I've struggled to find the place of manual therapy in my patient population. That's why I dedicated a whole Senior Rehab Podcast episode to the topic. Thankfully, Andrew Rothschild (@ARothschildPT) was so gracious enough to write a lovely post regarding manual therapy to bring some clarity. I know you'll enjoy reading this! -Dustin
If you pay attention to the photos in the manual therapy and orthopedic journals as well as clinic websites, it will appear as if manual therapy is only performed on young, seemingly active, and healthy individuals. This couldn’t be further from the truth. Manual therapy is not exclusive to only one segment of the population. Manual therapy can be a beneficial intervention for almost all of our patients, regardless of age or ability.
While the effectiveness of manual therapy has been documented in the literature for a variety of conditions, the mechanisms of manual therapy are not fully understood. So a word of caution first: prudence should be utilized when we describe how and why certain techniques might work. For example, we are not putting bones back into place, nor are we changing the "alignment" of joints. Whether or not we are affecting blood flow is also questionable.
What we think most likely is happening is a neurophysiologic response, both locally and centrally, on mechanisms that help alter pain perception, reduce muscle guarding, and reduce local muscle inhibition. What we are also doing is helping people FEEL good. We may be helping to reduce fear by demonstrating that certain movements and positions are not actually dangerous by modifying inputs into the central nervous system.
(For more in-depth information, see the article by Bialosky et al on the proposed mechanisms of manual therapy: http://www.ncbi.nlm.nih.gov/pubmed/19027342)
The laying of hands on someone with a therapeutic intent can be a powerful thing. There is research that manual therapy may help trigger the release of the hormone oxytocin, dubbed the "bonding hormone" (Plaza-Manzano G et al 2014). Oxytocin is one of the hormones that may be responsible for the bonding between a mother and newborn, among other things. Now, I'm not saying we should start cuddling with our patients--that would be highly inappropriate. Let me check my state regulations....yes, highly inappropriate. But you get the idea.
So, what conditions would manual therapy be appropriate for in the elderly population? For starters, anything that’s appropriate for almost any population--certainly post-operative conditions, such as total knee or hip replacements, which are common orthopedic issues especially in the home health arena. Soft tissue mobilization as well as mobilizing joints above and below the affected area is appropriate.
Determining the choice of technique to utilize with the senior population is when certain considerations need to be taken into account. What is the state of tissue? What comorbidities are present? What medications are they taking that could affect their tissue or general sensitivity status? For example, would I perform a thrust manipulation to the thoracic spine in an 80 year-old female? Probably not, because I need to consider issues such as bone density in the spine and especially the ribs. A low-grade mobilization will likely be better tolerated and received and will be effective if my goals are to modulate pain and improve perception of mobility. Bottom line, use common sense when it comes to application of force based on what you know about the patient in front of you.
Who should perform manual therapy? Any physical therapist or occupational therapist reading this or who listens to Dustin’s Senior Rehab Podcast is probably able to, as long as it’s within your professions scope of practice. Just because you may not have any specific formal training doesn’t mean you aren’t able to perform certain techniques, so don’t let that be a deterrent. However, if you are uncomfortable with certain manual procedures, that alone is an indication to not do them until you feel comfortable doing so. That being said, if you are interested in improving your skills and expanding your knowledge with manual therapy, there are several resources available.
And before you know it, your patients will be doing this.
Elderly residents performing "Whip/Nae Nae"
Thanks for reading,
You can catch Andrew on Twitter: @ARothsachildPT & find him writing awesome articles at the TheManualTherapist.com. Listen to his Senior Rehab Podcast episode with Erson Religioso below...