Manual Therapy

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Description

Manual therapy has a long history within the profession of physical therapy and physical therapists have greatly contributed to the current diversity in manual therapy approaches and techniques. Mechanical explanations were historically used to explain the mechanisms by which manual therapy interventions worked, new research reveals intricate neurophysiologic mechanisms are also at play and the beneficial psychological effects of providing hands-on examination and intervention should not be ignored.

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) defines manual therapy techniques as: “Skilled hand movements intended to produce any or all of the following effects: improve tissue extensibility; increase range of motion of the joint complex; mobilize or manipulate soft tissues and joints; induce relaxation; change muscle function; modulate pain; and reduce soft tissue swelling, inflammation or movement restriction.”

According to the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) Description of Advanced Specialty Practice (DASP), orthopaedic manual physical therapy (OMPT) is defined as: any “hands-on” treatment provided by the physical therapist.

Treatment may include moving joints in specific directions and at different speeds to regain movement (joint mobilization and manipulation), muscle stretching, passive movements of the affected body part, or having the patient move the body part against the therapist’s resistance to improve muscle activation and timing. Selected specific soft tissue techniques may also be used to improve the mobility and function of tissue and muscles.

Three Paradigms for Manual Therapy Therapeutic Effects

1. Physiological: positive placebo response
2. Biomechanical and Physical: facilitates repair and tissue modelling
3. Psychological: pain relief via- stimulates gating mechanism; muscle inhibition; reduction of nocioceptive activity; reduced intraarticular or periarticular pressure

Techniques Include

• Traction
• Massage
• Trigger Point Therapy
• Active Release Techniques: A practitioner determines where adhesions are through touch, the practitioner then couples a patient’s active movement with his/her touch.
• Assisted Active Range of Motion (AAROM)

• Passive Range of Motion
• Lymph Drainage
• Stretches (muscle, neural tissue, joints, fascia)
• Instrument Assisted Soft Tissue Mobilization

• Joint Manipulation: A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit* with the intent to restore optimal motion, function, and/ or to reduce pain.
• Joint Mobilisation: A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small-amplitude/ high-velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/ or to reduce pain. 

NB The terms “Thrust Manipulation” and “Non-Thrust Manipulation” have been used in the literature.  “Thrust Manipulation” is used to describe interventions described as Manipulation by IFOMPT, and “Non-Thrust Manipulation” would be synonymous with the term Mobilization as proposed by IFOMPT.  

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Guide to Grading of Mobilisations/Manipulations

Maitland Joint Mobilization Grading Scale:

Grade I – Small amplitude rhythmic oscillating mobilization in the early range of movement

Grade II – Large amplitude rhythmic oscillating mobilization in the midrange of movement

Grade III – Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement

Grade IV – Small amplitude rhythmic oscillating mobilization at end of the available range of movement

Grade V (Thrust Manipulation) – Small amplitude, quick thrust at end of the available range of movement

Kaltenborn Traction Grading Scale:

Grade I – Neutralises joint pressure without separation of joint surfaces

Grade II – Separates articulating surfaces, taking up slack or eliminating play within joint capsule

Grade III – Stretching of soft tissue surrounding joint

Additional Viewing

This 28 minute video gives a good overview of the hands-on/off debate and suggestions of when to use manual therapy.

Conclusion

Manual physical therapy is a specialised form of physical therapy delivered with the hands as opposed to a device or machine. It has an important place in Physiotherapy and when used appropriately by practitioners is a very effective set of tools literally at our fingertips.

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