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Treating Pain: Manual Therapy

Updated: Dec 25, 2023

”It is easier to find men who will volunteer to die, than to find those who are willing to endure pain with patience.” – Julius Caesar


What is manual therapy?

Manual therapy (MT) can be defined as “the use of skilled hand movements to manipulate tissues of the body to restore movement, alleviate pain, promote general health, or induce relaxation [1].” There is no standard definition to my knowledge. This shouldn’t be a surprise considering there are many different techniques being applied by many different practitioners. So for now, the above definition will do.


Different strokes.

As mentioned, there are several types of MT. Classifying MT by the target tissue to be treated is a reasonable approach [2]. For clarification, I have included a brief definition of each type. Again, there are no standard definitions, so I’ve attempted to piecemeal information together from different sources. This is by far not an exhaustive list of MT.


Joints:

  • Joint mobilization – “a manual technique directed to the patient's joint whereby the clinician imparts passive movements such as glides and distractions. The technique is characterized by low-velocity movements (i.e., rather than high-velocity thrusts) and is generally slow enough for the patient to stop [3].”

  • Joint manipulation – a form of joint mobilization that includes a high velocity, low amplitude thrust. Often it is a singular thrust targeted at a specific joint, which can be accompanied by an audible sound (“pop” or “crack”).

Muscles and fascia:

  • Passive static stretches – “Passive stretching is a technique in which you are relaxed and make no contribution to the range of motion. Instead, an outside agent creates force, either manually or mechanically [4].”

  • Muscle energy techniques – “treatment in which a patient produces a contraction (muscular) in a precisely controlled position and direction against a counter-force applied by a manual therapist [5].” There are several different sub-types of muscle energy techniques.

  • Massage – “A treatment, in which the soft tissues of the body are kneaded, rubbed, tapped, and stroked [6].” There are several sub-types of massage as well: Swedish, Myofascial, Trigger Point, and Deep Tissue just to name a few.

Nerves:

  • Neurmobilization techniques – “uses manual therapy techniques and specific exercises to help stress the neural tissues to improve pain, mobility, and functional tolerance [7].”

It’s not my intention to list and define every technique that exists, just to demonstrate that manual therapy is an umbrella term, and a broad encompassing one at that.


How does MT reduce pain?

As a Chiropractor who primarily treats patients using joint manipulation, I’m going to explain in exact detail how what I’ve been doing for the last 10 years helps people reduce their pain. Are you ready?


Just kidding. We don’t know how this stuff works. If you think that’s a hard pill to swallow, imagine being the Doctor that’s performing the treatment.


Of joint manipulation: “there is poor understanding of the physiological mechanism by which it may achieve its therapeutic benefit [8].”


“While many aspects of underlying therapeutic mechanisms are unknown… [9].”


Of manual therapy: “The mechanisms of manual therapy, however, are not fully understood… [10].”


“…however, the current understanding of these mechanisms is lacking… [11].”


“…the mechanisms through which MT exerts its effects are not established [12].”


And so on.


It’s not all guesswork, though. There are theories with solid scientific backing as to how MT works. Currently, it is accepted that MT exerts its beneficial effects through a combination of biomechanical, neurophysiological, and psychological mechanisms.


Biomechanical

In the good old days, everything pertaining to musculoskeletal treatment was explained away using the biomechanical model. A tight muscle pulled on this thing, which twisted this thing, which made this thing stuck, and that’s why you’re hurting.


The body is not as fragile as the biomechanical model would imply. Yes, bodily structures move when manual therapy is performed on them. It’s typically a very small amount (millimeters), and only for a short time. I want you to imagine for a second a professional powerlifter who squats 800 lbs. If the force used during manual therapy could permanently deform bodily structures, the force generated under the barbell of an 800 lb. squat would crush said powerlifter. But it doesn’t, because we are simply not that malleable.


If you’re familiar with Wolff’s law and Davis’s law, you understand that bones and soft tissues do model according to the stresses put upon them, respectively. But the tissues model according to the stresses put on them over time. So unless your manual therapist holds a thrust or sustains a stretch on you nonstop for a week, you’re not transforming bodily structures with MT. Something else has to account for its benefits.


Neurophysiological

Theoretically, MT decreases pain via both ascending (body to brain) and descending inhibition (brain to body).


In ascending inhibition, the stimulation of the neural receptors and subsequent nerves responsible for carrying the message of touch, inhibit or ‘close the gate’ on, the message of pain. This is readily observable when we massage an injured body part, like after smashing a thumb or stubbing a toe. This ascending inhibition is similar to how TENS units, topical pain-relieving creams, and the like work. For more information regarding ascending inhibition, you can check out our article, Treating Pain: Using the Pain Gate.


