Manual Therapy Techniques Explained
Registered Massage Therapists in B.C. are trained in various manual therapy techniques that they use according to the presenting pathology or patient complaint. Below is an explanation of our techniques:
- Orthopedic Assessment
- Swedish Massage
- Diaphragmatic Breathing
- Manual Lymph Drainage (MLD)
- Myofascial Release (MFR)
- Joint Mobilization and Joint Play
- Ischemic Compression
- GTO Release
- Cross-Fibre Frictions
- Muscle Energy Technique (MET)
- Proprioceptive Neuromuscular Facilitation (PNF) Stretching
- Rood Method of Exercise (Roods Technique)
- Actinotherapy (Light Therapy)
A thorough orthopedic assessment can include any of the following: Postural assessment, joint range of motion, muscle strength and tendon reflex testing, peripheral and cutaneous nerve testing, blood pressure and pulse, chest and lung functional testing, body movement functional screen, and special testing. Special testing can include hundreds of directed tests designed to support or refute causes of symptoms or pathologies, helping the therapist choose appropriate techniques to use and outline an effective treatment plan.
The foundation of massage, Swedish massage includes strokes such as kneading, stripping, wringing, lifting, and jostling, either with elbows, palms, knuckles, fingertips or thumbs. They follow the principles of massage that encourage return of venous blood on the heart, that must start light and build pressure, that work out towards limbs from the torso, and that treat surrounding areas before treating the exact painful spot. Generally, Swedish has a relaxing effect as it decreases the firing of the sympathetic nervous system (fight or flight), allowing the parasympathetic nervous system (rest & digest) to do its work. Swedish massage also includes “tapotement”, or short, fast stimulatory “tapping” techniques done with fingers, palms, or fists to increase local circulation, loosen mucus in respiratory tract, stimulate weak or hypotrophied muscles, and general stimulation to the sympathetic nervous system.
The use of ice, cold/warm water or heat can be very beneficial to the body, whether used during treatment or given as home care. It is one of the oldest forms of therapy, and the first human to discover the soothing effects of natural hot spring knew they had found a very good thing indeed. Do not underestimate the effectiveness of hydrotherapy, it is a very easy, simple, inexpensive and abundant resource that can and should be incorporated to your daily and weekly routine to maintain optimal health and performance. A heat pack at the end of the day can help prevent headaches and sore necks. “Contrast baths” on the arms and legs can improve circulation and help with tendonitis. A cold cloth on the abdomen first thing in the morning can relieve constipation. An Epsom salt bath can help with muscle spasms as your body absorbs the magnesium. And those are just a few examples!
This is a simple technique to teach patients how to breathe into their stomachs as opposed to their chest and shoulders. Good diaphragmatic breathing encourages nervous system relaxation, pumps lymph up from the legs and abdomen, and relieves tension on neck muscles that are overworked in chest-breathers. As adults, we learn to hold our stomachs in to give the appearance of a flat tummy, but try to let it all hang out when no one is looking, or when you are sitting down to allow for the stomach to expand with each breath. Deep, repetitive diaphragmatic breathing is contraindicated (not recommended) for those with long-term diabetes and kidney disease.
Manual Lymph Drainage (MLD)
MLD is a very light, repetitive technique that targets the interstitial fluid in the tissues and the lymphatic system as a whole. MLD can treat over 60 conditions, and because it is so gentle, it is great for acute injuries to reduce swelling and speed healing, and can even be applied before and after surgical operations to improve post-operative outcome. It can also help with skin conditions such as acne and eczema, or give pain relief from rheumatoid arthritis and fibromyalgia. It is perfect for fluid retention with pregnancy and is overall very relaxing. It is quite common to fall asleep during a treatment, so it is great for insomnia as well.
Developed in Europe in the 1930’s by physiotherapists Emil and Estrid Vodder, Manual Lymph Drainage (MLD) is a safe, effective, yet gentle approach to stimulating the body’s lymphatic system. MLD increases the pumping of lymph fluid along the lymphatic vessels (normally achieved with body movement, breathing, the pumping movement of your arteries and intestines), to return it to the blood via large veins near your collar bones.
