What if I told you that the neurophysiological effects of manual therapy are only 15-20 minutes.  Meaning, 20 minutes at the max, no more.  Surprising?

What if I then told you that the same effects from our modalities (ultrasound, heat, laser, etc), aka the ones we use for comfort but know there is no evidence of effectiveness, yield the SAME length of relief?

Warmth!
Warmth!

If you are a manual therapist, does this resonate poorly with you?  Does it make you mad? Or, just like that card game, you’re probably calling bulls#%!

Believe it or not, its true.  The question remains, then how does manual therapy yield better results than just modalities?

We do know the interaction can be just as important as the technique.  We also know that expectation, placebo and pre-existing beliefs have a huge role in benefits of musculoskeletal symptoms and resolution of pain.

But, don’t throw in the white flag on manual therapy and also don’t hang your hat on modalities.

I teach my interns that:

A mechanical stimulus is needed to start a chain of neurophysiological effects

The mechanical stimulus from manual therapy may be STRONGER than modalities.  It can have the same duration of relief, but a more pronounced load on the body.  In short, it can be the reset button needed, or buttons, needed to link the chains for recovery.

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11 comments

  1. HV,

    There are a few other things in general that manual therapy has over modalities. 1) It’s normally an interactive experience, more active than passive 2) It’s delivered in general by therapists with better levels of clinical decision making and thus probably enforced with a better HEP. It’s the HEP after all, that keeps the window of improvement open.

    These are broad generalizations, but I like yours as well. The OMPT inputs are most likely affecting a myriad of mechanoreceptors thus leading to greater PNS and CNS changes, versus less input from simple heat/cold, passive estim.

    1. Erson,
      Thanks for the feedback, as always, well written!

      You know people always say manual therapy is passive, which is true in definition, but I try to use it to find also an active approach for the patient. It can be trial and error to an extent. A prime example of this is MWM technique for the fibula head to improve DF (Mulligan’s technique). You take the manual therapy to see the results, and if it improves concordant symptoms (ROM, pain, etc.), then you can prescribe as active exercise. This adds to your statement #2 above…enforcing the results with a more specific HEP.

      Hv

  2. Any treatment that only gives to 15-20 minutes is not getting at the root of the problem. I can beat someone with a blue rock and they may feel better for 20 minutes but I consider that a failure. This is simply gate-control at work – distracting the body long enough to get a copay amount. Real success is achieved by restoring the primary dysfunction. If I have a motor control issues (weakness) that is causing me to overload another part of my body making the muscles work harder, the muscles will get sore. I can do some rubby-dubby on the muscle and make it feel and function better for 20 minutes but I have done nothing to change the function of the weak muscle causing the overload. If I instead, treat the weak muscle (not the painful one) then I can get a much better outcome. Conversely, if I have a joint or soft-tissue dysfunction which is causing the weakness, and I simply try to make the weakness stronger, I feed into the compensatory pattern and make the problem harder to get rid of. It’s not your treatment that needs improvement, it’s your diagnosis. “He who works at the site of pain is lost…and so is his patient.” – Karel Lewit. “Don’t bring a manual therapy treatment to stability problem- Don’t be a rookie” – paraphrased – SMFA.

    1. Hey Doug,
      Good points bringing in SFMA. I do it myself and definitely think it is helpful in identifying the bottom line.

      I’m just the messenger, don’t shoot me 🙂

      I would say the same thing, if someone only gets 20 minutes of relief, then I did not do my job.

      I do not say it quite like the article to my patients, but I do mention that the MT, modalities, etc. only give short term responses. It definitely assists in getting across importance of the exercise program.

      Hv

  3. I’ve always thought that manual therapy is adjunct to the real treatment, which is exercise and activity. That 20 minutes is a window of opportunity that allows the patient to begin to move in more appropriate and less harmful ways, setting them up for recovery.

    1. Dr. Landel,
      Great response and I appreciate your comment!

      I agree and definitely think it is a “way in”. If MT gets them to have greater ROM, improved timing (TrA, deep cervical flexors), less fear; then it seems obvious a much more improved outcomes in a daily treatment. The whole concept of within session improvements leads to between session improvements.

      BTW, bet your ears were on fire today! Taught my intern joint position error testing for Cervical Spine just this morning… 🙂

      Hv

    1. Hey Jarod and Dan,
      I originally got this information from an article written awhile ago by Chad Cook. Here it is:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3172950/

      The ~20 minute time frame has been something I’ve heard for some time. Do I believe it from my results too? NO! I treat full time and see longer results…but interesting to read though.

      I appreciate the back lash! Yes, I want this to turn into constructive feedback and hear clinician results.

      1. Harrison, let me start by saying I appreciate what you’re doing online and I value our interactions.

        Now for my feedback:

        The link you gave above goes to a research review, and the “20 minute” max timeframe on the neurophysiological results “of manual therapy” are primarily based on this article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3143008/
        … Which was designed to: “examine the temporal nature of neurophysiological effects after one session of spinal mobilization.”

        Here is the problem with this blog post:
        Your title is “Effects of physical therapy treatment: 20 minutes?,” and in the post you state, “What if I told you that the neurophysiological effects of manual therapy are only 15-20 minutes.”… “Believe it or not, its true.”

        Really?! How in the world can you equate “manual therapy” with “one session of spinal mobilization.” Yes, if all manual therapists did were spend 2 minutes with each patient and do a single spinal manipulation, I imagine our results would be quite transient.

        I’m really really surprised that you would extrapolate the short term effects of a single “back pop” and place those results on the whole of “manual therapy” or “physical therapy.”

        I truly hope you either change the information above to reflect what this 20 minute effect is actually from…. “single session of spinal manipulation” — NOT “manual therapy” or “physical therapy”

        Consumers of healthcare (as well as PT referral sources) who read a post like this, and don’t scroll down through these comments, are going to get some extremely misleading information that may turn them away from the very treatment approach that would do them (or their patients) the most good.

      2. Hey Jarod,
        I appreciate your input and ESPECIALLY your passionate response. I do think the interpretation of the post may be different than what was presented, and intended, by me.

        Yes, I agree that assuming modalities yield same benefits overall from manual therapy is garbage. We all know it.

        The title of the article was initiated for this type of discussion as it was a question. I was showing that, without getting into great detail, that it has been shown neurophysiological effects are similar.

        But, the quote and rest of the post show that a mechanical stimulus (manual therapy) needs to lead to neurophysiological results…especially those that last.

        I do not think the public will take this title as not seeking manual therapy services. That was not the intent, and definitely not the formal statement.

        Hv

  4. Hey Harrison, shouldn’t there be a link to the study from which you’re basing the above claims? I’d like to review the design of that study, because I can tell you right now that there’s no way my manual therapy practice would stay busy with people paying me $150 an hour if my treatments only yielded 20 minutes of relief per session.

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