Past the Plateau

Manual therapy can help patients progress to functional therapeutic exercise.

By Kirsten Bollinger, PT

It happens to every physical therapist at one time or another. Despite your best efforts and a solid treatment plan, your patient doesn't improve and continues to have pain with exercise. How can you get this person over the hump and onto functional therapeutic exercise?

The answer may be manual therapy.

We've all heard about the benefits of manual therapy, but many of us may hesitate to use it in our practices. Various reasons account for this. If you open any PT magazine, you'll see many ads for seminars promising amazing results. Attend one of these seminars, however, and you'll be given few, if any, references from scientific studies.

In addition, the fiscal pressures facing some facilities work against using manual therapy because it requires training and one-on-one time with patients. Lastly, patients need to be active participants in their rehabilitation, and manual therapy is mainly a passive treatment. While these are acknowledged problems with manual therapy, it doesn't mean we should completely avoid the treatment.

Numerous forms of manual therapy treatment exist, with each focusing on connective tissue and fascia. All require different skill levels and training procedures.

Most of these methods offer courses to teach therapists the technique and requirements for certification. Describing each technique goes beyond the scope of this article, but the underlying goal is to decrease pain and inflammation, normalize muscular movement patterns and break up connective tissue adhesions.

At our clinic, we've used manual therapy to help patients, who've had years of pain, return to normal ADLs and work activities. For those who need it, manual therapy is key to allowing them to exercise pain-free. Following are some examples proving this point:

A 65-year-old man, who had a diagnosis of status—post right shoulder arthroscopy, awoke from surgery with the same pain he had before the procedure. Manual therapy treatment to a right infraspinatus trigger point relieved pain, which allowed him to strengthen his rotator cuff. Consequently, he returned to his workcarpentry.

A 38-year-old male landscaper was injured at work and had chronic low back pain with one herniated and two bulging lumbar discs. Initial hamstring lengths using the 90º/90º test were -76º right and -80º left. With manual therapy to the gluteals, lumbar paraspinals and proximal hamstrings, he achieved pain-free trunk range of motion and hamstring lengths of -20º on both legs. This allowed him to perform functional strengthening exercises, pain-free. He returned to full-duty work after six months of light duty.

A 30-year-old woman had whiplash after a car accident. With marked decreased neck range of motion and daily headaches, she couldn't exercise. With manual therapy, she could begin upper body strengthening. Normal cervical range of motion returned, and she got rid of her headaches.

These three patients had undergone previous physical therapy care at other clinics, where treatment consisted of modalities and therapeutic exercise. By adding manual therapy to their treatment plans, we progressed them beyond the "plateau" they had reached with other providers.

Need for Research

Unfortunately, most evidence about manual therapy is anecdotal. This is the main problem. Case studies show certain manual therapies are effective, but there's a paucity of valid research into exactly how manual therapy works. Some researchers are working toward discovering the physiological changes, but limitations exist that make this a difficult topic to study.

One drawback is that our current technology lacks a reliable imaging technique to show changes in the fascial connective tissue. Another limitation is the number of techniques; each needs to be tested and its effectiveness verified on the physiological level. This is an important part of gaining greater acceptance in the scientific community. The lack of research needs to change, but until it does, we must rely on outcome measures to justify that these treatments help patients progress toward their goals.

The Guide to Physical Therapy Practice states that PTs should determine the expected outcomes for each treatment and participate in outcomes data collection and analysis.1 Outcome measures validate your treatment's effectiveness. They're important for all physical therapy treatments, but they're particularly crucial in manual therapy.

Outcomes help your case when you discuss manual treatments with case managers, doctors and insurance companies. Using a proven, reliable and valid measure will demonstrate treatment effectiveness because you can show improved patient function. It also may prove that manual treatment with therapeutic exercise is more efficient than that of your competitors, making your practice more marketable. Moreover, outcomes can show when your approach isn't working, so you can modify your treatment plan. In addition, reimbursement may improve if you can use outcomes to support successful treatment plans.

Our clinic uses joint-specific indices that have been proven reliable and valid, such as the Oswestry Questionnaire and the Neck Disability Index.2-6 Patients fill out these 10- item questionnaires by selecting their function level on various ADLs. We also have them fill out the SF-36, a general outcomes measure that determines emotional and physical well-being. The SF-36 examines eight health concepts: general health, physical functioning, bodily pain, mental health, emotional functioning, role functioning, vitality and social functioning. Patients fill out these forms at the initial evaluation, re-evaluation and discharge. We then score them to show progress through treatment.

Clearly, the objective measurements we learn in physical therapy school are also important. Goniometry is standard practice and is reliable and valid, especially when measured by the same physical therapist.7 We use the figure-8 circumferential measure for the ankle, which has been proven reliable and valid for ankle edema.8

Although not as well established, hand-held dynamometers provide an objective number to coincide with our manual muscle test scores. We also use a cervical range of motion device for testing cervical range, which has been found reliable and valid.9 The same physical therapist performs all of the measures to improve intratester reliability.

Many other outcome indexes and measurement tools can be used. So make sure you choose reliable and proven measures, and apply them correctly when you report your outcomes.

To determine a true positive outcome, you need to know the amount of change required for a statistically significant improvement. Otherwise, you may report a false outcome. Evaluate your final selections for ease in administering and scoring. Pick measures that will work best with your clinic's routine.

Testing Improvements

Occasionally, changes can be measured in one session, using a "before-and-after" test. Improvement is the goal of each session, but the measure will be more powerful if the change in range or strength is maintained between visits. For example, measure the hamstring flexibility before treatment to that area of strain. After treatment, remeasure and you will, ideally, see a statistically significant improvement.

At the start of your next visit, measure it again. If the patient has maintained the improvement, you know you've had a positive effect with treatment. This helps enhance patients' compliance with the home exercise program because they'll see the improvements.

Manual therapy can be the tool that helps your patients get "over the hump" and onto more functional therapeutic exercise. Of course, they must actively participate in physical therapy. But this can be difficult when exercise is painful.

Manual therapy can be a beneficial adjunct to treatment, but you must prove its effectiveness. Using outcomes enables you to do this. Until more research is done on the physiological level, outcome measures are your optimal tool for proving the necessity and value of manual therapy in your practice.

 

For a list of references, go to www.ADVANCEforDR.com and click on the references tool bar.

Kirsten Bollinger, PT, works in a private outpatient orthopedic setting in Champaign, Ill. She specializes in orthopedics, women's health and wellness issues, and can be reached at kirstenb@mettlercenter.com