Our Philosophy on Manual Therapy

The Evolving Model of Manual Therapy

Australian Manual Physiotherapy has evolved to consist of the physical examination and treatment of a large range of disorders, mainly of pain, of the neuromusculoskeletal system. This is now referred to as manual therapy.

Manual therapy previously referred to as manipulative therapy is now used to denote a broader scope of practice, than that associated with manipulative therapy. It embraces all aspects of disorder history, examination, and evaluation and includes in depth attention to medical opinion and interpretation of medical investigation reports.

Diagnostics are therefore the foundation of the evolving model for manual therapy and this is based upon a systematic interpretation and correlation of all the available evidence, not just the signs and symptoms. Treatment is then prescribed according to diagnosis.

The extent of differential diagnosis within manual therapy is still restricted, relative to medical practice as it is governed by the limits of physiotherapy practice. So it is still beyond the scope of manual therapy to diagnose disease processes and certain pathological processes.

However knowledge of the exclusion or inclusion of various diseases and pathological processes is continually being improved upon and these improvements now reflect the responsibility physiotherapists have as primary contact practitioners.

The approach within manual therapy involves clinical reasoning based on knowledge of the history, presentation of signs and symptoms, medical practitioner or specialist opinion and the informed interpretation of medical investigation findings.

Manual therapy management is then prescribed or medical opinion is sought, according to a diagnosis, while intervention is guided by careful and informed interpretation and evaluation of the signs and symptoms of the disorder and the manner in which they may change.

Management Vs Treatment

Manual therapy makes use of many different types of treatment and management depending on the diagnosis, category and stage of the disorder.

In general terms, treatment tends to mean direct therapist intervention. It may be active – towards the cure of the disorder; causal – directed against the cause of the symptoms; empirical – where experience has proved the beneficial approach; or expectant -directed towards the relief of symptoms.

On the other hand management indicates a broader and essentially a more complete approach to intervention. It may involve treatment as described or be palliative – designed to relieve symptoms without specifically effecting the disorder; preventative – to prevent recurrence; and supportive – designed mainly to maintain the strength of function.

The broader scope of Manual therapy attempts to provide a greater patient intervention options and improve both the quality and outcome of physical intervention.

The Broader Scope of Manual Therapy

Manual therapy treatment and management is not limited to hands on techniques. Actions may include from advising bed rest or rest from certain activities to walking. More specific interventions may involve such things as articular and peripheral nervous system mobilisation, soft tissue massage and stabilisation exercise, postural correction, ergonomic advice or functional strengthening.

Essential to this improved management paradigm is patient instruction in self management and preventative measures. Various techniques from articular self mobilisation and soft tissue self stretches to specific and general exercise, lifestyle advice, postural and ergonomic considerations can be given.

Treatment and management options are very much dependent upon the character and covenant of any referral for manual therapy and the expressed wishes and informed consent of an individual seeking or undergoing manual therapy evaluation for treatment.

Again the emphasis of this approach is the recognition of disorders suited to manual treatment and the treatment prescription according to the diagnostic recognition.

Manual therapy is therefore based upon a broad scope of clinical practice and is not aligned to any concept, approach or philosophy other than bio-scientific or evidence based clinical grounds.

The Technical Side of Manual Therapy

Techniques can be therapist directed or by patient self intervention. They may be passive, active assisted or active manoeuvres. Procedures referred to as mobilisation, traction, manipulation and high velocity thrust, are directed at the articular component to restore lost motion.

Muscle energy, proprioceptive neuromuscular facilitation(PNF), soft tissue release, massage, muscle stabilisation exercise are those that refer to techniques aimed at restoring normality in the soft tissue.

Management can include any of the procedures or may involve more comprehensive measures than previously considered and is not limited to just techniques.

Importance is also placed on the recognition of disorders not suited to manual therapy treatment. This does not simply imply “non-mechanical“ disorders or pathological disorders requiring medical treatment, but disorders such as some chronic pain states which may have commenced due to an underlying mechanical cause.

Patients referred to manual therapy treatment when the nature of the disorder is not suited to physical treatment may become worse. Some physical treatment which in another disorder would be painless may exacerbate the disorder and hence be detrimental. It is thought this is due to non nocioceptive afferent information being processed abnormally.

Therefore although we have various treatment options, the most effective management strategy is always emphasised.

The Importance of Diagnosis

The essential reason for diagnostics is for determination of the most appropriate intervention. Both categorisation and stage of disorder need to be considered. This enables a clinical reasoning process for selection and prescription of the most appropriate form of treatment and its application in the most appropriate manner.

