Manual therapists are not car mechanics.
Manual therapy can’t fix your joints and tissues. At least not in the direct, mechanical ways you might expect. A lot of people who show up to physical therapy think the purpose of manual therapy is to fix something structural: Reposition a joint that’s out of place. Correct asymmetries by moving body parts into optimal alignment. Break up adhesions between layers of soft tissue. Like dropping the car off at the mechanic, there’s a notion that we can drop off our bodies at a manual therapist’s office to get all fixed up.
When it comes to treating joints and soft tissues at a structural level, here are two common assumptions about hands-on therapy:
1. Joints that have become misaligned can be realigned.
Let’s look at the low back as an example. It is, after all, the most common site of pain in the human body. Word on the street (from many people who’ve landed in a manual therapist’s office) is that a lumbar vertebra has become misaligned, a disc has slipped, or the sacroiliac joint is rotated, tilted, or stuck. “I just need somebody to push it back in place.” Sound familiar?
People often visualize the low back region as being fragile, vulnerable, or overly sensitive. While there is a real and meaningful psychological component to these attributes—long story, deserves another post—from a purely structural standpoint, these representations couldn’t be farther from the truth. Lumbar vertebral bodies and the discs between them are tough stuff. The sacroiliac joint is an incredibly robust and rigid joint that transfers heavy loads between the legs and trunk with every step we take. These structures are not easily moved out of place. If they do shift, it requires massive forces or years of repeated stress to move them. Consider an activity like running. Running requires repeated hopping from one foot to the other. The impact of one’s entire body weight on a single leg delivers a magnitude of force to the SI joint and lumbar spine far greater than any therapist could reproduce with their hands in the clinic. So how could small, low force, hands-on adjustments jiggle things back into place? And if there is some temporary change, how would that change last beyond standing up and taking a few steps?
Several research studies have examined the use of specific vs. nonspecific mobilizations for the lumbar spine, revealing no significant difference between groups. Meaning, the manual therapy techniques that applied a precise direction of force to a specific spinal segment were no better at changing a patient’s symptoms than a randomly applied treatment in any direction to any region of the spine. Another study looked at mobilizations applied by experienced therapists with advanced training and certification in manual therapy vs. treatment applied by therapists with little experience or training, and no advanced certifications. Results demonstrated slightly better outcomes from the treatment by less experienced therapists. Shocking? Maybe. But only if we’re expecting a therapist’s treatments to operate on a mechanical level.
So if the precision or quality of the manual treatment doesn’t correlate with better patient outcomes, why is it that patients experienced decreased pain at rest and improved tolerance for previously painful movement after receiving any of the treatments in any of these studies?
Could it be that the positive outcomes are due to broader, secondary effects on the whole brain-body-movement system, as opposed to a small mechanical correction at the joint level? I mean, there happens to be a whole person attached to the lumbosacral joint, amiright?
2. Sensations of tissue tightness correlate with mechanical tissue tightness, and tissue changes can be reliably felt and interpreted by a trained practitioner.
When most people think of tightness in the body’s tissues, they’re probably associating it with an uncomfortable sensation. You know the feeling. Getting out of bed in the morning, the first few creaky steps after sitting through a long movie, or the discomfort in the legs and shoulders standing still at a concert. Many people seek out treatment by manual therapists with the expectation that tissue tightness can be released.
What we’re learning about sensations of stiffness is much like the latest research on pain—that it’s highly subjective. In the same way pain can exist without actual tissue damage, sensations of stiffness can exist without actual tissue tightness. Dense, ropy, tight textures in tissues don’t necessarily correlate with discomfort. Achy, stiff, uncomfortable sensations don’t reliably produce objective measures of tightness by hands-on palpation or other means quantified in the research lab. Further, there is little evidence of manual therapists’ ability to identify regions of a patients’ perceived “tightness” by feel.
Perception. Our bodies and brains are pretty good at telling us when something is wrong. Think of it as an internal alarm bell. If we remain inactive, in a static position for long enough the “alarm bell” will remind us to move. The brain sends out a signal in the form of pain, tightness, or both. All the body really wants is a change in position, some dynamic movement, or exercise to create contraction and lengthening of tissues. These strategies for relief aren’t as much about creating mechanical change in tissues as they are about the secondary effects: Increased blood flow to tissues, and novel sensory input to compete with, and in a way, override the alarm bell.
Can manual therapies like soft tissue mobilization help promote these secondary effects? Yep, they sure can. Is it any better than movement or exercise? According to the available research, no.
Stay tuned for another post on these secondary effects. We’ll cover how and why manual therapy plays an important role in managing pain, improving load tolerance, and reducing fear of movement.
In the meantime, if you’ve got a painful physical condition that’s been concerning you for a while, come see us for a check-up (in person or online). Click here to schedule a free discovery call. Share your observations and goals. Ask questions. Find out if one-on-one physical therapy feels like a good fit.