Manipulation in Pain Medicine -Cyriax Approach-

64

KPS 2019 Annual Meeting

Manipualtive Approach to Back Pain

Is the pain caused by a spinal disorder?

R/O psychogenic and visceral referred Pain

Is the condition an ‘activity-related’ (mechanical)

spinal disorder?

R/O non mechanical disorder like rheumatic dis-

eases, tumours and infections

Red Flag

? Sphincter disturbance: bowel or bladder

? History of cancer

? Unexplained weight loss

? Immunosuppression

? Intravenous drug use

? Recent onset of structural deformity

? Recent or on-going infection

? Fever

? Night sweats

? Non-mechanical pattern of pain

? Constant pain

? Wide spread neurological signs or symptoms

? Disproportionate night pain

? Lack of treatment response

? Thoracic dominant pain

If the spinal disorder is activity-related

(mechanical), to which ‘concept’ does it belong?

▣ KPS 2019 Annual Meeting ▣

Manipulation in Pain Medicine -Cyriax Approach-

Atlas Clinic, Korea

IL Hwan Kim

65

IL Hwan Kim: Manipulation in Pain Medicine -Cyriax Approach-

Manipulation Indication for Backpain

“Reduction by manipulation is possible in 2/3 of

all case of backache, and in 1/3 case of sciatica”

---Cyriax --—

Manipulation Indication for Backpain

? Acute annular lumbago

? Backache with favourable symptoms/signs

? Sciatica with favourable symptoms/signs

? Mixed protrusions

? Patient over 60 years

Symptoms and signs favouring manipulative

treatment of backache

Favourable symptoms

Patient over 60 years Sudden onset of pain:On

bending forward or On coming up

Favourable signs

Partial articular pattern Side flexion away from

the painful side hurts most Painful arc with or with-

out momentary deviation Absence of gross deviation

Absence of gross limitation on movement

Symptoms and signs favouring manipulative

treatment of sciatica

Favourable symptoms

Backache still continues after root pain has begun

Root pain is recent

Favourable signs

Lumbar extension and side flexion hurt in the

back but not in the limb

Absence of deviation or muscle spasm Straight leg

raising is only moderately limited, with absence of

spasm of the hamstring muscles

Absence of neurological deficit

Manipulation Contraindication for Back pain

Danger to S4 roots Anticoagulant therapy Aortic graft

Last month of pregnancy Weakened body structures

Muscle spasm Seriously neurotic patients

When manipulation Useless

Too painful Too large a protrusion Too soft Too

long a duration of root pain>6Mo After laminecto-

my, protrusion at the same

level

Unfavourable articular signs in: Backache Sciatica

Primary posterolateral protrusion

Side Effect of Manipulation

further prolapse of a herniated disc, resulting in a

cauda equina syndrome [1 per 3.7 million treat-

ments]

sprains of the costovertebral and costochondral

junctions

fractures of a transverse process

Easy and Effective Manipulation technique

in Back pain

Dr. Maigne Approach

PMID (Painful Minor Intervertebral Dysfunction)

1. Pain on axial pressure of spinous process

2. Pain on transverse pressure of spinous process

3. Pain on friction of facet joints

4. Pain on transeverse pressure of interspinous lig-

aments

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Pain on axial pressure of spinous process

Pain on transverse pressure of spinous process

Pain on friction of facet joints

Pain on transeverse pressure of interspinous

ligaments

Dr. Maigne Approach

Rule of no pain and opposite movement

manipulation ; at least 3 pain-free movements

repeated mobilization: 2 pain-free movements

contraindication; all movements are painful

Manipulation at least 3 pain-free movements

Repeated mobilization 2 pain-free movements

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IL Hwan Kim: Manipulation in Pain Medicine -Cyriax Approach-

Mr. Mckenzie Technique

Acute lumbago without deviation(D1)

prone lying 5min→lying prone in extension

5min→active extension in lying 10Rep

Acute lumbago with flexion deviation(D2)

prone lying with abdominal pillow 5min→pillow-

remove→gradual table head elevation→progression

to D1

Acute lumbago with lateral deviation(D4)

Prone lying lateral deviation correction→repeate-

dextension in prone→progression to D1

Mr. Mckenzie Technique

Centralization is the guide to all treatmentresults

Frequent repetition is important to maitaintreat-

ment effectiveness

Patient education(keep your back hollow)is the-

most important

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69

Jaeik Choi : Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince

Object of manipulation

Reduce discodural or discoradicular interaction by

moving a displaced cartilaginous rim away from

sensitive structures(dura, root)

Two principles

• position of intervertebral joint opening

• traction and tautening posterior longitudinal

ligament and causes suction in the disc, so ex-

erting a centripetal force

a) Indications

1) disc protrusion in the absence of contraindica-

tions

2) acute lumbago

- good indication, except if hyperacute.

