Although exercise alone is often prescribed for the rehabilitation of injuries and pain syndromes a study published in the Journal of Orthopedic and Sports Physical Therapy found that the addition of manual therapies directed at improving function produced far superior results. This article discusses why this is so and how you can benefit.
The trial results
The researchers measured the effect of treatment on the pain and function of shoulder pain suffers. They found that when compared with those who received exercises alone, those who recieved the additional manual therapy had clearly much superior results. It is best described by the following conclusion given by the authors.
"Manual therapy combined with supervised shoulder exercise is superior to supervised shoulder exercise alone for enhancing strength and function and reducing pain in patients with shoulder impingement syndrome. Our study also provides evidence that effective outcomes are obtainable after a relatively few physical therapy visits. It is important to recognise the functional interdependence of joints and soft tissues in the upper quarter when treating dysfunction of the shoulder".
Let us illustrate why this is so by sharing a simple analogy. When a car is running normally parts are balanced and aligned properly, so things run smoothly and wear is minimised. If something works abnormally the alignment and balance may change resulting in parts wearing rapidly or possibly breaking. This same principle applies to the body. Often pain syndromes occur as a result of abnormal function. When exercises alone were used the body did the them with the same abnormal function that probably caused the problem in the first place. When manual therapies were added these helped restore more normal function.
Exercised don't correct function
Though exercises are often thought to help correct such abnormal function they don't. The movement of most joints is largely controlled subconsciously rather than by conscious effort, and scientific testing has shown that exercises do not change it. It can be strongly argued that they would actually cause more damage. For the remainder of this article we will share with you how this function is controlled, how it becomes abnormal, and how it can be corrected so you get much better results from your exercises.
The control of function
Movement is controlled by the nervous system. Though it can be consciously influenced, most of the control happens subconsciously. For example, when walking one may consciously choose the speed and direction. One may even change things such as the stride length and even how high the knees are lifted. However, things such as the angles of the ankles, knees and hips, the contraction and relaxation of the many muscles, and even the correct tension of the various postural muscles to maintain balance are all worked out subconsciously. The nervous system is continually monitoring how hard the muscles are working plus the stress upon the joints and other body parts. It uses this information along with various learned and pre programmed patterns to control movement in such a way that is efficient and minimises the stress upon the joints and other parts.
What causes abnormal function?
When the nervous system detects a problem such as damage or something working abnormally it will make changes to adapt and compensate. An obvious example is a limp caused by an injured ankle. Limping is less efficient and adds stress to other body parts, but the nervous system does this to protect the injured part. Most adaptations and compensations are far less pronounced and caused by things far less obvious. The treatement used in the trial discussed by this article addressed two of these very common causes.
Cause one: abnormal joint function
The movement of most joints involves smooth joint surfaces either spinning or sliding across one another. Abnormalities occur when these joint surfaces stop spinning or sliding freely, restricting the joints ability to move normally. When movement is restricted in this way the nervous system is forced to adapt and compensate. In the trial adjustments or manipulations were used to help allow joints surfaces to spin and slide more freely. An excellent summary of these problems and their correction is found at https://www.physio-pedia.com/images/c/c0/Principles_of_Joint_Mobilization.pdf
Cause two: trigger points and tightened muscles.
Trigger points are those tender lumps in tightened muscles that masseurs love to find. As discussed in our article on trigger points these are sections of muscle that have gone into spasm and will not relax. As a result the whole muscle becomes tight and does not work normally. For example, research on trigger points in shoulder muscles found that these caused the control of the shoulder muscles to become abnormal. Further, it was found that treatment of these trigger points caused the nervous system to "re-program", with the neurological control patterns becoming normal.
We googled “exercises for shoulder pain” and found a huge number of listings of professionals, clinics and even a national professional body advising generic exercises for shoulder pain. The findings of this trial plus the others discussed raise serious doubts about this, and make it quite obvious that the issues that cause abnormal function should be dealt with first.
Bang M Deyle G Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome J Orthop Sports Phys Ther. 2000 Mar;30(3):126-37.
Despite the issues raised here the use of exercises alone without correcting function is common practice. We encourage you to share this information with your health care professional. Download the .pdf of the practitioner version of this summary: Web page, Download