Good for buy in and to set the stage for exercises.
130
u/KingCahoot3627
The deeper I get in my career, the less I use manual therapies.
But PT is an art. You have to recognize when to use those silly patellar mobs. It might be once per day, once per month, or once per yr. The skill is digging in your toolbox to use your knowledge when its right for the patient
59
u/tallpeoplefixer
What i can't understand is why people get so polarized about others who do manual? As long as the cornerstone of your treatment is progressive overload and exercises who gives a shit if you do 10 minutes of manual first and it makes the patient feel better and gets you a ton of buy in. Nobody who comes to see you with 8/10 low back pain wants to jump into barbell deadlifts despite what you evidence based crazy people think.
53
u/PleadInsanity
Manual therapy is well used for certain conditions, several CPGs have strongly supported the use of manual therapy and given A level evidence towards it for conditions like hip OA/ plantar fasciitis
I think it's out of date to think that manual therapy has no business to be in the treatment plan as long as you're doing manual therapy and there's etc.
47
u/angelerulastiel
I believe strongly in manual work. It absolutely will not solve the problem by itself, but I see it as a boost. It helps reduce pain and gain ROM. It helps with patient buy in and builds a relationship. And simple human connection is therapeutic. Trying to treat patients with exercise only is like building a house with only nails. There’s a reason we have different tools.
Edited to add the ending that apparently disappeared when I posted.
45
u/HammerLite75
I’d prefer manual as opposed to almost any modality. Manual then exercise will almost always go better than just exercise. Plenty of patients don’t require manual. I really enjoy providing that service, provided the patient needs it or benefits from it. I do work in private practice so buy in important. I believe that it facilitates trust and a level of care that these patients do not get from other practitioners. It’s been around for much longer than other treatments as well. I don’t think you should be doing more than a unit for almost any diagnosis tho, aside from a B/L or multi joint diagnosis/patient.
13
u/Lost-Copy867
It depends. For example there are numerous studies linking loss of terminal knee extension to poor outcomes. So if I’m addressing this problem then some manual therapy (extension mobs) is going to be a part of that but I am also going to stress to my pt that performing their HEP to improve extension is the most important thing. Also- if I do any manual I’m going to test and retest every time.
I have been an outpatient PT for 12 years and have taken a lot of NAIOMT classes and my overall view of manual is pretty neutral. It has a place but if you are going to use it you should be able defend why you are using it.
11
u/drumstixclix
Placebo has a well studied positive effect- therapy is an art!
We all know manual in isolation ain't doin sheeit. In combination with adequately dosed ther ex/ther act? Not harmful at worst, and makes the Pt feel good and creates buy in at best. Its a tool in my tool box that I don't discount solely on lack of strong evidence. Totally hear your frustration though, I hate doing it bc in my mind ik the mob/manual alone is barely gonna move the needle in terms of recovery, but I try and remind myself its an act of care and love. Just some OT thoughts
11
u/Sugar_on_the_rumpus
I actually find a lot of my knee OA patients like joint mobs for pain relief. I'll usually start with them for a few minutes then we get to active exercise.
10
u/TheRoyalShire
[deleted]
9
u/lalas1987
Sometimes manual is just a method of gaining someone’s trust. Sometimes manual can have an immediate effect on pain levels and that alone will allow the patient to do a thing or two they wouldn’t or couldn’t do before walking in the door. That’s a win. One of the problems with the art of PT is it’s very hard to study, hard to reproduce, and hard to develop really sound research around the manual/psychological/movement combo that a good session might entail.
I keep manual in my back pocket and bring it out when it’s the right time. And that’s not for every person. But to say what we do with our hands is not ever effective I have found to be untrue.
With that said I haven’t touched an ultrasound wand in 12 years. Taping I do rarely and cupping I suppose the most often.
