What is Manual Therapy, Part 2
Welcome to my second blog post of What is Manual Therapy. This blog post is going to look at techniques that are used more on joints in the body. With techniques below, it does not matter if the joint is in the spine, in your arm or foot. As long as the practitioner has the appropriate knowledge of the anatomy in the area these techniques can be modified to any area of the body. Enjoy!
Mobilizations are techniques that are performed on a joint, in the body. These techniques are done by holding one of the bones, in place, and moving the other bone. This technique uses slow, oscillating movements to get the joint moving. Mobilizations are done by the physiotherapist but actually controlled by the client. If the client finds the technique uncomfortable, all they have to do to stop the technique is to tense up the area of the body. The physiotherapist cannot perform a mobilization on an area of the body under tension.
This technique should be performed in a sequential fashion, something like this. The part of the body is assessed and a particular joint is stiff in a certain direction. It is explained by the physiotherapist to the client what is found, what treatment technique would be beneficial, in this case we are talking about mobilizations, what they should expect to feel, the goal of the treatment and anything risky about the treatment. This is called getting consent, possibly informed consent, from your client. This may seem unimportant but it is actually very important, maybe a blog post down the line. From there treatment can begin. There are five grades of mobilizations, with Grade V being a manipulation, see below. Grades I and II are generally used when the client is limited more by pain then by the stiffness in the joint, itself. Grades III and IV are generally used when the client is limited more by stiffness than pain.
How many/often are mobilizations performed to help a client? In general, it really depends on a person-by-person account, mobilizations are performed for 20-30 seconds, 2-5 times per joint in the direction of restriction. Sometimes they are performed longer or shorter or possibly more times or simply once.
After a mobilization is completed, the client should be asked to try and move that joint through the new range of motion, ROM, that the joint now has, under their control. This gets the muscles firing, joint receptors working, and joint surfaces lubricated in the newly available ROM. Most of the times, people can gain a lot of ROM from mobilizations. Sometimes after a physiotherapy session, the client may find that the joint gets stuck in the same position it was previously and it can be frustrating for the client. This reoccurring stiffness could be caused by numerous factors, which may be sleeping position, doing too much with in the new ROM and straining the muscles or causing little bits of inflammation or swelling to go into the joints and stiffen them up. Sometimes, this only happens once or twice with a client. Some people, if they have had a stiff neck for a number of months, need more treatments, than someone that comes in right after they notice their neck pain.
A manipulation is a technique that is similar to a mobilization but there is an important aspect that is different. A manipulation of a joint is performed in the same joint positions, in which a mobilization is done. The big difference between and mobilization and manipulation is that the manipulation is done under the physiotherapists control. A manipulation can be viewed as a more dangerous technique as there is a lot more force being put into/through the client’s joints. The speed of the technique could also be seen as a potential danger factor because the technique is applied so fast to the client, they do not have a chance to reacted until after it is over. In my mind, manipulations are a very useful technique to use but it must be used with caution.
Click on the photo to the left called Seated Thoracic spine manipulation to see a quick video of what a manipulation could look like.
A manipulation is known by many different names; an adjustment, grade V mobilization or a high velocity low amplitude (HVLA) thrust (short, fast thrust).
When performing a manipulation, the stuck joint, possibly facet joint in the spine, is taken to the end point and held for a couple of seconds and then taken out of that position. This is called the pre-manipulation hold (other tests should be done before manipulating a joint, not just that test). If the pre-manipulation hold is alright with the client, it should be almost uncomfortably tight, the client’s stiff joint is put back into that position and a high velocity, low amplitude thrust is applied. Sometimes there is a little ‘pop’ felt in the joint. The ‘pop’ sound/sensation is known as cavitation. Some people feel if cavitation did not occur then the manipulation did not work. There are numerous studies in the scientific literature that show this is false. Manipulations do work, even without the ‘pop’ as long as the manipulation as performed correctly. What seems to be the most important aspect is the quick, short thrust performed. We are not sure why, perhaps it is the quick stretch on muscles that are already stretched that cause the muscles to relax and let the joint open up?
After a manipulation, the practitioner should recheck the joint mobility and possibly the joint stability. If there is a single joint that always feels as if it is getting stuck it might be an issue of a joint that moves too much and gets stuck at the end of the range of motion. A manipulation can free the joint from being stuck but does not solve the larger issue. This is where exercise comes in to help stabilize the joint, to not let the bones move so far as to get ‘stuck’ again. Normally, these exercises are not very exciting, so many people stop doing them after a week or so. In reality, most people should be doing the exercises for 6-8 weeks, possibly longer.
I hope you found this blog interesting about what manual therapy is and the some of the different manual therapy techniques used by physiotherapists to help their clients.