they say – die a hero or live long enough to become the villain. That’s definitely what happened in the case of manual therapy. I’ve only been a PT for five years, so I’m not completely aware of when this change took place. PT definitely goes through its own fads and trends. When I was in school my professors taught manual techniques as an integral part of PT practice. They taught us Maitland techniques, Mckenzie theories, etc.
As time went on though, more research showed the long term benefits of manual therapy was minimal. Inversely, research found loading musculoskeletal structures did more in terms of lasting results. The focus on using evidence-based practice grew more with the transition of MPTs to DPTs. This transition also placed emphasis on PTs making sure we were viewed as more than glorified massage therapists.
People started to further research manual therapy and then found we weren’t actually lengthening tissues, putting joints back in place, or releasing muscle knots. This enforced the idea that it was a sham or only produced a placebo effect.
All these factors combined to make manual therapy considered more of a passive, non-skilled, non-effective treatment. I think this can be true when it’s used incorrectly. Before we get into that though, we need to discuss what manual therapy actually does and doesn’t do.
What Does Manual Therapy Actually Do?
Let’s get one thing clear right now. Manual therapy does not, I repeat, DOES NOT actually change the configuration, alignment, or length of tissues and joints. If all it took was some manual pressure to change all that then every NFL player would literally be dead. Now just because manual therapy doesn’t do this stuff, doesn’t mean it doesn’t do anything or can’t have some benefits.
What it CAN do is modulate pain through a number of mechanisms.
Through peripheral mechanisms, manual therapy can decrease inflammation and edema through changes in blood flow and inflammatory markers such as cytokines.
Decreased inflammation is obviously a good thing since that leads to decreased pain and better muscle function.
Positive benefits of manual therapy through spinal mechanisms such as pain control gate theory inhibit nociception and its neuromuscular responses such as hypersensitivity and muscle spasms. If we can make a patient less sensitive using manual techniques because of inhibited nociception that’s great. Typically a less sensitive patient is able to tolerate more exercise, get stronger, and achieve their goals.
Lastly, there is a psychological mechanism through affecting hormones such as dopamine and endogenous opioids. Some studies have shown touching, physically laying hands on the patient, leads to better outcomes. It’s not uncommon for our patients to go to several doctors appointments without anyone putting their hands on them. Many times I’ve heard a patient say “I was in there for five minutes and they barely even touched me during the examination.” Performing even a little manual on a patient can switch that narrative, build some trust between you and your patient, release some dopamine, and makes them feel a little less painful overall.
I highly recommend this video from Physiotutors that does a quick outline on what manual therapy does and doesn’t do if you want a little more context. Honestly each of these mechanisms alone could be its own blog post. Bottom line though, manual therapy does have some significant benefits when it comes to pain modulation which we sometimes need in order to get patients to progress.
Who Benefits the Most from Manual Therapy?
Manual therapy definitely has its benefits, but it’s not necessary for everyone. There are, in my opinion, a few groups who benefit more from manual therapy than others.
The first being athletes and other highly active individuals. A lot of the time, this population is getting enough exercise and loading outside the clinic. At a certain point you reach a loading threshold where it’s no longer therapeutic.
Did any of you watch the Quarterback documentary on Netflix? It was super interesting to see how those guys trained and recovered. I did see a fair amount of rehab professionals online bashing some of the PTs that treated the players using “passive” treatments. Here’s my thing though – those guys just spent the last day getting hit non-stop for 3 freaking hours. I think they’ve “loaded it up” plenty after getting hit by that 250 lb lineman. They don’t need anymore. What they do need is to recover quickly so they can do it all over again the next week.
When it comes to athletes and active individuals, a lot of time we’re looking for inflammation and pain reduction so they can keep participating in the things they love. As discussed earlier, manual therapy can do that. Here’s a great article I found on the use of manual therapy in sports. It even talks about the two sides of “active” vs “passive” therapies and is definitely worth a read.
The second group that benefits from manual falls at the opposite end of the activity spectrum. I’m talking about extremely low-level hypoalgesic patients. HOWEVER, I do put a big fat asterisk on it. I think introducing and using manual therapy with this group requires a little more finesse than with an active population.
When I say use manual therapy for this group I mean after you’ve tried the lowest of the low exercises or if they’ve really plateaued in the level of exercises they’re able to tolerate. If they’re the kind of patient where they’re reporting 10/10 pain with the easiest exercises or say they can’t continue multiple exercises due to too much pain, some manual therapy prior may be the right move.
I would advise not doing a whole session of manual therapy or using it every session. These patients can very easily become reliant on this and it becomes all they want. Manual therapy will only take them so far though and the benefits are short lived. Be very upfront about this. Frame manual therapy as a tool being used in order to help them tolerate more exercise and activity. I also find teaching some self-soft tissue techniques using a tennis ball, roller stick, or other tool reinforces the message of self efficacy and that they don’t need me in order to get similar results. Hopefully they do it outside the clinic as well so then you can spend less time on manual therapy and get to the good stuff in following sessions.
This by no means covers all situations where manual therapy is warranted. These are just two I’ve found it particularly helpful. In your practice, what situations do you find manual therapy the most helpful in? Share in the comments section.
Finding the Balance
In my opinion, manual therapy has its place in PT, but definitely shouldn’t be the primary tool in the toolbox. If you’re someone frequently using manual techniques for entire sessions, every session, I encourage you to ask yourself “why?”. There is something to be said for evidence-based practice which says manual therapy benefits are short-lived and may not get the functional results we aim to achieve.
On the other hand, if you never use it, I encourage you to be open to putting it in your toolbox. Even if it sits at the bottom. If PTs who overuse manual therapy make PTs look like glorified massage therapists, then PTs who only use exercise make us look like glorified personal trainers. Part of what sets PTs apart is being able to use BOTH of these and find the appropriate balance between the two.
So where do you sit in the great divide?? Do you gravitate towards the manual or exercise side and how much? What’s your overall opinion of manual therapy and where do you find it most helpful? If your opinion is negative, why? If not, what are some of your favorite manual techniques? Let’s get a discussion going so we all can find a good balance, become better at what we do, and get patients better faster.
I’ll be sharing some of the ways I teach patients self soft tissue techniques on Instagram in the next couple weeks so make sure you’re following @the_pt_page. If you missed the last post you can catch up on it here. Hit subscribe below to get all new blog posts directly to your inbox to stay up to date on all things PT.
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