Lymph is called “interstitial fluid” when it is in your tissues, and is made up of water, proteins, white blood cells, lipids, hormones, enzymes, and few other small particles. MLD helps drain fluid from your tissues, allowing fresh, new fluid to provide nourishment and healing. As the lymph travels along vessels, it encounters a string of lymph nodes to filter and concentrate the fluid, removing bacteria, viruses, dead cells, tumour cells and 50% of the water. Lymph nodes also store harmful substances your body can’t eliminate like coal or fibreglass dust, dye and inorganic elements, sometimes encapsulating themselves with fibrosis if they can no longer function properly. Lastly, they give access to the antigens stored in your lymph nodes to combat infection and disease – it’s your immune system keeping you healthy!
At rest, your lymphatic system pumps lymph 3-7 times per minute, whereas with MLD it can increase up to 30 times per minute, the same rate as what vigorous exercise achieves.
Vancouver RMT and MLD therapist, Denise Drisdelle, explains how MLD works:
MLD is best known for treating lymphedema, a chronic swelling of a limb due to damaged lymph vessels or nodes. However, MLD can treat over 60 conditions, and both Tracy and Lauren are trained at the Therapy 1 Level (excludes lymphedema and complicated postoperative treatment). Because the technique is so light, MLD is great for acute injuries to reduce swelling and speed healing, and can even be applied prior to planned surgical operations to improve post-operative outcome. It can also help with skin conditions such as acne and eczema, or give pain relief from rheumatoid arthritis and fibromyalgia. It’s perfect for fluid retention with pregnancy and is overall very relaxing – it’s quite common to fall asleep during a treatment. Check out the list below for more conditions that can benefit from MLD.
- ligament sprains & muscle strains
- contusion (bruise from blunt force)
- dental surgery
- reconstructive surgery
- hip or knee replacement
- wound healing
- leg ulcers
- acne, rosacea, eczema, psoriasis & seborrheic dermatitis
- multiple sclerosis
- optic neuritis
- trigeminal neuralgia
- Bell’s Palsy
- stroke or paralysis
- stress & insomnia
- fluid retention and leg swelling
- carpal tunnel syndrome from arm swelling
- minimize stretch marks
- C-section healing
- Rheumatoid arthritis
- venous & arterial insufficiency
- Raynaud’s phenomenon
- sinus congestion and chronic sinusitis
An MLD session always includes a treatment of the neck to stimulate the terminal vessels that drain back into the veins and heart. Then it is paired with treatment of the affected body area, such as face, back, chest, abdomen, hips, arm, or leg. Treatment time can range from 45-90min, depending on the size of the body part and severity of the condition. MLD is normally administered intensively for the first week or two, with 2-5 sessions per week, and then can be reduced to once or twice per week until desirable results are achieved.
Links for more information:
Myofascial Release (MFR)
Fascia is a connective tissue that is found throughout the body, at superficial, deep and subserous levels. Superficial fascia is found just beneath the skin and is loose and mobile when healthy, or restricted, adhered and shortened when it’s not healthy - often due to inflammation, trauma, surgery, pathology or a postural imbalance. Deep fascia is denser, tougher and tighter, compartmentalizing and surrounding organs and muscles to provide support. As an example, think of the white-silvery fiber in steak, or the delicate web produced when you pull apart raw chicken – that is fascia. Because fascia is thought to be continuously linked throughout the body, a pull or restriction at your wrist might have an effect all the way up your arm and into your neck. Therapists can use a variety of techniques to affect fascia, such as skin rolling or torqueing to reduce surface adhesions, gentle cross-hands stretch or spreading to release restricted fascia, bowing of a shortened muscle or muscle group to lengthen the deep fascia, and even visceral manipulation to affect deep and subserous fascia surrounding the organs. This technique is often used at the beginning of a treatment before oil is applied so the therapist can grip the skin properly.
Joint Mobilization and Joint Play
These techniques include many variations, but they all target the joint, joint capsule and its surrounding muscles. Muscle shaking, full body rocking, and limb jostling all cause reflex muscle relaxation, decrease muscle tone and loosen the joint capsule. Traction (eg. pulling on the arm, leg or head) can be used for assessment and treatment of joints, testing stability and stimulating the proprioceptors (motion sensors) in the joints, causing muscle tone to decrease. It also encourages the exchange of lubrication fluids between the blood/lymph vessels and the joint space. Joint Play includes two main types; oscillation and sustained glide. They can be applied in different grades, up to grade 4 (grade 5 is what chiropractors do). Joint play techniques assess dysfunctions, increase range of motion, stretch tight joint capsules, and reduce adhesions, pain and spasm. It is useful for stiff joints, frozen shoulder and chronic injuries that have a limited range of motion for that joint.
