Putting Manual Therapy Into Perspective

……..you utilize Mulligan as your primary joint mobs, but also use the Maitland system. You stated you use Kostopoulos for trigger point. If you were looking at manual therapy training now, how would you approach the different schools of thought and how they might apply to the movement system? Would you ever look to get a “certification” for manual therapy, if so, which one?

I’ve had this article in the queue for a while now because every time I sit down to add some things to do it, I pick up a new tool or a new principle as to the how and why of manual therapy.
Overall, I’m excited to write this in regard to these questions because my skills because so much has changed since I first answered this clinician on e-mail.

Got to be better than that Therapeutic Touch trash.

Basically, the role of manual therapy is really to be secondary to active movement, corrective exercise, and maybe too Reflexive Stimulation.  Kolar would have you believe that Reflex Stimulation and DNS should be able to neutralize a trigger point, and similarly, I think he’d say that there is nothing one can do to affect truly fibrotic tissue.  I’m not at all ready to dismiss the manual therapy I’ve learned over the years, but the fact of the matter is that manual therapy should not be the primary option to restore movement.  You use it if you need it.
I think it has a much different and broader place in recovery from training, but in restoring neuromuscular integrity, if it can be done without manual therapy, I think that’s preferred.  Prior to this end, if restoration can be done with Reflexive Stimulation, I’d say that’s even a better Plan B.
Manual therapy’s role is to work itself out of a job.  You do manual therapy so you don’t need to do it again.  Good movement should eventually and quickly become the primary input.

But when it comes down to it, sometimes it too tempting to not go for the quick fix, and more times than not, it’s just necessary when someone is so jacked up.

As I consider the different manual therapies I use to restore  mobility, we should first consider the definition of mobility.  I define mobility as the ability of a joint system to move through a definable range.
That desired range must be defined first because if you are looking for a quarter squat as your indicator of success (not sure why you would), that is the mobility you need to have “good mobility.”  Good or lousy mobility is always related to the movement at hand.  It should be a very relative term by definition.

How does this show up when you Google "mobility?"

The only way to truly assess mobility I think is through unloaded passive mobility.  When there is limitation, the loss can be from a number of different causes.  Ultimately each cause may warrant a different manual therapy approach.  You can have a loss of mobility from dysfunction of muscle/tendon, fascia, capsule, pain, mass, and probably a few other things that I’m not considering.  The more tricks you have in your bag, the more precise you can be with each indication.  There’s a lot of different sizes and shapes in a ratchet set.

1) Muscles can be short.
–Muscles can short, but I’m not really sure that’s often the case.  And if a muscle truly is short, it’s short because of another reason probably somewhere else in this article.  It is such a nebulous area in terms of what to stretch, how to stretch, maybe being tight in terms of sprinting is a good thing, etc., etc. that personally I don’t ever see poor mobility and automatically think short muscle and we better go stretch it.  I think this senario is rare if ever apparent.
In fact the more successful and congruent “stretching” methods like Active Isolated Stretching, Fascial Stretch Therapy,  3D stretching, yoga, whatever system that 40 year old Olympic swimmer used that takes like 4 people to stretch her at once, all rely on a combination of some of the other pieces that lie more in with other indications.
Make no mistake about it that there is plenty of evidence that LLLD passive stretching improves mobility, but I’m not sure that’s really a good thing all the time, and I’m also not sure it’s not closer to a combination of other things happening as well.  Here is an article I wrote some time with some specific opinions on what I think might be happening when we “stretch.”
Stretching can be manual therapy.  I’ve very confident in AIS  (Perry Nickelston has an excellent webinar and PDF on SRE.com and SCWebinars.com) and 3D stretching, and I may look at the Fascial Stretch stuff in the Fall, but the commonality to what I consider good attacks to a short muscle is not really stretching at all.  It’s NOT stretching because I don’t think the muscle is short in the first place.  I think it’s toned.

