Manipulations: The Good, The Bad and The Ugly

Manipulations: The Good, The Bad and The Ugly

When I went through therapy, just over ten years ago, manipulations were just being introduced to physical therapy. The “go to” move at the time were MET and mobilizations. Today, thanks in large part to Clinical Prediction Rules (CPR); manipulations are the “go to” move for therapist. Today we will discuss the good bad and ugly regarding manipulations.


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The Good:

Manipulations, generally speaking, have similar effects of other manual therapy techniques (MET, Mobilizations) - they provide an input to the body which is sent to the brain, which then (hopefully) produces a new output. The new output may change the perceived threat, sensitivity levels, or create a tonal change that all produce less pain. Manipulations differ from mobilizations as they have larger effects on the muscle spindle fibers and golgi tendon organ secondary to the quick stretch that occurs with the maneuver. This more or less creates a “Control, Alt, Delete” to the brain and reduces pain/tone/sensitivity.

Manipulations are temporary, of course, and should only be used in conjunction with other therapeutic activities/exercises. Manipulations produce a pain refractory period. This is a temporary period of time when the patient perceives less pain secondary to a therapeutic intervention. The patient is then able to experience larger freedom of movement without pain provocation. The freedom of movement that is created must be utilized during the refractory period by doing additional strengthening, stretching, and functional movement patterns. When paired with proper exercises the effects of a manipulation may become longer lasting and eventually permanent.

The Bad:

Patient perception regarding manipulations is - “My joint is out, and the clinician is manipulating it back in place.” There is significant research that suggests the theory of misaligned bones simply does not exist. Furthermore, it is important as clinicians that we do not continue to facilitate the concept of malalignment. Instead, we should focus on proper education on modern pain science concepts and focus on the freedom of movement activities that follow.

The Ugly:

Again, patient perception is that manipulations reduce misaligned joints. This concept of “my back is out” produces fear/anxiety regarding activities that may cause malignment - leading to fear and avoidance. Our goal, as clinicians, is to promote freedom of movement, reduce fear/anxiety, reduce tone, promote pain free movement and reduce pain. Improper education may promote the opposite. Remember always, our patients are listening, what and how we say things affect their pain!

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