3) backache

• sudden onset, minor partial articular pattern.

• davourable articular signs (see above).

• painful arc without deviation.

4) Root pain

• better if the patient is not too young.

• other favourable elements :

if some backache remains

if the root pain is recent

minor or no deviation

favourable articular signs

only slight limitation of SLR

no neurological deficit.

b. Contraindications

1) danger to S4 roots

2) anticoagulant therapy

3) aortic graft

4) last month of pregnancy

5) osteoporosis

6) severe muscle spasm(guarding)

7) neurotic patient

c. Not Useful

Manipulation is unlikely to succeed in the follow-

ing cases

1) pain is too severe

2) fragment is too large

3) protrusion is too soft (nuclear)

4) root pain has existed for too long (over six

months)

5) compression phenomena : mushroom phenom-

enon, nuclear self-reducing disc protrusion

6) after laminectomy.

7) unfavourable articular signs

8) PPLP(primary posterolateral protrusion


Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince

Dr, Choi’s Rehab. Med. & Pain Clinic, Korea

Jaeik Choi

70


d. Choice of techniques

Cyriax gives us some advices, partially based on

his own experience, partially because they are just

common sense

1) techniques with lever are avoided in elderly or

osteoporotic patients

2) rotation techniques usually do very well for an

L4-protrusion

3) extension techniques can be better for L5, S1

protrusion

4) no extension techniques for an acute lumbago

(the patient is fixed in flexion).

5) “stretch” is always the first technique (longitu-

dinal effect).

6) in a manipulation session several manoeuvres

are performed.

young adult : 7-8-9 manoeuvres in the same

session.

elderly patient : 3-4 manoeuvres

e. basic rules

1) each manoeuvre is first done at half the normal

intensity.

2) there is a control after each manoeuvre

(SLR if positive, articular lumbar movements in

standing)

3) a manoeuvre which helps the patient is repeat-

ed.

a manoeuvre which does not help is abandoned.

4) increase the intensity of a manoeuvre if the

slighter version has proved beneficial.

5) a manoeuvre ceases to afford further benefit,

another manoeuvre is chosen, again at half the

intensity first.

d. interpretation as an improvement

1) less pain

2) more movement (although the pain can be un-

altered)

3) fewer movements painful

4) “shortening” of the pain, i.e. centralization

5) appearance of a painful arc

e. Techniques

1) Manipulation : stretch

The couch is as low as possible.

Starting position : unilateral pain, patient lies on

the painless side.

central pain, either side or less SLR (+) side

Grip : one hand behind the greater trochanter

with the fingers pointing downwards, the other

hand at the front of the shoulder with the fingers

pointing upwards.

Maneuver : first shoulder and pelvic rotation, both

rotations being equal.

then adds a longitudinal taking up of the slack ris-

ing on tiptoe and using his body weight exactly

above the patient’s trunk with his arms extended.

Manipulative thrust with body drop

2) Manipulation : leg over

Starting position : one should estimate the correct

supine position of the patient. The therapist stands

at the painfree side.

Execution : right side is the painful one.

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therapist grasps the right knee with both hands,

flexes the hip to about 90° and, under traction,

brings the patient’s knee to well below the edge of

the couch a slight counterpressure of the therapist

against his shoulder suffices.

Taking up the slack

Manipulative thrust is a sudden push downwards

with the hand on the knee.

For an upper lumbar protrusion, more hip flexion

is needed.

3) Manipulation : Dallison

- this manoeuvre is a leg over with built-in side

flexion.

- used for patients with pain and deviation.

- immaterial whether the pain is left or right

what matters is which side the patient opens

spontaneously.

Starting position : the correct supine lying posi-

tion.

therapist stand at the side he wants to build in a

side flexion and crosses the patient’s right knee

over the left one ; his right hand grasps the back of

the patient’s left knee, his left hand is put at the

outer aspect of the right knee. Both hips are flexed,

a side flexion to the right is built in, and maintained

by the therapist’s left knee.

rest of the manoeuvre is the same as for the leg

over

4) Manipulation : reverse stretch

Starting position : the couch is as low as possible.

patient lies on the painfree side, upper arm is re-

laxed in front of him

upper limb is brought backwards and hooked on

the edge of the couch.

