Manual Therapy options

Got a recent question from a new grad basically on where to start to look for continuing education for soft tissue work and other manual therapies.  Below is a quick list that I compiled of places I have studied, where I’d like to study, or where I believe the teaching and evidence-basis is solid. They are probably in some kind of order by my affinity, but the key to remember is that is not the “brand” of manual therapy that you do, but how good you are at it.

I think it is fair, as Gray has taught me, to expect to have a soft tissue technique, a joint technique, and a trigger point technique. My soft tissues are Gua Sha, Pin and Stretch, and old fashioned digging.  My joint techniques are Maitland and Mulligan.  Trigger point training is from Rizopoulos and Kostapoulos.

One link that I don’t know exists is a formal training module in Lewitt’s methods.  I am sure Dr. Craig Liebenson’s Modern Spine Series teaches these @ an expert level. I hope and suspect we have readers that have experience in all of these schools of training, so please comment on the ones I am less experienced on.

http://handsonseminars.com/
–Probably the best option I can think of.  I first got a hold of these names by Gray saying this is where he learned his Trigger Point management, surprisingly not from Travell and Simons.  I believe Rizopoulos is Editor of Journal of Bodyworks, which is a fantastic journal that has all the EBP standards but presents novel and contemporary choices that you do not see in the APTA world.  These guys are read in every manual therapy there is and are brilliant educators.

http://www.activerelease.com/
–Certainly one of the more popular brand names out there utilizing pin and stretch method.  I am not formally trained, but certainly the results most hear about are legitimate in my eyes.  Unfortunately researching this technique can be troublesome as it is practiced by mostly chiro, who are real slick and invest in the certs and don’t really use the technique as taught and intended.  They just advertise ART to get you in the door and hook you up to stim and heat trash.

http://www.bmulligan.com/
–Non-painful joint technique where the master Brian Mulligan can’t even always explain himself.  Reducing positional faults is probably the best description I have, and it is often magic.  This is my primary “joint-based” manual therapy.

http://www.ozpt.com/
–Geoffrey Maitland model of joint mobilization extending off of one our our forefathers, Freddy Kaltenborn.  Model based on convex-concave joint congruencies in reducing pain and extending joint play.  I use this liberally as well, particularly in regaining lumbar extension mobility.

http://www.grastontechnique.com/
–I am not sure there is any difference in all these IASTM techniques, but we had Graston in Philly, and of all the models, I think their education is the best.  I at some point will take their course and apply it to Gua Sha.  I need some more knowledge before I give in to the steel of Graston being better for “feeling” the tissue than the plastic of Gua Sha Orthopedic.  SASTM is something I really want to try as well, but again, I would go to Graston for well-priced quality learning that you probably can apply to Gua Sha, Graston, SASTM, ASTYM, and Crochete.

http://www.usa.edu/files/8a1d1707-92ba-48d4-abef-58058ebfd837.pdf
–I am not sure if this was a complement or not, but one of my ortho professors for DPT, Dr. Susan Edmond, said I reminded her of a young Stanley Paris.  Obviously Paris is a genius.  I’m not sure I agree with his contra-McKenzie model, but I do know this is probably the best place for a PT to learn manipulation techniques.  And of course here in NJ, as a PT we can’t do manipulations, but we can do Grade 5 mobilizations.  You can learn these here too.  They actually look quite similar (wink, wink).

http://www.faktr-pm.com/
–Combination of IASTM and Mulligan techniques.  I was scheduled to take this in September, but I opted out in favor of Todd Wright’s mentorship in Austin.  This is a must-take for me as if somehow this blend of IASTM, Mulligan, and ART is legitimate, it will likely take manual therapy to higher levels.

http://www.anatomytrains.com/
–Thomas Myers model of Structural Integration is my most favorable “massage” approach.  It clearly defines regional interdependence, and the 12-week process is very complimentary to progressive exercise.

http://olagrimsby.com/index.cfm
–Don’t know much about their methods, but I do know the name is well respected on the West Coast.  I suspect it is old school as in Medical Level 2, me and Brad’s partner was a diplmat there, and he was totally lost in the SFMA model.  He probably had great manual therapy skills, but I don’t know where their assessment and functional component lies.

http://www.naiomt.com/
–These folks haven’t really been accessible to my locations and availabilities, but Tim Vagen came up with their horseman @ the San Fransisco Spine Clinic back in the day.  If Tim Vagen says they have good work, then I agree.

http://www.jiscs.com/Article.aspx?a=0
–I think there are a lot of excellent knock offs for learning Positional Release, but I think most would agree that Jones is the originator and the go-to book resource for learning his work.

http://discoverphysio.ca/courses/descriptions
–Maybe we’ll call it Demoneuromodulation where the manual therapy is purported to separate skin from nerves.  This is what Steve does with me in working on my shoulders.  Diane Lee’s name comes up quite a bit in recent times, and I will probably go through her book(s) one of these days before taking a course.

