All Physical Therapy is Not Alike

What you need to know about Manual Physical Therapy...

In 1994 The Agency for Health Care Policy and Research (AHCPR) released its recommendations for treatment of acute low back pain, based largely upon data published by the Quebec task force on the care of acute back disorders published as a supplement to the journal SPINE in 1987.  The Quebec Task Force, a team of North American spine professionals, reviewed all available spine related research  and determined which treatments enjoyed scientific support and which did not. In this report many traditional spinal treatments such as prolonged bed rest, heat, ultrasound, traction, TENS units, massage, and other traditional physiotherapeutic “modalities” provided no scientifically proven benefit. On the other hand, early activity, exercise and spinal mobilization enjoyed proven success. This landmark study, well received in the medical community, added to a growing body of knowledge within the physical therapy literature supporting Manual Physical Therapy as the premier method for the treatment of acute back and neck pain.

In simplest terms a manual therapist is a physical therapist who utilizes skilled hand movements to diagnose and treat his or her patients’ soft tissue dysfunctions. These hands-on techniques are applied with the goals of improving tissue extensibility, increasing range of motion, inducing relaxation, modulating pain, reducing soft tissue inflammation, optimizing posture and improving function. In reality, good manual technique requires considerable experience and talent to develop. The therapist must learn to move the small joints, discs and soft tissues in the spine, perceive the subtle differences in joint resistance and mobility through the fingertips and localize the areas of soft tissue and joint dysfunction. He or she then must create an individualized treatment plan to improve overall function through a series of passive mobilizations to the affected tissues and active exercise. Ultimately, he then must educate the patient to understand the processes at play and create an exercise program to permit that patient to independently maintain long term spine health.

     Manipulation and mobilization have been an integral part of medical science since the writings of Hippocrates (460-355BC). Through the ages, Galen (131-202AD), Pare in 1579, and others have written and taught spinal mobilization as an accepted technique. In the modern era, Osteopathic medicine was founded in 1874 by Andrew Taylor Still as a branch of medicine dedicated to the mobilization of joints to improve various disease states. Chiropractic invented in 1895 by Daniel David Palmer, a practicing magnetic healer, espoused the healing of disease through the correction of minute joint subluxations that obstructed normal neural energy flow. Both of these disciplines have moderated their approaches to manipulation over the last century. Most osteopaths have abandoned the practice of mobilization and manipulation in favor of more traditional medical treatment. The chiropractic community has divided its philosophy between the “straights” that believe in Palmer’s original theories, and the “mixers” who believe in more traditional scientifically based physiologic principles⁴.

Manual therapy as first described by Mennell and Cyriax during the early 20^th Century has developed as an extension of traditional medicine, focusing upon joint mobilization and targeted exercise to treat mechanical musculoskeletal dysfunction. Unlike chiropractic, manual therapy has always been guided by the stringent principles of scientific research creating a profound differentiation between the two disciplines⁴. Today this distinction has blurred as Chiropractic has partially abandoned its non scientific “obstructed energy flow” model of disease.  Manipulation has traditionally referred to the high velocity thrusts performed by chiropractors while mobilization referred to lower velocity joint movements performed by therapists. The historical differences in philosophy between manual therapy and chiropractic led to these terms taking on greater meaning than had been originally intended. Recently, the American Physical Therapy Association (APTA) defined mobilizations and manipulations as a continuum of skilled passive movements of joints or soft tissues graded on a five point scale, leaving the only difference between the two as a matter of degree.

The generally accepted fathers of modern manual physical therapy technique include Geoffrey Maitland from Australia, Robin McKenzie from New Zealand, and F. Kaltenborn from Norway. They have published extensively on manual technique, taking the science to an unprecedented level. Manual therapy is becoming more widely utilized within the USA and over the last decade has become a critical part of the undergraduate curricula of major Physical Therapy schools⁵. In modern practice, qualified manual physical therapists often use an eclectic assortment of techniques to best treat their patients, with contributions from Maitland, Paris, Kaltenborn, McKenzie, Mulligan and others.

A recent survey of therapists around the industrialized world found that in Britain and Ireland the Maitland and McKenzie approaches were the most popular with mobilization preferred by 83.7% of therapists for the treatment of back and neck disorders⁶. In the United States, the McKenzie method was rated most popular even though only 25% of therapists were versed in mobilization techniques. In the mid south, there are numerous excellent physiotherapists focusing upon sports medicine, total joint and upper extremity rehabilitation, however the percentage of therapists credentialed to perform manual therapy and mobilizations is even lower than the national norm, creating very real concern over the quality of spinal therapy available in our community. Although many may claim they use manual techniques, few can show certified training in proper technique.

In reality, good manual technique requires considerable experience and talent to develop...

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                                                    Last modified: 04/04/06