Manual therapy: Hands-off/hands-on or active or passive treatments: is this the right question? isn't it actually a false problem?

This tendency to compare active or passive treatments has become a recurrent theme. Pitting them against each other can only lead to an impoverishment of therapeutic care and encourage new generations of therapists to make an unfounded choice, or worse, to abandon manual therapy, which many still confuse with passive therapy.

What places do these two ways of dealing with Neuro-Musculo-Skeletal dysfunction have?

The active aspect or, more precisely, the difficulty in carrying out an activity (disability) is the reason for the consultation and the starting point of the visit. 

The aim of the treatment is to restore this function, i.e. activity. The journey therefore begins and ends with activity.

But how does this journey unfold?

What do we mean when we talk about manual therapy?

Manual treatment has been described and used since antiquity, and if you look closely at these descriptions, it has always been a question of manual techniques (hands-on).

Even if this message is outdated, the idea that manual therapy is limited to manual and therefore passive techniques is still firmly entrenched in the minds of professionals and patients alike.

It is this notion that always leads us to want to compare hands-on and hands-off techniques, but above all to oppose passive care to active care.

Isn't this a false problem, or a badly asked question?

Even though in 2016 IFOMPT defined OMT, Orthopaedic Manual Therapy, this question persists.  

The fact that there is another definition in relation to the abbreviation OMT may also explain the confusion. OMT,  Osteopathic Manipulative Treatment is defined as a hands-on treatment method. Is sometimes called osteopathic manipulative therapy or osteopathic manipulation.

What is the IFOMT definition for OMT abbreviation?

"Orthopaedic Manual Therapy” is a specialized field of physiotherapy for the management of Neuro-Musculo-Skeletal (NMS) problems, based on clinical reasoning, using a highly specific treatment approach including manual techniques and therapeutic exercises.

This definition could be translated by terms used since the dawn of time such as:

in French“ je vais prendre les choses en main”, in German “ im Griff haben” whose literal translation is “take in hand” which means nothing more than wanting to solve a problem , without mentioning the tools  to use

So what is orthopaedic manual therapy based on?

All the passive and active tools whose sole aim is to treat neuro-musculo-skeletal dysfunctions.

But the first concept set out in the definition is clinical reasoning.

M. Jones and J. Higgs define clinical reasoning as follows

It’s “the sum of the thinking and decision-making processes associated with clinical practice”. During this process, the therapist analyses multiple variables contributing to the patient’s limited physical capacity (the ability to execute a task or action in a specific environment) and performance (what the patient can do in his or her own current environment). The key elements of the process include the generation of hypotheses of factors assumed to underlie the limitations of physical capacity and performance and the postulation of the magnitude of those factors. The therapist interacts with the patient and other persons involved in the patient's care (family, other health care professionals) and guides the patient in finding meaningful goals and health management strategies^.

The most common form of clinical reasoning within the physiotherapy profession is hypothetico-deductive reasoning^. Within hypothetico-deductive reasoning, the clinician gains initial clues in regard to the patient's problem (from the subjective assessment), which forms the initial hypotheses in the therapist's mind. Further data is collected in the objective assessment, which may confirm or negate the hypotheses. Continual hypothesis generation may occur during management and reassessment. Identification and prioritization of pertinent clinical data to either support or negate the hypotheses form the basis of clinical reasoning.

Clinical reasoning is therefore a ongoing reassessment throughout the patient's management to validate hypotheses but also treatment technique choices”.

The second part of the IFOMT definition refers to the fact that the techniques used can be both passive and active.

So why do we always want to pit active care against passive care? What is the place of hand-on?

Lewis writes in his book 1983, The Most Recent Science, "Touch is the oldest and most effective tool of medical action".

Hands-on plays a decisive role in the management of Neuro-Musculo-Skeletal dysfunction.

Using the hands-on approach, we can confirm whether the pain mechanism is nociceptive, neurogenic, neuroplastic or ... and guide us towards the most appropriate choice for patient management, whether hands-off, hands-on, combined and/or psychosocial...

A few notions about the effect of passive movements to understand what place should be reserved to these approaches.

Manual therapy aims to modulate the afferences and afference patterns relevant to the system in order to regulate dysfunctional control circuits.

Using appropriate techniques, the therapist's hand can intervene in reflex control circuits by generating afferences, mainly proprioceptive, from different structures.

This activates pain inhibitory systems and often succeeds in breaking through control circuits of nocireactive dysregulation.

At the motor system activation level, the organism reacts to nociceptive stimuli via metameric and central circuits in the sense of nocireactive motor system activation.