MT also stimulates the brain to help control pain by way of descending inhibition. MT stimulates regions of the brain that are capable of eliciting the body’s natural pain-killing systems.

The form, frequency, intensity, and duration of MT and which part of this pain-killing system it activates are still under investigation. You can learn more about descending inhibition here: https://www.physio-pedia.com/Pain_Descending_Pathways.


For details on ascending and descending pain inhibition, I highly recommend you check out this article at Physiopedia: https://www.physio-pedia.com/Pain_Facilitation_and_Inhibition.


Psychological

Never underestimate the power of the human mind. The placebo effect, on average, accounts for 30% of the positive results with any medical intervention. Think about that, just the expectation of feeling better will make about one-third of people actually feel better. The environment in which MT takes place, the expertise or perceived expertise of the practitioner, and other factors likely determine the strength of the placebo effect.


What we do know.

Manual therapy is effective.

Knowing that something works, is different from knowing how something works. MT has been around for a long time. Hippocrates wrote about MT as a treatment for different ailments sometime around 400 BC. It’s surely been practiced even before then. A treatment simply wouldn’t persist that long if it didn’t work. After all, history is riddled with bizarre medical treatments that didn’t pan out, either due to their ineffectiveness, or worse their harm. Lucky for us, manual therapy is recognized to be effective and safe for treating pain [13-16].


Manual therapy can be effective for acute and chronic pain.

There are conservative treatments that work well for acute pain, and there are conservative treatments for chronic pain. Manual therapy has the unique distinction of being effective for both [17].

MT encompasses a wide range of techniques that can be scaled in intensity and duration.

It can be performed with differing amounts of pressure, at different velocities, and directed at different tissues. Some of the pain-relieving aspects of MT are likely universal, regardless of the specific technique.


“Nearly all types of manual therapy have been shown to elicit a neurophysiological response that is associated with the descending pain modulation circuit; however, it appears that different types of manual therapy work through different mechanisms [18].”


Who do I see?

There are as many different manual therapies as there are disciplines that perform them. Physical therapists, Chiropractors, Osteopaths, Physiotherapists, and Massage therapists all undergo extensive training in MT techniques and are all good options for treating acute or chronic pain.


Self manual therapy

It would be nice if we could get manual therapy where and when we needed it, but time and finance rarely permit. Luckily, there is a lot of MT that we can perform ourselves. Massage guns and foam rollers can help with sore muscles. Trigger point wands and tennis balls can break up trigger points. You can even use straps or bands to perform basic joint mobilization, but I would proceed with caution.


You don’t have to have extensive medical knowledge or training to perform basic self-maintenance. But it is a good idea to at least get instruction from a professional before you start working on yourself. Although most MT is safe, there are contraindications you may not be aware of that a professional is trained to detect.


Doctors notes.

MT is a tool to treat acute and chronic musculoskeletal pain. It is not the tool. It has been demonstrated in the literature that MT in combination with other passive therapies is superior to MT alone. For example, joint manipulation with TENS is better than just manipulation. Or massage with stretching is more effective than just massage, etc...

Active therapies such as exercise, in combination with MT, have consistently shown to be the most effective form of treatment for musculoskeletal pain.


Summary, Key Points:

  • There are many forms of MT.

  • It works, we’re not sure how, but have some ideas.

  • MT is effective for acute and chronic pain.

  • There are a number of manual therapists to choose from.

  • You can perform your own MT in some cases.

  • MT paired with other forms of treatment is better than MT alone.



Additional Resources

Entertaining and informative 2 part series on “Mechanisms and History of Manual Therapy” by Bradley Jawl, BSC, MPT.



Glossary


Bio/mechanical

-Bio: relating to life or living things.

-Mechanical: of or relating to physical energy and forces


Neuro/physiology

-Nervous system: the system of nerves in your body that sends messages for controlling movement and feeling between the brain and the other parts of the body.

-Physiology: the ways that living things or any of their parts function.


Psychological: of or relating to the mind.


Placebo effect: a beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient's belief in that treatment.


Passive therapy: when a treatment is being done to a patient. Examples include manual therapy, electrical stimulation, and ultrasound.


Active therapy: when treatment is being performed by the patient. For example exercising, and active stretching.

Works Cited

1. “Manual Therapy.” TheFreeDictionary.com, medical-dictionary.thefreedictionary.com/manual+therapy. Accessed 18 Apr. 2022.


