Description of Intervention
Hand therapists use manual therapy to treat musculoskeletal pain and disability through use of their hands rather than a tool. However, therapists and patients may also apply manually guided tools as part of this treatment. Many techniques comprise the category of manual therapy. Clinicians typically apply these in a painless manner. Out of the comprehensive list of manual techniques, hand therapists most often apply the ones listed below:1
- Manual therapy interventions addressing joint structure and alignment
- Joint mobilization2
- Mobilization with movement3
- Joint manipulation4
- Manual therapy interventions addressing muscle status and stress
- Strain-counterstrain5
- Muscle energy techniques6
- Manual therapy intervention addressing soft tissue mobilization (massage)
- Skin/scar modifications7
- IASTM (instrument assisted soft tissue mobilization)8
- Myofascial mobilization9
- Patient applied tissue mobilization via tools/devices
Joint mobilization seeks to restore accessory joint movements. Accessory movements consist of the glide and rotations that a person cannot consciously control but are integral to physiologic movement. Physiologic movements are the movements that a person can consciously control. Therapists perform joint mobilization with a speed and force that are unlikely to cause harm, that a patient can tolerate, and that a patient can limit.4
Joint manipulation occurs when a clinician manually creates an accessory or physiologic movement with a speed and force that the patient cannot limit once the therapist initiates it.
Mobilization with movement combines joint mobilization, the application of an accessory movement, with active physiological movement that the patient performs.3
Strain/counterstrain uses passive body positioning of hypertonic (spasmed) muscles or dysfunctional joints. When an insult triggers the muscle spindle to fire pathologically, pain in the muscle occurs. To treat this problem, the clinician must identify the tender point in the muscle. With the problem muscle identified during palpation, the technique involves approximating the muscle origin and insertion to the point where this tender point changes density. Repeated testing of this procedure has revealed that passive maintenance of this strategic position for 90 seconds often resolves the muscle spindle overactivity and thus the associated pain.
Muscle energy techniques include soft tissue manipulation methods that incorporate precisely direct and controlled, patient initiated, isometric and /or isotonic contractions, designed to improve musculoskeletal function and reduce pain. It uses principles of reciprocal inhibition to increase muscle length. Reciprocal inhibition refers to the relaxation of a muscle group that creates a movement with activation of the muscle group that creates the opposite or antagonist movement.
Soft tissue mobilization (STM) replaces what clinicians have called “massage.” STM involves graded stress application via pressure, stretch and vibration to soft tissues via the practitioner’s hand or handheld tool.10
Indications for Intervention
The manual therapy interventions addressing joint structure and alignment, joint mobilization with movement, and joint manipulation. These interventions apply when a patient demonstrates decreased joint A/PROM, decreased joint accessory movement (also sometimes termed “joint play”), or joint pain with A/PROM, edema/effusion, inflammation, mild joint malalignment, sometimes referred to as a “positional fault,” and radiating symptoms due to joint malalignment.11
Pain in hypertonic muscles or dysfunctional joints create the main indications for strain-counterstain technique.
Muscle energy technique has its greatest application in the case of decreased PROM, sustained muscle tension, and pain.
Therapists may apply soft tissue mobilization to scar adhesions, myofascial adhesions, and trigger points. Pain of soft tissue origin may also respond to soft tissue techniques. STM can assist in the achievement of muscle relaxation and lymphatic drainage.
Evaluation to Determine Need for Intervention
Evaluations that determine the need for manual therapy include:
- Interview to identify symptoms
- Pain evaluation via body mapping, descriptive word choice, interview to describe
Impact on function/ADL, palpation, pain scaling such as a visual analog scale (VAS)
- Goniometric joint A/PROM evaluation
- Joint play assessment
- Limb volume evaluation via volumeter or circumference measurement, palpation for assessment of fluid displacement (to determine presence of pitting edema)
- Visual assessment of limb color
- Visual assessment of muscle bulk/tone/trophic status
- Temperature assessment of skin
- Palpation of muscle to assess muscle tension, spasm, density, tenderness
- Palpation of skin/scar to determine extensibility/mobility, density, turgor, sensitivity
Parrish and Barrett have listed several scar assessment tools including the following:
- Measurement of Area and Volume Instrument System (MAVIS) III. This System is a portable three-dimensional active stereophotogrammetric imaging developed for noninvasive assessment of hypertrophic scar volume
- Spectrocutometry objectively documents and quantifies scar hypertrophy
- The Derma Spectrometer measures scar color and pigmentation, and also measures scar vascularization (erythema)
- The Tristimulus Colorimeter tool assesses color in wound and scar
- The Cutometer Skin Elasticity Meter 575 measures scar elasticity
Intervention Options
Even within the 3 main categories of manual therapy described, many techniques and application options exist. Please refer to the texts listed in the reference section to seek precise descriptions of these many options for intervention. While manual therapy is a hallmark of skilled upper limb management, competent application of the techniques requires individual training with subsequent practice, initially on non-patients. We also recommend the in-person training courses with expert therapists who can teach, demonstrate, and help a trainee learn and hone their skills.
Precautions/Contraindications for joint mobilization, mobilization with movement and joint manipulation include:
Joint instability
Joint hypermobility
Acute inflammation (with some exceptions)
Unstable fractures
Myositis ossificans
Exostosis formation
Avascular necrosis
Infection
Severe osteoporosis
Presence of loose body in a joint
A healing structure that lacks adequate strength or blood supply to withstand stress
Precautions for soft tissue mobilization include:
Cancer
Varicose veins
Burn scars
Acute inflammatory conditions
Kidney dysfunction
Inflammatory condition secondary to infection rheumatoid arthritis
Contraindications for soft tissue mobilization include:
Open wound (unhealed store site)
Unhealed fracture
Thrombophlebitis
Uncontrolled hypertension
Patient intolerance/hypersensitivity
Hematoma
Osteomyelitis
Myositis ossificans
Hemophilia