7
u/AlexADPT
It’s whatever
The issue is with the charlatan quacks who say dumb shit like how they’re putting joints into place, releasing fascia, breaking up scar tissue, re-aligning someone’s natural chi with their pelvic shotgun maneuver, and the list goes on and on
7
u/Spec-Tre
I use manual to get an idea for irritation around the joint/trx area based on muscle tone, ROM, reported pain, tenderness etc while also building rapport with the patient and figuring out where/when/how activities are still symptomatic.
It has value to further guide my treatment and can make the pt feel better so they can tolerate the therex/act I have planned for the session.
If it doesn’t happen in a session that’s cool too. I’m not doing manual bc my told me to
6
u/jmrdpt19
I will use it if my go-to exercises modifications/self mobilizations don't change the pain. I never go into the mumbo jumbo lingo with patients, but sometimes a little anterior tibial glide calms the system down enough that they can get back to exercise.
6
u/rj_musics
It has its place depends on what you’re trying to accomplish.
5
u/NeighborhoodBest2944
Of course some patients don’t REALLY need at all. But of you aren’t seeing a benefit to patients, you aren’t don’t it right. And that usually comes down to USING the new mobility/range immediately after and giving a home exercise that directly works on that.
5
u/Royal-Government3488
I often receive patients who transferred from other clinics because they felt the therapist never actually worked with them hands on. In reality, many patients simply want to feel that their therapist cares. They value that human connection and physical interaction. I do not mind spending eight minutes performing manual therapy. It helps me build relationship with my patients and, psychologically, it reinforces their sense that they are being cared for and supported during their treatment. Of course exercise is the best thing you can absolutely do for the patient. That has been scientifically proven. However, patients are humans that want to feel cared for. Nothing more. Nothing less.
5
u/Binc42
The effects of manual therapy span far beyond just the physical. Are we doing exactly what we think we are when doing mobs, STM, etc? Most likely not. But doing manual helps build rapport, build buy-in, get a feel for the joints/soft tissue in the affected area, and learn things about the patient to help guide sessions.
For example, during manual I learned a patient misses gardening but felt “they couldn’t do it anymore”. So our treatment for the next couple of weeks focused on that. And they were so happy to be back to gardening. I’m also a firm believer in the more different stimuli that can be introduced to affected tissue, the higher chance to decrease sensitivity and subsequently onset of pain.
Manual therapy should be less than 25% of the session though to prevent reliance or false perception of “the magic hands of the PT”
4
u/45SocksToLaunder
I like using it for some patients. It helps build the relationship, meet expectations, and can really alleviate some pain.
I am biased towards an exercise approach, but I do think we don’t criticize exercise as much as we criticize other forms of treatment. Exercise is also not always so much better than other more passive treatments, which is frustrating, but a reality.
I do think we provide a lot of benefit to our patients, but what types of treatments we choose…I think matters less than I would hope. I’m trying to be more of an optimist rather than a nihilist, but it’s hard when you start digging through the literature and find out how little we know.
(Greg Lehman terms and influence here).
4
u/buchwaldjc
I teach continuing education courses on manual therapy to both physical therapists and massage therapists and also teach the soft tissue mobilization lab at our local physical therapy program.
With most diagnoses, it doesn't make much sense to make a blanket statement that manual therapy is good for any specific diagnosis. Instead, it depends on what the specific deficits are within that diagnosis. If you take knee OA for example, if range of motion is an issue then manual therapy might be of some benefit. It might also have some benefit in pain reduction and reducing muscle inhibition. In contrast, if the major deficits are gait and balance, manual therapy might not be appropriate.
It has a time and place as any treatment. And there is plenty of research out there on it looking at comparing manual therapy plus exercise against just exercise alone and finding an added benefit with manual therapy with certain dysfunctions.
4
u/BigGambinoSosa
So would you say therex is the way to go?