Execution : taken up in rotation ; both rotations

should be equal.

second element is the distraction : the therapist

faces the patient’s head, rises on tiptoe and uses his

body weight above the patient in a longitudinal di-

rection. The manipulative thrust is a downward jerk

towards distraction using the body weight.

- unsuited for obese or very stiff patients who do

not have much pelvic rotation.

5) Manipulation : reverse stretch with thigh

Starting position : thigh is used as a lever in some

90° hip flexion. The therapist grasps the inner side

of the patient’s limb (at the knee) and brings it to-

wards himself.

take up slack is as follows : the therapist stands

with slightly bent knees and both feet together in a

45° direction to the couch.

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pulled the patient’s limb towards himself, applies

his body weight on the shoulder.

manipulative thrust is a swift trunk rotation away

from the patient.

- in order to have an effect in the lumbar spine

instead of at the hip joint the correct angle of hip

flexion is important.

6) Manipulation : central pressure

Starting position : the couch is at knee-height, the

patient lies prone.

Grip : first, the middle of the fifth metacarpal

bone apply between two spinous processes, the

other hand reinforces

maneuver : therapist leans against the couch with

his feet apart and his arms extended.

takes up the slack and the manipulative thrust

with the body weight

if, during the taking up of the slack, the patient

feels a pain in the buttock or the limb, the manoeu-

vre is abandoned. It is important, just before the

manipulative thrust, not to lose the slack.

7) Manipulation : unilateral pressure

Starting position : as for the central pressure. The

patient does not lie in the middle of the couch, but

as near as possible to the therapist.

The therapist’s position : at the left for a right

unilateral pressure.

With the pisiform bone, reserve of skin is taken

towards the midline, hand is pulled backwards for a

bony contact as close to the midline as possible,

thus avoiding the risk of fracture of a transverse

process.

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reinforces with other hand, therapist leans for-

wards beyond the midline

part of the body weight takes up the slack

manipulative thrust is performed with straight

arms in a medial and downward direction.

8) Mobilization : stretch in prone lying

Starting position : patient lies prone, open painful

side with trunk side flexion.

Execution : with a reserve of skin, the therapist

puts his hands (arms crossed) against the lower ribs

and the iliac crest.

manoeuvre (a mobilization rather than a manipu-

lation) is a rhythmic jerking downwards of the tho-

rax with elbows bent 90°, thus distracting the pain-

ful side.

9) Antideviation technique, rotation

Starting position : the patient lies on the convex

side, e.g. on the left side for a deviation to the right.

upper leg flexed with the foot behind the other

knee, and the knee hanging beyond the edge of the

couch.

Execution : the therapist stands before the pa-

tient, immobilizes his knee and leans with his body

weight on to the patient’s shoulder in a combined

rotation and distraction direction.

maintained for up to a minute, then released and

repeated again.

10) Antideviation technique, side flexion

In a left deviation side flexion towards the right is

limited. This direction will be mobilized.

patient lies supine,

therapist stands at his right side and crosses the

right knee over the other one.

Execution : the therapist’s right hand, under the

patient’s right knee and above his left knee, grasps

the back of the left knee.

hips are brought in flexion. The left hand is at the

outer aspect of the patient’s right knee. swinging

with both hands,

rhythmic side flexion movements towards the

right

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11) Antideviation technique, extension

therapist stands at the side of the deviation and

with both hands grasps the patient’s other pelvis.

The therapist pushes with his trunk and pulls with

the arms in order first to neutralize, then to correct

the deviation.

movement towards extension follows

maintained for a few seconds and performed three

times in succession.

Strategy

start is always the stretch at low intensity with the

painful side up.

1) first possibility

- stretch, followed by checking the SLR (or a

lumbar movement in standing if SLR is nega-

tive).

- patient is better, the stretch is repeated, again

with a control afterwards. repeated with increas-

ing intensity.

- a point is reached in which the patient is al-

ready much better but the last manoeuvre has

ceased to afford further benefit. change method

same direction as the previous rotation but

more intence : leg over. performed at low in-

tensity first, and then repeated a few times

- a patient with pain and also deviation : the use

of the Dallison. now 5 or 6 sessions will be re-

quired instead of 3 or 4 to obtain reduction.

each session we might use 2-3 times the stretch,

2-3 times the leg over and 1-2 times the Dalli-

son technique.

