Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.
To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):
Nonmanual (including exercise and education) = 80%
Manual = 20%
Modalities = 0%!!!!!!!!!!!!
Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:
PRI manual = 14%
Other manual = 6%
As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.
There’s a reason for the shift
I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.
I know needling is quite the controversial topic, but I was amazed at the sheer quantity of evidence supporting this modality. Like, an insane amount. I am not sure what the “haterz” found their criticisms on, so please comment if you have some ammo (I am a noob to this after all).
And Ray’s lecture on dry needling mechanisms? Oooohhh lawwwwd. Easily one of the best foundational science lectures I have ever heard. Period. The passion this group has not only for science but the physical therapy profession is inspiring. They made me excited to be a PT. Perhaps even inspired me to contemplate the PhD route.
Central sensitization is a phenomenon that occurs in the dorsal horn, which can be best described via 4 different states:
1) Normal: Inputs = outputs; innocuous sensations are perceived as such.
2) Suppressed: Inputs that would hurt do not; think an athlete who injures himself but finishes the game.
3) Increased sensitivity: Pain system has lower activation threshold, leading to pain spreading and pain with light touch and gentle movement. This change occurs because A beta fibers begin taking over C fiber locations in the dorsal horn.
4) Maintained afferent barrage, CNS influences, and morphological changes: Long lasting changes in the dorsal horn from a persistent driver, such as…
A fiber phenotype changes.
Persistent DRG discharge.
Gene transcription change in dorsal horn neurons.
Inflamed dorsal horn or DRG
Maladaptive beliefs, fears, and attitudes.
Dorsal horn sprouting; A Beta fibers take over C fiber space.
Persistent glutamate activity.
The CNS has an endogenous pain control system which activates during injury threat, noxious cutaneous input, or expectations and learning. Such an example of this is when you go to a healthcare practitioner’s office and no longer hurt. Another example of when this system is activated is during aggressive manual therapy. Think about how good your body may feel after sustained pressure or even a needle to a trigger point.
Central Sensitization Patterns
Symptoms not in neat anatomical/dermatomal boundaries.
Original pain spreads.
Multiple areas: Either linked or get one pain, then the other.
Contralateral side may be painful, though not like the other side (mirror pain).
Clinicians end up chasing pain.
Sudden, unexpected stabs.
Patients call the pain “It.” For example, “It has a mind of its own.”
Ongoing pain perception past normal healing times.
Summation via repetitive activities (sitting at a computer).
Distorted stimulus/response relationship. May get pain 10 seconds or days after stimulus is applied.
Unpredictable response to treatment/input, but ends up being predictable (x may only work 2 days).
Every movement hurts, but not big ROM loss (Symptom instability).
“It hurts when I think about it.”
Can be cyclical.
Change in other systems.
Links to traumatic life events.
Miracle cures can work.
Likely in most syndromes (fibromyalgia, complex regional pain syndrome).
2) Do not focus on finding an anatomical pain source which can make matters worse.
3) False positive are frequent on testing when tissues may be healthy (Eg, positive straight leg raise may just be adding slightly noxious input that results in an increased afferent barrage).
4) The physical exam is best considered a sensitivity test.
Increased levels of norepinephrine (physical stress), epinephrine (mental stress), and cortisol (shut down nonessential systems to maintain homeostasis) are upregulated and contribute to, but do not cause, pain. High sympathetic states can lead to problems that include tissue degeneration, mood swings, slow tissue healing, and increased infection susceptibility in people with chronic pain. Tissue change is particularly evident because the sympathetic nervous system innervates and interacts with muscles, joints, skin, connective tissue, inflammatory chemicals, AIGS, and the DRG. The parasympathetic nervous system is also important to mention to our patients in terms of healing effects of sleep and relaxation.