Clinically, a pain-related disturbance of motor coordination (e.g.   protection reflex, gait disturbance, incorrect posture in lumbar spine, blockage, signs of muscular imbalance) is impressive.

At the sympathetic system activation level, axon collaterals of the posterior horn neuron also excite sympathetic neurons of origin in the thoracic lateral horn and generate autonomic efferent.

Clinical symptoms may occur: Changes in skin perfusion, piloerection, increased sweat secretion, etc. Similarly, there are also pathways of parasympathetic dysregulation. An extreme form of sympathetic system activation is "complex regional pain syndrome type I".

In addition to the functional opioid and serotonergic descending inhibitory systems, the GABAergic inhibitory system plays a particularly important role in manual therapy (GABA: γ-aminobutyric acid). By generating proprioceptive afferents (manipulation and mobilization), pain-inhibitory action potentials are generated in GABAergic interneurons, which reduce the activity level of multi-receptive neurons in the posterior horn and thus weaken the transmission of nociceptive excitations. So it's not just a question of manually mobilizing a joint, but the effect of manual therapy also explains why it's possible to intervene in the neurophysiological regulation of pain. This does not only appear to have a segmental effect, as a corresponding study also demonstrated an increase in the pressure pain threshold at locations far from the manipulation.

The neurophysiology of pain inhibition has been known for a very long time, but has only recently been integrated into the planning of differential therapies. In clinical terms, all functional methods also target pain inhibition systems.  

But the effects of hands-on should not be limited to physiological mechanisms. Like all techniques, hands-on has a placebo effect and everyone is a placebo responder. The placebo (from the Latin "placeo” literally 'I will please'.") is created by a psychosocial context likely to have a positive influence on the patient's brain (Benedetti 2013). Placebo hypoalgesia appears related to descending inhibition of pain from the supraspinal structures and functional MRI is beginning to clarify specific brain regions likely involved in placebo hypoalgesia. Current studies suggest that placebo-related hypoalgesia is associated with responses in regions of the brain related to pain modulation, emotion, and cognitive appraisa. Studies have examined patients' expectations and preferences. Manual therapy, the act of being touched, is one of the treatments preferred and most eagerly awaited by patients. Research shows that multiple endogenous pain modulating processes are triggered in response to expectations to 'be cared for', “to be touched” (Bialosky 2017). So, meeting patients' expectations is part of the success of the treatment.

A second aspect of hands-on is the notion of contact. The choice of words is never random. When we don’t want to lose sight of someone, we talk about ‘staying in touch’. Touch is one of the elements to create a bond between two people, in this case between therapist and patient. The aim of the first visit is not only to gather the information needed to develop hypotheses for the patient's care, but also to establish a relationship of trust which is crucial for any productive and successful initial patient visit and for a smooth running of the treatment. The first visit will also include

- establishing a relationship of trust

- to identify communication barriers

- to identify patients' preferred learning styles.

- and to establish patients' physiotherapy goals.

The hands-on approach will also have the advantage of improving acceptance of the help offered, and not only from a medical point of view! Palpating and touching the patient's painful area, showed that the therapist was validating the patient's problem and taking it into account.

This positive interaction between patient and therapist demonstrates many benefits, including reduced pain and disability, and improved response to treatment.

If you think about it, many ‘hands-off’ therapists would be surprised at how often they touch their patients.

For example: a sign of encouragement or support (hand on shoulder), a sign to reassure, an invitation to go further in an exercise, to control the exercise, to feel if the right muscle is being recruited, to guide in the right direction, to recruit a muscle better, to give indications for control exercises.

It is therefore an excellent tool of non-verbal communication.

Geri et al. highlight that touch increases positive emotional responses such as feelings of safety and relaxation and reduces negative affective feelings with decreases in stress-related biomarkers (e.g. salivary Alpha amylase, salivary cortisol, heart rate) through deactivation of systems related to a stressful threat response. 

"Orthopaedic Manual Therapy” is a specialized field … including manual techniques and therapeutic exercises.

Hands-off or, more precisely, treatment based on therapeutic exercises are integral part of Neuro-Musculo-Skeletal management.

The definition leaves no doubt that exercises is an integral part of management

It's not possible to separate them, to propose a choice between passive and active treatment. it's two approaches depending on each other.

The disability described by the patient is a loss of activity. The name is very clear. It's a loss of “active” function.

The aim of the treatment is nothing more than to recover the loss of, we can use a pleonasm, the “active function”. and both approaches have common effects.

One example: by generating proprioceptive afferents during movement in pain-free space and mobilization, pain-inhibiting action potentials are generated in GABAergic interneurons, which reduce the activity level of the multireceptive posterior horn neurons and thus attenuate the transmission of nociceptive excitations.

