Where does manual therapy fit into our practice?

How does it assist with return to activity?

I recently had a conversation with a sports medicine physician with whom I have shared patients for the past 20 years. He is one of the ‘OG’ physical medicine and rehab physicians in my area, and he has always been a huge advocate for rehab therapies. This physician has spent countless hours in rehab gyms sharing with and learning from physical therapists.

He reached out to me about a mutual patient with a three-year history of pelvic girdle pain that was limiting their activities, including sitting and cycling. This patient was referred to me 6 months ago after plateauing with his sports medicine PT and interventional pain medicine physicians. They had undergone interventions including medications, injections, PT, and group therapy CBT for persistent pain. However, pelvic rehab shifted the needle for this patient, and the physician wanted to learn more about what helped.

Now, this patient has had amazing care already. They were seeing an awesome and skilled sports medicine PT. The patient was engaged and consistent with their self-care program including strengthening, movement, posture, breathing, stretching, bike fit, and activity modification.

What I brought to the table was a focused approach to the pelvic floor region – that was what was missing. We focused our sessions on education about the pelvic floor region including the functional role of the myofascial tissues of the perineum and rectal fossa specifically in the protection of the neurovascular tissues in the perineum, manual therapy, progressive exercise, and return to activities.

When the MD and I reviewed this case, our conversation revolved around manual therapy and how it helps our patients. He wanted to understand how we decide what interventions to utilize to help patients in their recovery. He specifically wanted to understand when to touch and when to focus on strength/movement only. My answer was simpler than that. I felt that most of our patients needed both throughout their course of care.

We discussed that one of the main things for this patient was that they did not realize that myofascial tissues attached in the perineum could impact their sitting. More specifically, they did not realize that there were muscles located in the pelvic region that they could engage, relax, lengthen, and strengthen. Upon assessment, this patient had decreased pliability of the tissues in the urogenital triangle and rectal fossa which contributed to less tolerance to sitting, likely due to compression of neurovascular structures in the perineum. With manual therapy, we were able to increase the pliability of those tissues and increase the patient’s awareness of the myofascial tissues. We also spent time in our sessions having the patient learn to engage, release, and lengthen the PF muscles.

With manual therapy, the patient became aware of those muscles and with tactile cues learned how to actively engage with those muscles. After about 4 weeks, the patient began gradually returning to sitting and to time on the bike. We continued manual therapy while the patient built tolerance and confidence to sitting on a chair and a bike saddle.

I utilized manual therapy to assist the patient with gaining awareness of the pelvic floor region, and we continued these manual therapy sessions to assist with recovery from increasing sitting. Ultimately, the patient could return to cycling and sitting without limits. The patient also learned how to self-manage with their already established self-care and we added focused pelvic floor region stretching, recovery, and awareness.

The Physician and I discussed the commentary by Short et al 2023 about manual therapy in return to sport and recovery. The commentary has a great statement supporting manual therapy usage: “The benefits of manual therapy, which includes building therapeutic alliance via touch, improving function via safe, cost-effective short-term pain modulation and facilitating education and exercise to be more impactful when they are limited less by pain and anxiety” for return to activity. In pelvic health rehab practice by using manual therapy, we can help the patient become aware of a part of their body, decrease apprehension to touch and pressure to the area, and then focus on the patient's self-care to promote long-term recovery and self-reliance.

This fostered further discussion with the MD about mechanical touch and how it affects the body. Short et al 2023 further stated “When a therapist provides a manual intervention, a mechanical stimulus is applied upon an athlete and produces input into the dorsal horn of the spinal cord…….initiating a multi-factorial cascade of neurophysiologic effects stemming from the nervous system. Both the peripheral and central nervous system provide signal pathways that induce responses throughout the body. These include neuromuscular (i.e., muscle activity), autonomic (i.e., heart rate, cortisol), endocrine (opioid) pain modulatory, and non-specific (context, beliefs fear, expectations, etc.) responses.” Put in these terms the physician had a better understanding of the multifactorial level that physical touch can assist with patient recovery.

Utilizing manual therapy techniques/therapeutic touch is foundational to helping patients become aware of their patterns of movement or stiffness and parts of their body. In Manual Therapy for the Abdominal Wall, scheduled on October 20^th, 2024, we discuss these concepts and apply manual therapy techniques to the abdominal wall. While for this class we utilize the abdominal wall to practice, the skills learned can then be applied throughout the body. This is a foundational class for anyone who wants to build their skills in manual therapy and then take those skills to further advance their patient care in any part of the body. We do discuss specific abdominal wall conditions such as abdominal wall post-surgical incisions and hernia, but we apply the basic manual therapy techniques to them that could then be applied anywhere in the body including the perineum and rectal fossa.

Reference:

Short S, Tuttle M, Youngman D. A Clinically Reasoned Approach to Manual Therapy in Sports Physical Therapy. Int J Sports Phys Ther. 2023 Feb 1;18(1):262-271. doi: 10.26603/001c.67936. PMID: 36793565; PMCID: PMC9897024.

AUTHOR BIO:
Tina Allen, PT, PRPC, BCB-PMD

Tina Allen, PT, PRPC, BCB-PMD (she/her) has been a physical therapist since 1993. She received her PT degree from the University of Illinois at Chicago. Her initial five years in practice focused on acute care, trauma, and outpatient orthopedic physical therapy at Loyola Medical Center in Illinois. Tina moved to Seattle in 1997 and focused her practice in Pelvic Health. Since then she has focused her treatment on the care of all genders throughout their life spans with bladder/bowel dysfunction, pelvic pain syndromes, pregnancy/ postpartum, lymphedema, and cancer recovery.

Tina’s practice is at the University of Washington Medical Center in the Urology/Urogynecology Clinic where she treats alongside physicians and educates medical residents on how pelvic rehab interventions will assist clients. She presents at medical and patient conferences on topics such as pelvic pain, continence, and lymphedema. Tina has been faculty at Herman & Wallace Pelvic Rehabilitation Institute since 2006. She was the physical therapist provider for the University of Washington on a LURN Multi-Center study for Interstitial Cystitis/Painful Bladder Syndrome treatment with physical therapy techniques. Tina was also a co-investigator for a content package on pain education for the NIDA/NIH on the treatment of pelvic pain.