Types of Manual Therapy
Kristen Higginbotham, Nadia Chughai, Ruben Corona, Kathryn Schlaudraff, Morgan McClellan
University of Texas at San Antonio
KIN 4043- 001
Dr. William Dean
November 2017
Manual Therapies
There are several different manual therapies and techniques that are used to treat varying musculoskeletal issues. These techniques can be divided into myofascial, or soft tissue, and manipulative, or joint based. In addition, they’re techniques that involve either the therapist’s own hands or specific instruments depending on what’s best suited for the patient. Manual Therapy can be broken into five different modalities, including but not limited to, proprioceptive neuromuscular facilitation, muscle energy techniques, tack and floss, traction and mobilization, and Graston, each of which can be used in the prevention and rehabilitation of injuries.
PNF also known as Proprioceptive Neuromuscular Facilitation is a type of manual therapy “stretching technique utilized to improve muscle elasticity” (Hindle, Whitcomb, Briggs, Hong, 2012) with a positive effect on passive and active range of motion that involves the contraction and stretching of muscles. PNF stretching is a technique used to relax and lengthen muscles as a method of flexibility. Medical Doctor Herman Kabat and Physical Therapist Margaret Knott to treat patients with neurological disorders founded PNF in the 1940’s. Since their development PNF stretching has become popular in the physical therapy field as well as other professions related to fitness and fitness training.
There are three types of PNF Stretching, including Contract Relax, Hold- Relax, and Contract- Relax- Agonist- Contract. Contract Relax stretching also known as active assisted is the “contraction of the muscle through its spiral-diagonal PNF pattern, followed by stretch” (Page, 2012). Contract Relax uses the development of tension in a muscle by an isotonic contraction in order to facilitate the relaxation of a muscle and therefore stretch a muscle. Hold- Relax is the “contraction of the muscle through the rotational component of the PNF pattern, followed by stretch” (Page, 2012). This method uses an isometric contraction to facilitate the relaxation of the muscles to gain ROM (range of motion). Contract- Relax- Agonist- Contract is the “contraction of the muscle through its spiral-diagonal PNF pattern, followed by contraction of opposite muscle to stretch target muscle” (Page, 2012). This method is similar to the Hold- Relax stretch where the muscle that is being stretched is isometrically contracted for a few seconds, and then the antagonist muscle will immediately contract for a few seconds.
PNF is a technique that is utilized to enhance muscle elasticity and has a positive effect on both passive range of motion and active range of motion. PNF is divided into two areas, stretching and strengthening techniques and patterning. The goal is to improve movement patterns, therefore progressing from basic stretching and strengthening to patterns is very important. Establishing the appropriate mobility of a joint and muscle must occur prior to strengthening the movement and/or pattern to create effective neuromuscular facilitation. Ensuring that the mobility is adequate will allow more effective transition into functional training. If the mobility isn’t established, movement compensations may arise during functional training. However, certain strengthening techniques are suggested under therapeutic conditions to sustain and influence muscle contraction.
PNF stretching has been very effective in the physical therapy field as well as other professions related to fitness and fitness training. “PNF stretching has been found to increase ROM in trained, as well as untrained, individuals” (Hindle, Whitcomb, Briggs, Hong, 2012) which usually employs the use of a partner to help provide resistance against the isometric contraction, which then leads the joint passively into an increased range of motion. Utilizing the three types of PNF Stretching, which include of Contract Relax, Hold- Relax, and Contract- Relax- Agonist- Contract, will cause an increase in joint ROM, or range of motion, by increasing the length of the muscle as well as increasing the neuromuscular efficiency. PNF has been beneficial as it targets different muscle groups, increases flexibility and ROM range of motion, and increases muscular strength as therapist and fitness related professionals continue to use it in everyday training.
Whether developing muscular strength and endurance, stimulating flexibility, increasing neuromuscular control and coordination, improving joint stability or increasing neuromuscular control and coordination, PNF is a valuable part of every rehabilitation program.
Muscle energy technique, or MET, is a manual therapy technique defined as an osteopathic manipulative intervention, which entails the muscle utilizing its own energy to lengthen in the treatment of musculoskeletal dysfunction. MET is a form of soft-tissue, or joint manipulations deriving from osteopathic medicine. MET involves the conscientious positioning of a region of the body, followed by the use of an isometric (sometimes isotonic) contraction, in which the amount of force applied, as well as the direction(s) and duration of the effort, are prescribed and controlled, as is the subsequent movement of the involved joint, or soft tissues, to a new position after (sometimes during) the cessation of a contraction. This new positioning may involve a degree of stretching, or might take advantage of a reduction in resistance to movement, following the contraction, allowing movement to a new barrier without stretching. METs are used to treat somatic dysfunction especially decreased range of motion, muscular hypertonicity, and pain.
