Physiotherapy: the “touch” and the context

Physiotherapy without touch/personal contact would be almost liken to a book shop without books. The use of touch in a therapeutic context is part of the identity of the Physiotherapist 1 and is undoubtedly something expected by patients. 2

It is important to understand the differences between touch and manual therapy techniques or hands-on techniques. Manual therapy techniques require touch, but touch does not require manual therapy techniques! 3

A physiotherapy session should be based on establishing a therapeutic bond, communication with the patient and contact between the physiotherapist and the patient. 4

The touch

Touch should be a vehicle for communication, a source of sensory feedback to the patient – whether it be safety, comfort, sympathy or support. Touch plays an important role in the well-being and health of the other 5 and is crucial in the non-verbal communication of intentions and emotions. 6

Geri, Viceconti, Minacci, Testa, & Rossettini (2019) suggest that combining the physical properties of touch (location, contact area, intensity and frequency) with the emotional properties (affectivity, firmness, care and responsiveness), there may be effects in three areas: analgesia by modulation of the neural pathways responsible for transporting nociceptive information; affective response by the consequent release of neurotransmitters and hormones; and somatic perception (mental representation of the body, distinction between threatening and non-threatening stimuli, amongst others).

Manual Therapy

By definition, manual therapy (MT) is the passive application of movement directly or indirectly on joint components (for example, manipulation), soft tissues (for example, deep massage) and neural components (for example, neurodynamic) 7 with the intention of positively changing some aspect of the pain experienced by the patient. 8

By giving suggestions – by health professionals and others – of structural fragility, misaligned and damaged structures, 9 as well as the excessive and misuse of technical terms, such as “contractures”, can trigger in patients a belief that something needs to be corrected. This need for correction (coupled with the idea that MT is capable of providing such correction) has led to the mistaken belief that MT techniques can provide a solution that they simply cannot provide. 9

Although there is no concrete data, it may be suggested that in the professional context this association may trigger a dangerous relationship of dependence on the possible techniques used.

Therapeutic effects of hands-on approaches

The initial premise on which these techniques were based have now been de-mystified. Therapeutic effects do exist through the hands-on approach; however, not to modify “wrong” positions of structures or the ability to rectify something that needs correction. 7

In addition, the reduced reliability of palpation as an evaluation tool has also been demonstrated, and, therefore, it is should not be used for defining a recovery plan and measuring progress. 10 The choice of a particular technique does not seem to be the decisive factor for a better response to treatment. 11

Despite this, after MT or hands-on approaches, therapeutic effects do occur. 8,7

Taking into account biopsychosocial aspects, the mechanical stimulus (gradual exposure of movement) and all the inherent involvement of manual therapy together demonstrate that they are all largely responsible for the effectiveness or otherwise of this approach, playing a decisive role in the results. 12

In fact, all recovery programmes are dependent on contextual factors such as placebo, expectations and psychosocial factors. 7,5,13

Contextual factors, the “atmosphere around the treatment”

Contextual factors (defined as physical, psychological and social conditioning factors capable of shaping the therapeutic relationship with the patient) can be divided into internal (memories, emotions, expectations), external (physical aspects of physiotherapy, place of treatment) and relational (verbal information, communication style and body language). 13

In the spectrum of Physiotherapy treatment, contextual factors are divided into 5 categories: physiotherapist characteristics (professional reputation, appearance, behaviour and beliefs); patient characteristics (expectations, preferences, past experiences, clinical condition, gender and age); physiotherapist-patient relationship (verbal and non-verbal communication);  treatment (diagnosis, explanation of procedures, observational learning, patient-centred approach, vision of the patient as a whole, therapeutic touch); and space conditioning (environment, interior design, colour, light). 13 Normal recovery time, especially in conditions of chronic pain, as well as greater responsiveness to treatment is influenced by this combination of factors. 13

These factors may be active participants with positive effects (e.g. placebo promoting analgesia) or negative effects (e.g. nocebo) 13 and so treatments performed in an overall positive context will result in better clinical outcomes.13

These effects on pain are justified by the activation of the same central pain modulation pathways as the physiotherapist’s various hands-on techniques. 7, 8, 14

Underlying the management of the patient’s condition is the Physiotherapist’s ability to establish a strong therapeutic alliance, based on the patient’s context and objectives, active listening and education. 9 In this situation, the Physiotherapist should not attribute his results to the techniques he uses, but rather to how he was able to “reach” the patient.

Let the patient value contact with the Physiotherapist more than the Physiotherapist’s contact!

Adapted from the original:

1. D. A. Nicholls and D. Holmes, “Discipline, desire, and transgression in physiotherapy practice,” Physiotherapy Theory and Practice, pp. 454-465, 2012.

2. S. Rutberg, C. Kostenius and K. Öhrling, “Professional tools and a personal touch – experiences of physical therapy of persons with migraine,” Disability and Rehabilitation, pp. 1614-1621, 2013.

3. T. Geri, A. Viceconti, M. Minacci, M. Testa and G. Rossettini, “Manual therapy: Exploiting the role of human touch,” Musculoskeletal Science and Practice, 2019.

4. M. A. Kelly, L. Nixon, C. McClurg, A. Scherpbier, N. King and T. Dornan, “Experience of Touch in Health Care: A Meta-Ethnography Across the Health Care Professions,” Qualitative Health Research, 2017.

5. D.-M. Ellingsen, S. Leknes, G. Løseth, J. Wessberg and H. Olausson, “The Neurobiology Shaping Affective Touch: Expectation, Motivation, and Meaning in the Multisensory Context,” Front. Psycho, 2016.

6. I. Bufalari and S. Ionta, “The social and personality neuro science of empathy for pain and touch,” Frontiers in Human Neuroscience, 2013.

7. J. E. Bialosky, M. D. Bishop, D. D. Price, M. E. Robinson and S. Z. George, “The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model,” Manual Therapy, 2009.

8. M. D. Bishop, R. Torres-Cueco, C. W. Gay, E. Lluch-Girbés, J. M. Beneciuk and J. E. Bialosky, “What effect can manual therapy have on a patient`s pain experience?,” Pain Management, 2015.

9. J. Lewis and P. O’Sullivan, “Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?,” Br J Sports Med, 2018.

10. S. Michael, N. Wadie, M. Shiraz, A. Alan, D. Vivian, M. Linda and R. Sibylle, “Reliability of Spinal Palpation for Diagnosis of Back and Neck Pain: A Systematic Review of the Literature,” Spine, pp. 413-425, 2004.

11. P. Kent, D. Marks, W. Pearson and J. Keating, “Does Clinician Treatment Choice Improve the Outcomes of Manual Therapy for Nonspecific Low Back Pain? A Meta analysis,” Journal of manipulative and physiological therapeutics, pp. 312-322, 2005.

12. J. Bialosky, M. Bishop and C. Penza, “Placebo Mechanisms of Manual Therapy: A Sheep in Wolf`s Clothing?,” J. Orthop Sports Phys., 2017.

13. G. Rossettini, E. Carlino and M. Testa, “Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain,” BMC Musculoskeletal Disorders, 2018.

14. J. Bialosky, J. Beneciuk, M. Bishop, R. Coronado, C. Penza, C. Simon and S. George, “Unraveling the Mechanisms of Manual Therapy: Modeling an Approach,” J Orthop Sports Phys Ther, 2018.


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