It Depends

By Daniel Wonnocott

What are some key factors that underpin the classic “it depends” response when a therapist asks what is the best technique to treat xyz?

It can be difficult to reconceptualise traditional learnings to integrate with current understandings. A lot has changed and evolved in our professional space that runs against what many of us spent years and thousands of dollars learning. My presentation at the AMT Virtual Conference 2020 aims to give you a better understanding of how manual therapy is more relevant than ever and provide you with an insight on how you likely already possess the skills to address most clinical presentations.

Not in my Presentation

My presentation won’t be:

  • SELLING you anything other than a newfound appreciation for the skills you already possess.
  • SUPER COMPLICATED – I’ll be aiming this presentation towards those who are hands on, people-loving therapists who enjoy learning on the job more so than taking a deep dive into research and textbooks.
  • BORING – I will be keeping it entertaining.
  • WORDY – It will be focused on practical takeaway rather than touring through every detail.

A quick look at the more direct effects of manual therapy on tissue healing

Tissue overload from manual therapy or exercise leads to an increased release of Mechanical Growth Factor (MGF). MGF has been shown to activate satellite cells within muscle and is important in cases of muscle injury as well as age-related muscle wasting.

Mechanotransduction mechanical load that stimulates healing can be broken down into 3 main components.

1. Mechanocoupling:

  • Shear, compression and tension forces deform tissue cells and create chemical signals.
  • The effect of cell deformation is not restricted to the local area of therapy as a result of cell to cell communication.

2. Cell to Cell Communication:

  • Signals conducted from the treated area spread throughout the wider tissue region
  • Gap junctions are formed at cellular touch points
  • Cells can then communicate directly with one another to create an effector cell response.

3. Effector cell response:

  • Integrins create a bridge between the outside and inside regions of cells.
  • Cytoskeleton of cell physically stimulates cell nucleus
  • Nucleus signals for beginning of protein synthesis and new protein is secreted into the extracellular matrix, causing it to remodel.

Finding the balance between creating a treatment effect without eliciting a protective response from the nervous system as a whole is an artform. It is important to acknowledge that the body has everything it requires to heal without manual therapy intervention. We should be aiming to create a balanced environment within the tissues whilst simultaneously helping clients navigate and engage the environments they wish to pursue.

The goal is to regulate pain and support the body throughout the journey. Good therapy is about facilitating rather than fixing, the body has that covered.

Tissue Healing Stages

Different tissues have their own unique responses when it comes to remodelling and maintaining integrity, but response to injury is a rather uniformed approach. Understanding the stages of tissue healing and targeting intervention that supports the process is important.

Injury
  • Bleeding ceases after approx. 4-6 hrs
  • Expect more bleeding in fitter/vascular athletes.
Inflammation and Swelling
  • Generally, lasts 1-3 days (up to 7). During inflammation, capillary bed opens and blood flow increases
  • Increased blood pressure and increased osmotic pressure forces fluid out into the interstitium
  • Lymph vessels open to assist in removing additional fluid and proteins
  • The pump action of muscle contraction helps remove excess fluid
  • Complete resolution occurs in presence of minimal disruption (irritation – not further damage).

Technique selection should support the above process without further irritating the area. Something as simple as light effleurage can be effective at soothing the nervous system to make it easier for a client to move (pump action). Knowledge in Manual Lymphatic Drainage application is a huge advantage as it is gentle, soothing and influences the fluid dynamics of the lymphatic system. Skilful application of kinesiotaping can be a great adjunct to therapy.

Chronic inflammation may occur in the presence of local irritants, reduced circulation and immune disorders. In this situation, more fibrous material is produced rather than swelling as inflammation and proliferation occur simultaneously. It is often caused by macrophages failing to fully debride the area of foreign substances (dead cells, extracellular blood, dirt). An encapsulating scar known as a granuloma is produced by collagen wrapping around the foreign substance to isolate it from the body.

It is important that we respect where the body is in its healing journey and look to support it rather than speed it up. Rushing and overworking the tissue will more than likely impair and delay the healing process. It is easy to get lost focusing on pain reduction in the early stages and overwork the area hoping to change someone’s pain.

Repair
  • Fibroplasia – the production of fibrous material
  • Angiogenesis – the production of new vessels.

The fibroplasia and angiogenesis processes are instigated by cytokines and growth factors released by macrophages during the inflammatory stage of healing.

Roughly around day 5 post-injury, fibrils of collagen begin to appear. External stress dictates how fibres lay down. Alignment will influence the stress–strain curve and have an impact on the strength of the tissue.

The lure of manually realigning collagen is pretty awesome but the reality is the forces we apply are not enough alone to make the magic happen. If your treatment approach to the localised area leaves a client sore and their daily movement is reduced or more irritable post-treatment you are likely reducing your client’s ability to apply external stress to the area. A net reduction in tolerable external stress is the opposite of what we should be striving for at this stage.

Remodelling
  • Overlaps with repair phase and can last 3+ weeks to over 12 months.
  • Characterised by a decrease in wound size, increased scar strength and an alteration in direction of scar fibres.
  • At 3 weeks post-injury, the quantity of collagen has stabilised but strength of fibres is still increasing.
  • Collagen is constantly being modified and refined to increase functional capacity.

It is normal to be focused and zoom in on the initial site of injury but if we fail to zoom out and look at the bigger picture, we can create a hypervigilance in the client, which may prove detrimental in the long term.

Through skilful interaction with our clients using touch and movement therapies, we can help draw the body’s attention to non-nociceptive information. The brain makes predictive decisions based on multiple sources and helping it explore non-threatening options and brings an opportunity for a more balanced response.

A Word On Nociception

Nociceptors are largely unresponsive to normal stimulation but have a low threshold to mechanical and thermal injury, anoxia and irritation from inflammatory products. Pain is an alarm to perceived threat; pain can exist without any actual damage to tissue. Often we don’t need to manage a healing process, we simply need to address the sensitivity in the nervous system from multiple angles.

The Predictive Brain

There are 2 directions involved with pain production:

  • “Top Down” – the output originating from the brain
  • “Bottom Up” – the input originating at the tissue.

The human brain is predictive in nature rather than purely responsive: instead of having hardwired default responses, several parts of your brain continually review all current information, situational context past experiences along with your thoughts about potential future scenarios. It then makes a prediction on the best way to respond. Kind of like a never-ending group assignment – what could go wrong?

Be mindful that poor reasoning for treatment intervention partnered with negative messaging may affect the person as a whole and those beliefs will last longer than our time spent with clients.

Chronic pain is widespread amongst the community and is slowly being better understood by treatment providers. Manual therapy approaches that may be tolerable and beneficial to most clients can be aggravating and painful for those with chronic pain. Without acknowledging the changes in top down processing and focusing our bottom up approaches accordingly towards sensations which feel good, are non-threatening and help reduce stressors, a positive response is unlikely.

By the end of Sunday’s presentation, I hope you have a better understanding of “it depends” and why one approach is unlikely to adequately address each one.


Daniel’s presentation will delve further into the nitty gritty, enthralling participants with details on monitoring of the tissue environment and nociceptive pathways. If you’re an attendee, catch Daniel on Sunday 25 October at 3.40pm AEDT (2.40pm in QLD, 3.10pm in SA, 2.10pm in NT, 12.40pm in WA).

About the Author

Daniel Wonnocott is a remedial therapist based in Ipswich, QLD. With an appreciation for the engineering behind round manholes, Dan is still perplexed as to whether the chicken or the egg came first.


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