Manual Therapy is hands-on care where the physical therapist identifies the tissues and areas that can be corrected with joint mobilization, soft tissue mobilization, nerve gliding, and instrument-assisted soft tissue mobilization.
John Guerriero, PT, DPT, discusses how manual therapy is used with individualized exercises to allow patients to return to their favorite activities and/or maximize their recovery and function.
Selected Podcast
Manual Therapy and Instrument Assisted Soft Tissue Mobilization
Featured Speaker:
John Guerriero, PT, DPT
John Guerriero is the Supervisor of St. Luke's Cornwall's Center for Sports & Physical Therapy in Fishkill, NY. John graduated from Stony Brook in 1996, and earned his doctorate in Physical Therapy from from A.T. Still University in 2010. He has 22 years of experience as a physical therapist in all levels of care. His main focus is in orthopedic manual therapy and sports, treating all ages from two weeks old to 100 years old. John has completed more than 700 hours of continuing education courses, combining the best of evidence-based manual therapy, exercise techniques and treatment. He is a certified Sole Supports casting technician, providing custom made sole supports foot orthotics. He also earned his certification in Instrument Assisted Soft Tissue Mobilization. Transcription:
Manual Therapy and Instrument Assisted Soft Tissue Mobilization
Melanie Cole: Injury and many conditions can often lead to muscular pain. Manual therapy is hands-on care where a physical therapist identifies the tissues and areas that can be corrected. My guest today is John Guerriero. He's the supervisor at St. Luke's Cornwall Center for sports and physical therapy in Fishkill. Tell us a little bit about what manual therapy is. What does it entail?
John Guerriero, PT, DPT: Manual therapy entails several things. We look at restrictions within joints and soft tissues. If it’s a joint restriction that we identify, then we have several things we can use to correct that restriction and that is joint mobilization, which is a graded amount from something very gentle to something that includes a high-velocity low amplitude thrust and everything in between. Basically, the clinician makes a decision on what to use based on what the patient is presenting with. Soft tissue mobilization is where we use hands-on techniques to address the soft tissues, so it's basically massage, but directed and targeted to the tissues that are restricted, not a general massage. It's directed to that specific tissue that's keeping you from moving pain-free.
Melanie: There are a lot of different techniques and as you say there's soft tissue mobilization, which is like a deep sports massage, but in one specific area, but people have heard about things like Graston technique, active release, scrapping therapy. Explain some of these and when you would use them.
John: One of the things I use is called instrument-assisted soft tissue mobilization. It uses a tool to do what we would normally do with our hands. The benefit of the tool is actually many. When you use a tool over the skin, you're actually doing a pro-inflammation response. We're bringing blood flow into the area, which is good for flushing out any toxins that may be in the area and bring oxygen and nutrients to the area to allow for improved healing. Another really nice thing is we improve fibroblast production after we do that. Fibroblasts eat up fibrosis and fibrosis is similar to scar tissue. If somebody has a muscle knot, that could be fibrosis. We do some of the instrument-assisted work right over that muscle mass gently just enough to bring blood flow to the area, a little bit of soft reddening. You don't want to break blood vessels, you don't want to bruise afterward, it'll bring more oxygen to the area, more blood flow and allow the fibroblasts to do what they're supposed to do.
Melanie: Interesting. Are these procedures that you're doing comfortably for the patient? For what conditions do you use them?
John: We allow for a moderate level of discomfort. If somebody has really tight muscles or a painful area, rubbing over it is not going to be comfortable. We tell people it's okay for it to be moderately uncomfortable, but we don't want to cause any severe pain because that's not useful. The patient is then going to guard and then you're going to be working against yourself instead of helping them. Moderately discomfort is okay. We'll use it for pretty much any soft tissue restriction that will come in the office. Somebody gets into a motor vehicle accident, they have what we know call whiplash associated disorder, neck pain, a lot of times the muscles will be overstretched due to the injury which allows some time for them to heal and when they come in for physical therapy. We'll work on the muscles that are in the front of the neck, back of the neck, getting them to move better. Another really nice technique to use along with instrument-assisted soft tissue mobilization is kinesiotaping. You can use tape right over the muscle to gently lift the skin and that allows for better fluid exchange under the tap so that promotes healing.
Melanie: Are there certain candidates for who these types of therapy are not a good idea and they would use standard physical therapy techniques?
