Fundamental Manual Therapy Skills

Massage therapy to the neck. Permission Joseph E. Muscolino. Advanced Treatment Techniques for the Manual Therapist – Neck (2012).

The value of massage therapy continuing education is often dependent on learning how to apply fundamental skill sets of manual therapy. If I were to distill effective clinical orthopedic manual therapy (COMT) to its fundamental essentials, I believe that the four essential tools when working on a client/patient are heat, massage therapy, stretching, and joint mobilization (whether it is Grade IV of Grade V).

Although each modality in and of itself is wonderful, I feel that the combination of these modalities is far greater than the sum of the parts. When performed together in one treatment session, I feel that each one works off the other to create an extremely effective session.

For the massage therapist, learning some of these skills is a part of core curriculum. But learning others is often done as a part of continuing education. This blog post article is meant to explore these fundamental treatment skill sets so the massage therapist is better informed about their massage therapy continuing education needs.

What Is the Purpose of Manual Therapy?

This is a big question and can be answered on many different levels. However, if we are to take a step back and answer with the most common big-picture reason that manual therapy is done, I would say that it is the make taut/tight soft tissues looser, in other words more flexible. This would include loosening tight musculature (which can be described as inhibiting muscle tone) and decreasing fascial adhesions (as well as fascial contraction).

When it comes to making taut/tight soft tissues more flexible, I strongly believe that heat is an essential component of the treatment plan. Heat is a central nervous system (CNS) depressant (down regulates the CNS) to relax musculature and also mechanically makes soft tissue softer and more pliable. For this reason, I like to precede stretching and joint mobilization with heat, especially moist heat. Note: I believe that using a hydrocollator machine is the easiest and more efficient way to utilize moist heat in practice.

Massage therapy (soft tissue manipulation) is a relative newcomer to the recognized and respected manual therapy modalities. Certainly, massage therapy itself (soft tissue manipulation) is the most key skill set for massage therapy continuing education.

More and more research is coming out every year that demonstrates the effectiveness of massage therapy. Although I am not sure that I feel that these research studies need to be done to believe in the power of massage therapy, it is always good to have evidence-based research to back up and reproduce the results that we have been seeing in our offices for years/decades. Although we could fill a book with the possible mechanisms of beneficial effects of massage therapy, it seems clear from looking at fundamental physical and neural mechanics that massage therapy works on the mechanical level of manipulation of myofascial tissue, as well as moving arterial/venous/lymph fluid, as well as working with sensory feedback into the CNS for neural effects. And this is beyond the wonderful effects of touch generally. For these reasons, I also regularly incorporate massage therapy into the treatment regimen for any region of the client’s body that I am treating. As with heat, I usually include massage therapy before I utilize stretching and joint mobilization.

Stretching the deep lateral rotators of the hip. Permission Joseph E. Muscolino. Manual Therapy for the Low Back and Pelvis – A Clinical Orthopedic Approach (2013).

Stretching has become a controversial subject in recent years, but I do not see how the fundamental concept of stretching can be doubted. Soft tissues are adaptable and will change based on forces placed on them. For example, the fundamental characteristic of soft tissue known as “creep” states that a soft tissue will deform based on a sustained force placed on it. Unless this principle of soft tissue is refuted, stretching, and specifically static stretching that involves a sustained force, must have benefit. And every study I have ever seen that examines stretching as part of one’s continuing lifestyle buttresses the fact that stretching is effective at making soft tissues longer / more flexible. Dynamic stretching that involves repetitive stretching positions that are not held for sustained periods of time (dynamic stretching positions are usually held for five second or fewer), seems an ideal way to warm up tissue.

Both static and dynamic stretching, which are essentially mechanical treatments, can have pin and stretch technique added. This allows us to focus a stretch to a specific region (end) of a muscle. And then we have neural inhibition stretching techniques that take advantage of neural reflexes that inhibit (relax) muscle tone. These reflexes are reciprocal inhibition and the Golgi tendon organ (GTO) reflex (there is some controversy of late as to the role of the GTO reflex). The stretching techniques that utilize these neural reflexes read like a list of alphabet soup names: CR (contract relax), PIR (post isometric relaxation), AC (agonist contract), PNF (proprioceptive neuromuscular relaxation), MET (muscle energy technique), etc.

There are many choices for massage therapy continuing education when it comes to stretching. Hopefully, the foregoing discussion clears up the concept of stretching.

Grade IV joint mobilization to the neck. Permission Joseph E. Muscolino. Advanced Treatment Techniques for the Manual Therapist – Neck (2012).

The most advanced manual therapy skill set that exists for massage therapists is joint mobilization. This is certainly a modality that must be found in the world of massage therapy continuing education.