Physical therapy treatment: Manual therapy!

Previously, we diagnosed Brad with a condition called patellofemoral pain syndrome (PFPS). This type of knee pain was a result of overuse and typically it responds well to physio – in particular, corrective exercises! Exercise progression is the key to victory with this type of injury.

Today, I want to talk about manual therapy as another rehab tool. Some injuries like PFPS can be resolved with exercise prescription. But some conditions respond well to hands-on treatment in addition to execise.

Nicolas-Cage-1024So when I would recruit these beautiful hands to help out? First, let’s introduce you to Nic. He’s a 50-year-old man who dinged up his lovely 1967 Ford Mustang Shelby in a minor car accident. Nic noticed some pain in his neck a few hours after the accident so he decided to get it assessed at a physiotherapy clinic. And thus begins a wonderful story of how rehab helped Nic return to full health!

Just like Brad, I took Nic’s history on the first visit. This is what I found out:

  • His car “Eleanor” was rear ended while photos_large_5he was stopped at a yield sign. He was wearing his seatbelt. The back of his head hit the headrest but he did not lose consciousness. No airbags were deployed.
  • He has not experienced dizziness, blurred vision, difficulty with speaking or swallowing, or fainting spells.
  • He has pain along the back of his neck and the top of his shoulders.
  • His pain is aggravated with shoulder checking and sleeping on his side.
  • He gets occasional headaches around his temples.
  • His recreational activities include riding his motorcycle and hunting for national treasures.

Now that I have an idea of Nic’s symptoms, I can collect some objective data. When I went through the objective assessment, the key findings were:

  • Range of motion: flexion 80%, extension 50%, bilateral side flexion 50%, bilateral rotation 75%.
  • Pain when moving into extension and rotation.
  • Hypomobile (stiff) spinal joints from C5-C7 (5th to 7th cervical vertebrae)
  • Increased tone (tightness) in cervical paraspinals (muscles beside the spine), upper trapezius, and levator scapulae.

Before we proceed, I should clarify neck range of motion. Ready to learn? Got your pad and paper? Okay, here we go! We typically look at four different movements when assessing the neck:

  1. Neck flexion = moving your chin toward your chest. Normal range? Touching your chin to your chest without having to open your mouth.
  2. Neck extension = looking up toward the ceiling. Normal range? Bringing your face parallel or within 10o of parallel to the ceiling.
  3. Neck side flexion = moving your ear toward your shoulder. Check bilateral (right and left) side flexion. Normal range? Bringing the midline of your face 45o away from neutral.
  4. Neck rotation = looking over your shoulder (aka shoulder checking). Check bilateral (right and left) rotation. Normal range? Getting your chin past the midline of your clavicle.Screen Shot 2014-11-09 at 5.28.58 PM

Why don’t we take a quick timeout so you can test out your neck range of motion and examine your family and friends! If you’re falling short of “normal” in one or more directions, don’t freak out and call your mom sobbing! Try out some stretching (which I’ll  outline later) and see if that improves your mobility. Then you can call your mom and tell her how these stretches saved your life.

After getting his history and assessing his neck, I can diagnose Nic’s injury as whiplash. Whiplash typically occurs when external force causes the head to whip forward and backward very quickly. In this case, the muscles in the neck sense that something is wrong and they suddenly contractWhiplash_shutterstock_93645706_72dpi very hard to hold the head in neutral. Consequently, the neck muscles continue to contract and spasm to protect all the bones, nerves, and blood vessels in the area. Good job, muscles! You guys get an A+! But when the muscles forget to relax, you lose mobility and you gain discomfort. This loss in movement typically results from two factors: joint stiffness and muscle tightness. When the neck muscles stay in this shortened, contracted position (muscle tightness), they end up squishing the neck vertebrae closer together (joint stiffness). Now the treatment goal is to loosen up the joints and relax the muscles!

“When I… bend my head back… something feels like it is… jamming,” says Nic with his drawl. This sensation is often due to stiff joints in the neck. There are seven vertebrae in your IMG_7440neck that sit stacked on top of one another. Each vertebrae slide and glide on top of the next vertebrae to create movement. When Nic lies down on the treatment table and completely relaxes, I can use my hands to feel which joints are moving normally and which are joints are jamming. And here is where manual therapy kicks in! There are many hands-on techniques that are designed to restore the normal slide and glide of each vertebrae. There are various techniques that physios learn to help with joint stiffness. My approach has been influenced by what I learned in school, what I’ve taken in manual therapy courses, and what my physio mentors have passed on to me. These hands-on skills can be used to improve joint mobility!

“When I… shoulder check… my muscles feel… very tense,” says Nic. Like I mentioned before, muscles will tighten up as a protective mechanism. Now it’s my job to restore the normal resting length of those muscles so Nic’s neck doesn’t always feel like it’s seizing up. Again, there are numerous hands-on approaches that can help loosen tight muscles. Screen Shot 2014-11-09 at 5.51.31 PMTwo of the more common and useful methods include muscle energy techniques (MET) and muscle release techniques (MRT). To avoid putting you in a coma, I’m not going to dive into the boring physiological stuff. In a brief summary, MET pairs a passive stretch with an active contraction to generate some muscle relaxation. On the other hand, MRT uses finger pressure to hold down a tight band of muscle while the patient moves through that muscle’s range of motion. I promise it makes more sense when you see it or experience it!

Disclaimer: Please leave these techniques up to a professional! Physios are well trained in these skills. If there is a method that is safe to try at home, your physio will show you exactly how to perform it. Don’t try this at home unless you want to look like the guy on the left! Wouldn’t you rather look like the lady on the right?

Screen Shot 2014-11-09 at 5.41.01 PMYou know what they say… A sore neck’s best friend is manual therapy! Now that Nic has a more relaxed neck, it’s time to give him some exercises to reinforce what he’s gained! At this stage of the game, it’s beneficial to show Nic some stretches so he can continue working on those tight muscles when he’s not at our clinic. These stretches are very simple and can be done anywhere at any time!neck stretches
Stretch your upper traps by bringing your ear to your shoulder. Then stretch your levator scapulae by bringing your nose to your armpit. With each stretch, hold in a comfortable position (aka no pain) for 30 seconds and repeat on both sides! And maybe you should wash your armpits or put on some deodorant before going to town with the levator scapulae stretch.

Hopefully Nic leaves the clinic with a better understanding of what his injury is and how a combination of manual therapy and exercises are used to treat it. He will also get a printout of his stretches (or personalized stick-man drawings if he’s really lucky) to help him remember his homework – even if he’s in the middle of a tense face off with John Travolta. These exercises are extremely important because it allows Nic to continue his rehab without having to come visit me every day of the week! I mean, I like the guy but it’s not necessary to see him 4 to 5 times per week. Plus that would really cut into his treasure hunting time…

Questions about manual therapy? Maybe you’re curious if it’s a valid treatment technique for your injury. Feel free to ask away! You can leave a comment or find me on Twitter!

– Chris (@yegphysio)

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