rolling my eyes

2) Muscles can be toned.
–This is where the money is at.  Muscles feel tight when they are both long and short.  Think of a rubber band pulled to its max length.  It’s tight, but you wouldn’t think to stretch it more to relieve the tension.  So when muscle feels tight, stretching can’t be the automatic thought.
Muscles get toned when the system is in danger.  It’s the body’s way of getting you to stop using the machine under inefficient circumstances.  If the brain can force you to stop by making you tight or maybe shortening your stride so you don’t pop a quad or hamstring, these are good protective mechanisms.
I like when you can find a position that gets the muscle on a length that the brain isn’t threatened by and start there.  That won’t make the changes though.  What makes the changes is using another body system that forces the “stretched” system to go through end range mobility.  You will use another limb, eye movement, breathing, some other dynamic pattern to get in and out of the “stretched” system’s excursion without losing stable form.  AIS holds for 2 seconds to limit that threat (“pain”) of pulling against tone.  You get in, and you get out, and you tell the brain, “Hey, it’s okay for this hamstring to allow for more hip flexion.”  And it works because everything is truly connected osteopathically and fascially, so the system is driven to change with positive proprioception.

But you see it’s not crank on a muscle and demand it to lengthen to increase mobility.  That tells the brain there’s a tug of war going on, and the brain never loses.  And when it’s on the ropes, it leaves you with a bag of poop on your door in terms of even tighter muscles or even worse in closed head injuries.  The brain never loses in the end.

What in the hell does this have to do with stretching?

Does Plan A work all the time?  I don’t think so.

3) Muscles can be very toned.
–The above approaches tuck away the notion of short muscles and thinks of them more as toned.  And that tone is the body’s protective mechanism against failure or degeneration.  Muscle tone changes joint centration, and such things as synergistic dominance take over movement patterns.  Here’s where some of the hands-on techniques come into play.  Now every manual technique is ultimately neuromuscular, but this category starts with some techniques that are more neuro than muscular.
Obviously Reflex Stimulation falls into this category.  This method involves applying vectored pressure into specific zones that influence neurodevelopmental patterns and muscle action within developmental kinesiology.  These zones are the very areas that Baby pushes into the floor or other surfaces to establish points of stability and verticalization.  As a part of DNS though, this comfortable manual approach, through its keyhole into upper cortical regions, has amazing affects to affect the body’s centration at all joints.  As I’ve mentioned before, you wouldn’t believe it until you saw it in terms of how a person reacts with “volitional involuntary” movement.
You’ve also got Muscle Energy Technique and Contract- or Hold-Relax in this category that are not particularly uncomfortable and affect tone and quite remarkably.

I can make you crawl.

My belief though is that these Jedi mind tricks work on tissue that is remarkably healthy.  A lot of times it’s not.

4) Muscles can be very toned and seriously jacked up.
–This is where I break up some artillery.   Operating aggressively on a system that is under tone begets more tone and decentration.  This is not good.  Adhesions, trigger points, lack of glide, or imbalance can all be associated with different structures and reactions.  Because everything is connected, you can get results with a great set of hands regardless of the technique.  You pick your letters; just use them well.
Here’s my analogy to why everything works.  First there can a problem at the switchboard operator.  This is local scar tissue, adhesion, trigger point, tender point, etc.  There is a problem at that local level.
Then there can be a problem through the phone wires, which are housed by the fascia.  And because the fascia is one pocketed entity, it’s dysfunction in terms of lack of glide between its layers, it can crimp, crush, twist, wrangle the phone wires, which are our nerves.  And when the local fascial dysfunction is set in within fascia, its effects are both distal and proximal, affecting afferents and efferents.
Lastly, the brain is the mainframe.  When all the messages get to the brain all garbled, it spits back out a motor plan for protection, tone, and imbalance.  Like I said, you can attack the brain first, but maybe that doesn’t work.  THIS is where manual therapy comes into play.

Yeah, not gonna work.

Here’s what I use……
IASTM – I use Gua Sha.  It’s simple and easy and inexpensive.  In the end, I think all the tools are the same.  If someone that has done Graston for 15 years says they feel fibrotic tissue better through the steel tools, then that’s fine.  I am nobody to disagree.  The fact of the matter is that all of the tools are affecting the body in the same way.  There is global soft tissue destruction, demanding remodeling.  But that destruction is necessary to allow for vessels and/or nerves to become “uncrimped.”  Is this how the Graston folks teach it?  I’ll find out in August, but this is the best way to explain why these tools works.  Following up the unadhesed tissue with excellent movement and stabilization is the approach.
This tool should work for muscle and fascial restrictions.  A problem is that is typically very uncomfortable, and there may be destruction of healthy tissue as well.
It’s value is not only myofascial, but as long as the breathing pattern indicates integration (circumferential expansion and umbilicus descent), the brain reads this proprioception as positive.
This tool is the bazooka.  It blasts through a lot of bad tissue with fair direction.