3
u/Far-Finger8964
I feel you on the losing trust part and feeling like we go through alot trends especially with manual therapy. This is one of the reasons that I haven’t spent a lot of time or money getting certified in any particular manual technique. I’m still a very hands on therapist, but I mostly focus on soft tissue to help alleviate symptoms because I find that leads to better patient buy in. If my patient leaves a session in less pain than when they walked in then they’re more likely to be compliant and be an active participant in their PT.
3
u/idkshit69420
As a COMT I do a lot of manual. I do take ROM before and after but I'm doing ONE technique then reassignment. No I do not do manual on everyone. Yes EVERYONE does exercise. For knee OA specifically, in the COMT program we were to read articles that actually show there was no difference in recovery if we did or did not do manuals for that population.
3
u/oscarwillis
Should t be about how much value YOU (therapist) puts in manual therapy, but what the patient values. Yes, you need to educate. But a patient not coming back because you don’t meet them where they are…. No bueno for everyone. Shared decision making goes a long way.
3
u/BoomerSkunk
It’s another arrow in my quiver.
2
u/ReFreshing
Depends on what you're doing and what for. For example knee mobs and assisted flex/ex stretch after TKR definitely helps. STM to get rid of perceived "knots"? Not so much. Yes a lot of what we learn turns out to be ineffective but through experience you should pick and choose what you believe best benefits the patient. If you don't believe manual helps in certain cases you shouldn't feel compelled to do it.
Now when it comes to using it for buy in, placebo, improving behavior compliance.... Then that's another set of reason for using it and it has positive effects outside of the biophysical model. It definitely has its place in the psychosomatic realm. Just gotta know when to use it for each patient.... It's an art like many have said.
2
u/Queen-of-Wands-13
I'm a lurking SLP here. Manual therapy was super super effective for me and my tension issues. I do a lot of oral motor and feeding therapy and manual therapy changed the way I could move my tongue even after years of self therapizing. I also work with a lot of babies who receive PT and the manual therapy I am trained in is really helpful for a lot of them (they are generally seeing me for feeding issues but end up at PT first). These babies make progress in both feeding and reduction in tension/torticollis and usually increase in ROM in neck that they have not made with just traditional PT. Obviously I have a small sample size but I see a lot of anti manual therapy thought on here, and it's super helpful for a lot of my patients and myself!
2
u/OddScarcity9455
Modulating pain, getting buy in and patient expectations are like 75% of outcome. So yes it matters a lot for a lot of patients. (Number is not based on research, don’t come at me)
2
u/Extension-Bicycle-54
Someone clearly hasn’t seen the karate kid and Mr. Miyagi’s miracle hands
2
u/fauxness
Not gonna lie I have a lot of patients leave other PT places because they did no manual whatsoever. They come to me, I do some manual (nothing fancy) and they feel better. Why? Idk but I’ll put my hands on a patient for 8 min if it means they get better. There wouldn’t be a whole profession dedicated to massage if people didn’t think it helped.
2
u/capmapdap
My tiny hands can’t do much for obese patients as I can hardly palpate any anatomical landmarks and/or move a limb.
A lot of patients now are obese. So no, not doing manual.
2
u/deadassynwa
Very little but it has its place
1
u/climbingandhiking
Doeneds on how much my patient values it tbh
1
u/finks_finks
It depends on the patient. Some will benefit from it, whether for improving ROM or pain modulation or just building rapport. If a patient wouldn’t benefit from it or doesn’t seem to care for it, I won’t do it. If most of your patients are improving and coming back to you, then you’re fine without it. If patients are not improving or plateauing or canceling, then it’s something to try. Just another tool in the toolbox. Use your clinical judgement.
1
u/Big-Count-3329
Im a new PTA, but for me personally i like to start off with more manual therapy during the first few visits, however after like 2 weeks max i only save heavy manual sessions for flare ups.
