The Role of Manual Therapy in Early Injury Recovery


In this webinar, you will learn about:

  • How manual therapy promotes early case closure, a vital key to cost control
  • Leading causes of musculoskeletal injuries and factors that prolong recovery
  • What manual therapy is and how it helps accelerate recovery
  • Advantages of combining manual therapy and early intervention care

Presented by:
Mark Glover, DPT, Vice President of Therapy and Specialist Services

Opening and agenda


Thanks for joining the webinar today. We're going to be discussing the role manual therapy plays in early injury recovery. Let’s look at our agenda. We're going to be talking about important COVID-19 pandemic considerations, top musculoskeletal injuries and their causes, what prolongs return to work, unpacking physical therapy, a typical therapy visit, and what manual therapy means and what it does. We will talk about some reasons manual therapy is effective and why it all matters. We will then get into the early intervention treatment model and early intervention manual therapy. We'll go through a couple of case studies, some key takeaways, and then we'll have a Q&A period.

Important considerations for you to know


So, how do we provide physical therapy services during a pandemic? By following CDC guidelines and strict protocols. Concentra® has implemented many safety measures to ensure employees can receive the care they need. These include screening questionnaires, temperature checks, mandatory masks, eye protection for employees, and stringent cleaning standards. Despite the concerns with COVID-19, Concentra therapists will provide all necessary treatment, including manual therapy.

An important consideration for employees who are uncomfortable with or unable to do in-person treatment is that Concentra has a Concentra Telerehab® option. Although, not always as effective as in-person therapy, it is better than not receiving care at all. Concentra therapists can assess range of motion and movement limitations and conduct a thorough history through the Concentra Telerehab® platform. Employees are issued a customized home exercise program and complete the exercises during a live video treatment session with a therapist.

Another important consideration is that you need to remember to evaluate the state practice acts of any state in which you have operations to determine if telerehab is an option.

Top musculoskeletal injuries and their causes


Let’s look at some of the top musculoskeletal injuries and their causes:

  • Sprains. That’s when a ligament is stretched beyond its limit. Typically this occurs from twisting motion of a joint.
  • Strains. These occur when muscle fibers pull apart, typically from overexertion of the muscle.
  • Repetitive motion injuries occur when muscle and tendon fibers wear out over time due to repeated use. Repetitive motion injuries cause damage similar to a strain but take longer to heal. An example might be tennis elbow or a knee-overuse injury.
  • Acute joint restrictions. These occur when a joint becomes jammed. This can occur due to trauma or movement and is often diagnosed as a sprain or a strain. The employee may experience immediate and intense acute pain and significant strength and movement limitations.

The top causes of musculoskeletal injuries that we see are most often poor ergonomics, awkward postures, required overtime, and productivity demands. We see these frequently in the warehouse industry where employees are picking and packing. Other top causes of musculoskeletal injuries are slips, trips and falls; repetitive processes moving bulky items; the aging workforce; and, sometimes, just bad luck. A box falls on your shoulder, your knee, or your foot. Sometimes it just happens.

What prolongs return to work


So, what prolongs return to work? There are several factors. One is inflammation, which is pain and swelling. Another is loss of range of motion due to muscle guarding and joint restrictions. Loss of muscle strength is another, and this can be due to muscle damage from injury and muscle inhibition. Nerve irritation, which can cause each of the limitations we’ve discussed, can also prolong return to work. Time is another factor. Injuries need time to heal. The way treatment is provided can either positively or negatively affect the recovery time needed. Finally, there are biopsychosocial factors. These relate to the different ways individuals experience, tolerate, and deal with pain, their fear of pain or re-injury, and their own personal beliefs, experiences, and job satisfaction.

Unpacking physical therapy


You may frequently hear a lot of these terms that appear on the slide, but what do they really mean?

  • Therapeutic exercise. These are targeted exercises to address limitations found during an evaluation. They are specific to each individual’s program and developed for each employee. A home exercise program, as an example, is always indicated and given to each employee.
  • Therapeutic activities. These are functional activities that simulate essential job functions. Examples are lifting, carrying, and pushing and pulling.
  • Modalities include cold and heat, electrical stimulation, and iontophoresis ultrasound. These modalities help increase or decrease blood flow to an area and control pain and inflammation.
  • Manual therapy, the topic we’re talking about today, is a hands-on treatment by the therapist to improve joint and soft tissue mobility.

Remember, several or all of these interventions are utilized during one treatment session.

