What is Manual Therapy? Manual Therapy is a specialized approach within Physical Therapy that analyzes the biomechanics of structures in the body, and aims to restore normal functioning and relieve pain. We use our hands to feel how far a joint surface can glide on the adjacent surface (passive accessory movement) and then restore the normal movement. We check how adhered a muscle area is to its neighbor (myofascial mobility) and then restore its normal mobility. We correlate these findings with the pattern of symptoms to determine which findings are most relevant. We use this method to develop a treatment plan to resolve these functional deficits. Although the emphasis is on hands-on treatment, we often teach home exercises or self-treatment techniques to reinforce what we achieve in the clinic, or for specific strengthening, stretching or movement re-education.
How is what we do different from other physical therapists? Our approach includes listening closely to you, taking the time for a careful assessment of your condition, using skilled manual therapy, and applying specific therapeutic exercise. We believe that a thoughtful, specific treatment will achieve the best outcome. A more generic approach may miss important components of the problem. We spend the entire treatment time with you, without any aides or assistants.
How is what we do different than massage? We perform a thorough evaluation to determine the cause of the presenting symptoms, and treat using techniques that we believe will best resolve those symptoms. We use a wide variety of techniques and instruction, individualized for each patient. We utilize massage or soft tissue techniques when we believe they can best resolve our patient’s disorder, but also utilize techniques to effect joint, cranial, visceral, lymph and nerve tissues, as well as teaching movement re-education and specific exercises. We don’t do full body massage; our work is more specific.
How is what we do different than chiropractic? Chiropractors focus on the alignment of the spine, and perform Spinal Manipulation (called adjustments) to correct misalignments as their primary treatment. We also use Spinal Manipulation with a small percentage of our patients, but as only one technique in an overall treatment approach. We find that non-thrust techniques such as Joint Mobilization, Muscle Energy Technique, Strain-Counterstrain, and Myofascial Release are extremely effective. Some patients benefit tremendously from Manipulation, but others respond poorly. We find many of our patients who had previously received chiropractic care benefit when we provide a soft tissue and whole body approach.
Does pain come from joints or muscles? It can come from either or both. Research into the cause of pain has included experiments with normal, asymptomatic volunteers getting injected with irritants into different structures and reporting where it hurts. Researchers have produced maps of pain referral for each joint, muscle, ligament, disc and fascia. These maps overlap extensively, so it’s not always easy to differentiate one structure from another. But with a thoughtful examination, we can usually come to a good understanding of the symptom pattern, and know which techniques are likely to help the condition. For a condition that is predominantly a joint problem, we will use techniques that are designed to reduce inflammation and restore normal flexibility of the joints involved. If it is predominantly muscle or fascia, we will apply techniques designed for them, which are different than the joint techniques. If we see a nice reduction in symptoms, we know we’re on the right tract. If not, we re-assess and see if we missed anything, and may try a different technique.
What is the most common cause of headaches? Cervical headache, or pain arising from structures in the neck, is the most common cause of headaches. The pain referral patterns of the top 3 levels of the joints in the cervical spine include areas in the back and front of the head. Several muscles in the neck also refer pain into the face and head. We have seen many headache patients come to us after having undergone extensive imaging and medical evaluations that were negative, only to find they had a common cervical joint or muscle problem that was easily resolved with therapy.
What are the common effects of prolonged sitting? People who sit a lot develop tight and shortened tissues in the lower thoracic and upper thoracic spine and rib cage. There is often muscle weakness in the rhomboids, lower trapezius, deep neck flexors and erector spinae muscle, with associated tightness in the diaphragm, pectoralis and intercostal muscles. This pattern can be corrected with manual therapy and an exercise program to stretch the tight structures and strengthen the weak ones.
How do you treat muscle guarding after car accidents? I see many people following a car accident or other trauma whose pain is largely generated by muscles that have gone into spasm, as a protective response. There is a wonderful technique called Strain-Counterstrain, which is able to relieve the pain and spasm by resetting the muscles back to their normal level of tone. This gentle technique involves positioning the contracted muscle into a specific, shortened position and holding that position for 90-120 seconds. This technique can be used along with other techniques to help recover from injuries.
Can a malposition or strain of the atlas cause symptoms? The atlas (C1 vertebra) is the topmost vertebra in the spine. It has a unique shape, like a washer or ring that connects the head with the neck. There is a tendency for it to shift away from its normal position, especially with prolonged sitting, or from an injury. When this occurs, it can create strain in the adjacent joints, causing pain. It can reduce flexibility, cause congestion in the head, and contribute to TMJ or jaw pain. There are manual therapy techniques that can guide the atlas to its neutral resting position and restore normal mobility, which relieves symptoms.
