What Manual Therapy Techniques Do You Use The Most?
August 12, 2010 
17 Comments
It seems like there are so many different manual therapy techniques overloading the market with overlapping concepts and vague acronyms. There is almost a cult-like following to many, as terms like ART and Graston are very trendy now, to both clinicians and clients. But what really are the differences between some of the techniques? Are 
they really better than traditional deep tissue massage? Are some of them really worthy of the extremely expensive training and tools (which is hugely disappointing to me and a limiting factor of why I haven’t supported some of them)?
You tell me.
Which of the below have you received training on and utilize in your practice? I’m curious to the popularity of each of the below manual therapy techniques, select which of the below that you utilize (you can select as many as you would like) and then comment on this post and tell us what you use and why. Did I miss any? Tell me. Feel free to share some thoughts on any courses or books you have read as well. What would you recommend to others?
Personally, I like to take bits and pieces from each one and use an integrated approach. I try to not “sell out” to one technique as I am sure they all have benefit. What about you?
What about old fashioned passive release techniques with nothing but the therapist and the patient. No tools, localized as Cyriax taught with TFM, Kaltenborns joint mobilization, soft tissue release that can be confused with ART, Rolfing and Funtional Release, all depending on the one who taught the course. So many forms run into each other and expensive tools may help but not necessarily the answer. Ask Leon Chaitow, DO and he most likely will speak to many forms work so why not integrate them with the patient depending on their need and response. Good post to bring up thought and consideration.
Hey Mike,
since you are naming Graston in the post and I've seen it done in some of Eric Cressey's videos I wonder what your thoughts are on Graston.
Aswell in hindisight to this blog post by Mike T Nelson: http://extremehumanperformance.com/blog/tag/graston/
Graston's invaluable. Saves your hands and normalizes fascia which make the chiropractic adjustment so much more effective.
You can also do Myofascial Release with the Graston Tools. When I went through the Graston certification, many of the doctors were ART practitioners but told me their hands couldn't take it so they were going to use the Graston Tools to help perform ART.
Hi Mike,
I like to use and recommend a variety of methods as they relate to the injury/condition/individual. I also think that self-care is so important to identify problem areas. If I had to pick one (and I did on the survey) it would be Myofascial Release.
What about this summary?
http://www.sciencebasedmedicine.org/?p=3170
I think Graston is not a good option for soft tissue therapy. Perhaps instead of sharing instructors we can see who is being flown first class to work with Athletics, Tennis, and Football Clubs.
What is being sold as technique is don't by blokes that can't do.
Andrew
I was trained on Graston about 2 months ago and so far I like it. I was skeptical at first, but it does really seem to loosen up soft tissue. Patient's find it pretty comfortable as well. They say one of the tools can be used for trigger point releases, but I haven't found that to be as effective as using my hands.
Not on the list is joint mobs/manips. I have had some good success.
Donny
Hi Mike,
I'm glad you posted this because I think we need more frank discussion about how best to combine modalities at certain phases of the rehab process. Fragmentation does nothing to help advance evidence based treatment, or to cross borders (DO, DC, PT, AT, etc) and truly give a patient the best care possible. That being said, I utilize a lot of MFR (working from superficial to deep), MET (I think contracting in the full ROM does wonders as opposed to a pathologically restricted ROM), SCS (positional release is very similar) works to limit protective guarding so that joint mobs and STM is not met with resistance. I like the concept of MFR with movement (whether you call it SI, ART, or STM), and lots of patients feel an immediate change in fluidity of movement (the proverbial lifting of the straight jacket). I would like to learn more about performing MFR to the whole body (such as the concepts of Anatomy Trains) to make a change at say the shoulder (up/down one joint might not be enough to evaluate!!). I trained with a PT who did ASTYM and it seemed a bit brutal. He got decent results, but bruising was almost guaranteed, and some pt's downright dreaded the tools (he spent time talking people into it). And jt manips are invaluable (even though I can't do any in WA- but that's another story).
I think that it's great that there are a variety of techniques out there that can be utilized. Definitely don't believe in a tunnel vision approach, but I do think there are a lot of people out there performing techniques that they may not understand what they are trying to accomplish w/ these techniques. So,just curious as to what everyone feels is the actual (or theorized) physiology behind the techniques chosen? Are you trying to decrease blood flow to a specific area when using "release" techniques? Does it vary w/ the "release" technique? Are you trying to overide a guarding response when performing joint mobilizations and influence gamma motor neurons? Alpha motor neurons? Or, are you simply just stretching the capsule or both? Would like to hear back. Thanks
Walt Lingerfelt
Not much evidence to support any of those techniques listed in the poll. Manipulation is the technique with the most bang for your buck so to speak (quick, effective for the right patients, and it has some evidence behind it)… surprised it was left out.
Hi, Mike.
My question will piggyback a bit on Seth's comment above with regard to ASTYM, with the only difference being that I was wondering about Graston. I've seen some rather nasty bruising occur with such treatments (and while the forearms didn't bruise so much, they looked rather beaten up / burned from some very aggressive friction (not sure if this is just par for the course with Graston or if whatever sort of lubricant may be used with the tools needed to be applied more liberally.
