Manual Therapy in the Secondary Setting- Friend or Foe? By Cat Webb

Personally I have been using manual therapies in my secondary setting for a couple of years now. At first I was hesitant in my career and soon realized the benefit they had to offer. My top 3 go to manual therapies are: Positional Release Technique (PRT), Muscle Energy Technique (MET) and Mulligan manual therapies with mobilizations. Each of these techniques did require additional certifications and education. Nevertheless, as an athletic trainer in the secondary setting I am improving my overall treatment time by reducing my clinical treatments from an average of 5 days (5 treatments) to 2 days (2 treatments). I am also able to perform all of these manual therapy treatments on the field and return patients to play pain free immediately.

I have had great success using PRT with headache patients including concussion patients, neck pain/soreness and low back pain/soreness.  Positional release technique (PRT) is a unique method that has been gaining popularity as a manual therapy technique with lasting effects by decreasing muscle tension, fascial tension and hypomobility, in turn increases range of motion (ROM) and decreases pain.¹   PRT is a method that uses a total body screening evaluation to locate tender points (TP) while placing the patient in a position of comfort (POC) to resolve dysfunctional tender points.  This indirect technique involves positioning the patient away from resistance and towards the direction of greatest ease, opposite that of stretching.   Theory behind PRT,  is that by placing the compromised tissues into a position of  relaxation for a period of time you will decrease gamma gain and facilitate restoration of normal tissue length and tension.^1,3,4  The application of PRT by the clinician relaxes the muscle-spindle mechanism and breaks down the contraction,³  allowing the clinician to provide biofeedback while palpating the TP and breaking the chain of muscle contraction that causes pain or weakness from the point of dysfunction. 

On the other hand, I have had great success treating patients with MET that complain of pain or soreness along the following muscles-sartorius, rectus femoris, iliopsoas and quadratus lumborum.  MET is a direct mobilization technique that uses voluntary contraction by the patient to treat soft tissue restrictions.¹ MET was developed based on the principles of proprioceptive neuromuscular facilitation (PNF).  MET has been found to normalize joint ROM,² increase joint mobility, increase flexibility,³ strengthen muscles and relax hypertonic shortened muscles.  Exact theories are unclear as to why MET works, one theory suggest that MET releases restricted joints through isometric muscle action known as autogenic inhibition.⁴  This theory addresses treating postural and phasic fibers through MET.  In order to isolate both fibers the patient contraction must occur between 10 and 30 percent.  This allows for avoidance of fatigue which can occur during a more vigorous contraction, such as in PNF.  The second theory addresses only the postural muscles, also known as non-fatiguing muscles.  This type of contraction occurs with less than 30 percent to avoid the stretch reflex.  MET works during this type of muscle contraction by resetting the gamma gain of the muscle spindle and possibly creating a voluntary contraction of the opposite muscle. Muscle energy techniques can be applied in two different methods based upon the patient’s pain.  Patient’s reporting with tightness should be treated with a post isometric relaxation technique where the agonist muscle is being isolated.  This isolation increases the neurofeedback through the spinal cord during the isometric contraction.  This in turn causes re-education in the muscle tone.  This is very similar to PNF with relaxation after an isometric contraction however performed with less intensity.  If the patient reports pain then the clinician would choose the method of reciprocal inhibition muscle energy techniques.  Reciprocal inhibition treats the antagonist and is used for acute injuries that are painful.  This allows the clinician to treat in mid-range instead of end-range and avoid pain by treating opposite of the injured muscle.²

Mulligan Mobilization with movement (MWM) is a system of manual therapy interventions developed by Brian Mulligan that I have had great success treating lateral ankle sprains, tennis/golf elbow, loss of supination/pronation, loss of interphalangeal joint movement and tight hamstrings.  This manual therapy combines a sustained manual ‘gliding’ force to a joint with concurrent physiologic (osteokinematic) motion of the joint, either actively performed by the patient, or passively performed by the operator. The manual force, or mobilization, is theoretically intended to cause repositioning of ‘bony positional fault’. The intent of MWMs is to restore pain-free motion at joints which have painful limitation of range of movement (ROM). Therein lies one of the key aspects of the mobilizations with movement system: a trial of MWM at the time of the initial patient examination will determine whether MWM is an appropriate therapeutic intervention for that patient’s dysfunction. If a trial of MWM is able to eliminate the pain associated with an active movement, then MWM is an appropriate intervention; if not, then MWM is not an appropriate intervention. In the event that a trial of MWM is not able to eliminate the pain associated with an active movement, the therapist should not employ the MWM, and other therapeutic interventions should, therefore, be explored.

All in all, manual therapies are your friend. They reduce your patient load by decreasing your overall treatment time and accurately treating the patient’s pain instead of using a band-aid. I hope they become your friend as they are mine and you begin the research process of finding the best ones that fit your practice. Hopefully the 3 listed above are a good starting point.