- patient with pain and deviation has lost his pain

after 5 or 6 sessions, but the deviation has re-

mained unaltered.→ antideviation techniques

are called for.

2) second possibility

low intensity stretch was the first manoeuvre ; no

effect

→ low-intensity reverse stretch : effective

avoid more forceful stretch or to try a leg over.

→ reverse stretch with thigh.

3) third possibility

- we start with the stretch. Either it helps or it

does not.

If it helps, we repeat it several times ;

if not, we do it only once. choose a second

technique :

→ central pressure. Why ?

* patient is elderly or osteoporotic, or he has an

osteoarthrotic hip, we cannot use the thigh as a

lever.

* L5-disc protrusion, which might better respond

to an extension than to a rotation technique.

* patient, in standing, has a good extension and a

very painful flexion.

→ unilateral pressure on the painfree side first, on

the painful side afterwards

→ stretch in prone lying to end the session.

- taking up the slack for the central pressure

causes a pain in the limb abandon this tech-

nique, try unilateral pressure

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Conclusion

Cyriax manipulation is easy to learn and apply.

Manual treatment of lumbar spine helps to im-

prove symptoms and to prevent recurrence.

It is important to recognize that manual treatment

has its own limitations and is a secondary treatment

of injections treatment for lumbar spine problems.

Thank you!

Search for the “시리악스” keyword on YouTube to

revisit today's unabridged lecture video.

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History of osteopathy

- Andrew Tailor Still

- M.D.

- 1828-1917

- American Osteopathic Association

Dr Still's philosophy

- unity of the body

- healing power of nature

- somatic component of disease

- form and function

- use of manipulative therapy

osteopathy current situation in USA

- 70 % of D.O. is primary physician like M.D.

- about 100000 D.O.s

- Different point of D.O. from M.D. is using ma-

nipulative therapy

34 osteopathic colleges in USA

OHWI(osteopathic health & wellness institute)

- international osteopathic manipulation educa-

tion program(www.ohwi.org)

- osteopathic college of Ontario, Canada program


All about osteopathic manipulation

Yonsei Rehabilitation Clinic, Korea

Jae Hwan Lee

77

Jae Hwan Lee: All about osteopathic manipulation

Unity of the body

- integration of the total human organism rather

than a summation of parts.

- connection between viscera and viscera, muscu-

loskeletal and musculoskeletal, between viscera and

musculoskeletal.

- connection between mind and body.

Healing power of nature

- He recognized body's ability to heal itself and

stressed preventive medicine, eating properly and

keeping it.

Somatic component of disease

- every disease contains abnormality of musculo-

skeletal system.

- based on anatomy.

- osteopathy is called 整骨醫學

Form and function

- every human organ correlates with its function

- form and functions are interrelated.

Use of manipulative therapy

- manipulation corrects the body structure.

- Correcting the body structure release the ten-

sion of fascia, improve blood supply and lymphatic

drainage, and wash out the cellular wastes.

- so helps the body to heal itself.

Many manipulation method

- counterstrain

- MET(muscle energy technique)

- visceral osteopathy

- cranial osteopathy

- myofascial release

- HVLA(high velocity low amplitude)

- ligamentous articular strain

Osteopathic diagnosis

- Involves using hands to "listen" to the patient's

body.

- When the particular tissue is ill, it loses its elas-

ticity, disrupts the patient's membranous equilibri-

um, and becomes a new axis or pivot point for mo-

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bility and motility.

The listening method

- Global listening

- Local listening

- Thermal listening

- Cranial rhythm listening

- Visceral rhythm listening

Physical diagnosis

T: Tissue texture abnormality

A: Asymmetry

R: Restriction of motion

T: Tenderness

Radiologic diagnosis

F: Flexion E: Extension R: Rotation R: Right L:

Left

S: Side bending

예) FRRSL - Flexion Rotation Right Side bending

Left

Counterstrain

- invented by D.O. Lawrence Jones

- He recognized the decrease of muscle spasm

when the position of spasm muscle's origin and in-

sertion is put in most relaxed position for 90 sec-

onds.

- tender muscle or ligaments' origin and insertion

is put in the shortest position for 90 seconds

- 90 seconds?: the time for reaching a new appro-

priate set point for gamma motor fiber.(longest limit

time to decrease the muscle spasm in Lawrence ex-

periment.)

- Tender point, trigger point, acupuncture point,

neurolymphatic point, neurovascular pint: all simi-

lar.

- chronic, repetitive trauma causes histamine,

prostaglandine release: inflammatory proliferation

and vessel contraction.