However the absence of diagnosis in physical medicine has meant that it commonly appears that many different techniques are described to treat the same disorder or the same techniques described to treat many different types of disorder. Diagnostic accountability has been neglected. .

As a result conjecture has often arisen in medical opinion about the value of physical treatment. Therefore as a solution to this weakness, there is a new emphasis on treatment choice according to disorder selection or classification. Diagnosis with categorisation and stage of disorder is used to determine the most appropriate prescription of treatment technique.

Theoretical Model for Manual Therapy

Treatment is prescribed with the thought of improving functional activity such that normal recovery and repair processes occur. The premise is held that if a disorder prevents or disturbs normal musculoskeletal function for whatever reason, improvement may not be possible until such time as function or functional activity is also improved or normalised to some degree.

This model regards passive movement treatment to restore or normalise function strictly as a requirement only in the absence of normal active function. In addition, the absence of normal active function may indicate aberrant movement, such as may occur with instability, rather than limitation of mobility. In this case, passive movement would not be a requirement except where certain motor control patterns were being established.

Background to this model is the general acceptance that appropriate biological forces result in repair, healing and remodelling of musculoskeletal tissues and hence the alleviation and restoration of function.

Biological forces can therefore be influenced by physical treatments and following the initial acute stage when rest or immobilisation may be required, physical activity in the form of functional movement and exercise is the basis for recovery.

Pain and Passive Movement

Although certain pathologies, age related changes, morphological changes and structural features of a disorder may adversely effect the restoration of functional activity, what appears to commonly frustrate the improvement of such disorders otherwise suited to physical treatment is the presence of pain.

Pain would not seem to adversely influence biological repair, except in cases where the nervous system mechanisms related to nociception are abnormal, such as in neurogenic inflammation.

However the detrimental effect of pain is the inhibitory influence and adverse effect it exerts on functional activity. The beneficial effects of functional activity and exercise may, therefore not be realised in the presence of a disorder of pain.

If pain can be controlled by any means, particularly with pharmacology, and functional activity can then occur, exercise again should be effective. However, pharmacology for pain relief does not always fully prevent pain associated with active movement. Nor does exercise enable function to be restored so that a disorder will improve.

Therefore in certain pain disorders passive movement used to simulate the effects of active movement and exercise on physiology and biology becomes a valuable physical technique of treatment.

The Use of Passive Movement

The use of passive movement as treatment can be regarded as simulating functional movement. This may not be ordinarily possible to a variable degree due to the inhibiting effects of a disorder, especially pain, on active function.

Passive treatment technique has to be one which will replicate the actions of functional movement on pathological tissues. Passive treatment or combinations of treatments must therefore influence musculoskeletal physiology, and therefore the affected tissues, in such a manner that a stimulus for biological repair results.

Therefore, passive treatment seems appropriate only in the absence of specific function or movement, or in the presence of aberrant active movement.

When functional activity is possible and exercise can be prescribed which will specifically influence the pathological area or cause of the disorder, the use of passive technique as treatment may not always be justified. The beneficial effects of passive treatment when correctly prescribed and performed should always result in improved functional activity

Considerations for Effectiveness

Different considerations or mechanisms have been suggested and documented for the improvement of a disorder which may occur as a result of the effectiveness of physical treatment.

There are two common considerations. Each has its own advocators seeking support for a mechanism for effectiveness of physical treatment. These considerations or mechanisms can be summarised as:

1. Treatment is administered to alleviate or control pain and as a result movement is increased or restored.

2. Treatment is administered to control, normalise or increase movement or to control, normalise or increase function and as a result, pain will be alleviated.

The principles of treatment for the first consideration are mostly based upon the theory of peripheral modulation of pain by the stimulation of articular nocioceptors with the use of appropriately applied passive movement techniques. The principles for the second consideration are based on biomechanics.

There may be strong clinical bias towards the adoption of one mechanism while other opinions may advocate a mix of the two mechanisms at different stages of the treatment. The administration of the treatment in both cases may be passive therapist intervention or active patient participation, or a combination of both.

The tendency for the apparent bias in one mechanism over the other appears to lie in its differing conceptual approach and emphasis. However both mechanisms appear to be based on signs and symptoms of a disorder and do not appear to take into account a diagnosis, other than when it precludes the use of physical treatment.

Therefore it is with this in mind that the most important consideration now acknowledged is the choice of physical treatment according to disorder selection/diagnosis.