??? Post-Manual Therapy Exercise Prescription

[Jason Silvernail]

As a therapist who does a lot of manual and manipulative therapy with my patients, I wanted to get a feeling for how people structure their exercise interventions after their manual treatments.

I was trained, like most PTs, in the osteopathic model, so exercise that supports the manual therapy was relatively straightforward. Meaning if a spinal technique was a flexion/opening technique or an extension/closing technique, the exercise was designed to foster more of that biomechanical movement we were seeking to accomplish manually.

Popular courses (including these DVDs I like) usually use this same principle.
For example, if the patient had neck pain with attempting flexion and I used an "opening" mob/MET/manip on his neck, I would follow that by prescribing an exercise for neck flexion or for rotation toward the treated side, toward the restriction.

I have watched with interest as research (as well as supporting clinical practice) has thrown our biomechanical models of manual therapy efficacy into question and pointed toward neurophysiological and/or nonspecific effects as the most likely mechanism for the pain relief associated with manual therapy. Clearly, manual and manipulative therapy works, but maybe for different reasons than we originally thought, and maybe for smaller patient populations (see Lumbar manipulation CPR) than we originally thought.

Given all this information, how do you prescribe exercise therapy after a manual treatment? What considerations guide and what theory or paradigm do you use and why?

[oljoha]

Honestly, I don't care what exercises the patient uses. As long as they 1. use the involved body part and 2. pay attention to the body part being exercised. This in order to improve the [ what ever you want to call it ] between the mind and the body part. I.e. involve the brain.

[Eric C]

Jason,
The paradigm I would consider that I currently use is evidence informed.
I will give an example for the cervical spine.
my treatment today consisted of manipulation of C1/C2 for rotation, and then upper thoracic spine manipulation.
The exercises consisted of deep neck flexor training per Jull et al. I always test the deep neck flexors and give the according training regime if that is found to be impaired. I also had the patient perform exercises training the periscapular muscles. The overall focus was for control and endurance.
There are times when I will prescribe an exercise that follows the improvement of the arthrokinematic motion that the manual technique was intended to improve. But as you mentioned with all the current evidence this is happening less frequently in my practice now.

[matt c]

hi jASON, i usually encourage the patient to move in the most pain free and comfortable ROM available in the region around where i treated, for eg tx pain/treatment, id encourage movement in the tx, cx and lx spine area

[Bas Asselbergs]

Eric, have you ever found that the apparent "weakness" of the deep flexors completely disappears after manual treatment? It seems to happen rather often in my practice, and that is why I tend to move more towards Ole's point of view.

In those cases, I can really imagine the assessed weakness being nothing more than inhibited function: then getting restored by the recovering neurophysiological processes. I have to admit doing the deep flexor exercises approach for a couple of years, but I am much less focused on the actual "strength" of those muscles, but more on restoration of the neurophysiology of the person.
It means more smooth and comfortable motion without fear avoidance behaviour, with the help of diaphragmatic breathing, with the help of increased cognitive functions - all allowing reduced "defense mechanisms" and reducing summation in the brain.

In other words - not so specific anymore. And still within the standards of evidence: Mosely, Shacklock, Ramachandran, etc.

[Eric C]

Bas,
I will give you one example that I see all the time. CCFT is performed and found impaired. Usually overactivation of the SCM and anterior scaleni. Mobility testing of
forward nodding of the cranium on C1 is lacking. Perform the mobilization to improve forward nodding and the CCFT test improves significantly.
But I dont always consider the impairment of the test to be weakness. I agree with you that it is simply inhibited function. for the past year or so I have been considering this to be due to a lack of movement awareness. I often find the patients dont even realize how gaurded they are with these global muscles.

I, (especially now) am moving more toward the aproach that Ole describes.

[Barrett Dorko]

"Overactivation"?

What is that?

[Eric C]

I would describe the overactivation as a compensatory contraction of the global musculature, Jull describes contraction of these muscles during the test to inhibit the longus coli and capitus function.