This technique uses static compression on a trigger point, with enough pressure to cause temporary local ischemia (decreased blood flow) within the patient’s pain tolerance. As the compression is held for 10sec up to one minute, the pain should decrease to almost none, as the muscle is forced to stop holding the contracted muscle fibres (hypertonicity and spasm). Heat post-treatment can help with any soreness that may follow that day or the next. A modified version of this technique can also be applied to sinuses to help relieve congestion.
This technique uses static bowing, rhythmic pressure or muscle approximation on tendons and muscle attachment points to affect the Golgi Tendon Organs (GTOs). GTOs are nerve receptors that monitor muscle tension and if they detect excessive load or stretch, they will cause your muscle to relax so you do not tear a tendon or muscle. When applied during treatment, with firm pressure for 30 seconds, your muscles relax to reduce tone and spasm. This technique works well if trigger points in a muscle are too tender for direct touch with muscle stripping or ischemic compressions. For example, we can bow the Achilles tendon to relax the calf muscles, or the IT band at the knee attachment, or Common Flexor and Extensor Tendons at the elbow for tight forearms.
This technique was made popular by the British osteopath Dr. James Cyriax in the 1980s, but he credited it to Hooker in 1849 where he used it for tendonitis. The goal is to disrupt and break down existing and forming adhesions or scar tissue in muscles, tendons and ligaments using firm, short strokes across the directions of tissue fibres. It allows for a smaller, more functional scar to form, which is especially useful in the sub-acute healing stage. If it is a chronic scar, deeper and more vigorous frictions will be needed. Frictions are applied with increasing pressure for 20-90 seconds, usually repeated three times, all within the pain tolerance of the patient. Recreating minor tissue damage and inflammation signals the body to devote more time and energy to healing the area properly, instead of a quick, nonfunctional scar.
This non-invasive, osteopathic technique aims to relieve pain in muscles by “re-setting” the neuromuscular signaling of that muscle. First, a tender point or trigger point is located with static compression, then the patient is placed in a position that shortens the muscle as much as possible, so as to diminish or completely eliminate the pain sensation. The compression and position are held for 90 seconds, then the patient is SLOWLY returned to a neutral position. It is best if the therapist can passively move the patient back to neutral, as opposed to the patient actively contracting the treated muscle.
Muscle Energy Technique (MET)
A gentle, yet very effective, osteopathic technique that is most often used to improve range of motion on the cervical, thoracic and lumbar spinal joints, as well as the sacrum. It incorporates submaximal muscle contractions of the patient for several seconds, held in a specific position and with the resistance of the therapist. It is followed by a stretch to lengthen the limiting muscles, thus improving the range of motion of the affected joint. It is very similar to PNF stretching as described below and uses the same physiological principles. It is useful for people with a decreased ability to rotate the head/neck or spine to its full range, whether that is due to injury, postural imbalance, poor biomechanics, or ageing.
Proprioceptive Neuromuscular Facilitation (PNF) Stretching
This stretching technique has several different combinations of active or passive stretching with submaximal muscle contraction of the patient. It takes advantage of “reciprocal inhibition”, meaning when you contract one muscle, the opposing muscle must relax and lengthen in order to accommodate the contraction. Using slight resistance with the contraction can also help fatigue the muscle to inhibit hypertonicity and spasm. It can achieve a greater increase in range of motion than regular, passive stretching.
Rood Method of Exercise (Roods Technique)
This rehabilitative technique was developed by the American physiotherapist Margaret S. Rood in the 1940s. It is a combination of facilitatory and inhibitory touch with repeated movement exercises. It targets the neuromuscular system in an effort to re-educate the body and brain connection with respect to lost functional movement patterns. It can be useful for contractures and hyperactive muscles associated with cerebral palsy, ALS and Parkinson’s, or with paralysed muscles from a stroke or spinal cord injury.
Actinotherapy (Light Therapy)
RMTs in British Columbia are allowed to use two therapeutic light instruments; infrared and UV lamps. These are currently not available at Marpole Physiotherapy Clinic, but please let us know if you are interested in these treatment modalities and we may add them to our services.
Source credit: Clinical Massage Therapy – Understanding, Assessing and Treating Over 70 Conditions by Fiona Rattray & Linda Ludwig (2000).