I’ve been asked for protocols for my manual therapy for decades! I’ve seen questions posted on chat groups asking for ‘how long, how much, where, what techniques’ for mobilization or manual therapies for various musculoskeletal ailments. I’ve had conversations with other physiotherapists in regards to newly graduated canine rehab professionals asking these questions from them as well – these physios then ask me, “How do you answer, Laurie?” Well, this blog is my answer to that!
THERE ARE NO MANUAL THERAPY PROTOCOLS.
Manual therapy isn’t like prescribing a medication. It’s not even like choosing a laser or ultrasound dose. It’s even less specific than ‘guessing’ how long a dog should exercise. It’s about what the practitioner feels. It’s about the goal of the treatment and the underlying pathology. It’s about the techniques chosen. It’s about the skill level of the practitioner. It’s about clinical experience. It’s about the dog in front of you. It cannot be prescriptive. It should not be prescriptive. It is a professional skill that requires clinical reasoning.
What factors need to be considered when choosing manual therapy? And for this discussion, I’m going to limit our thinking to MOBILIZATIONS or MANIPULATIONS.
What is the goal of your Manual Therapy?
I’ll simplify this for everyone. You are allowed to choose between “to treat stiffness” or “to treat pain”. This matters because to treat stiffness, you choose a higher grade of mobilization, from Maitland’s Mobilization Scale that serves to stretch the joint capsule. To treat for pain, you choose a technique and that does not invoke stretching of soft tissue structures (i.e. grades 1 or 2 on Maitland’s scale). Then, just to complicate or add to the fun, if the joint you want to treat has both pain and stiffness (i.e. an osteoarthritic joint), then you choose a large amplitude grade in the middle that helps with improving vascularization and joint nutrition.
Where do you treat?
This becomes a bit of an ‘art’, because you either treat the joint(s) that are stiff or the joints that are painful… or both. Essentially, you assess and treat. When teaching my Advanced Manual Therapy Course for the International Academy of Veterinary Chiropractic, I was asked about my sacroiliac joint mobilization techniques, “So, Laurie, you treat the side that is painful?” I said, “Yes”. “Because you believe the problem side is the one that is painful?” “Yes”, I said again. The next question was, “Does it work?” I said, “Yes”. This exchange had me scratching my head. I immediately asked, “Wait! Does that mean that you always treat the non-painful side?” His response was, “Yes.” “Because you think it’s hypomobile, cause hypermobility and pain on the other side?” I questioned. “Yes”, was the reply. “And does it work?”, I asked. “Yes”. We both left the conversation going, “Hmmm.”
What does this tell you? I take it as, BOTH ways of treating work! Why? Most likely because the effect we are having is neurophysiological, not biomechanical. So any movement of the joint will provide a stimulus, a response, and an effect on the joint and surrounding tissues.
What techniques do you use?
What techniques do you know? Time to load up your tool kit. The more techniques you know, the longer you practice, the more you will come to develop YOUR best approach to scenario XYZ. In other words, this is where the “art” of manual therapy also comes into play. To be less esoteric, your clinical reasoning guides you based on what you know and what you’ve seen before.
When I teach, I talk about passive versus active movements, physiological movements and accessory movements. As an example, I can flex the dog’s spine. That’s a physiological movement (i.e. a dog can also flex its spine volitionally). I can also do traction. That’s an accessory movement (i.e. this movement can be done, but not volitionally. A dog cannot actively increase the distance between its own vertebra). Both techniques have a place. As a general rule, if the area is painful to touch, choose a physiologic movement first. Otherwise, your accessory movements are ‘purported’ to the ones you should start with first.
One could also select a technique based on presumed pathology.
Nerve root signs? Try traction.
Disc signs? Try rotation (or traction).
Facet joint signs? Use localized accessory techniques.
Osteoarthritis? Use large movements throughout range of motion.
How long do I mobilize for?
There is no real answer for this question. There’s not even a point to documenting the answer to this question in your treatment notes. When reading Maitland’s book, he confessed to making up the answer because he was tired of getting the question asked of him. So his ‘made up answer’ was if the joint in question is irritable, then mobilize for 20-30 seconds, and repeat 1 or 2 times. If the joint is non-irritable, then mobilize for a minute, an repeat 4 to 6 times.
How many techniques do you use per session?
Add them in. Reassess the joint and area before and after each new technique. Perform the most effective technique again (last).
What else do you need to factor in?
- Gross foraminal or spinal canal encroachment, soft tissue elements / instability, stage of healing, inflammatory disease, medications. All of these may require you selecting a lower grade of mobilization and special techniques that do not irritate structures.
- Fractures, dislocations, bone cancer in the region, bone infection, bleeding disorders, etc. (i.e. this is not a complete list). These are contraindications to mobilizations or manipulations
- Your skill, your confidence, your knowledge of contraindications, your findings on exam, your ability to have conducted an examination. If these are factors, then don’t do manual therapy.
- Temperament of the dog, anxiety of the owner. Take these into account to ensure your safety – physically or from a liability stand point. Maybe you take more time. Perhaps you explain more. Should you consider a gentler form of therapy as a first intervention (i.e. craniosacral or myofascial release)?
THERE ARE NO MANUAL THERAPY PROTOCOLS.
I had one physiotherapy professor back in my 4th year mobilization class that I like to quote. He said, “Just find it and fix it.”
So, that’s all I have to say about that!