Janice McConnell, DVM, CCRT, cVMA
The role of manual therapy in physical rehabilitation
Manual therapy is a tremendous tool we can include in a physical rehabilitation program to help your patients safely return to function after injury or surgery. Approaches to manual therapy have been adapted from human physical therapy to our veterinary patients, providing us with the means to greatly enhance our patient’s comfort, healing, and quality of life.
Manual therapy can be defined simply as skilled use of the practitioner’s hands in a therapeutic manner. It involves manipulation of soft tissues, joints, or the spine in a controlled manner with the therapeutic goal of assisting the body in two processes: the repair process and the adaptation process. Manual therapy can benefit many conditions, including muscle strains, joint injury, post-operative recovery, spinal conditions, and osteoarthritis.
We carefully select our manual therapy techniques based on knowledge of the patient’s injury or surgery and findings from a full body examination. In our physiotherapy assessment, muscles are palpated for symmetry, pain, taut bands, myofascial trigger points, and flexibility. Tendons are palpated for symmetry, thickness, and pain on palpation or stretch. Joints are put through passive range of motion and any loss of normal range is noted. When a joint has reduced range of motion, the therapist will classify how the end range of that motion feels, then evaluate joint play if appropriate. Joint play assesses accessory movements of the joint, which are movements that can only occur passively but must be present for full physiologic range of motion to be intact. Joint play may be reduced if, for example, the joint capsule has become tight or adhesions are present.
Manual therapy techniques include joint glides (translatory movements at a joint), stretching, soft tissue mobilization, and massage. The effects of manual therapy may be localized to the tissue involved and/or systemic via neurophysiological or neuroendocrine pathways.
Local Tissue Effects
Manual therapy takes full advantage of the fact that our musculoskeletal tissues are adaptable and highly responsive to mechanical stimuli. At the tissue level, manual therapy allows us to influence fluid flow, tissue repair, and adaptation.
The benefits of manual therapy approaches that enhance fluid flow include reducing edema or joint effusion, clearing inflammatory products, and circulating joint fluid, all of which help to maintain health of articular cartilage and provide an optimal environment for tissue repair. In addition, studies have demonstrated that there is improved circulation to the joint during and after manual treatment.
Providing optimal guidance for tissue repair will result in healthier tissues and a stronger repair. In general, tissues under repair will benefit from the same form of loading they experience normally. For instance, articular cartilage will remain healthier when some compressive forces are applied after surgery; likewise applying low load tensile forces to a healing tendon will improve the quality of fiber alignment in the repair process. Yet, we must also acknowledge that loading too soon or too intensely will adversely affect healing.
Adaptation refers to the long term changes in tissues that result from the types of mechanical stimulation that are applied to the tissue. Maladaptive changes, such as adhesions or tissue shortening, may occur if injured tissues are not exposed to normal mechanical forces while under repair. For instance, repetitively using a muscle only within a reduced range will ultimately lead to shortening of this muscle.
Manual therapy interacts with the neurological system to influence pain pathways, sensory feedback, and motor function. The primary mechanism by which manual therapy reduces pain is through sensory gating. Stimulation of mechanoreceptors in the vicinity of a painful site will block some transmission of noxious stimuli.
Loss of proprioception can occur following musculoskeletal injury or surgery (partial loss) or damage to the nervous system (partial or complete). Proprioceptors are an important source of feedback for the motor system; with proprioceptive loss, we can see alterations in movement patterns and inability to accurately correct movement. Manual therapy techniques can stimulate receptors in skin, muscle spindles, and synovial joints. Dysfunctional motor patterns may develop following musculoskeletal injury as a result of pain avoidance, weakness, or proprioceptive loss. In neurological conditions, abnormalities in muscle tone, incoordination, and postural instability also contribute to dysfunctional patterns. The role of manual therapy in restoring normal motor patterns may involve manual guidance through a functional activity, re-establishing motor control and timing, or addressing pain and inflammation.
Putting it all together
Developing a goal-oriented manual therapy plan for a patient considers the nature of the injury (musculoskeletal, neurological, or both), the phase of tissue repair, pain level, and functional abnormalities.
Let us consider an example. A post-operative stifle patient in the inflammatory phase of tissue repair will benefit from manual techniques that encourage fluid flow, increase proprioceptive input and reduce pain in the stifle. Many stifle patients develop restrictions in the tarsus, most of which will respond favorably to joint mobilization techniques. We may also consider manual therapy if we find distant areas of discomfort or tightness due to compensatory postures. Our manual techniques at this stage may be combined with modalities such as LASER, TENS, or therapeutic ultrasound to further relieve pain and inflammation, or make tissues more pliable for manipulation. As the patient progresses through the regeneration and remodeling phases of tissue repair, we will encourage a gradual increase in compression loading to the stifle. We continue to work toward restoring normal range of motion in affected joints and correcting any abnormal tissue adaptations. At this stage, manual therapy techniques can be done more vigorously and with greater amplitude.
As we achieve our goal of improved, comfortable, and functional joint motion, then what do we do? We use it! A therapeutic exercise plan is designed to promote normal posture and gait, active range of motion, active stretching, improved balance and proprioception, and strengthening within the newly restored range of motion.