John: There are contraindications to manual therapy. If somebody has an active infection in the area, you don't want to do any manual therapy. If somebody has osteoporosis, you would not want to do joint mobilization at a higher level. Gentle joint mobilization is okay, but you don’t want to do anything above a grade four or five. You don’t want to do any thrusting techniques at all. If anybody has active cancer to the area, you don’t want to do that. Healing fractures as well, you don’t want to do anything right over the site. People that it’s great for is something I've touched upon already if somebody has an acute injury. I myself strained my pectoralis muscle doing pushups the other day and I have a tool at home and I taught my girlfriend how to do it, she was able to do it on my just 60 strokes total and I felt much better today. Today, it doesn't hurt at all and yesterday I was in a moderate level of pain. Anyone with an injury that doesn't have the contraindications, that’s who you want to use it on.
Melanie: You are going towards my next question. Will you be sore afterward and how soon do you notice results?
John: It depends on the patient on their response. Some people are what we call rapid responders where you will use the technique on them and they'll be pain-free right away. That may or may not last depending on what they do afterward on people. You'll work on them and they'll go out and play four games of tennis and then their pain level is worse because they've done too much. You have to find a balance of rest with activity to promote healing. Most people, if they have a treatment reaction, if they get sore afterward, these are patients that tend to get sort even with regular exercises. What I inform them is you may be sore for up to three days afterward and what they should notice is they feel better than prior to the treatment.
Melanie: What about other techniques in physical therapy? Are you using this as an adjunct therapy to what you would normally do? Do you do them both together?
John: Definitely adjunctive. We do manual therapy techniques on patients that have various injuries and certain patients don’t require them because I'm not in for a restriction to a joint of soft tissue. They may have had a stroke or multiple sclerosis and for those patients, we'll be focusing more on strengthening muscles, teaching them how to use an assisted device such as a cane, crutch or walker. When someone comes in for a sports injury, then most of the time we're going to be adding manual therapy because that helps them exercise without pain. If you get things moving better before they start exercising, their exercises will be more effective. They’ll get more out of it.
Melanie: Do all physical therapists use manual therapy techniques or instrument-assisted manual therapy?
John: We've all been trained in school to use manual therapy. Not all physical therapists prefer to use it and not all physical therapists are trained in instrument-assisted soft tissue mobilization. I am certified in soft tissue mobilization one through Medical Minds and Motions, it’s a continuing education group that I got certification through, so I have advanced training.
Melanie: What about the neck? People are a little afraid to either let chiropractors or physical therapists or anybody go about the neck because there's a lot of myths out there. Bust up a few of those as far as the neck is concerned and using manual therapy.
John: The cervical spine you need to be cautious with because there are arteries within the cervical spine that can be damaged from too aggressive techniques. You have the internal carotid artery, the vertebral artery and those are known especially with certain techniques that can cause a rupture of the artery and then unfortunately strokes. In the United States to date, no physical therapist has caused that. There have been instances of chiropractors some osteopaths and the techniques that tend to cause these things are high cervical techniques. With a lot of extensions and a lot of rotations. That's basically tipping your head back and then turning at the same time and manipulating at that very end range. There's been a lot of studies that are showing that people have had vertebral artery dissection just turning their head to look over their shoulder while driving, so some of the things happen even just normal everyday activities, even much more than when they receive a manipulation. I was trained in spinal manipulation and when we do techniques to the upper cervical spine, we do them in the midrange, the safe range, so we don't cause those. We also do screening techniques to see who is safe. We do several tests to see if a patient is safe for these techniques and that's really important. We want to make sure the ligaments are intact to the upper cervical spine, specifically C1 and C2. We want to do tests that check their blood pressure, make sure they don't have high blood pressure. If they have a history of migraines, if they're a smoker, these are all things that place patients at higher risk for cervical artery dissection.
Melanie: Wrap it up for us because it's great to hear from a physical therapist about manual therapy and instrument-assisted soft tissue mobilization and what these are so that patients have a better understanding of what it is you're doing when you suggest these techniques. Wrap it up with your best advice and questions that you would like patients to ask you before you do any of these techniques.
John: When a patient comes to me, I think they should be asking what will their physical therapy entail, how long will they need physical therapy, will they need a certain skill such as instrument-assisted soft tissue mobilization throughout their care or just the beginning of the care? What I tell patients is that we use it until you no longer need it. That’s when we stop physical therapy. We teach patients to do their exercises on their own so they could be independent. One really nice thing about manual therapy is you have someone touching you with a healing intent so that in it of itself is very helpful to people. It reduces what we call the neurological tone. It reduces the threat level. That in of itself can help patients feel better.
