Your Hands-On Treatment Is The Start Of The Graded Exposure

Manual therapy is a controversial topic amongst therapists these days. Some therapists swear by manual therapy and some don’t like even touching their patients nowadays.

Here’s how we integrate manual therapy in the 8 pillars of the ‘Go To’ Therapist step-by-step system…

If you have already implemented pillar 4 and all previous pillars, you are now ready to progress the treatment plan in the form of hands-on treatment. This is the starting point in the person’s nervous system’s physical load tolerance. 

From the objective assessment, you will have 1-2 peripheral tissues that you have identified from pillar 2 to ‘desensitise’ and reassure the nervous system it is safe for these tissues to absorb load again.

Desensitising these tissues to load will also usually restore the physiological joint range of motion pretty quickly.

We can do this by placing a load via our hands on the areas of the tissues that will need to lengthen during a particular joint movement.

We do this with active movement while reassuring the nervous system further with the help of specific breathing techniques to ensure the patient’s autonomic nervous system is in ‘rest and digest’ at all times.

The direction that we load these tissues and ‘reassure’ the nervous system will be dependent on the findings of pillar 2 and the direction that is not tolerating load very well.

For example, let’s say our groin pain/osteitis pubis patient had decreased hip flexion and a pinch in the groin mid-range of the ‘2nd third of the physiological joint range of motion’.

Also, our findings were that the gluteus medius tissues have an inability to coordinate with the peroneals and other tissues along that line and work isometrically at a perceived load of around 40% MVC.

We hypothesize the medial direction has been taking more load when decelerating and potentially also pushing off and this has now contributed to groin pain developing on the medial hip area.

This strategy may possibly be due to overloading the medial tissues with ground reaction forces due to an inability to absorb loads through the lateral hip in the posterior lateral direction.

The hands-on treatment intent would be to restore the ability to absorb load through these soft tissues in this area and in the direction of the posterior lateral direction.

This loading locally of the tissues is the starting point of the graded exposure in restoring the ability to tolerate load in the particular direction identified. This will then be progressed straight away with pillar 6.

It is important to note that the intention of the hands-on treatment approach is not to break up scar tissue or anything like that but to simply REASSURE the nervous system it is safe to tolerate load in the direction you’ve identified in the assessment.

A better term may be the ability to tolerate tension. We want these tissues to tolerate tension which is important for movement efficiency and coordination because when these tissues tension or lengthen their receptors will be stimulated, giving important sensory information to the spinal cord and higher centres. 

A higher level strategy for the ‘Go-To’ Therapist is to simply restore full physiological joint range of motion and the ability to tolerate load through these tissues in every direction. We give the nervous system access to as close to full sensory information as possible and then leave it to figure out the rest. 

The biggest mistake I see therapists make with hands-on treatment is to be too compressive. Compressing tissues and then asking them to lengthen while keeping them compressed will usually put too much tension on some parts of the tissue and not enough on other parts. From my experience, this will result in the patient going into ‘fight or flight’ as can be witnessed with their breathing strategies and the tension in their whole body. 

It is important to point out also that the exact mechanism of why this works is still unclear. I am very comfortable in ‘not’ knowing the exact mechanism and resisting the urge to make up ‘far-fetched’ explanations to the patient. Remember at all times, WE are the GUIDE and NOT the HERO in this story. The patient is the HERO. 

Therefore my explanation is a very simple one that informs the patient that I am just helping them to tolerate some loading going through these tissues again and helping them update their nervous system’s belief that it is now safe to use these tissues again. 

The actual hands-on strategy should look something like this:

The first session or two is when the majority of hands-on treatment takes place and then, as we progress through the treatment plan, the majority of time is taken up coaching and reassuring the patient in the movements that there are still ‘perceived threats’ present or where further graded exposure in the loading plan is still needed.

Towards sessions 4 or 5, there should actually be very little, if any, hands-on treatment taking place. A quick reassessment of the objective assessment and coordination testing and you should be good to go with the next progressions.

If the patient has slightly reduced physiological joint range of motion, then it is OK to help them restore this quickly with hands-on if you wish, although the graded exposure warm up will usually get this back anyway.

The key component to the hands-on treatment desensitisation for me is the clinical reasoning of WHY you are needing to desensitise these tissues in the first place. If these tissues relate to the injury history or have meaning for the patient’s story, then that is great. If they don’t and it is simply a reaction, then I am slow to desensitise tissues just for the sake of it and would rather step back and think on a higher level of WHY these tissues have reacted like this in the first place.

The final thing I want to warn you about also is not respecting the need for a graded exposure plan.

The novel stimulus applied by your hands with your first treatment session will usually create some kind of nervous system response/adaptation anyway and this can be a tripwire for therapists and patients where the patient leaves the session feeling great but then the pain comes back again shortly after.

The trap some therapists can fall into then is to repeat the same hands-on treatment process. What they commonly find is that in the second session, there is some relief in symptoms but it is not as great as in the first session, which can be puzzling for both the therapist and the patient. However, the problem, in my opinion, is that this hands-on treatment is a little bit less novel now and so the reaction for the nervous system is not as great.

Therefore this is why I believe you truly need to have that step-by-step graded exposure plan in place to keep the gains between sessions, to ensure the pain or loss in range of motion does not return and to get the patient capable of tolerating these loads at both high loads and high speeds, specific to their needs to be able to enjoy their life.

Let’s now look to the next pillar at what the ‘Go-To’ Therapist will do after applying the hands-on treatment to the patient.