What are the most common causes of neck pain? Joint inflammation is the most common cause of neck pain that I see in my practice. The facet joints in the neck become inflamed, swollen and stiff after trauma, overuse, degenerative changes or postural strain, and cause pain locally and referred into areas of the head, upper back and torso. The second most common cause of pain is the muscles of the neck, triggered by trauma, overuse or postural strain. Trigger points in the muscles can also cause local and referred pain. Each of these problems can be helped by manual therapy.
What is sciatica? Are there any other causes of pain going down my thigh and leg? True sciatica is caused by compression on a lumbar spinal nerve, often from a bulging disc, which can cause numbness, weakness and pain down the back and side of the thigh and leg. This is called radicular pain. Pain in the very same area can be caused by irritation of a joint structure (such as sacro-iliac joint or hip), a muscle (such as gluteus medius or piriformis), or another soft tissue structure (such as the iliolumbar ligament or the sacro-tuberous ligament). This is called somatic referred pain, and is more common. Because pain referral patterns overlap, a careful evaluation must be made to find the correct source of the symptoms, in order to give the correct treatment. An MRI study may show a bulging disc or other abnormality, but cannot determine whether that abnormality is causing the symptoms, or is unrelated to the symptoms. Spinal abnormalities are extremely common in the general population, and are often asymptomatic.
Does stress cause my pain? Although stress may contribute to pain, there usually is underlying biomechanical or biochemical dysfunction that is the primary cause. Physical Therapy can calm down these underlying issues and help reduce stress.
What problems are caused by adhesions in the abdomen? Adhesions can form in the abdomen following a surgery, a trauma or infection. These adhesions glue one structure to another, and restrict the normal gliding motion that occurs during digestion, elimination, breathing, or active movements. They can cause a feeling of tightness, restriction, or pain, or can interfere with digestion, elimination, fertility or other function. The type of treatment used to break up these adhesions is a direct hands-on manipulation of the tight structures called Visceral Manipulation. We have been trained to find the location of the restrictions and apply techniques that release them.
What problems are caused by adhesions in the pelvis? Adhesions can cause pain by irritating nerves, muscles or other structures both internally and externally in the pelvis. The pelvic floor muscles are designed to support the pelvic organs yet allow an opening when required for elimination, childbirth or sex. They must be both flexible and strong enough to do that. Adhesions restrict their ability to expand, contract, or shift position, which can cause pain or impair functioning. Manipulation to these areas can release these adhesions to restore normal functioning and relieve pain.
What causes pain with sex? Having sex involves strong muscle contractions and vigorous stretching of many tissues. The muscles involved, including the pelvic floor muscles, often develop painful trigger points just like other muscles in the body, and can be painful when compressed or stretched. Connective tissues that have shortened as a result of trauma, infection, surgery or disuse can hurt when stretched. Adjacent organs, such as the cervix, normally move in certain directions during intercourse and orgasm, and may hurt if they are unable to move that way. Sometimes the coccyx is stiff or shifted in position and can cause pain during sex. These muscles, tissues and organs usually respond very well to specific manipulation to restore their normal flexibility and tone.
How do you help tailbone pain? The tailbone, or coccyx is often hurt from a fall, or after childbirth. The tailbone consists of between 3 and 5 separate coccyx bones. These bones can get jammed together, causing joint pain and inflammation. They can also get bent into a flexed or side bent position, which causes joint and myofascial pain. Additionally, many cases of tailbone pain have their source in the adjacent muscles and ligaments of the pelvis. Neil and Michelle have been successfully treating this painful condition since we studied this approach with Dr. Jean-Pierre Barral in France in 1997. In many cases, it is necessary to perform internal anal manual treatment to be able to mobilize the coccyx and reach deep pelvic floor muscles.
Is there motion between the bones of the head? Yes, small motions between the cranial bones are possible and occur normally. These movements allow some give when there is a trauma to the head and play a role in the circulation of cerebrospinal fluid. Sometimes there are twists and compressions in the skull that may come from imbalanced tensions of the neck muscles that attach into the skull, or from a trauma. There are dural membranes within the skull that can have abnormal strain patterns. These can give rise to various symptoms, including headaches, neck pain, autonomic imbalance or tension. The techniques we use can restore normal mobility and balance. We have seen wonderful results over many years with these techniques when applied to the appropriate patients.
How do you feel about MRI and X-rays? Medical imaging is extremely helpful to help doctors diagnose conditions. We also believe that medical practice has developed an over-reliance on imaging, with insufficient hands-on examination. Most musculoskeletal conditions require careful palpation and manual testing to correctly understand the nature of the problem. Imaging can’t see the effect of movement and provocative tests on reproduction of pain, alterations of joint play, tissue adherence, and locations of tenderness. These hands-on tests give us the understanding necessary to resolve many problems. Many patients with headache, neck pain or low back pain have a biomechanical dysfunction with inflammation that can be effectively treated with competent manual therapy, advice and exercises. That should be the first course of intervention in most cases.
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