Manual Therapy:

• Mobilization, manipulation of soft tissues, massage

• A systematic method of evaluating and treating dysfunctions of the neuromusculoskeletal system in order to relieve pain, increase or decrease mobility, and in general normalize function

History of Manual Therapy– Hippocrates (460-380 BC)– Galen (131-202 AD)– Bone-setter (England):

– .Stiffness and pain in joints were immobilized for a long period of time after fractures, dislocations, or sprains

– .Stiffness and pain resulting from disuse after soft tissue injuries

– .Internal deragements after rupture of the meniscus

– .Subluxations of small bones of the hands and feet

– .Ganglion development around the wrist

– .Treatment of neck and back disorders

• Graham (1884-1918)– Massage:

• any procedure done by the hands (friction & manipulation)

William Merrell (1853-1912)

– A scientific mode of treating certain forms of disease by scientific manipulation, including passive range of motion, mobilization, and manipulation

Osteopaths: Andrew Taylor Still (1828-1917)

• The body as a unit had the ability to fight off all disease and that the cause of all disease was mechanical pressure on blood vessels and nerves produced by dislocated bone, abnormal ligaments, or contracted muscles in the back(osteopathic lesion)

Chiropractors: Daniel David Palmer (1845-1914):

• To put bones back into place• .Straights:• .Mixers:

Medical Manipulators for Physical therapist

• Mennell: – NAAMM merged with AAOM (American

Association of Orthopaedics Medicine)• Cyriax

Practice of Manual Medicine

• the functional capacity of the human organism

• dynamic processes of disease• musculoskeletal system comprises over 60%

of the human organism• Structural diagnosis

– to evaluate the musculoskeletal system for its particular disease and dysfunctions

– to evaluate the somatic manifestations of disease and derangement of the internal viscera.

– to increase mobility in restricted areas of l k l l

Goals of Manipulation

• To restore maximal, pain-free movement of the musculoskeletal system in postural balance (1983)

Concepts

A. Holism:

• the musculoskeletal system deserves thoughtful and complete evaluation (treat patients, not to treat disease

B. Neurological control: (fig)

• 1. somaticosomatic reflex pathways

• 2. viscerovisceral reflex arc

• 3. sympathetic reflex pathways

• 4. ANS

– a) parasympathetic

– b) sympathetic

B. Circulatory function

• 1. Arterial system2. venous system3. lymphatic system4. muscular activity5. diaphragm

• C. Energy expenditure: musculoskeletal activity

D. Self-regulation:

• 1. homeostatic mechanism2. iatrogenic disease

Manipulable lesion

• “osteopathic lesion”, • ”chiropractic subluxation“ ,• ”joint blockage“, • ”loss of joint play“, • ”joint dysfunction“

• current “somatic dysfunction”

Manipulable lesion

• A. defined as impaired or altered function of related components of the somatic (body framework) system; skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic, and neural elementsB. emphasized is on altered function of the musculoskeletal systemC. The art of structural diagnosis is to define the presence of somatic dysfunction(s) and determine any significance to the patient‘s complaint or disease process presenting at the time.

Diagnostic triad for somatic dysfunction

• “ART“ through observation or palpation

• 1. A: Asymmetry

• 2. R: Range of motion of a joint, several joints or regions of musculoskeletal system

– a) Active or passive movement

– b) Hypermobility or Hypomobility

• 3. T: Tissue texture abnormality of soft tissue of the musculoskeletal system for location, status (acute, or chronic), prognosis, treatment response

Relief of nerve-root pressure-reacting only to the spine

• A. Specific- chiropractors recommend the movement of one specific vertebra on another.

• B. Nonspecific- Cyriax recommends general manipulation with traction

Relief of pain- relating to the spine or extremities

• A. Graded oscillations- Maitland believes in mobilizations subthreshold to pain

• B. Contrary movement- Mainge recommends therapeutic movement in a direction exactly opposite to that which cause pain

Normalization of joint mobility-relating to the spine or extremities

• A. Osteopathy- osteopaths advocate specific techniques for mobilizing the spine and extremities

• B. Treatment of stiffness- & Kaltenborn advocates the use of arthrokinematic principles to regain mobility without regard to pain

• C. Paris: a concept of facet disorder as the primary cause of spine dysfunction

• D. The cause of the dysfunction and treatment of pain

Joint mobilization

• Passive exercise• Physiologic movement:

– the creation of motion within a joint by an outside force taking the body part through all or part of its range of motion

• Accessory movement: – movement that occurs between the articulating

surfaces of a joint that is involved in a physiological motion, either active or passive.