The MET was originally developed by Thomas Jefferson Ruddy, who termed his approach “rapid resistive duction.” In this approach, the patient’s muscles were carefully positioned to allow the patient to contract the muscles against resistance offered by the therapist. Rudy outlined his technique as follows: “1. Resist the levers to which the correcting muscle is attached. 2. Patient contracts the muscle repeatedly, synchronous with the pulse rate and faster, to double the pulse rate or higher, counting one-two, two-two, three-two, up to ten-two, the frequency at the close to be five-two in five seconds, if not an acute painful movement. 3. Press the part to be moved aiding the contracting muscle. 4. Counter pressure on the part articulating with the restricted unit. 5. Employ skeletal muscle contraction to pump visceral circulation.” Later he was credited by Fred L. Mitchell Sr, DO in the 1940s for inspiring his version of “muscle energy treatment.” The first technique manual was published in 1979. Mitchell learned about Ruddy’s approach and came to call it his own “muscular cooperation technique.” A couple years later, Fred Mitchell Jr. changed the name of the approach to “muscle energy technique” which is widely used in present day.
The basic MET protocol is one of the various MET variations that exists that pertains to the origin and insertion of the targeted muscle remaining constant during the contraction. This is regularly used in clinical practices to treat shortened restricted muscles and joints, and treatment for pain. It is important to note, it involves identification of a restriction barrier. Once a barrier is engaged, an isometric contraction of the agonist muscle is introduced to the patient. Followed, should be instructions as to the direction and degree of force to employ, for 5-7 seconds usually, followed by repositioning of the structures. The degree of effort wanted as the patient attempts to isometrically move against the clinician’s resistance should be light.
Pulsed MET, also formally known as Ruddy’s rapid resistive duction, calls for the patient to introduce minute repetitive contractions, involving the antagonist muscle(s) to restricted soft tissue structures (the ‘agonist’), so facilitating and toning the antagonist, and possibly inhibiting the agonist, with potential circulatory and proprioceptive benefits.
Rapid eccentric isotonic stretch is also known as isolytic stretch because it induces controlled tissue damage. This method is opposed to the slow eccentric stretching (SEIS) that does not damage tissue. The clinician’s resistance is greater than the patient’s efforts, resulting in the rapid elongation of the targeted muscle while it is in the act of contracting. Slow eccentric isotonic stretch (SEIS) involves a slow resisted stretch of the antagonist of the shortened soft-tissue structures, a process that nonetheless tones the antagonist isotonically, after which the agonist is stretched.
Isokinetic MET involves multidirectional resisted active movements, designed to tone and balance muscles of an injured joint, during rehab. The force that the clinician applies is less than the patient’s resistance, allowing the muscle to gradually become shorter. This type of MET is used solely to build muscle strength, motor control, and endurance.
Thera-bands are common in the rehabilitation setting and are often used for typical ankle injuries like sprains for strength and recovery. Many are familiar with the resistant bands that Thera bands sell that are usually very thin but most patients and athletes are not familiar with the thicker seven foot by two-inch band. Another brand name for this is called Voodoo Flossing. A few benefits of the Voodoo Floss Band (Tack and Floss) is athletic performance, reduction of injury with improved coordination and decreases in post activity muscle soreness pain, and stiffness because of the increasing flexibility that this particular treatment causes. The Voodoo Floss Band was originally developed by Kelly Starrett, which used this in the lifting community as a method of wrapping a muscle group tightly while stretching or performing exercises to improve mobility and strength. The point of the band is for myofascial release by wrapping a specific muscle group with the band between fifty percent and ninety percent. With newer patients it is preferred to start with fifty percent and gradually increase the tension over time throughout the recovery phase. A small goal is to eventually get the patient or athlete to ninety percent tension.
For instance, if a patient came in with muscle soreness/tightness around the gastrocnemius and the soleus muscle a method to help remove the built up lactic acid could be the band. Simply start distal of the gastrocnemius, and wrap the muscle with half of the band being overlapped. The tension can vary depending on patient compliance but for the best outcome ninety percent would work well. Once the band is wrapped around, have the patient go through simple motions to fire the gastrocnemius. Four-way ankle seems to floss the gastrocnemius and soleus very well, and helping the patient with the plantar flexion, dorsiflexion, inversion, and eversion will get a deep myofascial release.
