Principles of Manual Medicine

Jack Dolbin, DC CSCS

When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping the patient with a myriad of disease processes.

Philip Greeman DO, Professor of Biomechanics

Michigan State University School of Osteopathy Medicine

The goal of manual medicine is to restore maximal, pain free movement of the musculoskeletal system in postural balance.

Dvorak J, Dvorak V,Schneider W : Manual Medicine 1984,

Goal of manual medicine

1. Holistic man 2. Neurologic man 3. Circulatory man 4. Energy-expending man 5. Self-regulating man

Role of the musculoskeletal System in Health and Disease

The musculoskeletal system comprises most of the human skeleton and alterations within it influence the rest of the human organism.

Our role as physicians is to treat patients and not disease.

Holistic Man

Most highly developed nervous system in the animal kingdom.

All functions of the human body are under some form of neurologic control.

Control of all glandular and vascular activity is under the control of the ANS.

Neuroendocrine Control: Substabnce P, endorphines, enkephalines, and neurotransmitters can be altered by biomechanical alterations

Alterations in neurothropin transmission can be detrimental to the health of target cells.

Neurologic Man

Anything that interfered with with sympathetic autonomic nervous system outflow, segmentally mediated, can influence vasomotor tone to the target end organ.

Maximal function of the musculoskeletal is important to the efficiency of the circulatory system and maintainance of a normal cellular milieu.

Circulatory man

Restriction of one major joint in the lower extremity increase the energy expenditure in walking by 40%, two major joints in the same extremity 300%.

Multiple minor restriction of movement, especially in the lower extremity gait can have a detrimental effect on the total body function

Energy expending man

The goal of the physician should be to enhance all the body’s self regulating mechanisms to assist in the recovery from disease. ( injury).

One in seven hospital days are the result of adverse reactions to pharmaceuticals.

Anything placed with in the body alter the self regulating mechanism.

Self-Regulating Man

Primary goal is to determine the specific spinal motion segment that is dysfunctional, determine the direction of altered motion, and determine the tissue involved in the restrictive motion.

Primary emphysis is placed on motion loss and its characteristics

Manipulatible Lesion

Asymmetry

Range of motion

Tissue texture

A R T

Pelvic unleveling: Effect on lower extremity function. Shoulder function.

Scapular Winging:

Anterior Shoulder posture: TOS

Pronation

Asymetry

Pelvic Unleveling

Passive: note end feel. Hard or mushy

Active: Neuromuscular Control

Range of Motion

Spasm

Contracture: Hypertonicity

Shortening: Chronic adaptation

Adhesions: Scar Tissue

Temperature: Inflammation

Tissue Texture

The most important element in the postural model has been the restoration of maximum pelvic mechanics in the walking cycle.

The Pelvis from below to above must be considered to achieve the symmetrical movement.

Shoulder Injuries Hamstring strains Knee, ankle, foot injuries

Greenman

Check Pelvic leveling in the standing position.

If unlevel: does it level in the sitting position.

If so check leg length. Look for structural or functional short leg.

If functional check SI joints and pronation. If Structural: broken leg or past injuries. Equestrian Illustration: Broken Femur

leading to shoulder entrapment.

Evaluation of symmetry

1. Range of movement 2. Quality of movement 3. End feel

In the spine: Goal is to determine which specific vertebra is dysfunctional

Which joint within that segment is dysfunctional

The direction of altered motion Tissue involved in the restricted movement.

Range of Motion

Motion loss and its characteristics are more important diagnostic criterion that the presence of pain and the provocation of pain by movement.

Greenman: Michigan State University School of Osteopathic Medicine.

Alteration in the characteristics of the soft tissues of the musculoskeletal system.

Skin Fascia Muscle Ligament

Tissue Texture

Muscle Energy

Impulse Adjusting

High Velosity/ Low amplitude

Indirect Function technique: Sherringtons Law

Myofascial Release: Cyriax Crossfiber

Techniques

Mobilize Scar tissue

Breakdown Adhesions

Allows muscle to broaden

Controlled Imflammation

Pain modulation 1. Right Location 2. Right amount of pressure

Cyriax Crossfiber

During first 24-48 hours. Light mobilizing maximum of 5 minutes.( usually less)

After 48 hours 5-15 minutes Muscle Injury: Across the relaxed muscle to

facilitate broadening. Followed by eccentric exercise or Faradic.

Tendon/Ligament Injuries: Across the ligament in an elongated position.

Every other day

Cyriax: Continue

Lateral Ankle Sprain

Rotator Cuff Tendonitis

Isometric Contraction of shortened muscle. Improves resting length Increase Joint movement Improves overall range of motion.

3-5 repetitions 5-7 seconds. Inhalation/Exhalation as activating force

Muscle energy

Achilles Tendon Injury

Quadraceps Injury

Percussion cadencee: Seguin 1838 Manual Vibrations: Kellgren mid 1900 Janse, Wells, Howser 1947 Repetitive Thrusts: Maitland 1964 Fuhr: Activator Colluca-Keller: Impulse Adjusting

Impulse Adjusting

By Stimulating the Golgi Tendon organs the shortened muscle lengthens. Myotendinous Junction.

Reset Neurological bed. Bone and muscle belly

Activates mechanoreceptors:

Can be alternative treatment to myofascial release: Opinion

Impulse Adjusting

Mobilizes fixated JointsImproves Range of Motion in Dysfunctional

segmments.Activates mechanoreceptor in Joints: Pacinian

and Ruffini corpucles.Allows for normalization of afferent

proprioceptionEffect on Visceral Function ??

Joint Mobilization/Manipulation

History: 7 Point History MinimumObservation of injured partInspection of Injured partExamination: Palpation, Range of MotionProvocative tests.Evaluation of motion deficits in the kinetic

chain.

Treatment: Manual Medicine Prescription

Procedure For Sports Injury

Have a purpose in your treatment. Not cookbook therapy

Have a reevaluation process to assess the effectiveness of your treatment

A. If not responding do revel and change plan.

Transition to active care: Usually concurrent with your manual therapy

Volume: Maximum of 30-35 patients per day.

A goal of developing a volume based practice is antithetical to the practice of manual medicine