Maximizing Your Manual Therapy By Administering An effective HEP

I once had a teacher tell me, "A physical therapist is only as good as his/her home exercise program." At the time I did not fully understand the scope of this statement. Of course a home exercise program (HEP) is an essential component of physical therapy, but the really important aspects are completed in the clinic...or so I thought. Once I complete each initial evaluation, I start educating my patients on their HEP by giving them a frame of reference. I discuss how little time each week is spend with the physical therapist. If they come in 2 times a week for 45 minutes, they would not even be with me for 1% of the week. Getting better is a commitment that should require them to think about their HEP daily. Prescribing the correct exercises is another factor the must be considered of course. We want to combine the primary impairments found during the examination with results from any manual therapy to determine which exercises are most critical. While the patient is responsible for being committed to performing the HEP, it may be unrealistic to expect every patient to perform every exercise that we would prefer as clinicians, often leading to a selection of the most key exercises.

I recently read a post from The Manual Therapist about the 5 articles that most significantly impact his practice (I highly recommend reviewing it). Several of the articles covered really had an impact on me regarding my understanding as to what my manual therapy techniques actually are and are not accomplishing. One of the articles is a basis for the differing views regarding Instrument Assisted Soft Tissue Mobilization (IASTM). IASTM techniques such as Graston and ASTYM preach the effect collagen remodeling, while other perspectives view it as a neurophysiological effect. One study showed that it requires over 100# of force to remodel fascia by 1% (Chaudhry et al, 2008). Why is it we spend so much time on soft tissue techniques and see results? Schleip did an extensive review on the fascial systems. He reminds the reader of the high number of mechanoreceptors located in the skin and other soft tissues. Different parts of the body are intricately connected via this fascial system, suggesting treatment of one location may impact another. When stimulated via our techniques such as soft tissue massage, trigger point release, foam rolling, etc., we are in fact encouraging the receptors to alter the sympathetic nervous system and alter tone in the muscle and fascia, which can be portrayed as a "release" in soft tissue restrictions. This leads us to believe that many of our manual therapy techniques achieve their results due to a neurological effect. To get mechanical changes, we would need high levels of force for prolonged periods (this may not apply to manipulations - high velocity low amplitude thrusts). If the fascia were as easy to deform as some think with manual therapy techniques, actions such as running, jumping, or even sitting provide larger forces than we are providing with our hands on our patients. Another study looked at spinal mobilizations/manipulations and their effect on various outcomes. Manual therapy techniques like these have been shown to have effects on the sympathetic nervous system via the dorsal peri-aqueductal matter of the midbrain (Hegedus et al, 2011). The study also found that these neurophysiological effects only last typically 5 minutes. They pain-modifying results lasted up to 24 hours.

So what does all this mean? If we want any lasting changes, it is imperative we distribute a HEP that encourages movement in these gained patterns and establish the necessary changes in posture, habits, work space, etc. needed to reinforce proper tissue mobility and stability. It means our manual therapy techniques can be effective, but maybe not due to the reasons we previously thought. We can instill immediate or near-immediate changes with any manual therapy skills we have but they may not last more than anywhere from 5 minutes to 24 hours. To put it simply, manual therapy is not enough. Without an effective home exercise program, we would be likely to see our patients returning week after week with little retention of the gains we had achieved during prior treatment sessions.

-Chris

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References:

Chaudhry H, Schleip R, Ji Z, Bukiet B, Maney M, & Findley T. (2008). Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy. Journal of the American Osteopathic Association. 2008;108(8):379-390. Web. 5 April 2014.

Hegedus EJ, Goode A, Butler RJ, Slaven E. (2011). The neurophysiological effects of a single session of spinal joint mobilization: does the effect last? J Man Manip Ther. 2011 Aug;19(3):143-51. Web. 5 April 2014.

Schleip R. (2003). Fascial Plasticity - A New Neurobiological Explanation. Journal of Bodywork and Movement Therapies. 2003;7(1-2):1-22. Web. 6 April 2014.