Myofascial release is the main objective that the tack and floss creates when this specific modality is used on a patient. When tack and flossing a specific muscle, for example the gastrocnemius, the tack and floss is focusing on the fascial layers. As the patient goes through different gastrocnemius exercises, the patient will have difficulties with active range of motion while the band is attached. Before the clinician removes the tack and floss band, the tightness of the band will cause a form of ischemia, but blood will rush back flushing some lactic acid, and as well as fibrous adhesions. This is because of the myofascial release that the tack and floss band creates. The band is tightly wrapped making it difficult for the muscle to fire and elongate, therefore the band acts as a flossing mechanic to directly apply pressure into the layer of the muscle. The end goal is to increase range of motion in the affected area, and as stated in the journal “A Pilot Study: Perceptual Effects of the Voodoo Floss Band on Glenohumeral Flexibility.” “Soft tissue flexibility is considered essential to normal biomechanical functioning in athletics.” This is because the increase of flexibility one has then the lower the risk is for an individual to become injured or receive an injury.
On the other hand, tack and floss is not only used for post injury. In fact, just like many other manual therapies, tack and flossing is great for maintenance on the human body by decreasing post activity soreness and stiffness, because of the fact that this is increasing flexibility. This makes tack and flossing very versatile. Although, the band does have its limitations. For instance, the band cannot be used for muscles like the gluteus maximus, latissimus dorsi, or any portion of the back muscles. This is because the band will not be able to pinpoint directly onto the particular muscles. Therefore, the band is limited for the most part, to the limbs of the human body because of the leverage the band has to directly apply pressure on the specific muscle or muscle group.
Manual therapy is a highly varied modality, yet all are very hands on. One technique is that of manipulation and mobilization. Mobilization, which is synonymous with manipulation, is “a manual therapy procedure that comprises a continuum of skilled passive movements to joints &/or related soft tissues applied at varying speeds & amplitudes” (Wise, 2009, p. 1). These movements are such that the limbs move relative to the stationary body. Additionally, mobilization can be done to distract the joint space as well as glide the joint space. Mobilization and manipulation have many effects, many techniques, and many grades.
There are numerous benefits to mobilization. According to Wise (2009), mobilization can restore articular relationships, help with symptom relief and pain control, and increase and maintain mobility (p. 6). Additionally, mobilization has been shown to enhance motor function, decrease muscle guarding, and improve nutrition to intra-articular structures (p. 6). It also stretches join restrictions and breaks adhesions. While these benefits stem largely from the increase in mobility due to the created joint space from distraction or the fluidity of the joint space from gliding, mobilization also accomplishes these effects through the firing of mechanoreceptors as well as proprioceptors. These are simply a few of the beneficial effects of mobilization and manipulation.
There are numerous mobilization techniques. There are many approaches to mobilization such as the cyriax approach, Maitland technique, translational mobilization, and a number of other. The key factor in these is that collectively, “the most common use for joint mobilization is to treat hypomobility” (Mangus, 2002, p. 238). Hypomobility is the lack of joint mobility. While each of these maintains its own efficacy, one particular mobilization, the Kaltenborn technique, involves not only mobilization by gliding the joint in its space, but also retracting and separating the bones from each other. The Kaltenborn technique is a “traction method” which is “safe and effective” (Moon, 2016). While traction and mobilization have similarities, one study found that in the case of non-specific neck pain (NSNP) in patients greater than 55 years, “patients who received JM [joint mobilization] as a primary treatment modality indicated a greater decrease in VAS [visual analogue scale] scores” (Breed, 2014, p. 41). Additionally, those who received joint mobilization indicated “a greater relief from acute NSNP” when compared to traction.
Lastly, there are numerous mobilization grades. Typically, especially in the Kaltenborn technique, the techniques are grades I-IV. While the Kaltenborn technique makes use of traction in addition to mobilization, mobilization is “used to increase the accessory motions about a joint” (Prentice, 2014, p. 441). The five grades range from least to most intrusive. According to Prentice, grade I mobilizations use “small amplitude” glides and is perfect for pain. Grade II mobilizations are larger glides “within the midrange of movement.” Grade III glides are large mobilizations that bring the joint “up to the pathological limit.” Grade IV glides are very similar but are “small-amplitude glides.” Lastly, grade V mobilizations are “quick thrust[s] at the end range of motion” (p. 442). This often results in a popping sound. In this system, grades I-II are best used for pain management (p. 442). The next two grades best treat stiffness. These grades are purposefully designed to improve the joint mobility and thereby having many positive effects.
