How Manual Physical Therapy Can Help Rheumatology Patients

Throughout human history, we have used our hands as a tool to survive, create, offer, communicate, heal, and comfort others. As physician and writer Abraham Verghese said, “Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch.” Though many different professions provide hands-on treatment, the following article will discuss specific, evidence-based manual therapy techniques that physical therapists can offer your patients. When a physician refers a patient to physical therapy (PT), manual therapy will likely be a part of their treatment, as human touch is a crucial component in the PT treatment philosophy and approach. The common manual therapy techniques that will be discussed include functional dry needling (FDN), specific soft-tissue mobilizations (SSTM), myofascial release (MFR), muscle energy techniques (MET), and joint mobilization and manipulation. This article will provide knowledge regarding the benefits of manual therapy techniques that PTs perform, help you gain understanding of the principles and physiology behind each technique, and provide evidence to support each technique.

Functional Dry Needling

FDN is also known as intramuscular manual therapy. It is a procedure in which a solid filament needle is inserted into the skin and muscle directly at a myofascial trigger point. Physical therapists may use dry needling to treat myofascial pain. A myofascial trigger point is a contracted muscle, which can be related to the production and continuation of chronic pain. Commonly mistaken for acupuncture, FDN differs in that it is specific in its selection and search for precise trigger points and soft-tissue dysfunction relevant to the patient-specific symptoms, and it must be interpreted by extensive evaluation and examination. Very few schools of acupuncture include the assessment, identification, and dry needling techniques of myofascial trigger points.¹

This does not discount the vast benefits acupuncture provides many patients. The advantages of FDN have been increasingly documented and include an immediate reduction in local, referred, and widespread pain, restoration of range of motion and muscle-activation patterns, and a normalization of the immediate chemical environment of active myofascial trigger points.² Trigger-point dry needling should be based on a thorough understanding of the scientific background of trigger points, the differences and similarities between active and latent trigger points, motor adaptation, and central sensitized application.²

Each state differs in its regulation of physical therapy practice. For example, in Colorado, a physical therapist must be licensed for two years prior to taking the FDN courses. The courses include approximately 27 contact-hours per level, in which a written and practical test are administered. For more information about whether physical therapists practice FDN in your state, please visit: www.kinetacore.com/physical-therapy/Dry-Needling-Scope-of-Practice/page63.html.

Specific Soft-Tissue Mobilization

SSTM uses graded and progressive applications of force in order to increase the tensile strength of the tissue and restore the functional biomechanical properties of the soft tissue. Soft-tissue dysfunction can occur when the load is excessive in relation to the mechanical properties of the tissue, or when the biomechanical properties of the tissue have decreased in relation to a “normal load.”³ A manual therapist must establish the etiology, identify the site, and apply specific treatment in order to appropriately treat soft-tissue dysfunction. Physiological, accessory, and combined SSTM are the three classifications that have been proposed to help identify and treat problems effectively.⁴ Although SSTM is specific, graded, and progressive, the mechanical properties of soft tissue are based on biophysical principles and strong supporting evidence is not available.⁵ If interested in the SSTM technique (along with all others mentioned below), physical therapists may obtain continuing education to enhance their skill of identification and treatment of soft-tissue dysfunction.

Myofascial Release

As described by Andrew Taylor Still, the father of osteopathic medicine, the MFR approach is a form of soft-tissue therapy used to treat somatic dysfunction that may be causing pain and restriction of motion. The idea of MFR is to relax contracted muscles, increase circulation and lymphatic drainage, and stimulate the stretch reflex of the muscles and overlying fascia. Current research has focused on the effects of MFR and fibromyalgia. Peripheral pain generators in fibromyalgia include: degenerative joint disease, myofascial trigger points, inflammatory joint disease, bursitis, tendinitis, hypermobility syndrome, neuropathic pain, injuries, traumas, repeated muscle pulls, visceral pain, disk herniation, spinal stenosis, and recurrent cephalalgia.^6,7 A recent 2010 randomized controlled trial researched whether myofascial release therapy can improve pain, anxiety, quality of sleep, depression, and quality of life in patients with fibromyalgia. Statistically significant findings revealed improved anxiety levels, quality of sleep, pain, and quality of life in the experimental group over the placebo group immediately after treatment and at the one-month mark.⁸

