Is Manual Therapy Worth It in Late Phase Rehab?

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What's up, everybody. You are listening to the Strength and
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Knowledge Podcast. I'm doctor Zach Baker and doctor Corey Jones
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is with me today and we're going to talk a
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little bit about manual therapy, which in the PT world,
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I think you can probably talk to ten different people
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and get ten drastically different opinions on when to do it,
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how to do it, why to do it, or if
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we should even be doing it at all. So hopefully
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Corey and I can kind of unpack a little bit
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of that discussion and just bring to mind a couple
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times of when we think manual therapy is relevant to
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be incorporated during late stage rehab, which at times it
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may not be on top of people's minds. So Corey,
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we've got a couple of different ways that we want
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to go with this, But what are a couple ways
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that really stick out to you in regards to manual
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therapy with late stage rehab?
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Yeah, So, I think the biggest thing that changes when
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we start talking late phase is that maybe we're finally
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getting out of pain. We have our range of motion,
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we've got our base level body weight strength, and now
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we're really moving into heavier loads. So we're figuring out
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force production, we're figuring out force absorption, and then in
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phase three and four we're even talking adding velocity to things. Right,
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so we're doing like xl dcell kind of stuff, maybe
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introducing some more pliometrics, and then as far as strength goes,
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we are loading heavy because.
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We want to be able to manage the forces of sports.
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So I think the big thing when I think about
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manual therapy in this stage is understanding what comes along
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with some of that heavier loading and xl dcell things
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in clinic is just changes within.
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The cell matrix.
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Right There's there's gonna be a little bit of cell edema,
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there's going to be some metabolites within the tissues, There's
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physiologically going to be some changes because of the load
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and the amount of work we're putting on the body.
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So I think it's big when we get to this point.
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You see massage therapists, pts and all kinds of people
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working manually in professional sports, not always because somebody's injured,
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but because we're trying to keep going and keep playing.
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So I think in late phase our goal is to
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keep rehabbing all the way to the end of the
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plant care making sure people get all the way back
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to sport.
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So manual therapy tends to be something that helps with recovery.
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We're loading heavy, we're doing all this extra work we're
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trying to improve, like fatigue, resistance, and volume, and sometimes
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it really helps to do some of this manual therapy,
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whether it's mobilizations, deep tissue masauce from dry needling, or whatever,
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just to really help regulate the system and allow this
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like downtning after training so that we get back to baseline.
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I think, just because if we don't get back to baseline,
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then we have to work our way back to baseline
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in order to train again just as hard the next time.
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So it really helps with this kind of like hey,
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let's activate things, get things going, but also recover getting
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back to that zero. And then part two of that,
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we all know that manual therapy really helps neurologically with
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different things. So if because of this added velocity, added force,
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all of these different things acting on the body, if
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we have a little more central nervous system guarding, which
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is normal to a degree, maybe the manual therapy really
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helps us downregulate to the point where we're not getting
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as much of that CNS involvement too, so that we
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can really get everything calmer, not have this protective guarding
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state in the muscles, but more so just finding that
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minimal effective dose in late stage, doing the manual therapy
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to bring us back to neutral, and then keep going.
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So I feel like those are the big things that
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it makes me think of, But I know there's other
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times too, So I know you have your two cents
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to add, Like what would you say manual therapy makes
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you think of in some of those later stages.
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So one thing that comes to mind, and it goes
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right along the same path that you were just talking
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about in regards to we're training heavier, we're training at
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higher intensities, and at times you may not feel at
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your best, and that could just be because as a fatigue,
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that could be because of tightness. So I do think
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that getting manual work done it's almost like a It's
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a way for you to utilize kind of like a
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check engine light within your body, and as you're getting
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work done after practices, after games, after a high intensity
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lifting session, it's a very easy way for athletes to
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stay in tune with their body and make sure that
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they are staying on track and the amount of times
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that I've worked with an individual or I've just like
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hopped on a film roller myself or started doing some
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mobility work. After just a period of higher intensity training,
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you become aware of some things that may not have
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been as obvious that were an issue, and you start
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to realize, hey, we're in later stages of rehab. I'm
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no longer dedicating a large chunk of my training to
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mobility to some of these recovery tools, and we don't
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need to because it's not the primary concern. But we're
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also not getting that immediate feedback of hey, what is
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my overhead flexion look like? Can I still reach down
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and touch my toes easily? What does a straight leg
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raise or what's my hip or look and feel like.