Manipulation and mobilization are not to be underestimated as valuable tools in the manual therapy toolbox. Because manipulation allows the examiner to feel the resistance in the joint space, it allows to very personalized and purposeful therapy. Manipulation and mobilization, however, are no less valuable than any of the manual therapy modalities. It is up to the wisdom of the practitioner to decide which modality will best treat his patient. Often, this involves combining multiple modalities.
Although not typically combined with mobilizations, a common therapeutic modality used by many different healthcare professionals includes the Graston Technique. Graston Technique is the use of a stainless steel instrument on the body to treat soft tissue dysfunctions and the implementation of eccentric exercises. Many therapists argue that manual therapy and human touch is the best form of therapy. However, Graston has been reported to help enhance and improve the after-effects associated with therapy. The technique, which includes several different angles and pressures, reduces the stress associated with manual therapies on the therapist’s hands. It can be used anywhere on the body where superficial or deep fascia and reticulum need to be treated.
Graston utilizes a stainless steel instrument that comes in various curvilinear edges and sizes to treat different types of injuries all over the body. The technique used is similar to that of scraping, where the therapist will scrape the affected area of the body with the instrument. During the scraping, the skin will turn red from the friction but is not punctured, thus avoiding external bleeding. The scraping will induce an inflammatory response, causing more blood flow to reach the affected area. With an increase in blood flow to the site, the injury is able to heal faster. In addition, this method assists in breaking down scar tissue that builds up after injury or surgery and causes demobilization. Furthermore, the recruitment of fibroblasts is much higher with the Graston technique when compared to any other manual therapy. The function of “fibroblasts include maintaining homeostasis in the body by separating into myofibroblasts to produce contractions and extracellular matrix proteins to close the wound,” (Li, B., and Wang, J. H., 2011).
Due to the many different instrumental shapes and sizes, the Graston technique can be applied anywhere on the body. Recent studies reported high rates of success when applying Graston to any soft tissue injuries. Some of these injuries include lumbar compartment syndrome, carpal tunnel, and tendonitis. While Graston is very successful in these cases, it should only be used for superficial soft tissue dysfunctions with muscle fibers that are parallel to the injured site. Graston may not be effective when there’s excessive fat in between the skin and adhesion, (Chris, 2017).
After the Graston technique is used, the body responds by providing more blood flow to the affected area and increased fibroblast recruitment to aid in faster healing. Graston creates micro trauma damage to the soft tissues, causing an inflammatory response to promote remodeling of the injured site, (Simmonds, N., BSc, Miller, P., BSc, & Gemmell, H., DC, 2010). According to research studies, fibroblastic stimulation, an inflammatory reaction, cytoskeletal remodeling, altered ion transport, and the diminishing of cell-matrix adhesions all occur with mechanical loading on soft tissue (Hammer, 2017). Graston provides this mechanical loading causing the body to remodel and repair itself much faster when compared to other therapeutic modalities. Immediately after the Graston treatment, it is normal for bruising to develop over the affected site. However, after the bruise has subsided, normal range of motion and increased mobility should be implemented (Hammer 2017).
Graston is a treatment used by medical professionals primarily for athletes to accelerate the recovery process, treat pre-existing injuries, and eliminate pain associated with soft tissue dysfunctions. The stainless steel instrument can be used anywhere on the body due to its various shapes and sizes. Through scraping, the body is able to emit an inflammatory response to cause remodeling and repair. In addition, Graston is becoming more common in therapeutic settings because medical professionals find that it enhances their palpation skills and allows deeper penetration with more specificity, (Chris, 2016). Graston is a therapeutic modality that has treated countless athletes and patients into a speedy recovery for the past 20 years, (Chris, 2016).
From most aggressive to least, PNF stretching, muscle energy techniques, tack and floss, traction and mobilization, and Graston are each implemented to provide the patient with an increased mobility and range of motion. Manual therapy is key in allowing the practitioner and patient to build a relationship while undergoing therapy. It allows the practitioner and patient to build a relationship while undergoing therapy. Arguably the greatest benefit, manual therapy allows the practitioner to be hands-on with the patient. Each practitioner is able to directly feel how the therapy is affecting the patient, and easily adjust any movements or techniques as needed.