Originally published here.
If your patients are anything like mine, they will report to you that there is commonly a degree of discomfort, soreness or stiffness a day or so following manual treatment no matter how gentle or appropriate that treatment might have been. As a result, I offer advice regarding home care of such problems, and I tend to repeat a mantra to most patients who have received treatment for musculoskeletal problems as they depart. I ask them to largely ignore any soreness they might feel the next day. I tell them that it is perfectly normal for there to be an adaptive reaction/response to treatment for a day or so of their knee, neck, or whatever focal point of distress brought them to see me and that it will probably not be until around 48 hours later that they will know whether today’s treatment was helpful.
And of course, if your patient happens to have a chronically painful problem, it’s highly likely that a degree of sensitization will have occurred, making their responses and reactions to treatment far less predictable and potentially excessive. For more on that subject please see my May 2011 article, “Understanding Central Sensitization”
How common are short-term adverse effects following manual therapy? Bronfort et al (2010), conducted a major review of the effectiveness of manual therapies and it also looked at negative effects: “Adverse events associated with manual treatment can be classified into two categories: 1) benign, minor or non-serious and 2) serious. Generally, those that are benign are transient, mild to moderate in intensity, have little effect on activities, and are short lasting. Most commonly, these involve pain or discomfort to the musculoskeletal system. Less commonly, nausea, dizziness or tiredness are reported.”
Carnes et al (2010), also conducted a detailed review of the evidence relating to the safety and side-effects following use of manual therapy modalities and concluded that: “Nearly half of patients after manual therapy experience adverse events that are short-lived and minor; most will occur within 24 hours and resolve within 72 hours. The risk of major adverse events is very low, lower than that from taking medication.”
Even in relation to muscle energy technique (MET), one of my favorite modalities because of its extreme versatile efficacy, gentleness and safety, there are commonly minor degrees of discomfort for a day or two following treatment, even when appropriately applied. Greenman (2003) has explained some of the processes leading to post-MET-treatment discomfort: “All muscle contractions influence surrounding fascia, connective tissue ground substance and interstitial fluids, and alter muscle physiology by reflex mechanisms. Fascial length and tone is altered by muscle contraction… The patient’s muscle effort requires energy and the metabolic process of muscle contraction results in carbon dioxide, lactic acid and other metabolic waste products that must be transported and metabolized. It is for this reason that the patient will frequently experience some increase in muscle soreness within the first 12 to 36 hours following MET treatment. Muscle energy procedures provide safety for the patient since the activating force is intrinsic and the dosage can easily be controlled by the patient, but it must be remembered that this comes at a price. It is easy for the inexperienced practitioner to overdo these procedures and in essence to overdose the patient.”
In other words, when correctly applied, MET will commonly lead to mild discomfort for several days, BUT, when incorrectly applied (contractions too strong, stretching too vigorous, etc.) more severe reactions may result and without the bonus of benefits that correct usage might offer! For more on muscle energy techniques, you can visit my web site,www.leonchaitow.com/muscle.htm.
Are there strategies that you might be able to teach patients to manage this adaptive stage? What else might you offer your patients as self-care for minor reactions to treatment? Depending on the specifics of the individual’s problems, a number of options are available, ranging from simple hydrotherapy (hot and cold compresses, ice massage) to relaxation methods, self-stretching (if appropriate) and from my perspective the most potent self-care we can teach patients in pain is self-applied positional release.
Derived from osteopathy, Positional Release Technique (PRT), or that version of it known as Strain-Counterstrain (SCS), can relieve pain by relaxing tight (shortened) tissues and improving local circulation. Unlike massage and stretching, PRT is safe to apply even on damaged or inflamed tissues. If painfully shortened (hypertonic) soft tissues can be gently placed into a position in which they are made even shorter, pain is usually temporarily removed. If that “position of ease” is maintained for a minute or so, the tight, tense muscle (and often trigger points housed there) are likely to release and relax, sometimes permanently, but at least for a while with pain diminishing subsequently.
Try the following exercise, self-treatment of tense suboccipital muscles, and consider teaching it to patients as an example of this remarkable method of self-care. This is adapted from Chapter 5 of my book, Positional Release Techniques.
Patient instructions for suboccipital self-treatment using SCS:
- Lie on your side with your head on a low pillow.
- Feel for tender points at the base of your skull, especially in the hollow just to the side of the center of the back of the neck.
- Palpate a tender point on the side which is lying on the pillow with the hand on that same side, and press just hard enough to register some pain. Score whatever the level of pain you feel as “10.”
- To find an ease position for this point, the head should be tilted very slightly backwards – and also slightly leaned, and perhaps turned, towards the side of pain.
- First, ease your head slightly backwards very slowly as though you are looking upwards.
- If the palpated pain changes give it a score.
- If it is now below “10,” you are moving in the right direction.
- Fine-tune slightly with a little more backward bending of the neck, done very slowly until the score is as low as you can achieve by that tactic, and then allow the head to turn and perhaps lean a little towards the pain side. If the score is reducing, you are moving in the right directions. If it rises, reverse the direction that causes that to happen.
- Keep fine-tuning the position as you slowly reduce the pain score.
- You should eventually find a position in which it is reduced to 3 or less.
- If the directions described above do not achieve this score reduction, the particular dynamics of your muscular pain might need you to turn the head away from the side of pain, or to find some other slight variation of position to achieve ease.
- Once you have found the position of maximum ease, just relax in that position.
- You do not need to maintain pressure on the tender point all the time; just test it from time to time by pressing.
- Remember also that the position which eases the tenderness should not produce any other pain. You should be relatively at ease when resting with the pain point at ease. Stay like this for at least 1 minute and then slowly return to a neutral, starting position.
- Turn over and treat the other side in the same way.
- Previous tension and pain should be much reduced or absent.
General Guidelines For SCS Self-Care Of Pain Anywhere Else
If a painful point/local area is on the front of the body, bend forward to relieve it; the further it is to one side, the more you should slowly turn toward that side. If the point is on the back of your body, bend slightly backward until the pain reduces a little, then turn away from the side where you feel the pain, and “fine-tune” to release the discomfort. If the point is on a limb, try to shorten the relevant muscles (don’t stretch them) by slowly moving the area to find the position in which the pain is most reduced. When there are many areas of pain it is often best to start with those nearer the head and nearer the middle of the body, using this extremely noninvasive and effective form of treatment.
- Bronfort et al. Effectiveness of manual therapies: the UK evidence report 2010 Chiropractic & Osteopathy 18:3.
- Carnes D Mars T Mullinger B et al 2010 Adverse events and manual therapy: A systematic review. Manual Therapy15:355-363.
- Greenman PE. 2003 Principles of Manual Medicine. 3rd Edition. Lippincott, Williams & Wilkins.