http://www.myofascialrelease.com/
–I have never heard positive things from a John Barnes course attendee, but he has been around forever, and by my admission, I don’t know a lot of people that are in his camp.  I had a story once from someone that went.  His buddy was the model up on stage, and Barnes was demonstrated something that supposed to be magical, and the model, another student at the course, ran off the stage because Barnes jabbed his thumb into his side when there was “supposed” to be a reaction.  Hearsay?  Yes.  Shady?  Probably.

http://www.guyvoyer.com/eng/index.htm
–Another name like Diane Lee and Canadian as well that I think we should be reading and learning more about.

https://www.tnseminars.com/home/courses/met
–This is Mike Rosenberg’s company, and there is also a Manual Therapy module that is available.  Like Positional Release and Myofascial Release, there are many knock offs to Muscle Energy Technique.  I have lost touch with this technique as I think the manual palpation specificity is beyond my skill set, but if you are good at MET, it is just as powerful as a lot of other stuff.

http://www.muscleactivation.com/
–I took a 1-day on this about 10 years ago right when I graduated PT school.  It seemed like it was a lot like MET, but I suspect that is incorrect.  I really have no idea what is going on here in terms of “muscle activation,” but I do know folks that I seriously trust like Ben Shear and Robert Lardiner use this method as a go-to move, so there is reason to look further.

http://www.nmtcenter.com/
–Manual therapist formally trained in NMT are a place to look when looking for a great individual.  I hold a lot of favor for their teachers and many practitioners that I know personally.  Unfortunately, as this is more a massage genre crowd, there is a lot of foolishness with candles and metaphysical slop that gets in the way of quality practice.

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29 Responses to “Manual Therapy options”

  1. Laree says:

    Charlie, that is a GREAT post. I’ll bet a lot of your readers follow up on some of those links.

  2. Patrick Ward says:

    Good post.

    I’ll second the courses from http://nmtcenter.com/. You are correct about it being more of a “massage” crowd in attendance and peope being more interested in candles and nonsense. Judi does do a good job of putting on a solid clinic with good information though. She was the previouis editor for the Journal of Bodywork and Movement Therapies and has co-authored two textbooks with Leon Chaitow, so she can has a lot to teach professionals in different disciplines (even though most that show are massage therapists).

    Another source is Willem Kramer’s Anatomy Links (http://www.anatomylinks.com/). Willem does a great job of taking the idea of regional interdependance and expanding it to all of the systems of the body, not just musculoskeletal and fascial. He notes connections between the nervous system, vascular, and lymphatic system, giving you many things to look at, evaluate, and treat in your manual therapy approaches.

    Patrick

  3. Charlie says:

    Yes, as you know, Patrick, we have tried to get Judy to the East Coast based on your recommendation.

  4. Great post Charlie, lots of valuable resources. Two questions:

    1. Where does Rolfing fit in to this list? Is it no different than myofascial release?

    2. Also, you mentioned MET when talking about Muscle Activation Techniques. What is MET?

  5. I have a course with Judi this weekend. Im excited!!

  6. Mike Janusak says:

    Charlie,

    You mentioned Guy Voyer. Are you at all familiar with what he calls ELDOA?

    And I also wanted to ask a question related to Graston. I have a few friends who have gone for this treatment, and they came back looking like they’d been caned (in terms of the superficial bruising) and rug burned. Would that type of thing be atypical with Graston or other implement-assisted methods of treatment, be related to poor application of the techniques, or just par for the course with such treatments and just part of the process sometimes?

    I have heard very good things about the treatment, but this was a bit concerting to me when I saw what happened to them, as I have limited experience in this area.

  7. Charlie says:

    Nick – The Anatomy Trains version of Rolfing is Structural Integration. Rolfing is also an excellent choice, but I don’t believe you can learn it in a continuing education module like everything else on the list.

    MAT = Muscle Activation Technique
    MET = Muscle Energy Technique
    MET is about manipulating bones via very low load resisted contractions of agonists and antagonists. It is a neuromuscular technique.

  8. Charlie says:

    Mike – I have no background on Voyer other than he exists, and we should expect quality progressions.

    The serious bruising you are seeing from Graston is considered normal. The purplish sections are called petichiae, and given that the technique is literally causing new injury via destroying fibrotic tissues, the bruising is expected.
    One angle as to why Graston and other IASTM works is that healing is retarded because fibrotic tissue constricts blood flow from its constant tension. So if we destroy the adhesions, we will also rip up the blood vessels that traverse them. Instant blood flow often yields quick and maybe now not so amazing results. But also with appropriate movement post-treatment, we can expect a more appropriately layered and less restricted remodeled tissue in due time.

    There are other reasons these manual therapies work, but this is why you get the bruising and why it’s okay as per my understanding.

  9. Great post Charlie! I have to agree with Patrick that Judi does a great job trying to keep the work more “clinical” and less “massagy-touchy feely.” I also got a lot of similar and solid information from Paul St. John and his method of NMT: http://stjohnseminars.com/seminars.html

    Ironically, he is no longer part of the company and has started his own new company (which he can’t term NMT anymore for some legal reasons. Here is his new webiste: http://www.neurosomaticeducators.com/

    Keats

  10. Michael Hartman says:

    Thanks for sharing all these resources. This page is getting bookmarked. I really like your soft tissue, joint and trigger point approach. I have used the Graston technique sine 2005 and can say the discoloration is commonly associated with treatment. Sometimes it is so pronounced I show patients before they leave so they do not get shocked when they or others see it. There are also other flavors of IASTM. ASTYM and SASTM have diffrent tools and methods and each claims to be best. There is also a low cost instrument the STARR tool. I have found using a tool to be easy on my hands and a very effective form of treatment. Especialy when combined with joint and trigger point treatment.

