Before beginning manual therapy or any type of physical
therapy, the practitioner usually performs a full assessment
of the blood and nerve supply in the area, as well
as a bone and muscle assessment, in order to decide
whether or not there is an increased risk of complications
from the use of these back pain management techniques. Depending
on the results of that assessment and each individual
back pain patient’s particular situation, the
healthcare provider may perform some or a combination
of the following types of manual physical therapy:
Soft tissue mobilization
It is important to recognize the role of muscles
and their attachments around the joints. Muscle tension
can often decrease once joint motion is restored, but
many times the spasm will continue to be present. In
such cases, muscle tension should be addressed or the
joint dysfunction may return. The goal of soft
tissue mobilization (STM) is to break up inelastic
or fibrous muscle tissue (called ‘myofascial
adhesions’) such as scar tissue from a back injury,
move tissue fluids, and relax muscle tension. This
procedure is commonly applied to the musculature surrounding
the spine, and consists of rhythmic stretching and
deep pressure. The therapist will localize the
area of greatest tissue restriction through layer-by-layer
assessment. Once identified, these restrictions
can be mobilized with a wide variety of techniques. These
techniques often involve placing a traction force
on the tight area with an attempt to restore normal
texture to tissue and reduce associated pain.
Strain-counterstrain
This technique focuses on correcting abnormal neuromuscular
reflexes that cause structural and postural problems,
resulting in painful ‘tenderpoints’. The
therapist finds the patient’s position of comfort
by asking the patient at what point the tenderness
diminishes. The patient is held in this position
of comfort for about 90 seconds, during which time
asymptomatic strain is induced through mild stretching,
and then slowly brought out of this position, allowing
the body to reset its muscles to a normal level of
tension. This normal tension in the muscles sets
the stage for healing. This technique is gentle
enough to be useful for back problems that are too
acute or too delicate to treat with other procedures. Strain-counterstrain
is tolerated quite well, especially in the acute
stage, because it positions the patient opposite
of the restricted barrier and towards the position
of greatest comfort.
Joint mobilization
Patients often get diagnosed with a pulled muscle
in their back and are instructed to treat it with
rest, ice and massage. While these techniques feel
good, the pain often returns because the muscle spasm
is in response to a restricted joint. Joint mobilization
involves loosening up the restricted joint and increasing
its range of motion by providing slow velocity (i.e.
speed) and increasing amplitude (i.e. distance of movement)
movement directly into the barrier of a joint, moving
the actual bone surfaces on each other in ways patients
cannot move the joint themselves. These mobilizations
should be painless (unless the operator approaches
the barrier too aggressively).
Muscle energy techniques
Muscle energy techniques (MET’S) are designed
to mobilize restricted joints and lengthen shortened
muscles. This procedure is defined as utilizing
a voluntary contraction of the patient’s muscles
against a distinctly controlled counterforce applied
from the practitioner from a precise position and in
a specific direction. Following a 3-5 second
contraction, the operator takes the joint to its new
barrier where the patient again performs a muscle contraction. This
may be repeated two or more times. This technique
is considered an active procedure as opposed to a passive
procedure where the operator does all the work (such
as joint mobilizations). Muscle energy techniques
are generally tolerated well by the patient and do
not stress the joint.
High velocity, low amplitude thrusting
The goal of this procedure is to restore the gliding
motion of joints, enabling them to open and close
effectively. It is a more aggressive technique
than joint mobilizations and muscle energy techniques
that involves taking a joint to its restrictive barrier
and thrusting it (low amplitude of less the 1/8 inch)
to, but not past, its restrictive barrier. If
utilized properly, increased mobility and a decrease
in muscle tone about the joint should be noticed. This
technique is utilized for restoration of joint motion
and does not move a joint beyond its anatomical limit. Therefore,
no structural damage takes place and the patient
should not have an increase in pain following the
treatment.