What are other objectives of therapeutic exercises? what do exercises offer in addition to passive techniques?

The therapeutic exercises aimed to allow patients to take control of their condition, to make the patient independent.

But also reassure, educate, reduce fear and anxiety, restore confidence in movement, to recover pain-free function to its maximum amplitude, improve strength, load capacity and endurance, encourage activity.

The role of hands-on is to ensure the transfer, to prepare and facilitate to the return to function. The idea that hands-on may can discourage patients from taking control of their condition is a false one, hands-on is useful in reducing patients' fear of movement. Once the symptoms are under control, the patient will be in the best condition to carry out his active work to recover his main problem, his disability, his function.

As we wrote at the beginning, the tendency to present two different ways of treating our patients is a mistake, and even to put them in competition with each other can only lead to an impoverishment of therapeutic care and encourage new generations of therapists to make an unfounded choice.

But competition also allows us to question ourselves, to ask the right questions and to put things in their place.  

We need to put the passive/active team back in its rightful place and see it as the winning team, in line with the IFOMPT definition, and not as two rivals or a choice to be made, as some physiotherapists interpret it.  

United we stand, divided we fall.

References

- Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs J, Jones MA, Loftus S, Christensen N. Clinical reasoning in health professions. Amsterdam: Elsevier;2008. p. 4-19.

- Gummesson C, Sundén A, Fex A. Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews. 2018 Jan 2;23(1):29-34.

- Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using the International Classification of Functioning, Disability and Health (ICF) framework and patient management model. Physical therapy. 2011;91(3):416-30.

- Locher. Grundlagen, Manuelle Medizin, manuelle Therapie. Wirkmechanismen, Indikationen und Evidenz May 2021Unfallchirurg. 2021; 124(6): 433–445. 

- Goadsby PJ. On the functional neuroanatomy of neck pain. Cephalgia. 2008;28(Suppl 1):1–7.  

Locher H. Inhibitorische Systeme. In: Locher H, Casser HR, Strohmeier M, Grifka J, editors. Spezielle Schmerztherapie der Halte- und Bewegungsorgane. Stuttgart: Thieme; 2011. pp. 61–63.

- Vinzelberg S, Beyer L. Funktionelles Denken – Vermittlung im Kurssystem der Manuellen Medizin. Man Med. 2020;58:279–285. 

- Xanthos DN, Sandkühler J. Neurogenic neuroinflammation: inflammatory CNS reactions in response to neuronal activity. Nat Rev Neurosci. 2014;15:43–53.

- Joel E Bialosky, Mark D Bishop, Charles W Penza Placebo Mechanisms of Manual Therapy: A Sheep in Wolf's Clothing? J Orthop Sports Phys Ther. 2017 May;47(5):301-304.

          - F. Benedetti.  Placebo and the new physiology of the doctor-patient relationship - Physiol Rev.        2013 Jul;93(3):1207-46.

 - Watson A, El-Deredy W, Iannetti GD, Lloyd D, Tracey I, Vogt BA, et al. Placebo conditioning and placebo analgesia modulate a common brain network during pain anticipation and perception. Pain 2009;145:24–30 

- Zubieta JK, Bueller JA, Jackson LR, Scott DJ, Xu Y, Koeppe RA, et al. Placebo effects mediated by endogenous opioid activity on mu-opioid receptors. J Neurosci 2005;25:7754–62

- Petrovic P, Dietrich T, Fransson P, Andersson J, Carlsson K, Ingvar M. Placebo in emotional processing-induced expectations of anxiety relief activate a generalized modulatory network. Neuron 2005;46:957–69  

- von Mohr, M., Kirsch, L. P., & Fotopoulou, A. (2017).The soothing function of touch: affective touchreduces feeling of social. Scientific reports, 7(1), 1-9.

- Maratos et al. Maratos, F.A., Duarte, J., Barnes, C., McEwan, K., Sheffield, D., Gilbert, P., 2017. The physiological and emotional effects of touch: assessing a hand-massage intervention with high self-critics. Psychiatry Res. 2017 250, 221-227. .

- Testa, M., & Rossettini, G. (2016). Enhance placebo, avoid nocebo:how contextual factors affect physiotherapy outcomes- Manual Therapy.2016 Aug: 24:65-74

- L.M. Andersen. D. Lundqvist. Somatosensory responses to nothing: an MEG study of expectations during omission of tactile stimulations. Neuroimage  Jan 2019 184, 78–89.

Comments

You are logged in as {{user.name}}

Name

Email

Your comment {{ comment.length }} / 2000

• {{ error[0] }}

Post Comment