Exercise prescription versus manual therapy, or do they work hand in hand? The aim of a sports therapist, or indeed any practitioner, is to rehabilitate an injury and help maintain and improve performance. This is done through the use of manual therapy and exercise prescription, but there is no hard and fast rule on how much manual therapy should be done versus exercise prescription. This article will explore current literature and aim to give insight into the basis for clinical decision making when it comes to methods of treatment.
Manual therapy includes massage, joint mobilization and joint manipulation; it aims to reduce pain and increase mobility of joints. Exercise prescription can be used in a reactive or proactive way, it will aim to improve the flexibility, stability, strength, endurance and power.
Chronic low back pain (CLBP) was prevalent in the research, one study by Aure et al. (2003) suggests that 60% to 80% of the western population will experience low back pain at some stage. The study had 49 participants, one group received manual therapy with the addition of 11 exercises for the spine, abdomen, lower limbs, spinal segments and the pelvic girdle. Another group performed general exercise therapy for 45 minutes; the programmes were individually designed. Results, with a one-year follow up, showed that there were significant improvements in both groups but the manual therapy group showed better results. A contrasting study by Geisser et al. (2003) found that CLBP was improved following manual therapy alongside a specific exercise program but it did not improve perceived function, stating that other psychological factors need to be addressed. Both studies were randomised control trials which are seen as the gold standard for research. However, neither study effectively blinded participants or therapists which is likely to influence the results.
Moving away from CLBP, a study by Hoeksma et al. (2004) looked at the use of manual therapy versus exercise therapy in osteoarthritis of the hip. The graph below (Figure 1) details the effect of manual therapy versus exercise therapy, it shows that manual therapy had better results on range of joint motion from flexion to extension. This result is unsurprising as the manual therapy group included manipulation and ‘vigorous stretching’ while the exercise therapy group included exercises to improve muscle function and joint motion. Diercks et al. (2004) found the opposite in a contrasting study looking at manual therapy for frozen shoulder versus exercise therapy.
The manual therapy group (physical therapy) received passive stretching and manual mobilisation and the exercise therapy group (supervised neglect) received exercises within pain limitations. Results (Figure 2) showed that the exercise therapy group had better outcomes up to 24 months after injury. This is depicted by the graph below, which shows the difference in treatment over a 24 month period; the exercise therapy group was more successful in this case.
Hoving et al. (2002) conducted an alternative study, investigating the use of manual therapy, exercise therapy and care by the GP for neck pain. Neck pain is common in the general population and this study found that the success rates after 7 weeks for manual therapy, exercise therapy and care by the GP were 68.3%, 50.8% and 35.9% respectively. Although it would appear that manual therapy was the most successful, patients were allowed to continue exercises at home throughout the trial and continue taking medication which makes it difficult to control the outcome measures in isolation. Figure 3 shows that manual therapy was most successful. However, the outcome measures (perceived recovery, severity of physical dysfunction score, average pain intensity score and neck disability index score) are subjective measures relying on the patients to report how they feel. This is an unreliable way to measure due to a potential lack of understanding, dishonesty or outside influence from the patient,
In conclusion, from a brief look at the literature it is clear that manual therapy and exercise prescription work in varying degrees depending on the injury. There is no one course of treatment that is best overall and the choice depends on the stage and severity of the injury. It is also important to note, when using a patient-led approach to therapy, manual therapy may be more appropriate for one person but another may prefer exercises. It is not necessarily a question of manual therapy vs exercise prescription, but instead using a patient-led approach and selecting the most appropriate course of treatment.