By: Richard A. Owens, PT, MS, OCS, Cert. SHT, CWcHP, Cert DN
Professional Rehabilitation Services Physical Therapy

Many patients arrive at their first physical therapy appointment expecting to receive hot packs, ultrasound and instructions on how to complete a series of exercises. In many cases these modalities are justified and most therapists would agree that exercise is needed to help restore muscle imbalances. However, many therapists now approach the restoration of function from a different perspective. These therapists are interested in why a muscle is not functioning properly and view exercises not as the single, driving mode of recovery but as a complement to manual therapy.

Manual physical therapy is a specialized form of physical therapy delivered with the hands as opposed to a device or machine. In manual therapy, practitioners use their hands to put pressure on muscle tissue and manipulate joints in an attempt to decrease back pain caused by muscle spasm, muscle tension and joint dysfunction.

While patients may be referred for physical therapy treatment by their primary care doctor, an orthopedic surgeon, or other doctor involved in their back care, most states have direct access laws permitting patients to seek help for low back pain from a licensed physical therapist without having to seek a written referral.

While all physical therapists have the option to use manual therapy in their practices, many do not spend the time or the resources to become efficient in this area of practice. Manual therapy can be a very effective approach for the treatment of joints that lack adequate mobility and range of motion in certain musculo-skeletal conditions. These limitations can cause discomfort, pain, and an alteration in function, posture, and movement. Manual physical therapy involves restoring mobility to these stiff joints and reducing muscle tension in order to return the patient to more natural movement without pain. Thus, manual physical therapy may provide back pain relief both for patients with chronic back pain involving joint problems, such as sacroiliac joint dysfunction, and acute back pain from soft tissue injuries such as a muscle strain or a pulled ligament.

Before beginning manual therapy or any type of physical therapy, the practitioner usually performs a full assessment of the blood and nerve supply in the area, as well as a bone and muscle assessment, in order to decide whether or not there is an increased risk of complications from the use of these back pain management techniques. Depending on the results of that assessment and each individual back pain patient’s situation, the healthcare provider may perform some or a combination of the following types of manual physical therapy:

• Soft tissue mobilization (STM) is a widespread technique with many therapists it covers techniques that range from generalized massage to more specific myofascial release techniques. The goal of STM is to break up inelastic or fibrous muscle tissue such as scar tissue or adhesions from a back injury, move tissue fluids, and relax muscle tension. The therapist will localize the area of greatest tissue restriction and once identified, these restrictions can be mobilized with a wide variety of techniques.
• Strain / Counterstrain techniques focus on correcting abnormal neuromuscular reflexes that cause structural and postural problems, resulting in painful ‘tenderpoints’. The therapist finds the patient’s position of comfort by asking the patient at what point the tenderness diminishes. The patient is held in this position of comfort for about 90 seconds, during which time asymptomatic strain is induced through mild stretching, and then slowly brought out of this position, allowing the body to reset its muscles to a normal level of tension. This normal tension in the muscles sets the stage for healing. This technique is gentle enough to be useful for back problems that acute or to delicate to treat with other procedures. Strain-counterstrain is tolerated quite well, especially in the acute stage, because it positions the patient opposite of the restricted barrier and towards the position of greatest comfort.
• Muscle energy techniques (MET) are designed to mobilize restricted joints and lengthen shortened muscles. This procedure is defined as utilizing a voluntary contraction of the patient’s muscles against a distinctly controlled counterforce applied from the practitioner from a precise position and in a specific direction. Following a 3-5 second contraction, the operator takes the joint to its new barrier where the patient again performs a muscle contraction. This may be repeated two or more times. This technique is considered an active procedure as opposed to a passive procedure where the operator does all the work (such as joint mobilizations). Muscle energy techniques are generally tolerated well by the patient and do not stress the joint.
• Joint mobilization involves loosening up the restricted joint and increasing its range of motion by providing slow velocity/speed and increasing amplitude/degree of movement directly into the barrier of a joint, moving the actual bone surfaces on each other in ways patients cannot move the joint themselves. These mobilizations range from extremely light (pain and spasm inhibition) to more aggressive (joint mobility) depending on the goal of the technique.
• High-velocity, low-amplitude thrust (HVLAT) techniques aim to restore the joint motion, enabling them to open and close effectively. As the name states this technique is a very fast and relies more on speed than power to increase mobility and inhibit muscle tone around a specified joint. This technique is utilized for restoration of joint motion and does not move a joint beyond its anatomical limit. Therefore, no structural damage takes place and the patient should not have an increase in pain following the treatment.

To continue the healing process and prevent recurring pain, back pain patients are encouraged to engage in other appropriate treatments (including an exercise program) during and after manual therapy treatment. Exercise programs for back pain usually include stretching and strengthening exercises and low-impact aerobic conditioning, and should include a reasonable maintenance exercise program for patients to do on their own. Lifting techniques may also be discussed to prevent re-injury or aggravation. The goal is to maintain the right type and level of activity to prevent the pain from re-occurring and avoid the need for frequent return visits to the therapist.

Brian Kinmartin PT, DPT, MTC, OCS, STC, CWcHP, Cert. DN is the Owner/Founder of Professional Rehabilitation Services. Dr. Kinmartin is a Board Certified Clinical Orthopaedic specialist through the American Physical Therapy Association and the American Board of Physical Therapy Specialists. Brian has achieved the prestigious credential of MTC, or Manual Therapy Certification, recognizing excellence in manual therapy skills including the spine and extremities through the Univeristy of St. Augustine.

Richard A. Owens, PT, MS, OCS, Cert. SHT, CWcHP, Cert DN, Senior Partner of Professional Rehabilitation Services. He is a Board Certified Clinical Orthopaedic Specialist through the American Physical Therapy Association and the American Board of Physical Therapy Specialists. Ricky has achieved the credential Cert. SMT, Certification in Spinal Manipulative Therapy, awarded for achieving excellence in the performance of high-velocity low-amplitude thrust manipulation procedures of the spine through the American Academy of Manipulative Therapy.

Professional Rehabilitation Services is a Physical Therapist owned Private Outpatient Physical Therapy Practice. Our Physical Therapists continually strive to provide our patients with the best manual care possible, and are constantly challenging themselves to improve the services offered to our clients. For more information about this topic or if you feel that manual therapy may benefit you please contact us to schedule a FREE 15 minute Consultation at our Pawleys Island office at (843) 235-0200 or our Myrtle Beach/Sayebrook office at (843) 831-0163 or visit us at: www.prsrehabservices.com.