Muscle Energy Techniques

Muscle energy is classified as a direct technique in which the restrictive barrier is actively engaged to contract a muscle against a distinct counter force.⁹ It can be utilized to stretch tight muscles and fascia or assist in mobilization of a restricted joint. The physiological approach of MET is to act on the Golgi tendon organ’s reciprocal inhibition of the agonist and antagonist musculature, thus allowing for brief relaxation and engagement of the restrictive barrier.⁹ Soft-tissue irritation can be interpreted as pain, which, in return, reacts by increasing agonist muscle tension and weakening of the antagonist. Chronic myofascial dysfunction feeds this positive feedback cycle, thus contributing to the “toilet bowl” effect of chronic pain syndromes.

MET is commonly used with a wide variety of musculoskeletal disorders in conjunction with mobilization and manipulation. The current literature reveals that MET directed at the lumbopelvic spine significantly reduce pain and disability scores.¹⁰ However, this evidence is level C, and further research needs to be performed. This technique is widely used by physical therapists. The overall treatment goal of MET is to restore normal physiologic motion of the joint or affected area.

Joint Mobilization and Manipulation

Physical therapists, along with other practitioners, will commonly refer to a joint as hypomobile, within normal limits, or hypermobile. Joint play is assessed in the physical therapy evaluation to determine whether restriction or pain is present. It is suggested that normal joint play is necessary for pain-free movement of the synovial articulation and, if restricted or absent, voluntary movement will, in turn, become restricted and painful.^11,12 The main purpose of mobilization is to improve motion and normalize joint function.

There are five types of joint mobilization. Grades I and II are applied to a patient for the main purpose to decrease pain and muscle guarding. Grades III, IV, and V are provided to increase joint mobility and function with stretch into joint structure. Grade V manipulation is also referred to as high-velocity, low-amplitude (HVLA) thrust. It is proposed that the HVLA has a neurophysiological, nutritional, and mechanical effect on the joint, resulting in increased mobility and decreased pain. The stimulation of large mechanoreceptors helps to decrease pain (according to the gate control theory) on the neurophysiological level.¹¹ Nutritionally, the movement of synovial fluid acts to improve nutrient exchange. Mechanically, with the use of Grade III–V mobilization, capsular adhesions are directly impacted to increase joint mobility. Note that absolute contraindications include malignancy, tuberculosis, osteomyelitis, osteoporosis, fracture, ligament rupture, or herniated disc with nerve compression.

The current research on manipulation and mobilization is extensive. For example, with patients with lower back pain, there is strong evidence that mobilization and manipulation are similar in effect to a combination of medical care with exercise instruction. There is moderate evidence that mobilization and manipulation are superior to general practice medical care and similar to physical therapy in both the short and long term.¹³

Physical therapists obtain general manipulation and mobilization skills with their DPT degree, but continuing education is always available to those who want to build on their skill level and knowledge. Organizations such as the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) offer fellowship programs in manual therapy. You can recognize a manual therapy fellow if they have FAAOMPT within their title.

Conclusion

Myofascial pain commonly is overlooked in patients who present with multiple comorbidities or complex disease states. A physical therapist is skilled in evaluating and treating soft-tissue dysfunction with the use of a variety of techniques, and the most common are mentioned above. Hopefully, this article has given you a better understanding of the principles, physiology, and evidence surrounding the techniques of functional dry needling, specific soft-tissue mobilization, myofascial release, muscle energy techniques, and joint mobilization/manipulation.

Alicia Lovato is a physical therapist at Azura at Home and Azura of Lakewood Rehabilitation Suites in Wheat Ridge, Colo. She studied physical therapy at Regis University and is a member of the ARHP Practice Committee.

References

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11. Simmons SL. Osteopathic manipulative medicine: Review for the boards. 1st ed. Ft. Worth, TX: Stephan L. Simmons, DO; 2011.
12. Jones LH. Spontaneous release by positioning. The DO. 1964;4:109-116.
13. Bronfort G, Haas M, Evans R. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Spine J. 2008;8:213-225.