Shall we talk about manual therapy?

I have never written such a controversial opinion piece before, like today's writing. In my opinion, it's controversial to the point where one must either challenge every sentence or agree with all I wrote. There's nothing in between, including, but not limited to, no room for any demagoguery, just a reality check.

One of my followers, who prefers to remain anonymous, forwarded the report to me. Please read below

Dry Needling Versus Manual Therapy for Patients With Mechanical Neck Pain: A Randomized Controlled Trial

AUTHORS

Jeevan Pandya, PT, PhD^1,2

Emilio J. Puentedura, PT, PhD³

Shane Koppenhaver, PT, PhD³

Josh Cleland, PT, PhD, FAPTA²

AFFILIATIONS

• ¹Rehabilitation & Therapeutic Services, Hendricks Regional Health, Plainfield, IN.
• ²Doctor of Physical Therapy program, Tufts University, Boston, MA.
• ³Doctor of Physical Therapy program, Robbins College of Health and Human Sciences, Baylor University, Waco, TX.

Journal of Orthopaedic & Sports Physical Therapy

Published Online:March 20, 2024Volume54Issue4Pages267-278

https://www.jospt.org/doi/10.2519/jospt.2024.12091

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Abstract

OBJECTIVE: To compare the short- and intermediate-term effects of dry needling to manual therapy on pain, disability, function, and patient-perceived improvement in patients with mechanical neck pain.

DESIGN: A single (therapist) blinded randomized controlled trial.

METHODS: Seventy-eight patients (mean ± SD age, 50.74 ± 13.81) were randomly assigned to one of the 2 groups: (1) dry needling and therapeutic exercises (DN + Exercises) and (2) manual therapy and therapeutic exercises (MT + Exercises). Both groups received 7 treatment sessions over a maximum of 6 weeks. Outcome measures, collected at baseline, 2 weeks, discharge (7th treatment session), and 3 months after discharge, were as follows: Neck Disability Index (NDI), numeric pain-rating scale (NPRS), Patient-Specific Functional Scale (PSFS), global rating of change (GROC), Fear-Avoidance Belief Questionnaire (FABQ), and Deep Neck Flexor Endurance Test (DNFET). Data were analyzed with mixed-model analysis of covariance (ANCOVA), using pretest scores as covariates, and a Mann-Whitney U test for GROC scores.

RESULTS: The ANCOVA revealed significant group-by-time interaction for all variables. Significant between-group differences, favoring MT + Exercises, were observed at all 3 time points on the NDI (2 weeks: F_1,446 = 172.68, P≤.001, P> = .27; discharge: F_1,446 = 254.15, P≤.001,  class=texMathImage v:shapes="_x0000_i1026"> = .36; and 3 months: F_1,446 = 339.40, P≤.001, P = .43). Results for the MT + Exercises group exceeded recommended minimal clinically important difference for all variables, at all follow-up points.

CONCLUSION: MT + Exercises was more effective, both in the short term and intermediate term, than DN + Exercises in reducing pain, disability, and improving function in patients with mechanical neck pain. J Orthop Sports Phys Ther 2024;54(4):267-278. Epub 29 January 2024. doi:10.2519/jospt.2024.12091

I asked what the purpose was for her forwarding this report to me. The answer was, "This is good evidence for you to use in your articles." I simply replied, "We are massage therapists; this report means not much to us, practically nothing, just not useful information. We treat cases like mechanical neck pain, but we do not use dry needling. Also, when it comes to the term 'manual therapy,' it's kind of confusing, and physical therapists give different explanations describing manual therapy. Some claim there are different types of manual therapy. In this paper, it is not specified what type of manual therapy was employed in these studies. I believe when it comes to manual therapy as a modality, it's a lot about the manual therapy CPT code. Just to clarify, the American Medical Association only first published the CPT edition in 1966. CPT stands for Current Procedural Terminology. Physical therapy has existed forever, so what was the name of manual therapy prior to 1966? Besides, in the first edition, manual therapy wasn't even mentioned. Some of you may say that prior to the term manual therapy, it was manipulative therapy. And I would agree. When talking about manipulative therapy, should we go back to 400 BCE? Or would it be enough to focus on modern osteopathy and chiropractic? Or let's give well-deserved credit to the physical therapy community, which during the last 20 years has advanced therapies by hands? In any case, the massage therapy field is unique and different. Instead of using the term manual therapy/manipulative therapy, we should advance our skills. 100% of our focus, with no distractions, should be on improving massage procedure outcomes. Instead of using terms that are practically not legal for us to use, we have to reach out to PTs, DCs, and promote an integrative medicine approach, including when it comes to treating mechanical pains. By the way, mechanical pain sources can be disc problems, spinal joints, or soft tissue dysfunctions. We can contribute a lot when treating all of the above causes.

Of course, I can be wrong. In such a case, please correct me. In my strong opinion, evidence-based claims are applicable when, for example, statistics of mechanical neck pain would change for the better, as well as statistics of neck surgeries. If authors were to ask for my advice, I wouldn't recommend testing dry needling against any types of manual therapy, simply because dry needling is used as a trigger point therapy tool. We all know that only trigger point therapy done by dry needling, or corticosteroid injections, in the presence of buildups of tension within muscles and fascia, wouldn't work. At the time, successful connective tissue massage to release tensions within fascia, including muscular mobilization to reduce tension within muscles, won't help to sustain results in case if each trigger point wouldn't be addressed by adequate ischemic compression/trigger point therapy we are providing. I would advise combining a selective type of manual therapy and dry needling and trialing it against any movement therapy, including but not limited to therapeutic exercise. And then, after this trial I mentioned in the previous sentence, to combine all these methods, including appropriate passive and active movement therapy. I am a big proponent of an integrative medicine approach. Again, I can be wrong, but the curriculum of DPT, DC programs does not include training in massage; therefore, cases like mechanical neck pain or any other mechanical pain disorders should be treated integratively. Everyone has to contribute to the best of what they are trained and do daily.

Please post replies, including agreements.

Best wishes.

P.S. Soon, my master class will be available where I will explain in detail and demonstrate hands-on additional techniques that can sometimes magically change conditions in the rehabilitation of neck and upper back, lower back and hips, knees, and ankles mechanical pains. I believe these additional explanations and contributions will enhance today's discussion. Please stay tune