Active Manual Therapy

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Background

Active manual therapy suggests that the patient and clinician are active participants in the therapeutic process and are both involved in an ongoing physical as well as verbal dialogue. The concept is applicable to all hands-on interventions which can be modified in real time according to patient response including, for example, mobilisation or massage, but not manipulation or electrophysical agents.  

Passive or active?

Manual therapy (link Manual Therapy) has traditionally been considered to be a ‘passive treatment’ which has been suggested (without evidence) to increase patient dependency. The presumed passive nature of manual therapy has been challenged by the concepts of patient-centred manual therapy and manual therapy as a form of tactile communication. Active manual therapy includes both of these concepts of patient centeredness and interactivity.

Principles

There are various schools of Manual Therapy with each having their own type of diagnostic reasoning based on principles and/or rules which can be described as ‘reasoning that results in action'. In other words the therapist gathers information, makes decisions using clinical reasoning that may or may not involve an actual diagnosis, and acts on those decisions. Others suggest the reasoning process by experienced clinicians extends beyond gathering of information to include intuitive (Forde 1998) or ‘gut’ feeling (Langridge et al 2015). These non-cognitive processes which can be used in diagnostic reasoning are not mystical messages from the universe, but rather involve making decisions based on experience which the clinician may not be able to explain verbally. If clinical reasoning is limited to diagnostic reasoning, then manual therapy can reasonably be thought of as a passive modality – something that is done to a patient without their participation.

Rather than using this simple process of diagnostic reasoning, most physiotherapists use an iterative process (originally advocated by Maitland) where interventions are revised and modulated based on precise reassessments that punctuate interventions. This type of iterative process involving a series of discrete decisions is referred to as ‘reasoning in action’ or ‘reflection in action’.

Many experienced therapists (although often subconsciously), take this a step further by continuously adjusting their interventions as real-time responses to changes occurring during, rather than just after, a treatment application. This interactive process has been described as Reasoning in interaction or reflection in interaction.

Although to the author’s knowledge, the main schools of Manual Therapy do not explicitly teach this type of real-time adjustment/interaction, some allude to a similar approach. Maitland, for example advocated ‘getting inside the joint’ which was famously described by now Emeritus Professor Gwen Jull as ‘the inspired fiddle’. Although not explicitly taught, I personally observed Maitland, Kaltenborn, Evjenth, and to a lesser extent Mulligan, while treating patients, modifying and refining treatment techniques within as well as between application of techniques.

Summary

In summary, Active Manual Therapy describes an extension of the Manual Therapy paradigms which moves from punctuated to continuous patient-centered clinical reasoning.

A transcription of what this type of dialogue might look like is shown.

From https://www.frontiersin.org/articles/10.3389/fresc.2022.1027344/full).

Tactile content from the patient is in plain text;

Tactile content from the therapist is in italics;

Verbal content from the patient is in bold;

Verbal content from the therapist is in bold italics.