[nari]

Post-neurodynamic movements:
Only Butler's free movements for the respective or combined nerves, eg radial and median. I always liked the fact he calls them movements and disapproves of the word "exercises".

Post-mobilisation:
Cervical - used to do chin retraction and all that but as many patients seemed to do it incorrectly, I stopped. Small range, low++ amplitude nodding and shaking; plus McKenzie's flexion work. Later, neural movements.
Thoracic - Rotation and flexion work, usually. Later, neural movements.
Lumbar - Used to do extension as per McKenzie with very mixed outcomes. General rotation and LF work, and later, neural mts.

This predates 2004 (after Butler's SNS course) - after that, almost exclusively neurodynamic work and ceased all passive mobs.

nari

[Diane]

After manual therapy (which in my patient population of mostly persistent but ordinary mechanical pain consists mainly of slow applications) I usually use a combination of ideomotor movement for homework/ teaching people to just feel their bodies better using the floor for feedback, learning better sensory awareness: this has the disadvantage of decreasing the threshold for felt discomfort, but in the long run it does reduce the opportunity for "pain" states to arise. By increasing awareness of the need to move before the brain has to produce a pain state to get the attention of the resident externally focused individual living inside that particular nervous system, full blown pain states can be more easily prevented from occurring/recurring.

[Jason Silvernail]

EricC-
Yes, the CCFT/DNF (craniocervical flexion test/deep neck flexor) issue is getting a lot of attention in the literature lately, and is becoming a common exercise treatment for both mechanical neck pain and headache. I think its an interesting movement to talk about, since so much is going on up there, and its kind of fun to see what people end up rationalizing it as.
It really depends on what your paradigm is, I think.

1. Muscular paradigm. People aren't doing the CCFT properly have weakness of their longus colli and longus capitus, and so are "compensating" with their scalenes and SCMs. Strengthening the muscle allows them to do the exercise "properly" and focus on the deep neck muscules. Barrett's question about the overactivation issue is very relevant here. Those who teach this movement like to think there is one proper way to nod your chin and one set of muscles that should be used. If other, more global muscles like SCM come into play, this is thought of as "bad" and should be retrained, to allow the proper muscles to work. I suppose this is analogous to the TrABD and Multifidus in the lumbar spine. Existing research (such as G Jull's) on neck pain and HA shows people's outcomes improving when doing an exercise regimen that includes this movement. I think what those advocating the muscular approach have not done is shown that it is this particular movement that is necessary, or that that such weakness or dyscoordination is not simply a consequence of the pain experience which resolves when the pain resolves without need for special training. I have also not seen any study on what percentage of asymptomatic people do this the "wrong" way when tested. I have a feeling its kind of like the forward head posture. Everyone seems to think its bad and should be corrected, but just about everyone seems to have it.

2. Articular paradigm. This is a lack of flexion at the OA joint, which typically "lives in" extension. When the OA joint is treated with the appropriate Mob/MET/Manip, this movement improves because the joint is moving better. This paradigm probably doesn't take into account the neurophys mechanism of the manual therapy, which may be improving the movement due to pain reduction or motor system feedback.

3. Neurodynamic paradigm. This is how I see this movement, mostly. People talk about the longus colli and longus capitus, but all I see is the neurodynamic effect on the spinal cord, nerve roots, and suboccipital nerves that have been implicated in cervicogenic headache. I believe in Diane's DNM approach she works this area in an attempt to improve the blood supply to the nerve tissue back here and treat pain (is this correct, Diane?) and when I see a "chin tuck", I just imagine all those nerves moving and sliding around. They're the sensitive tissue, after all.

4. Motor control paradigm. This is related to the coordination of the movement and the inhibition of movement due to a painful guarding response, and could be improved by manual therapy or movement therapy via feedback mechanisms to the motor system.

So, I guess I'm saying I think its a little more than the longus colli. Though we certainly are excited to study that little muscle with realtime ultrasound, aren't we? I think that's another example of studying what we are traditionally used to looking at (muscles of course) and something that is easy to measure, rather than considering what pain science tells us is really relevant about this movement and its possible role in the pain experience.