Amazing green things.

Old fashioned elbows, fingers, and knuckles – Call it whatever in terms of style or technique, but the I think the physiology is the same as IASTM.  Different areas closely situated to bony prominences like proximal hip flexors and subscapularis, for me, seem more effective to use direct manual contact.
I’ll consider this using an M-16.  Probably a lot more precise than the bazooka, but without careful palpation and manipulation, I am probably beating up on healthy tissues.

ART – I am recently ART Upper certified, and before getting this done, I would have said ART was a fancy way to say pin and stretch.  No.  Pin and stretch is hammering a tender spot and asking the individual to move.  ART is far more precise and it seems like it is much less about fatiguing or remodeling 1 specific trigger or tender point, but getting adjacent tissues to slide over/next to each other.  As a part of that garbled messaged and protective system, these adhesions develop and foul up the whole system.
I’ll consider this tool like using a pistol in close combat.  You must have great aim, but you get your exact target without collateral damage to healthy tissue.
ART isn’t killing trigger points.  It’s reversing the local adhesion of structures getting stuck to each other as a result of a poor motor plan.

I'm allowed to use the logo, and there's a good chance that you're not.

My belief right now is that all of the above along with the more specific “fascia” techniques can all be used to treat fascia if 1) applied expertly, and 2) honor the fascial meridians and Centers that Myers and Stecco discuss.
Fascial Manipulation is the technique that I will be adding to my list of tricks in the near future.  I expect to find a lot of money in its blend of Eastern and Western approaches.

Maitland – I think more contemporary literature suggests that the Convex-Concave rules really don’t apply as much as previously thought.  Maitland is more than accessory glides.  This method also teaches physiological movement within a similar 1-4 grading process.  I thought it was quite ridiculous to crunch passive movement as a pain reliever into a full system of evaluation and treatment.
The capsule can be the cause of mobility loss, but I’m not sure my comfort level with what I’ve learned from Maitland is useful for me.  I probably need to gain more, and where I’m at is mainly P-A glides through the spine and global shoulder mobilizations post-surgical.  And I’ll never use these moves without some combination of things above.
I don’t have a gun analogy for this technique.  The Extremities course I took was one of the worst I’ve ever taken.  If the cards fall right, I hope the KE Method is a better fit for me.

The capsule though leads to local joint limitations.  Bones can be out of place.  Not frank dislocations, but rather positional faults are very real.

Mulligan – Brian Mulligan, who is one of the most entertaining speakers there is, fits in when there is local joint pain limiting mobility loss.  The painless handholds restore a positional fault, much like the amazing results of the other methods above.  I think this method is much more similar to Reflex Stimulation than anything else where the hands on location are influencing centration.  And keep in mind, it doesn’t always work.

As a Janda clinician, I believe the brain and the muscles are the primary players in dysfunction.  I think joints are stupid and just do what they’re told.  But I am not so ignorant to say the restoring the joint through mobilization or manipulation is useless.  Smashing through a locked door with a log may be a lot of fun, but I don’t know if a blasting a locked up joint that doesn’t want to move is always a great idea.  On the flip side, if you move a joint, you move the capsule and stimulate a lot of proprioceptors.

Great, great stuff.

Trigger Points – Several years ago now, Gray told me that it was not Janet Travell that he based his trigger point treatment on.  It was rather PTs Dimitrios Kostopoulos and Konstantine Rizopoulos.  True trigger points will have a referred pain pattern, so this technique as well as TDN become a primary thought for me when there is mobility limited by pain in a specific pattern.  The expected referral patterns of trigger points can at times be very reaching such as the soleus referring to the lateral border of the sacrum.  It’s why sometimes folks that go to sorry PTs and chiros live their whole life with an “SI problem” that has nothing to do with the SI.

I think ischemic release or dry needling are comparable options, different comfort levels aside.  The true etiology of a trigger point and mechanism as to why the needles work are still debated.
I consider the needles, which I use more than manual ischemic release, as remote explosive detonation in a very specific location.

