Manual Therapy: Optional but Often Times Optimal
I am a retired physiotherapist who, for the last 30 years of a 50-year career, provided manual therapy for pain.
I loved the way it shortened recovery after injuries or helped people with pain problems they had had sometimes for years and were tired of dealing with.
I love manual therapy, period: It is the only thing that ever helped me with my own various physical “pains” in life that I couldn’t manage by myself, including both knees, a frozen shoulder, a whiplash event, low back pain and upper back pain (not all at once thank goodness!).
Manual therapy has usually been taught procedurally, loaded with assumptions to do with changing structural tissue (disproven; 1, 2, 3) or joint positions (disproven; 4, 5), without any regard for learning about the sensory nervous system or even much about pain. As a result, manual therapists usually see themselves as “operators” who do things “to” people, often just hit or miss. The hits feel great but the misses not so much.
My project involved changing that attitude in myself; I worked to become more intelligent with my hands, learn to feel through them instead of regarding them as tools or what they could accomplish as somehow magical. It included learning to recognize better which sorts of pain problems would respond to manual therapy and which ones wouldn’t. It included learning that it wasn’t about “me.” At all.
Becoming an avid reader of pain science helped. Learning all about neurodynamics (6, 7, 8), the sensory nervous system (9, 10), nerve physiology (11), and cutaneous nerves. If the human brain is the most complex object in the known universe (12), it made sense to me that maybe it was entirely self-corrective, but on occasion perhaps needed physical contact with another human brain, through hands-on. Perhaps a brain in someone who considered the entire nervous system from skin cell to sense of self (13), as needing just a bit more information so it could solve a problem within itself.
I called this approach “interactive” as opposed to operative (14, 15).
There are a lot of pain conditions that manual therapy is unable to affect. However, there is one kind it is brilliant for: pain that is confined to a limb or region (doesn’t spread), and changes with position/use or rest, commonly referred to as “mechanical” (which I think is simple neuritis secondary to neural deformation) (16, 17). For that kind of pain problem, manual therapy is an obvious answer.
Luckily, it seems to be the most common kind of persisting pain. I think it explains why, as manual therapists, we exist in such large numbers in our various professions.
I adopted physical, interactional attitudes which I am quite sure improved the success rate a lot. Here are 12 things that I did:
- Deleting all the “tissue-based” ideas I had ever entertained because someone else had thought they were important.
- Way more listening/way less talking. (18, 19)
- Completely non-nociceptive handling of somebody’s body. Telling them beforehand that I was not going to hurt them. And if I did, to tell me right away so that I could adjust my grip or angle.
- Much slower, much lighter, much kinder, much more responsive handling.
- Way more static holding of a person’s skin organ or body part in a position that allowed them to not have to feel the pain they had brought with them. New space to move into, perceptually, sensorially.
- Anything that made my physical exertion during treatment more minimal. (I became a big fan of using hand-size chunks of Dycem).
- Low angle of contact (non-perpendicular), waiting for “grippage” to occur naturally before proceeding to very slow sliding of skin organs away from sore spots.
- Involving the patient in their own treatment by putting them in charge of telling me what they were sensing in their body as we went along.
- Making sure they understood they had “locus of control” over the handling they were sensing and perceiving.
- Giving them room to choose from options: “Which way feels best to you? If I move your skin nerves this way… or this other way?”. Giving them time inside their own nervous system to choose. I think asking their opinion and choosing something made them focus their attention and hold it there.
- All geared toward affording them an opportunity to just feel themselves/their physicality differently, encouraging them to focus on what felt different to them in an attempt to anchor interoceptive changes in their minds.
- Asking them, at the end, “Does it feel like there is more room in there for you, now?
I systematized all this into an approach completely void of structural tissue concerns, that I called dermoneuromodulating – skin, nerves, change. Not me changing anything, rather their nervous system changing itself via the sensory nervous system, self-correcting with a little help from a friend (20).
For about a decade I traveled and taught this approach, and now others are teaching it in various countries around the world. My hope is that in its own small way it can help manual therapy improve its outcomes.
If you’re interested in learning more about manual therapy, here at Physio Network we have teamed up with Dr Mark Bishop to produce a 2hr Masterclass for you – Manual Therapy in the 21st Century. Be sure to check it out!
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- Threlkeld, A.J., 1992, The Effects of Manual Therapy on Connective Tissue. Physical Therapy Dec. vol. 72 no. 12 893-902
- Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M., and Findley, T., 2008, Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. Aug;108(8):379-90
- Downey, P.A., Barbano, T., Kapur-Wadhwa, R., Sciote, J.J., Siegel, M.I., and Mooney M.P., 2006, Craniosacral therapy: the effects of cranial manipulation on intracranial pressure and cranial bone movement. J Orthop Sports Phys Ther. Nov;36(11):845-53.
- Tullberg, T., Blomberg, S., Branth, B., and Johnsson, R., 1998, Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 23:1124–1128.
- Wellens, F., 2010, The traditional mechanistic paradigm in the teaching and practice of manual therapy : Time for a reality check. www.physioaxis.ca
- Butler, D.S. (Author), 2000, Sensitive Nervous System. Noigroup Publications; 1 edition January 1
- Shacklock, M. 1995, Neurodynamics. Physiotherapy, Jan. Vol 81 No 1 p9-16
- Shacklock, M., 2015, Nerve movement in 2015 – 20th Anniversary of neurodynamics in physical and manual therapy. Neurodynamic Solutions newsletter, Dec
- Smith, C.U.M. (Author), 2008, Biology of Sensory Systems. Chapter 3 pp31-39
- Ossipov M.H., (Author), 2009, Pain Pathways: Descending Modulation. Pp.393-399; Squire, L.R., (Editor), Encyclopedia of Neuroscience, Elsevier Ltd
- Jacobs, D.F., 2016, REFERENCES for NEURONS, NERVES and TUNNEL SYNDROMES. Google doc
- Christof Koch, 2013, Decoding the Most Complex Object in the Universe, NPR Science podcast June 14, 2013
- Jacobs, D.F., 2011, What is the operator model? What is the interactor model? Google doc.
- Jacobs, D.F., and Silvernail, J.L., 2011, Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. May; 19(2): 120–121.
- University of Alberta, 2013, Physiotherapy patient interaction a key ingredient to pain reduction, research says. June 5, Medical Xpress. Retrieved May 8, 2016.
- Note regarding “Neuritis”, IASP taxonomy page, http://www.iasp-pain.org/Taxonomy#Peripheralneuropathicpain
- Pećina, M.M., Krmpotić-Nemanić, J., Markiewitz, A.D., (Authors), 2001, Tunnel Syndromes. CRC Press; 3 edition, August 16
- Benedetti, F., Lanotte, M., Lopiano, L., and Colloca, L., 2007, When words are painful: Unraveling the mechanisms of the nocebo effect. Neuroscience 147 p.260 –271
- Colloca, L., and Benedetti, F., 2007, Nocebo hyperalgesia: how anxiety is turned into pain. Curr Opin Anaesthesiol. Oct; 20(5):435-9
- Jacobs, D.F., 2016, DermoNeuroModulating. Chapter references.
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