Melanie: It’s great advice. Thank you for joining us and sharing your expertise so we can all understand what physical therapists do and how they can help with some of these musculoskeletal injuries and pain. You're listening to DocTalk presented by St. Luke’s Cornwall Hospital. For more information, please visit stlukescornwallhospital.org. That’s stlukescornwallhospital.org. I'm Melanie Cole. Thanks so much for tuning in.
Manual Therapy and Instrument Assisted Soft Tissue Mobilization
Melanie Cole: Injury and many conditions can often lead to muscular pain. Manual therapy is hands-on care where a physical therapist identifies the tissues and areas that can be corrected. My guest today is John Guerriero. He's the supervisor at St. Luke's Cornwall Center for sports and physical therapy in Fishkill. Tell us a little bit about what manual therapy is. What does it entail?
John Guerriero, PT, DPT: Manual therapy entails several things. We look at restrictions within joints and soft tissues. If it’s a joint restriction that we identify, then we have several things we can use to correct that restriction and that is joint mobilization, which is a graded amount from something very gentle to something that includes a high-velocity low amplitude thrust and everything in between. Basically, the clinician makes a decision on what to use based on what the patient is presenting with. Soft tissue mobilization is where we use hands-on techniques to address the soft tissues, so it's basically massage, but directed and targeted to the tissues that are restricted, not a general massage. It's directed to that specific tissue that's keeping you from moving pain-free.
Melanie: There are a lot of different techniques and as you say there's soft tissue mobilization, which is like a deep sports massage, but in one specific area, but people have heard about things like Graston technique, active release, scrapping therapy. Explain some of these and when you would use them.
John: One of the things I use is called instrument-assisted soft tissue mobilization. It uses a tool to do what we would normally do with our hands. The benefit of the tool is actually many. When you use a tool over the skin, you're actually doing a pro-inflammation response. We're bringing blood flow into the area, which is good for flushing out any toxins that may be in the area and bring oxygen and nutrients to the area to allow for improved healing. Another really nice thing is we improve fibroblast production after we do that. Fibroblasts eat up fibrosis and fibrosis is similar to scar tissue. If somebody has a muscle knot, that could be fibrosis. We do some of the instrument-assisted work right over that muscle mass gently just enough to bring blood flow to the area, a little bit of soft reddening. You don't want to break blood vessels, you don't want to bruise afterward, it'll bring more oxygen to the area, more blood flow and allow the fibroblasts to do what they're supposed to do.
Melanie: Interesting. Are these procedures that you're doing comfortably for the patient? For what conditions do you use them?
John: We allow for a moderate level of discomfort. If somebody has really tight muscles or a painful area, rubbing over it is not going to be comfortable. We tell people it's okay for it to be moderately uncomfortable, but we don't want to cause any severe pain because that's not useful. The patient is then going to guard and then you're going to be working against yourself instead of helping them. Moderately discomfort is okay. We'll use it for pretty much any soft tissue restriction that will come in the office. Somebody gets into a motor vehicle accident, they have what we know call whiplash associated disorder, neck pain, a lot of times the muscles will be overstretched due to the injury which allows some time for them to heal and when they come in for physical therapy. We'll work on the muscles that are in the front of the neck, back of the neck, getting them to move better. Another really nice technique to use along with instrument-assisted soft tissue mobilization is kinesiotaping. You can use tape right over the muscle to gently lift the skin and that allows for better fluid exchange under the tap so that promotes healing.
Melanie: Are there certain candidates for who these types of therapy are not a good idea and they would use standard physical therapy techniques?
John: There are contraindications to manual therapy. If somebody has an active infection in the area, you don't want to do any manual therapy. If somebody has osteoporosis, you would not want to do joint mobilization at a higher level. Gentle joint mobilization is okay, but you don’t want to do anything above a grade four or five. You don’t want to do any thrusting techniques at all. If anybody has active cancer to the area, you don’t want to do that. Healing fractures as well, you don’t want to do anything right over the site. People that it’s great for is something I've touched upon already if somebody has an acute injury. I myself strained my pectoralis muscle doing pushups the other day and I have a tool at home and I taught my girlfriend how to do it, she was able to do it on my just 60 strokes total and I felt much better today. Today, it doesn't hurt at all and yesterday I was in a moderate level of pain. Anyone with an injury that doesn't have the contraindications, that’s who you want to use it on.
