Manual Therapy Musings

When I think About You… 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. Rarely is learning involved in manual therapy.

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Course Notes: Spinal Manipulation Institute’s Dry Needling 1

You Mean Zac Didn’t go to a PRI Course? Yes. From time to time I occasionally take a gander at what else is out there in PT land. It was probably about time I check out this whole dry needling thing and see what the fuss is about. I took the Spinal Manipulation Institute’s version based on some recommendations from a few colleagues I trust. Ray Butts was MC’ing for the weekend. 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. All that said, I am unsure as to where needling will fit into my practice. The assessment that would point you toward needling someone was sorely lacking. I’ve noticed this problem to be quite common in manual therapy courses. It’s pretty much you hurt here/have this diagnosis, then use this protocol.

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The Sensitive Nervous System Chapter IV: Central Sensitivity, Response, and Homeostatic Systems

This is a summary of Chapter IV of David Butler’s “The Sensitive Nervous System.” Intro 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. Persistent inflammation. Supraspinal influences 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. Descending Control 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 Areas/descriptors Symptoms not in neat anatomical/dermatomal boundaries. Original pain

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