Trigger points are the bridge to mobility loss from a myofascial and sensory integration/pain causation.
Figuring out the true cause of pain trumps all the decision making process in when/if to use manual therapy.

One of the best books known to man.

So after all of this rhetoric and opinion, here are some end-all, be-alls for me.
1) Manual Therapy is at best Plan B.  Learn DNS, and it will be Plan C.
2) You can’t make a system out of a method.  Everything above are methods.  The system is how you look at the whole body.  Pain and dysfunction are osteopathic, fascial, and neuromuscular.  Only the expression is local.
3) Being great at the method is far more important than deciding which method is the greatest.
4) You need a trigger point technique, a soft tissue technique, and a joint technique.
5) “Reset-Reinforce-Reload” –Gray Cook.
–Reset the ultimate dysfunction.  Reinforce the fix.  Reload the pattern.  Intervene as you see fit.  Reinvent how you look at the body.

  • May 30, 2011

Leave a Reply 9 comments

Robert Vignoli Reply

Excellent article, Charlie, I couldn’t agree with you more. This is the reason why as a manual (massage) therapist, I study other modalities (i.e corrective exercises, Personal training etc) even though I may not use these methods in our massage setting.

Our body is a system and one method will not work and as I learn more, I am able to help our clients even more because sometimes we as massage therapists are “plan A” when they come see us for a “massage” to get rid of stress or pain. And sometimes we are plan B or C after they that lousy PT, or Chiropractor. And if we know more about the system, we can refer out when necessary and we do. But more importantly its knowing what to look for when choosing someone for referring out.

“The body works in the same way no matter if you are Osteopath, Chiropractor or a personal trainer” or something like this was a quote that I picked up from your video series and I truly believe that and it has empowered our massage business and me personally.

Thank you.

craigliebensondc@gmail.com Reply

Good stuff. I started as a manual therapist and learned a multitude of methods. But, it seems quite obvious that neural adaptation results from learning new patterns of usage. Passive care may be needed, but it is certainly not necessarily so.

How would we know when soft tissue or other passive care approaches are needed? I think the key is to begin w/ a trial of active care & only if the “key” faulty movement pattern does not improve should be move on to passive approaches. Karel Lewit taught that this is diagnostic. For instance, if you assume a muscle is short due to connective tissue factors test your hypothesis by providing an input that you think will inhibit the so-called tight structure. Then re-assess. If by some distant or active intervention passive mobility of the tight structure is restored then we know it was a secondary compensation driven by the nervous system.

Great post!

Mark McGrath Reply

Great overview and honesty about the reality of real change and education with treatment.

Mark McGrath Reply

Upon reflection on this blog I would say that the role of good bodywork is to change the perception of how the body feels. This is because of ‘debauched kinesthaesia’ (Alexander term) or ‘Somato-sensory amnesia’ (Thomas Hana term)
Compensations in the bodymind complex have become automatic and we need to give the client a new way to feel or check in.
‘The brain needs a new beginning’ Janda phrase.
So bodywork prior to movement re-education makes a lot of sense.

Michael Tankovich Reply

This is a great post! I’m curious what your opinion is on AMNT. In my very limited experience, it seems that a lot of the perceived ‘tightness’ I find in patients is really neural tension. This may be one reason that AIS is often effective, you tension the nerves then relax without the long static hold.

Thanks again for providing your opinion, I really enjoy your posts.


Charlie Reply

Dude, that’s is a great last name.

Aaron Hague Reply

Hi Charlie,

Speaking in terms of scope of practice. Where does the line fall between massage therapists and clinicians in the manual therapy techniques listed above? Or is there a distinct line?

My guess is that the soft tissue is open to LMT’s but everything else is restricted to the clinician’s expertise. I have seen instructional videos for sale at the massage therapy school I am considering attending that teaches nerve mobilization techniques, which I thought was restricted to clinicians.

Great post, thanks in advance for your time, and i’ll be looking forward to reading your comments on facebook after you see the green lantern.


Charlie Reply

Aaron – I think everyone should know the information so as to know when it is required. Whether you are the one to do it is secondary.

I think every state is different in who is allowed to do what.
I’m sure there’s a state out there that has a Practice Act of like chiro or PT, and it will say that anyone not them can’t do something. It’s really quite ridiculous.

loanemu Reply

I really liked your article post. Fantastic.

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