A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy

Key Points

1. Manual therapy is a symptom modifying strategy that can be used to keep athletes active whilst managing injury.
2. Manual therapy is safer than medications and less expensive than modalities.
3. Updated narratives, critical thinking and clinical reasoning are required for effective manual therapy utilization when working with athletes.

BACKGROUND & OBJECTIVE

Many conditions in the musculoskeletal field (particularly sports medicine) have been overmedicalized. This has led to an over-emphasis on pharmacological and surgical interventions for conditions that could have been managed by a physiotherapist. A low cost, and safe symptom modification tool such as manual therapy may reduce medical utilization while increasing patient autonomy.

This clinical commentary paper explores the role of manual therapy in the sports therapy arena. They comment that “black and white viewpoints” on manual therapy drive polarization in the profession and that a pragmatic grey area exists, in which proper clinical reasoning regarding the use of MT can provide athletes with pain relief and effective injury management. Education and exercise are accepted as the mainstay of physiotherapy (PT) intervention. The authors point out that athletes already exercise and train at high levels and that symptom modification is a valuable component of a multidimensional injury management system.

Black and white viewpoints on manual therapy drive polarization in the profession.

Outdated narratives of “correcting faults” and nociceptive descriptors may result in athlete’s developing negative perceptions of their capabilities

METHODS

The paper is based on expert opinion and commentary involving a 63-article reference list. Five main points and management examples via two case studies are provided.

RESULTS

Positive Utilization of PT & MT

When applied appropriately MT has the potential to decrease over-medicalization of athletic injuries (1). Early MT is associated with less need for MRI, interventional radiology and opioids (2). Current clinically reasoned utilization of MT depicts that MT is not totally passive therapy, see figure 2 (3).

Limitations & Pitfalls of MT

Narratives based on outdated and inaccurate pathoanatomical dogma present a danger in therapy. Athletes may suffer fear of movement, increased levels of anxiety and develop a dependence on MT to “fix a fault” (4). Anxiety re an injury or “fault” in athletes is a risk factor for future injury (5). Narratives that should be avoided include:

• Inaccurate injury mechanisms e.g., bone out of place

• Specificity of what an MT technique does e.g., “put the vertebra back in”

• Use of unsupported mechanisms e.g., functional LLD, pelvic obliquities

Therapist Understanding & Strategy with MT

Purely pathoanatomical and biomechanical explanations for the effects of MT are outdated. The athlete should understand there is a combination of neuromuscular, autoimmune, endocrine and non-specific factors involved (6).

Prescription, Dosage & Progression

Due to the pragmatic n=1 nature of clinical work, defining these factors regarding MT in the sporting arena can be difficult. Intra-session steps depicted in fig. 2 are recommended.

In elite and professional team sports, the availability of therapy is completely different to the general population athlete. Greater availability of therapy (often 1 + daily) may enhance the short-term beneficial effects of MT.

Titration of MT to prevent dependence and promote autonomy of the athlete is important. Athletes should be taught symptom modifying mobility exercises that reinforce the MT and replace the therapist.

Practical Implications in Sport

In sport, appreciation of time-cost benefits is important. Interventions that manage pain whilst allowing the athlete to train and compete are paramount. Therapists must decide which “passive” therapies will provide the best outcome. Electrotherapy modalities are still common in sport, despite their use being theory based and not outcome informed. It is argued the cost of the machinery for possible minimal benefits makes MT a more cost effective and mobile resource.

LIMITATIONS

This is a Level of Evidence 5 paper (the lowest level of evidence in the EBM hierarchy), based on literature commentary and expert opinion. Having said that, the RCTs performed on MT often have challenges due to the use of “one size” MT applications to improve internal validity and from simply not being conducted well. Inconsistent findings and small effect sizes are an issue in MT RCTs.

CLINICAL IMPLICATIONS

Therapists should strive to provide an updated approach when using MT with athletes (6). Decreasing pain and enhancing safe and efficient movement through the short- term symptom modification produced by MT has utility. Outdated narratives of “correcting faults” and nociceptive descriptors may result in athlete’s developing negative perceptions of their capabilities and increased anxiety re poor performance/recovery.

Therapists need to use clinical reasoning and become comfortable working in a “grey zone” during a treatment session. Reassessment and adjustment of MT techniques is optimal

Depending on country physiotherapist may hold different roles, particularly in professional sport. S&C prescription may not be the role of the physiotherapist working with athletes. Collaboration and dialogue are required with the multidisciplinary team.

Another important clinical point is that pain in an athlete may not be an indicator of injury. Athletes (professionals in particular) are under significant demands from sponsors, team, coach, trainers, family etc. This (7) article and its infographic are highly recommended reading.

+STUDY REFERENCE

Short S, Tuttle M, Youngman D. (2023). A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy. IJSPT;18(1):262-271.

SUPPORTING REFERENCE

1. George SZ, Fritz JM, Silfies SP, et al. Interventions for the management of acute and chronic low back pain: revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.03 04
2. Fritz JM, Brennan GP, Hunter SJ.(2015). Physical therapy or advanced imaging as first management strategy following a new consultation for low back pain in primary care: associations with future health care utilization and charges. Health Serv Res. 2015;50(6):1927-1940. doi:10.1111/1475-6773.12301
3. Rhon DI, Deyle GD. Manual therapy: always a passive treatment?(2021). J Orthop Sports Phys Ther. 2021;51(10):474-477. doi:10.2519/jospt.2021.10330
4. Stewart M, Loftus S. Sticks and stones: The impact of language in musculoskeletal rehabilitation.(2018). J Orthop Sports Phys Ther. 2018;48(7):519-522. doi:1 0.2519/jospt.2018.0610
5. Timpka T, Jacobsson J, Bargoria V, et al. Preparticipation predictors for championship injury and illness: cohort study at the Beijing 2015 International Association of Athletics Federations World Championships.(2017). Br J Sports Med. 2017;51(4):271-276. doi:10.1136/bjsports-2016-0965 80
6. Bialosky JE, Beneciuk JM, Bishop MD, et al.(2018). Unraveling the mechanisms of manual therapy: modeling an approach. J Orthop Sports Phys Ther. 2018;48(1):8-18. doi:10.2519/jospt.2018.7476
7. Hoegh M, Stanton T, George S, Lyng KD, Vistrup S, Rathleff MS. Infographic. pain or injury? Why differentiation matters in exercise and sports medicine. (2021). Br J Sports Med. 2021;56(5):299-300. doi:1 0.1136/bjsports-2021-104633