I find this movement helpful for conditioning when pain is mostly gone, especially for Soldiers that wear helmets and those who participate in contact sports.

[occulomotorcar]

(With my limited clinical experiences) I have noted that it is not so much what exercise I give, than whether the patient has actually done the exercise regularly by the time they come to see me again. Patients who do the exercises usually feel much better, patients who don't do them often don't. Sometimes I give an exercise to a patient and as soon as I have asked them to demonstrate it to me I get the feeling that the few minutes explaining it have been a complete waste of time - I guess via their lack of enthusiasm...
How do you best encourage a patient to do the exercises? It often feels like the patients who might benefit most from a bit of movement are the least keen to give it a go!

I agree with Nari regarding the word “exercise” - it sounds like a chore to a lot of people. “Movement” sounds like a great word - I think I'll adopt it. I sometimes use the word “game” - it's not just a thing for kids, adults love games too - give me a game over an exercise any day. A particular favourite of mine is ABC painting for thoracic articulation - drawing the letters of the alphabet in big letters into the air, using the elbows with the hands clasped behind the neck - by the time the patient has done 26 letters they've had a lots of movements through the thorax and they have an easy reference for the duration of the exercise

[JimA]

Getting patients to do exercise is managed easier with a clear and acceptable(to the patient) explanation about the physiological effects and benefits gained from doing them. Also I now tend to try movements and ask the patient how it feels, if they say it feels good I go with that. I also get them to do some activity they enjoy and see as relevant to their problem.

[Luke Rickards]

Eric,

It would appear we need to be careful about the idea that improved motor performance is responsible for changes in pain following the neck exercises being described here.

Falla D, Jull G, Hodges P. Training the cervical muscles with prescribed motor tasks does not change muscle activation during a functional activity. Man Ther. 2008 Dec;13(6):507-12. Epub 2007 Aug 27.

Both low-load and high-load training of the cervical muscles have been shown to reduce neck pain and change parameters of muscle function directly related to the exercise performed. The purpose of this study was to investigate whether either training regime changes muscle activation during a functional task which is known to be affected in people with neck pain and is not directly related to either exercise protocol. Fifty-eight female patients with chronic neck pain were randomised into one of two 6-week exercise intervention groups: an endurance-strength training regime for the cervical flexor muscles or low-load training of the cranio-cervical flexor muscles. The primary outcome was a change in electromyographic (EMG) amplitude of the sternocleidomastoid (SCM) muscle during a functional, repetitive upper limb task. At the 7th week follow-up assessment both intervention groups demonstrated a reduction in their average intensity of pain (P<0.05). However, neither training group demonstrated a change in SCM EMG amplitude during the functional task (P>0.05). The results demonstrate that training the cervical muscles with a prescribed motor task may not automatically result in improved muscle activation during a functional activity, despite a reduction in neck pain.

[Barrett Dorko]

Jason's explanation of how several schools of thought see this problem through their lenses is a classic and displays the sort of understanding we might all acquire if we just keep listening.

I'm more likely to see things as he recounts them in the neurodynamic paradigm but would add this: I feel that the term "overactivation" coined by Jull (I presume) is a capricious and indefensible description of the muscle and it doesn't take into account the simple self-corrective nature of our very being, and I'm confident that no less than Patrick Wall would agree. Too often we assign such activity the task of protecting or compensating when it makes a great deal more sense to interpret it as the beginning of correction; it's resolution and ideomotion ready to express itself if only given some encouragement from a therapist who understands this. I look at this situation, assume I need to change the context for the patient and proceed as I usually do. The alteration in the patient's autonomic state clearly indicates that the right movement is then occurring. As Butler pointed out long ago, we're treating the physiology, not the anatomy.

Pain is output when the brain makes this decision: There's danger in the tissue and you need to do something. The tissue most easily thought to be in danger is neural and the "something" that needs to be done is both active and instinctive. I doubt that this naturally occurring process of correction needs much in the way of intervention from another's hands or effortful, repetitive movement.

One more question: Is this "overactivation" a defect or a defense?