A typical physical therapy visit


So what does a typical therapy visit look like? It might start with a warm up. We may use modalities to improve blood flow and decrease pain, or we might use a light cardiovascular workout on the exercise bike or a treadmill. That might lead into a manual therapy technique. If manual therapy is indicated, it may come before the warmup but more likely after the warmup and before activities.

Therapeutic exercises, again, are targeted exercises to address range of motion and strength limitations, and therapeutic activities are those functional exercises that simulate job actions – for example, lifting, carrying, pushing, pulling, and climbing. And then, we always finish with education and give the employee a home exercise program that may include proper body mechanics and certain therapeutic exercises that they can do at home. We may also instruct them in self-care activities for pain and inflammation. The most important thing is mobility; that is, to keep moving between sessions.

What manual therapy means and what it does


So what does manual therapy mean? The definition of manual therapy is the use of skilled, hands-on treatment to facilitate the movement of joint and soft tissue. I have listed four types of manual therapy techniques that you typically will see during a session. The first is joint mobilization. That's when the therapist will push the joint through the available range of motion. Joint manipulation is when we take that joint to the end of its range and then, a quick thrust technique afterwards. This is where you hear the cavitation or the “pop” of the joint that you would typically experience with an osteopathic or a chiropractic type of manipulation. Soft tissue mobilization is similar to deep tissue massage, but it's used to break up adhesions and decrease muscle guarding. Last is manual exercise facilitation using hands-on cues and palpating motion to ensure proper completion of the exercise.

Manual therapy addresses the common symptoms of joint and soft tissue restrictions, all of which can result in delays in return to work. So what do we typically see when we're performing a manual therapy technique? It may be due to muscle guarding, pain and inflammation, muscle inhibition, nerve sensitivity and irritation like a sciatica, blood flow restrictions, and joint mobility limitations.

So, what can manual therapy do for those conditions? It can cause a relaxation effect to reduce muscle guarding. It can relieve pain-inhibiting chemicals in the body. It can cause muscles to contract normally, improving strength. It can improve blood flow to nerves and elimination of nerve restriction points. It can improve blood flow to the injured area, which improves and speeds healing, and it can improve joint motion resulting in improved ability for the body to move normally.

Manual therapy is almost never used as a standalone intervention. Therapeutic exercises, especially a home exercise program, are issued to ensure follow-through of the manual therapy techniques.

Four reasons manual therapy is effective


There are four reasons we want to talk about related to why manual therapy is effective. We have talked about some of these already, but let's go into a little bit more detail.

  • Manual therapy lessens muscle guarding. Muscle respond to pain and inflammation by tightening around a restricted joint in an act of self-protection. A lot of times when someone injures a body part, the muscles will tighten around it to protect the individual from moving more, to prevent from further injury or continuing to do harm to the joint. That's just a protection technique that our body has.
  • Manual therapy can improve muscle strength. Muscles seek to self-protect to prevent stress and pain and become guarded around the restricted joint. This makes normal work and full capacity difficult, if not impossible. We typically will see someone walk into our center who is moving in a very limited fashion, very tight, and almost robotic in nature.
  • Manual therapy reduces nerves sensitivity and nerve irritations. When a joint is restricted, nerve sensitivity to pain shoots up and nerve irritation soars, sending pain traveling to other body parts. An example of this would be a nerve injured in the low back becomes irritated. The pain may travel down the leg, in the back of the leg, into the lower part of the leg. That’s called sciatica. Many of us have experienced sciatica ourselves or have seen other family members go through this. It's very painful.
  • Manual therapy increases function and promotes earlier return to work. By restoring normal muscle activity and decreasing nerve irritation, manual therapy can rehabilitate a body unable to move correctly into one that moves flexibly and comfortably when performing normal activities.

Why does this matter?


When we look at the injury facts from the National Safety Council, we see some numbers that are pretty astounding. Number one, each total claim cost on each injured worker costs about $41,000. We typically see about 103 million days per year of lost productivity at a total cost of about $170 billion to the employer industry in terms of dollars spent on administrative costs, lost wage and productivity, and in medical costs. And you'll typically see, if you lump the first two together, administrative costs and loss of productivity – that’s typically referred to as indemnity – that’s always the most expensive part of managing and treating a claim.

Early intervention treatment model


Concentra's treatment model is one of an early intervention, function-based, active hands-on approach. Research shows very clearly that early intervention improves recovery time for musculoskeletal injuries. In addition, early intervention therapy has been shown to decrease total health care costs, opioid use, numbers of injections, and diagnostic imaging. We typically see a focus on ability or function versus disability or pain and limitations. Active treatment and therapy keeps people focused on function, and that's our whole purpose.

