Is everything you know about manual therapy wrong? A novel perspective and application

I want you to think of manual therapy as the recovery of localized, dynamic spaciousness within a tissue or structure via an applied external force — wait what?

When we train, we apply local and systemic forces to the body. Similarly, manual therapy also exerts an external ‘force’ on the tissue, which the body will still have to respond ‘reflexively’ to. In this sense, we shouldn’t think about manual therapy as being ‘passive’ and strength training as being ‘active’. Rather, it’s more useful to differentiate them on the basis of HOW (and to what extent) the force is applied.

You can conceptualize this with exercises like strength training versus jumping and plyometric loading.

In movements like weightlifting, muscular tension is what gets things started, with kinetic energy moving from the muscle, through the tendon, and finally to the bone. This is force that’s being created internally (internal force production) and then exerted on an external object (a weight).

In contrast, in athletic activities like running and jumping, energy originates from the impact with the ground and is transferred in the opposite direction, from the bone, through the tendon, and into the muscle. Impact with the ground (or an external object) triggers a reflexive muscle contraction.

In the latter example, we wouldn’t call a jump or a plyometric exercise passive simply because the muscular response was generated more via the myotonic/stretch reflex (spinal cord, tracts, and unconscious preflexes) rather than the CNS and alpha motor neuron (think big, conscious movements like a muscle contraction). In both instances, a force is being applied and the body responds accordingly.

When we think about what manual therapy fundamentally is, it simply involves the external application of force to a tissue.

Now, it goes without saying that the magnitude of force applied in manual therapy versus plyometric weight-bearing activities is going to be very different in scale and intensity. But it’s important to keep fundamental definitions in mind.

Manual therapy is movement. And all movement fundamentally conveys something important to the body and nervous system

Internal pre-stress, also known as self-stress, is a concept often used in programs like Advanced Biomechanical Rehabilitation (ABR) that focus on the use of specific manual therapy techniques to help individuals create tension within the muscles and connective tissues. ABR practitioners often work with disabled individuals who have conditions like cerebral palsy and extreme morphological/structural defects.

This population provides a good way to understand manual therapy as more than a ‘passive’ intervention; we can almost think of manual therapy and exercise as being on a continuum rather than hard, separate entities. Rehabilitation in individuals who do not have a lot of conscious understanding of coaching cues or voluntary control of their muscles needs a bridge to increased proprioception and body awareness.

As manual therapy is applied to patients in these settings, it can be likened to the process of kindling a fire. Just as repeatedly striking a flint eventually produces a spark that ignites a fire, the gentle forces applied in manual therapy elicit reflexive responses from the body's tissues. Over time, these repeated stimuli help to 'awaken' the tissues, gradually restoring dynamic equilibrium and function to the system.

We can also this about manual therapy similarly through the lens of the tactile stimulation involved in walking. Anytime we take a step, we are providing proprioceptive information to our body about where we are in space

we can view manual therapy as the ‘step’ — a localized ‘packet’ of proprioceptive information to a a joint structure, ligament etc. In patients with severe debilitating injuries, disabilities or even movement restrictions, this can be invaluable.

Remember, in order for our body to ‘self-correct’ things like posture and orientation, the body needs information about itself: where it is in space and relative to other anatomical structures. In the severely disabled (and or after injury) this ‘proprioceptive bandwidth’ is often disturbed. Certain forms of manual therapy can help improve this — no doubt.

We can also think of what might be referred to as ‘traditional’ manual therapy and ‘active’ interventions (even though I don’t like completely differentiating between the two) like exercise as being synergistic — a practitioner may ‘passively’ guide a patients limb through a particular range of motion, while giving the patient specific cues (resist, amplify etc)

Another way we can think of specific manual therapy techniques as proprioceptive interventions is through the use of force transfer mediums and their ‘volumetric’ effect on the tissues being treated. This is similar also to Guy Voyer's ELDOA and osteopathic pumping technique, which is an specific manual therapy method used in osteopathy to address restrictions within the body's connective tissues, joints, and fascia. The technique involves rhythmic and gentle oscillatory movements applied to targeted areas to promote fluid exchange, improve tissue mobility and therefore…proprioceptive awareness. Similarly, one of the primary ways ELDOA (which is an active technique/exercise similar to FRC) works is via the enhancing venous, epidural, and emissary circulation to the intervertebral discs, which contributes to improved proprioceptive awareness of the spinal and vertebral articulations.

In soma therapy (founded also by voyer) hands on manual therapy techniues can also be used to amplify particular breathing patterns and autonomic responses. Practioners will often place hands on the patients diaphragm with pressure, and then quickly release them on the exhale in order to create a ‘plyometric’ or ‘rebound’ effect in the diaphragm and respiratory muscles. This is (quite literally) a form of training. You can almost think if it like a overspeed exercise.

These techniques( often referred to as receptor mediated somatic therapy) involve the use of hands-on manual therapy to stimulate receptors in the body, such as those found in muscles, tendons, and other tissues. By applying pressure and then quickly releasing it, as described in the context of the diaphragm and respiratory muscles, the goal is to create a reflexive response in the body that can help improve awareness and control of a tissue. Think if it like a micro, localized plyometric,

The concept of using this technique to create a plyometric or rebound effect in the diaphragm and respiratory muscles is aimed at training and conditioning these muscles in a way that can enhance their function and responsiveness, especially in under trained populations. The rapid pressure changes can help stimulate the proprioceptors and mechanoreceptors in the tissues, leading to improved neuromuscular coordination and control

In some practices, this technique is called negative oscillation therapy. Instead of imposingexternal oscillations (vibrations or movements) on the patient, the therapist uses the patient's own natural movements (like those from breathing) and redirects them into a ‘corrective’ output as mentioned above. This can help improve the movement of the trunk, ribcage spine by working with the body's own rhythms and movements, effectively using the body's natural resistance and movement (often via respiration) to guide therapy

In individuals with compromised proprioception due to disability or injury, the targeted application of manual therapy techniques DO help to improve proprioceptive awareness and contribute to the restoration of severe postural abnormalities. By framing manual therapy as a provider of essential proprioceptive information that supports the body's self-corrective mechanisms, we can get beyond a lot of the false dichotomies surrounding ‘passive’ vs ‘active interventions.

We shouldn’t be thinking of manual therapy as a way to ‘break up’ fascia of adhensions. But rather as a form of low grade, proprioceptive training for the body.

While manual therapy may not be implicated for all individuals, it can hold a valuable place in the rehabilitation of complex conditions and injuries.

Here’s a little experiment if you want to see how this plays out in ‘healthy populations— next time you have a client who’s struggling to squat, have them roll out the bottom of their feet for 30-45 seconds wirh a lacrosse ball to provide tacticle feedback. You might be suprised what happens