2. Bialosky, Joel E., et al. “The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model.” Manual Therapy, vol. 14, no. 5, Oct. 2009, pp. 531–538, 10.1016/j.math.2008.09.001. Accessed 18 Apr. 2022.


3. “Joint Mobilization - an Overview | ScienceDirect Topics.” Www.sciencedirect.com, www.sciencedirect.com/topics/nursing-and-health-professions/joint-mobilization.


4. Riverview Health. “How to Perform Static, Dynamic, Passive and PNF Stretches.” Riverview.org, 30 May 2018, riverview.org/blog/fitness-2/how-to-perform-static-dynamic-passive-and-pnf-stretches/.


5. Thomas, Ewan, et al. “The Efficacy of Muscle Energy Techniques in Symptomatic and Asymptomatic Subjects: A Systematic Review.” Chiropractic & Manual Therapies, vol. 27, no. 1, 27 Aug. 2019, 10.1186/s12998-019-0258-7. Accessed 29 Apr. 2022.


6. “Https://Www.cancer.gov/Publications/Dictionaries/Cancer-Terms/Def/Massage-Therapy.” Www.cancer.gov, 2 Feb. 2011, www.cancer.gov/publications/dictionaries/cancer-terms/def/massage-therapy.


7. “Neurodynamic Mobilization.” Achieve Ortho, achieveortho.com/neurodynamic-mobilization/.


8. Potter, Louise, et al. “Physiological Effects of Spinal Manipulation: A Review of Proposed Theories.” Physical Therapy Reviews, vol. 10, no. 3, Sept. 2005, pp. 163–170, 10.1179/108331905x55820. Accessed 9 May 2022.


9. Xia, Ting, et al. “Similar Effects of Thrust and Nonthrust Spinal Manipulation Found in Adults with Subacute and Chronic Low Back Pain.” Spine, vol. 41, no. 12, 15 June 2016, pp. E702–E709, 10.1097/brs.0000000000001373. Accessed 9 May 2022.


10. Vigotsky, Andrew D., and Ryan P. Bruhns. “The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review.” Pain Research and Treatment, vol. 2015, 16 Dec. 2015, pp. 1–11, 10.1155/2015/292805. Accessed 11 May 2022.


11. Bialosky, Joel E., et al. “Unraveling the Mechanisms of Manual Therapy: Modeling an Approach.” Journal of Orthopaedic & Sports Physical Therapy, vol. 48, no. 1, Jan. 2018, pp. 8–18, 10.2519/jospt.2018.7476. Accessed 11 May 2022.


12. Bialosky, Joel E., et al. “The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model.” Manual Therapy, vol. 14, no. 5, Oct. 2009, pp. 531–538, 10.1016/j.math.2008.09.001. Accessed 11 May 2022.


13. Voogt, Lennard, et al. “Analgesic Effects of Manual Therapy in Patients with Musculoskeletal Pain: A Systematic Review.” Manual Therapy, vol. 20, no. 2, Apr. 2015, pp. 250–256, 10.1016/j.math.2014.09.001. Accessed 11 May 2022.


14. Bokarius, Andrew V., and Vladimir Bokarius. “Evidence-Based Review of Manual Therapy Efficacy in Treatment of Chronic Musculoskeletal Pain.” Pain Practice, vol. 10, no. 5, 30 Aug. 2010, pp. 451–458, 10.1111/j.1533-2500.2010.00377.x. Accessed 11 May 2022.


15. Miller, Jordan, et al. “Manual Therapy and Exercise for Neck Pain: A Systematic Review.” Manual Therapy, vol. 15, no. 4, Aug. 2010, pp. 334–354, 10.1016/j.math.2010.02.007.


16. Bervoets, Diederik C, et al. “Massage Therapy Has Short-Term Benefits for People with Common Musculoskeletal Disorders Compared to No Treatment: A Systematic Review.” Journal of Physiotherapy, vol. 61, no. 3, July 2015, pp. 106–116, www.sciencedirect.com/science/article/pii/S1836955315000582, 10.1016/j.jphys.2015.05.018.


17. Hidalgo, Benjamin, et al. “The Efficacy of Manual Therapy and Exercise for Different Stages of Non-Specific Low Back Pain: An Update of Systematic Reviews.” Journal of Manual & Manipulative Therapy, vol. 22, no. 2, 6 Dec. 2013, pp. 59–74, 10.1179/2042618613y.0000000041. Accessed 11 May 2022.


18. Vigotsky, Andrew D., and Ryan P. Bruhns. “The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review.” Pain Research and Treatment, vol. 2015, 16 Dec. 2015, pp. 1–11, 10.1155/2015/292805. Accessed 29 Apr. 2022.




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