- destruction of sarcoplasmic reticulum, interferes

with actin, myosin reaction through invasion of cal-

cium ion overflow

- countestrain technique reduces the continuous

abnormal hypersensitivity of gamma motor neuron

in muscle spindle.

MET

- developed by D.O. Fred.L. Mitchell, Sr. (1909-

1974)

- decrease the muscle spasm by letting patient

contract the muscle isometriccally in unpainful di-

rection , blocking the patient's motion.

- postisometric relaxation: decrease the muscle

tone causing reflex inhibition of Golgi tendon organ

after isometric contraction.

- reciprocal inhibition: release the muscle tone by

contraction of the muscle's antagonist.

Visceral manipulation

- developed by D.O. Barral

-mobility: The gross movement of the visceral in

relation to diaphragmatic movement

-motility: The inherent motion at the visceral as it

relates to embryonic

development

- all motion has axis

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Jae Hwan Lee: All about osteopathic manipulation

- mobility and motility has same axis of rotation in

healthy condition

- every healthy organ has appropriate motion

without restriction

- if there is any restriction, it causes functional

abnormality even if it is small

- if that restricted motion repeats and accumu-

lates hundreds of, thousands of time every day, it

causes serious change in that organ's function

- the visceral motions controlled by

1. somatic nervous system

2. autonomic nervous system

3. craniosacral rhythm

4. visceral motility

- mobility

Intracavitary Pressure

Exhalation

Inhalation

Articulations

- intracavitary pressure

thoracic cavity pressure: negative abdominal cav-

ity pressure: positive

so, thoracic cavity negative pressure reduces liver

weight adjacent to diaphragm

( relates to right shoulder pain)

- motion restriction

Articular restrictions

adhesion / fixation

Ligamentous laxity

ptoses

Muscular restrictions

- visceral manipulation in musculoskeletal pain

Reflex: somatovisceral, viscerosomatic

Fascia release is effective for all kinds of pain,

anywhere because pain is from fascia restriction,

low blood supply and poor lymphatic drainage.

- contraindication

1. right after surgery

2. surgical abdomen

Cranial manipulation

- developed by D.O. W. Sutherland

- introduced by D.O. Upledger to general popula-

tion as CST(craiosacral technique)

- D.O. calls it osteopathy in cranial field

- craniosacral rhythm

generated by CNS autonomic motility( primary

motion of occiput and sphenoid: flexion, extension)

other cranial bones move secondary to above

mentioned primary motion.

abnormal cranial rhythm causes disease.

Vault hold and various technique

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HVLA

- Dr. Still used this technique in his early age, but

avoided later due to side effect such as ligament

laxity.

- D.D. Palmer created chiropractic in the same

period

- HVLA used a little different mechanism and di-

agnosis from chiropractic

ex) different terms in X ray listing

HVLA : R(rotation) S(side bending) chiro: PI AS

different bed

HVLA: general plain table chiro: Cox, Thom-

son, Leander etc

different mechanism

HVLA: short lever, long lever technique chiro:

mainly short lever technique

different diagnosis

HVLA: leg length difference is not so important

chiro: leg length difference is quite important

- HVLA is used in spine and extremity joint by

high velocity low amplitude thrust, resulting in re-

duction of subluxated joint

Ligamentous articular strain

- developed by D.O. H.A.Lippincott(1949) and

DOSG( Dallas Osteopathic Study Group)

- Membranous strain = Fascia strain

No Thrusts, No jerks, No lever

Dr. Still‘s principle: exaggeration of the lesion to

the degree of release and then allowing the liga-

ments or tendons to draw the articulations back into

normal relationship

If the injured ligaments or tendons are released

to the direction of injury vector, resistant tension

occurs not to be further injured in ligaments them-

selves. so they are released and stopped to a certain

point. That point is called balanced tension point!

- after injured ligaments reach the balanced ten-

sion point, several seconds later, they try to go back

to the original physiologic joint position(recenter-

ing) and go through healing process. ( they say no

need for immobilization)

- terminology

1. indirect: like pushing on the tail of the vector of

injury ( to the direction of no resistance) usually

used in ligaments or tendons injury

2. direct: like pulling on the tail of the vector of

injury or pushing on the point of the arrow( to the

direction of resistance) usually used in muscle inju-

ry. developed into myofascial release

Soft tissue technique, technique of Still, Lymphatic

technique etc

Documents

Manipulation in Pain Medicine -Cyriax Approach-