Manual “Hands-on” Therapy

Manual therapy or “hands-on” therapy refers to the therapists use of their hands to provide treatment to you. This may include soft-tissue mobilisation or massage, passive joint mobilisation, mobilisation with movement or joint manipulation. These techniques are applied when indicated.

Read on below to learn more regarding joint mobilisation and Mulligans mobilisation techniques. 

Manual Therapy PAIVM

What are we as physiotherapists doing when we push on your back?

We are performing a technique known to us as a PAIVM or passive accessory intervertebral movement. A PAIVM involves a small movement of one vertebrae in relation to the vertebrae above and/or below. We use this technique as an assessment and as treatment.

In assessment we push on segments of your back and are feeling for the amount of movement and the feel of this movement i.e. is it stiff or loose.

In treatment we are trying to stretch the fibrous tissue surrounding each particular joint and desensitize the area. Research has shown that PAIVMs can have a significant effect on pain and range of motion. It is useful for those with pain, stiffness, temporary jabs of pain and some specific disorders of the back.

When mobilising the spine we are often trying to change the resistance/stiffness felt at a joint, at other times we may be trying to determine whether a segments movement creates pain or the symptoms you have reported. Once we establish a relationship or believe the resistance we feel is related t your presentation we will then aim to mobilise it. Most commonly we are trying to find the maximum amount of resistance within a segment with minimal pain to then improve joint motion with a corresponding reduction in pain during movement. In other words maximum movement with minimal pain. That’s why the ‘feel’ we get from our hands is so important. Did you know we can detect resistance changes effectively measuring between 5N and 20N force (ie. the force to click a pen or push a pump on a hand soap).

What’s the difference between a mobilisation and a manipulation?

A manipulation is simply a progression of a mobilisation. Mobilisations consist of Grades I, II, III, IV and Grade V signifying differences in the depth and speed of joint mobilisation. Manipulation is the greatest of these (Grade V) and is often associated with a ‘crack’ or ‘pop’. This occurs when a high velocity small amplitude movement is applied at the joint surfaces, resulting in an audible release thought to be due to the process of cavitation. Gas bubbles are created within the joint when low pressure is present, and then there is an  implosion of the bubbles as joint pressure increases during manipulation.

Spinal manipulations can relieve back pain by taking pressure off sensitive nerves or tissue, increase range of motion, restoring blood flow, reducing muscle tension, and, like more active exercise, promote the release of endorphins within the body to act as natural painkillers.

Mobilisations should be performed progressively. This means a manipulation should not be used as a method of first treatment. There are also a number of pre-manipulative procedures that should be performed for end of range mobilisations and manipulations. These include screening tests in the neck for vascular compromise as well as obtaining informed consent. Informed consent is not just a matter of “can I do this” but should include:

  • an explanation to you of what the proposed treatment involves
  • potential benefits and risks of the proposed treatment in the context of your presentation
  • alternatives to the proposed treatment
  • opportunity for you to follow-up
  • opportunity for you to ask questions
  • check you have understood and give consent

So if you have any stiffness or pain in your back, come in and see us so we can relieve you’re pain/niggle and get you moving better. Better still, lets find out the reason for it and see if we can stop it happening again.

Do physiotherapists perform manipulations?

Manipulations can be performed on many joints of the body, including the ankle, elbow, and spine. Whether a physiotherapist performs a joint mobilisation depends on a number of factors including appropriateness, screening, progress, etc. Not all physiotherapists perform manipulations. This is sometimes because the physiotherapist has not had extensive training or experience in manipulating the region and hence chooses not to, or perhaps they feel the risk exceeds the reward. This is often the case for the cervical spine (neck) where risks vary but include stroke. This is why the screening process is so important. Where a manipulation is not part of the treatment plan, the therapist will continue with other appropriate interventions. 

Mulligans Mobilisation

This refers to a technique of treatment, founded by a New Zealand Physiotherapist Brian Mulligan. The underlying premise of the technique is explained by looking at the mechanics of a healthy verse unhealthy joint. A healthy joint has a normal axis of movement, produces no extra load on surrounding tissues, and is therefore able to achieve full range of motion pain free. An unhealthy joint has a positional fault which results in an abnormal axis of movement, this produces abnormal stress on tissues, which causes pain and limitation of movement. With the Mulligan technique we aim to restore normal alignment and axis of movement in a “faulty/ painful” joint to reduce stress on surrounding tissues and therefore restore full range of movement. The technique is pain free and produces immediate and long lasting changes to your pain and range of movement. Additionally we are able to provide you with exercise and taping methods at home to compliment restoring correct alignment of your joint to aid in your rehabilitation.

Written By: Scott Ward


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Tuttle N & Hazle C (2018). Spinal PA movements behave ‘as if’ there are limitations of local segmental mobility and are large enough to be perceivable by manual palpation: A synthesis of the literature. Musculoskeletal Science and Practice, 36, 25-31.