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So getting some of this manual work done, it's kind
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of an easy way for you to also check the boxes,
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get an idea of what feels different, whether that's for
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better or worse, and just see are things trending in
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the direction that you would like them to trend and
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do you need to modify and of your current programming
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because of some of these things that you're picking up
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on the second piece to that is, just because somebody's
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in late stage rehab, does it mean that they are
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completely out of the woods. Yet they are not bulletproof.
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At some point you're going to realize rehab is not
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a perfectly linear process, and somebody may take three steps
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forward and one step back, and it is okay to
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put your hands on that patient when they take that
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one step back, to tell them, hey, suck it up
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or it'll get better on its own. You can encourage
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them and facilitate a productive dialogue that allows them to
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keep moving in a positive manner with positive thoughts. But
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don't be afraid to manage symptoms as well. You know,
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you get an issue on your car, your tires get
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worn down a little bit. You can change your driving habits,
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you can fix your alignment, but you got to take
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care of the tires too. You got to put a
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new set of tires on them if they don't work anymore.
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So I think a lot of times we almost feel
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guilty at times that we're regressing or doing something that
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may not be the best use of our time. But
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I think as long as it's intentional and it's serving
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a means to an end, then I think it's more
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than appropriate to do. So I don't know if you
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have anything to add to that.
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Yeah, No, I think that's the biggest thing, is what
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you just said, Like, it doesn't mean they're going back
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a whole phase if you put your hands on them.
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I think there's always these different trends in therapy, and
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some of these trends have led us away from manual therapy,
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and yet we've seen over the years how impactful it is,
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how helpful it is in different circumstances. To really exactly that, like,
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make sure people are still moving forward, make sure they're
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still able to participate as much as they can, and
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make sure they can keep loading as much as they
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can in order to finish therapy. So yeah, I think
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it's big just not letting the trends swing us one
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way or the other, but just making sure that we
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know the circumstances are the context in which to go
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ahead and do the manual therapy because it can be
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super helpful. So yeah, I think you hit the main points.
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But yeah, that would be my big thing is just
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being open to the fact that that could be an
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answer in that moment that allows you to keep doing
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some of those phase three, phase four things.
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So yeah, that's.
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Huge, awesome. I think the only other thing that we
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didn't really mention that I have used it and I've
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seen other people use it commonly, is when you talk
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about your athletes, especially in like a training room environment
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that are kind of PLMPD to playing field. They're coming in,
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they're in season and they're still actively participating, or they're
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beginning to actively participate, but they're still under the supervision
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of athletic trainer or pt on staff. It's not uncommon
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to segue some manual therapy symptom management right into some
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preparatory work before they go out onto the field. So
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maybe you're working on this individual shoulder, you're doing a
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little bit of soft tissue work, you're restoring that end
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range mobility, and then you're following that up with some
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sort of P and F or rhythmic stabilization or position
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specific isometrics. Then they hop off the table and they
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go start warming up. So you're using this manual therapy
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not only to potentially downregulate nervous system, but also stimulate
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or activate it in a manner that's productive for what
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they're about to do as well.
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So thank sure, Corey.
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Appreciate the time, Appreciate the thoughts. If you listening have
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any other thoughts on this, feel free to share them.
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You're listening to the Strength and Knowledge podcast. I'm doctor
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Zach Baker. That is Cory Jones. Thanks for listening.