1
u/MossyBubble
As an LMT and CPT who has almost exclusively worked in PT and chiro settings to do manual therapy and teach therapeutic exercises (also working on corrective exercise specialization and potentially going back to school to further my education into DPT) this thread is devastating. Are we not inhibiting overactive musculature to help reduce neural drive and increase activation ability/room for movement in the opposing under active muscle? Are we not using the relaxation effects of manual therapy to ease the client/patient when they’re scared and in pain? Do mobilizations of joints and soft tissue not help increase range of motion? I’m confused. In practice I’ve found that using manual therapy techniques really helps people live with more mobility and less pain - even before the implementation of stabilizing and strengthening movements. Isn’t that the goal? To help people live better in their bodies? Patients/clients love it and loving treatment creates the adherence to it which helps in the long run. Why leave out a good chunk of the equation? I’m serious I truly don’t understand.
1
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u/browdogg
I love the discussions of previous cases and uses of techniques in this thread. Is there a subreddit where we can discuss pt stuff without endless bitching about the profession? I’d love that
-1
u/Dewey_PT
Progressive resistance exercise and education trumps all manual therapy. I have taken every manual class under the sun and also gone through a manual therapy/orthopedic residency…it’s useful but only if it helps get the patient off the table quickly and onto progressive resistance exercise.
-5
u/VO2VCO2
Almost no value at all. Same goes for dry needling & other gadgets.
It's very important that we use methods that are proven to be effective in randomized controlled trials. It sounds boring, but honestly, that's the way it is. If doctors don't see physical therapy as evidence based practice, they'll stop using us.
I don't think there's any danger in trying shockwave, especially since the classic approach didn't work for you. No guarantee it'll work, but it may help restarting the healing process and increase your pain tolerance. Sure many physios here will disagree because of all the passive (and sometimes manual) modalities hate
8
u/CommercialAnything30
Hyperbaric is over rated unless your job relies on your Achilles. I researched this for someone not long ago and it requires 90 minutes a day for 12 weeks to get the benefit. Beyond that, no one knows the minimum requirement for maintenance beyond that initial protocol.
Shockwave is worth it imo since you have tried everything else. Shockwave plus exercises.
5
u/DrgnFly5
[deleted]
4
u/Ezdoesit1
Anecdotal but I like shockwave for stubborn tendinopathies that are more chronic
4
u/SentientScarecrow
There is some good research for it and it can't hurt to try if you have the money. I would also recommend you look into percutaneous needle tenotomy. If there's a provider in your area who offers it, I would recommend consulting with them. We see good results in treatment-resistant Achilles issues.
ETA it's typically done by Ortho MDs
4
u/OddScarcity9455
No
3
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Please read the rules here if you have not done so already: https://www.reddit.com/r/physicaltherapy/wiki/rules
1. No Medical Advice: We cannot provide diagnoses, exercise prescriptions, management or treatment plans. Requests for medical advice will be removed, and users/clinicians involved may be banned. If you need care, please see a therapist in person or via telehealth.
2. School Inquiries: Please post admissions and application questions to r/PTschool. Discussion regarding clinical placements and professional development from students is welcome here.
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2
u/halfserious3
two years in with solid pt means the fundamentals are there. shockwave has legit research but the real issue is usually how people ramp back up, not the tissue itself. most get the same result from being way more conservative with the progression and that's free.
2
u/VO2VCO2
Since it's lasted so long I would try combining few Shockwave treatments with heavy resistance exercise. Did you actually go hard with the exercises for an extended period of time?
Skip on the other two. Placebo effect at best but small chance of serious consequenses = skip.
2
u/Living-Protection250
I think most people I’ve seen in that situation end up realizing it’s less about finding the “next thing” and more about how well the loading and progression actually sticks long term.
Some of those options do get used, but from conversations I’ve had, they seem to work best as an adjunct, not a replacement for a solid, consistent loading plan. Otherwise it’s easy to get temporary relief without real carryover.
You’re definitely not overthinking it though, chronic tendinopathy can be frustratingly slow and non-linear.
Curious what others here have actually seen move the needle in these stubborn cases.
1
u/1giftedangel
Shockwave has produced results in myself and others.
1
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