Given that a lot of female patients would be less than thrilled about looking like they were just caned (and male patients, too, for that matter, short of a select few who may enjoy showing off a nasty bruise or bruises) this left me wondering if any of the proposed rewards from such treatment outpace the downside of (at least from what I saw) leaving the patient with beat up skin and unsightly bruising.
Some would contend that the bruising is inevitable if working on someone with particularly poor tissue quality and that it will lessen over time as fiber layering and alignment improve. But again I am curious there are options that are just a valuable or more so for the intended purpose minus the downside of friction burns on the forearms and bruising (in one particular instance I witnessed when observing a local therapist in action, the resultant discoloration of a female patient's back resembled a nearly perfect purplish-red road map of her trapezius complex.
While some patients may bruise with Graston, it is not what you should be after. If the tissue is warmed up before hand and exercise and stretching performed afterwards, then bruising should be minimized. You don't have to be overly aggressive with to be effective.
Donny
Donny… then I would assume the chiro in the video doing the Graston treatment to Cressey's forearm on his site has no clue what he is doing. That is one B-R-U-T-A-L video… and that's going to leave a mark for a while.
As I stated I've been using Graston for a short time so I'm not the end all be all of Graston. The instructor I had made a it a point that brusing was not necessary. Now there will be reddening of the tissue and some petechiae.
I was a demonstration dummy for the hamstring techniques and I did have some bruises the next day. But, I wasn't warmed up and I didn't exercise or stretch after.
I think I found the video and the technique looked fine. Cressey is a pretty athletic guy and probably has some good pain tolerance. I would hope that same aggressiveness wouldn't be used on some 85 year old grandma.
I like to start conservative with the technique. If I bruse a patient up on their first treatment, they probably aren't going to be too excited for a second. As treatment progresses there will be less soft tissue restriction and less chance of brusing as well.
Here's a video of the instructor that I had:
http://www.youtube.com/watch?v=pUYKIS3Ty8A&NR=1
Donny
Geoff Maitland's system for assessment and treatment is phenomenal and I use it regularly. In our clinic we termed the quick, positive, lasting results "Maitland Miracles"! I also use a lot of David Butler's neural mobilizations, trigger point releases, and PNF principals.
Hey Mike,
I use pretty much a combination or some form of nearly all the techniques you mentioned. I think its good to have a few tools in your box in case something doesn't respond to your treatment. An interesting article on this topic is
Joel E. Bialosky, Mark D. Bishop, Don D. Price, Michael E. Robinson, Steven Z. George. The mechanisms of manual therapy in the treatment of musculoskeletal pain:
A comprehensive model. Manual Therapy, Vol 14 Page 531.
It discusses the many possible physiological effects manual therapy may have and really made me wonder if the treatments I am doing are actually working for the reasons I think they are.
Great topic! I have treated for 20 years and have tried almost everything ie myofascial release, craniosacral, strain/counterstrain, PNF techniques, acupressure, Maitland mobs, graduate of one year residency program in Norwegian OMT. I am of the opinion that the majority of orthopedic dysfunction is soft tissue related and that a thorough biomechanical evaluation can identify these imbalances. I am also of the opinion that PT's are very deficient in their ability to effectively treat soft tissue lesions. Our training programs are very exercise-based. Massage therapist have more skill in identifying soft tissue lesions. Please dont take offense to my comments as these are my observations over 20 years of proctoring students and working with other senior therapists. My clinic in Beverly specializes in the treatment of soft tissue dysfunction. I opened my clinic because I knew there was a better approach. Unfortunately for evidence-based therapists such as myself, there isnt much validation for the technique that I use the most: Active Release Technique or ART. It has been an invaluable addition to my practice as a PT. The subscapularis release post is one example of an ART technique which I have incredible results using to treat all impingement syndromes. I have never experienced with other techniques what my patients sometime call a "miracle". The results can be amazing, but quality results come with developing ones palpation skills and enhancing ones biomechanical/anatomical knowledge. If anyone is interested, please visit my website at http://www.walkwellrehab.com. My new website is currently under construction and will feature a blog as well.
Hi Mike,
I perform alot of soft tissue work in my practice, and with the athletes I treat, so I had many of the same questions and concerns you expressed. I tend to be a bit skeptical whenever one treatment is identified as the "greatest" or "best" approach to use. I gave a presentation at NATA last year that explored the various instrumented soft tissue mobilization techniques, as well as ART and Barnes MFR. While the research is promising on the use of IASTM, the reality is that, at this point, no research exists to support any one approach over the other. Hands-on approaches like ART have even less solid research to support their assertions, yet they are wildly popular (and expensive!). It really comes down to clinician preference, followed by practical experience in their (techniques) implementation. On a side note, I have found that instruments made of stainless steel seem to resonate better, but fortunately, there are cheaper alternatives that work well also.
Ken Cieslak, DC, ATC, CSCS
Teaneck, NJ USA