Melanie: You are going towards my next question. Will you be sore afterward and how soon do you notice results?
John: It depends on the patient on their response. Some people are what we call rapid responders where you will use the technique on them and they'll be pain-free right away. That may or may not last depending on what they do afterward on people. You'll work on them and they'll go out and play four games of tennis and then their pain level is worse because they've done too much. You have to find a balance of rest with activity to promote healing. Most people, if they have a treatment reaction, if they get sore afterward, these are patients that tend to get sort even with regular exercises. What I inform them is you may be sore for up to three days afterward and what they should notice is they feel better than prior to the treatment.
Melanie: What about other techniques in physical therapy? Are you using this as an adjunct therapy to what you would normally do? Do you do them both together?
John: Definitely adjunctive. We do manual therapy techniques on patients that have various injuries and certain patients don’t require them because I'm not in for a restriction to a joint of soft tissue. They may have had a stroke or multiple sclerosis and for those patients, we'll be focusing more on strengthening muscles, teaching them how to use an assisted device such as a cane, crutch or walker. When someone comes in for a sports injury, then most of the time we're going to be adding manual therapy because that helps them exercise without pain. If you get things moving better before they start exercising, their exercises will be more effective. They’ll get more out of it.
Melanie: Do all physical therapists use manual therapy techniques or instrument-assisted manual therapy?
John: We've all been trained in school to use manual therapy. Not all physical therapists prefer to use it and not all physical therapists are trained in instrument-assisted soft tissue mobilization. I am certified in soft tissue mobilization one through Medical Minds and Motions, it’s a continuing education group that I got certification through, so I have advanced training.
Melanie: What about the neck? People are a little afraid to either let chiropractors or physical therapists or anybody go about the neck because there's a lot of myths out there. Bust up a few of those as far as the neck is concerned and using manual therapy.
John: The cervical spine you need to be cautious with because there are arteries within the cervical spine that can be damaged from too aggressive techniques. You have the internal carotid artery, the vertebral artery and those are known especially with certain techniques that can cause a rupture of the artery and then unfortunately strokes. In the United States to date, no physical therapist has caused that. There have been instances of chiropractors some osteopaths and the techniques that tend to cause these things are high cervical techniques. With a lot of extensions and a lot of rotations. That's basically tipping your head back and then turning at the same time and manipulating at that very end range. There's been a lot of studies that are showing that people have had vertebral artery dissection just turning their head to look over their shoulder while driving, so some of the things happen even just normal everyday activities, even much more than when they receive a manipulation. I was trained in spinal manipulation and when we do techniques to the upper cervical spine, we do them in the midrange, the safe range, so we don't cause those. We also do screening techniques to see who is safe. We do several tests to see if a patient is safe for these techniques and that's really important. We want to make sure the ligaments are intact to the upper cervical spine, specifically C1 and C2. We want to do tests that check their blood pressure, make sure they don't have high blood pressure. If they have a history of migraines, if they're a smoker, these are all things that place patients at higher risk for cervical artery dissection.
Melanie: Wrap it up for us because it's great to hear from a physical therapist about manual therapy and instrument-assisted soft tissue mobilization and what these are so that patients have a better understanding of what it is you're doing when you suggest these techniques. Wrap it up with your best advice and questions that you would like patients to ask you before you do any of these techniques.
John: When a patient comes to me, I think they should be asking what will their physical therapy entail, how long will they need physical therapy, will they need a certain skill such as instrument-assisted soft tissue mobilization throughout their care or just the beginning of the care? What I tell patients is that we use it until you no longer need it. That’s when we stop physical therapy. We teach patients to do their exercises on their own so they could be independent. One really nice thing about manual therapy is you have someone touching you with a healing intent so that in it of itself is very helpful to people. It reduces what we call the neurological tone. It reduces the threat level. That in of itself can help patients feel better.
Melanie: It’s great advice. Thank you for joining us and sharing your expertise so we can all understand what physical therapists do and how they can help with some of these musculoskeletal injuries and pain. You're listening to DocTalk presented by St. Luke’s Cornwall Hospital. For more information, please visit stlukescornwallhospital.org. That’s stlukescornwallhospital.org. I'm Melanie Cole. Thanks so much for tuning in.