Accessory movement

• glide, spine, roll• Accessory movement

cannot be produced actively

• Component motion:– the motion occurring

in a related joint that allows the primary joint to function normally

Joint play:

• the motion that occurs within the joint but only as a response to an outside force and not as a result of voluntary movement

Joint Mobilization:

• the attempt to improve joint mobility or decrease pain originating in joint structure by the use of selected grades of accessory movement

Classification of synovial joints

• Simple: – one joint space with two surfaces ( one concave and

one convex) and a single capsule (metacarpophalangeal joint)

• Compound:– one joint has more than two joint articulating

surfaces within a single capsule (elbow)

• Complex:– an anatomically compound joint with meniscus or

intracapsulaar disk (knee)

structural forms of joint-articulating surfaces

• Unmodified ovoid-– ball-and-socket articulation, spheroid, (3

axes and 3 degree of freedom) (hip, shoulder)

• Modified ovoid-– ellipsoid and sellar, (2 axes and 2 degree of

freedom), (metacarpophalangeal joint) (2 axes and 2 degree of freedom)

structural forms of joint-articulating surfaces

• Unmodified sellar-saddle,– the surfaces are convex

and concave at right angles (2 axes and 2 degree of freedom)( 1st metacarpal joint)

• Modified sellar-– a hinge, ginglymus, or

trochoid joint( one axes, one degree of freedom) (interphalangeal joint, the ulnohumeral joint, and knee)

Joint Positions: Congruence• Close-packed

position:– occurs when the joint

surface are most congruent

– a testing position but never used for mobilization because there are no degrees of freedom of movement

• Loose-packed position:– any other position of the joint

aside from the closed-packed position.

– The maximal loose-packed position: resting position (the optimal position for mobilization)

– elbow flexed to 70 degrees and supination

– the knee in 30 degrees of flexion with a slight external rotation of the tibia

Osteokinematics:

• the study of movements of the bone• Spin: a pure rotation around a mechanical axis,

clockwise or counterclockwise, (the head of femur, humerus, and radius), not simultaneous with a spin, transverses the shortest route between two points

• Swing: any movement other than pure spine– pure or cardinal swing– impure or arcuate swing

Arthrokinematics:

• the study of the joint• Gray‘s anatomy• Gliding (translation): an arc surface simply

slides over another surfacewithout adding a component of angulation or rotation

• Angular movement• Circumdution: conical outline• Rotation: movement around a longitudinal axis

MacConaill and Basmajian

• Spin: rotation around a stationary mechanical axis

• Gliding or sliding: one point on a moving surface comes into contact with new points on another surface

• pure gliding (involuntary motion)(translation or translatory glide

• Rolling: when new points on one surface come into contact with new points on a second surface

• Rolling and gliding motion are usually found to

Kaltenborn:

• more gliding---> nearly congruent• more rolling---> nearly incongruent• The rolling portion of the combined roll-

glide movement always follows the direction of the bone movement

• The gliding portion of the combined roll-glide movement

Kaltenborn:

• whether the moving surface is convex or concave

• If the moving surface is concave---> both the gliding and the bone movement follow the same direction

• If the moving surface is convex---> the gliding follows the opposite direction

Traction

• Stage I (grade I): piccolo traction– which involves

neutralizing pressure in the joint without actually separating the joint surface

– pain relief and prevent the trauma of grinding when performing mobilization techniques

Stage II (grade IV):

• to separate the joint surfaces and take up the “slack” in the joint capsule

• “slack”: the amount of looseness or play allowed by the capsule and ligaments in a normal joint

• pain relief

Stage III (grade IV+)

• involves an actual stretching of the soft tissues

• used to increase the mobility in a hypomobile joint

Mobilization• Pain relief

– Grade I-II– Traction – Vibration and oscillation

• Relaxation – Grade I-II– Traction

• Stretch – Grade III– Stretch traction– Stretch-glide– Rotation

Three-dimensional traction:

• spine, positioned relative to all three cardinal planes (with relative position such as flexion, lateral flexion, and rotation)

Translatoric gliding:

• used to increase mobility in a hypomobile joint, preceded by piccolo traction to eliminate the compressive force

Maitland• Grade I

– is a small-amplitude movement conducted from the beginning of the available range of motion

• Grade II– is a large-amplitude movement conducted within the range. It does not

reach either end of the range

• Grade III– is a large-amplitude movement that does reach the end of the range of

motion

• Grade IV– is a small-amplitude movement conducted at the very end of the range of

motion

• Grade V– is a high-velocity thrust of small amplitude at the end of the available range

of motion and within is anatomical range.– “Popping”, “ manipulation”

General Rules of Mobilization Techniques

• The patient must be relaxed• The operator must be relaxed• Do not move into or through the point of pain• When performing any of the joint mobilization

techniques, one hand will usually stabilize while the other hand performs the movement

• The operator must consider

General Rules of Mobilization Techniques

• Direction of movement• Velocity of movement

– slow stretching for large capsular restriction– faster oscillation for minor degree of

restriction• Amplitude of movement:

– graded according to pain, guarding and degree of restriction

General Rules of Mobilization Techniques • Compare accessory joint movement to opposite

side ( extremity), if necessary, to determine presence or degree of restriction

• One movement is performed at a time, at one joint at a time

• Each technique can be used as – Examination procedure: slack only to see accessory

movement and pain– Therapeutic procedure: High-velocity, small-amplitude

thrust or graded oscillation• Reassessment

Indications:

• Joint dysfunction• Restriction of accessory joint motion• Capsuloligamentous tightening• Internal derangement• Reflex muscle guarding• bony blockage

Contraindication• Absolute:

– bacterial infection, – neoplasm, – recent fracture

• Relative– Joint effusion or

inflammation

– Arthrosis ( e.g. degenerative joint disease) if acute, or if causing a bony block to movement to be restored)

– Rheumatoid arthritis– Osteoporosis– internal derangement– General delilitation ( e.g.

influenza, pregnancy, chronic disease)

To increase proprioceptive input

• to the spinal cord to inhibit ongoing nociceptive input to anterior horn cells and central receiving area

• Grade I-II• cycles/second