    Michael

  11. Charlie says:

    Michael – Agree with all of the above. My consensus is that they are all more the same than different, but Grason has the best education. Use the tool(s) you like, but take the Graston education.
    ASTYM seems to be a scam with leasing their tools and exclusive nonsense.
    We also take pictures of body segments that are out of site like the posterior spine and hamstrings. We’ll never do it with a young person without someone present.

  12. Michael says:

    In reference to the link posted for the MET course, https://www.tnseminars.com/home/courses/met

    This actually is not my company, Therapy Network Seminars, but one I contract with to teach a Manual Therapy of the Upper Extremity Course and a Intro. to Joint Mobilization Course. The course I teach is combined soft tissue and joint mobilization as well as evaluation and exercise considerations. The MET course is Muscle Energy and Soft Tissue techniques. Appreciate the recognition to the course.
    Michael

  13. Sam Leahey says:

    Charlie – for the Strenght & Conditioning coaches out there, would you recommend the same skill set of a 1)soft tissue technique 2) a joint technique 3)a trigger point technique?

    I fully understand that some certs and skill sets are only available to clinicians but i would love to hear your suggestions anyway. Thanks.

  14. Charlie says:

    Sam – I do not delineate between “names” of professions. If you do not possess the manual therapy skills that encompass things you may see, that just means you need to incorporate someone who does on your team.
    I don’t know how a strength coach will be able to maximize athletes getting bigger, faster, and stronger if indeed there is an indication for manual therapy.

    As these topics make the rounds over the last several weeks, maybe the best thing is to just work in a setting where they have a great team of like minds and everybody just does their part.

  15. Charlie,
    How great to hear someone speak about getting beyond the “names” of discplines. Your stripe doesn’t matter, it’s all about what you know & how you apply it. Today fitness trainers do better rehab than most PTs! The question is “who can exercise someone who has pain soonest & safest?” No profession owns his skill. But, hopefully everyone is after it!

    Thanks,
    Craig

  16. Charlie says:

    Dr. Liebenson, this is a message that I would fly over the beach on a little prop plane.

  17. Sam Leahey says:

    Well said Dr.Liebenson!

  18. As an amateur writer from Canada, I seldomly come across really well written publications like this blog which really helps me inspirationally. It shows me what superb postings are all about. There are tons of poor writings on the web and it’s very sad. Thank you for your well written posts! I frequently read your blog and enjoy the content you share. I look forward to more of your work.

  19. ELDOAS are specific stretching protcols designed to decompact spinal segments.
    It is grounded in osteopathy. Voyer is known a little more in Canada, I imagine he will become more well popular in the next few years, as people become more interested in his work.

  20. Do you subscribe to ANY single theory that doesn’t contradict many others leading to “manual therapy options” that aren’t, well, senseless in light of what we know?

    Is every idea of equal value?

  21. Charlie says:

    Barrett – I’m not really sure.

    Senseless in what context?
    In light of what who knows? Is it possible we know different things? Have a different standard to what we “know?”

  22. A standard? You’re serious?

    This is a great answer. May I speak of it elsewhere?

  23. Anoop says:

    Hi Charlie,

    Who is Gray you are referring to? Is it Gray Cook or Gary Gray?

  24. Charlie says:

    Barrett – No, you may not speak of my answer elsewhere.

  25. Charlie says:

    Anoop – Gray as I referred to above is Gray Cook.

  26. Chris says:

    Dorko – Could you please explain what you mean by those comments? They are a bit vague.

  27. Donald Berry says:

    What a great post and wonderful responses.

  28. Anoop says:

    Check this article: http://bodyinmind.org/jointhead-diskhead-musclehead-fasciahead/

    It talks about where Charlie and Gray got it wrong.

  29. Don Stanley says:

    I took several NMT certification classes from Judith Walker in 95-96. Being a massage therapist with a clinical mind Ive always been alone in a sea of “gurus and spiritualist.” The classes I took were concise and clinical in nature. Spartan setting and very straight forward teaching and instruction without a hint of the wishy-washy. This is how I prefer it. Maybe its changed over the years. Most massage therapists are shaky on anatomy anyways, so the nature of the coarse would tend to exclude a lot of that.

    I studied structural integration and myofascial release under George Kasaleos at the Core Institute. George is a Harvard grad and a brilliant lecturer. He teaches structural integration in the traditional recipe of Rolfing. I have since studied with Eric Dalton and prefer his more modern approach to structural integration without the strictures of the traditional recipe format. I tend to prefer tools over philosophies or dogmas. For anyone interested in high-level myofascial release/structural integration I highly reccomend Eric Dalton’s coarses and books.

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