Early intervention manual therapy


Early intervention manual therapy is the most effective in acute injuries. The body is typically forced to move sooner than it would on its own. Acutely injured tissues respond faster to treatment. Early intervention prevents secondary problems from occurring in terms of compensations, improper tissue healing, and muscle atrophy. The key point to remember is that early intervention with the appropriate treatments, such as manual therapy, increases the likelihood of earlier and safer return to work. That's what we all want for employees in our workforce.

Case study #1


You can see an example here of an individual who is lifting some boxes and develops severe low back pain at work. We're going to talk about some of the findings and how we're going to treat this individual. An exam reveals nine out of ten pain, a stage one or 20 percent achievement of the FReSH scale, a 90 percent lumbar spine range of motion reduction, normal X-rays, and a significant decrease in the ability to lift, carry, push and pull. The employee meets all of the physical therapy referral criteria and is referred to therapy the same day. The physical therapy evaluation reveals a mechanism of injury and clinical findings consistent with lumbar facet (low back joint) restriction.

Treatment typically would be a joint manipulation of the lumbar spine, education, and a home exercise program with a focus on mobility exercises on that very first visit. When the employee comes back a couple of days later for the second visit, in this scenario, he has achieved an 80 percent improvement in pain. The FReSH score went up to a stage four or 80 percent ability to perform essential functions. Exercises were progressed. Lumbar and hip strengthening were started. Functional training was initiated.

On the third visit, the employee is pain-free. The FReSH score is at a 90 percent. Full range of motion. The employee has progressed up through all essential job functions. The therapist evaluates him for a return to work, sends him to the physician, and the employee successfully returns back to work after three visits. If we go to the next slide, we can see the timeline of what we discussed. The key part here is in the Official Disability Guidelines, or ODG, which we care a lot about. The recovery time for a lumbar sprain or strain of this severity would be about 10 visits. Due to the appropriate use of manual therapy in this case, we've reduced that to needing only three visits before the employee is discharged to regular duty.

The key points to remember are:

  • Properly evaluating the underlying dysfunction allows for specific treatment techniques to be applied in a timely manner.
  • This allows earlier and more pain-free range of motion and strengthening.
  • We're able to start job-specific tests earlier in the treatment cycle.

Case study #2


So, in this particular example, an employee hurts his ankle after stepping down from a ladder at work. The physical exam reveals swelling, loss of range of motion, loss of strength, abnormal gait pattern due to limited tolerance of weight bearing, and a normal X-ray. Since this was a musculoskeletal injury that required work restrictions, the employee was referred to therapy immediately.

The physical therapist verified the doctor’s findings and also found an acute joint restriction of the muscle joints in the foot and the ankle. The physical therapist performed a joint manipulation of all three involved joints after confirming the ligaments were intact. The employee demonstrated immediate improvement in range of motion and pain. A home exercise program was issued to maintain joint mobility.

On the next visit, the employee demonstrated almost normal gait pattern, nearly full range of motion and strength, and minimal swelling and pain. Joint mobility was significantly improved, but joint manipulation was utilized again to ensure normal joint mobility. Exercise work progressed to strengthening, including weight-bearing activities.

At the third visit, the employee presented with a normal gait, full range of motion and strength, and experienced pain only when going up and down steps. Exercises were progressed further to include walking on the treadmill, climbing a ladder and steps, and lifting and carrying.

At the fourth visit, all goals were met, and the employee was discharged from physical therapy to regular duty.

A diagnosis of an ankle sprain can often take from two to four weeks to complete resolution.

Again, here is the Official Disability Guideline. It specifies nine visits. But with the application of manual therapy to quickly restore joint mobility, he was discharged after four visits. The point here is that we intervened early, avoiding bracing and non-weight-bearing gait progression that leads to swelling and joint dysfunction. By maintaining weight bearing, we prevent loss of mechanoreceptor function and retraining, and save several visits in the process.

Key Take-Aways


Manual therapy is one of the multiple treatments the physical therapist will use, as appropriate and allowed by state practice acts.

Concentra's early intervention model focuses on function and active hands-on therapy, while also utilizing manual therapy to accelerate recovery time, achieve earlier return to work, and help reduce workers' compensation costs, due to earlier case closure and less need for diagnostic imaging, prescription opioids, and injections.

And with that, I will open it up to Q&A.