Manual Therapy: How To Implement It
Today’s post comes as a follow-up to a previous post regarding manual therapy and how we can begin to formulate a thought process to implement manual therapy to better achieve our desired outcomes. If you missed part one where we discussed what exactly manual therapy is and its effects, you can check it out here.
During our curriculum at the University of St. Augustine we learn a plethora of manual therapy techniques in regards to joint mobilization/manipulation. One area which we have not had a lot of focus on thus far is the role of soft tissue manual therapy. As I mentioned previously, my cohorts and I are currently on our second of three clinical rotations, and I was ready to get in the clinic and practice the vast amount of techniques we have learned throughout our program. As my week began at Foothills Sports Medicine Physical Therapy, I noticed something a little different. There was a ton of soft tissue manual therapy being performed. Much of which I was not very familiar with, if at all. I approached my clinical instructor (CI) Allen Gruver to gain some perspective on the role of soft tissue manual therapy and his approach of how he applied it. What he shared was a simple but excellent thought process, and the first of many #GruverGifts, on how he approaches each patient individually and applies his clinical reasoning skills to decide which technique he should apply where and why. He summarized his thought process into four main categories: Pathology, Pain, Pattern, Nervous System. Let’s break these down below.
Pathology – In regards to the model proposed above, treating a pathology via manual therapy is based upon your objective findings during your orthopedic examination. These techniques are geared towards treating the actual pathology. For example, if an individual were to present to your clinic with shoulder pain. Upon your examination, you may find they present a supraspinatus tendinopathy or some other pathological condition resulting in their pain. As mentioned above, these interventions would be geared toward treating the actual pathological tissue.
Pain – Without knowing, our patients often subconsciously guide us in the direction our treatment should be aimed. During our examination, it is quite common for us to ask an individual to provide the location of their pain. Whether that be with body chart diagrams or just a simple question asking them to point to the area involved. How the individual expresses their location of pain is what drives this treatment parameter. For example, following the Fascial Distortion Model (to be discussed at a later time) if an individual presented to your clinic with upper back and/or shoulder pain and demonstrated that the pain ran from the base of the head down the neck and towards the posterior shoulder. You may decide to evaluate, and based upon your findings, direct your treatment towards the upper trapezius area as this individual presents with what the FDM classifies as a triggerband. When using this thought process, think of treating pain via manual therapy as treating the patient’s expression of pain.
Pattern – Treating patterns via manual therapy may seem similar to treating the pathology with manual therapy. However, when we think of treating pathology we are looking at treating a specific pathological condition. With patterns, we are thinking about what structures/tissues play a mechanical role in the pattern the patient is presenting with. For example, if an individual presents to your clinic with anterior torsion/rotation of the ilium, we’ll pick the left side for this case. Biomechanically, we know that this will create a pattern of the left ilium being anteriorly tilted placing the left hip in a state of flexion. Since the pelvis operates in a tri-planar fashion, we also know that in addition to being anteriorly tilted, the left ilium also abducts and externally rotates. As a result of this position, the left femur is placed into a position of flexion, abduction, and external rotation. In this scenario, we begin to think about which tissues may be contributing to the positioning of this pattern. You may decide to address the hip flexors, hip external rotators, hip abductors, etc. Again, when addressing patterns via manual therapy, think about the tissues with associated mechanical involvement that create the position of the pattern.
Nervous System – When it comes to treating the nervous system with manual therapy, anatomy reigns king. Knowing the pathway of the suspected nerve involvement you are addressing will allow you to better direct your treatment. For example, a patient presents to your clinic with symptoms replicating Median nerve involvement. Knowing the pathway of the Median nerve allows you to direct your examination and treatment to determine the area of restriction causing the production of neural symptoms. While you may be quick to provide treatment just at the area of restriction, performing manual therapy anywhere along the distribution of the nerve may also lead to some symptom relief. To treat the nervous system via manual therapy, treat the area of restriction and the distribution pathway of the nerve.
When it comes to providing manual therapy and using the proposed thought process above. The goal should be to address the conditions that will include the greatest number of categories within the model.
Thank you for checking out today’s post. I hope this information has provided a starting point for which you can begin to determine the best course of action when implementing manual therapy. As always, please feel free to leave some comments below or reach out and contact me via the contact page. Until next time!