Introduction to Manual Therapy

Introduction to Manual Therapy

• Manual therapy is a deliberate application of force on body tissue, typically with the hands, for a therapeutic purpose. (Kerry 2024)
• It involves touch-based interventions, including mobilization, manipulation, soft tissue mobilization, and neurodynamic movements.

Objectives

• Understand the definition and brief history of manual therapy in treating orthopedic conditions.
• Understand the current evidence on how manual therapy relieves pain.
• Review joint kinematics, emphasizing roll/slide movements and convex/concave rules.
• Define joint mobilization and manipulation.

History of Manual Therapy

• Evidence for manual therapy dates back thousands of years, including practitioners known as "bone setters" in various cultures (Nepal, Russia, Norway, etc.).
• Hippocrates described manipulation and traction techniques in the 16th-19th centuries.
• Multiple physicians in textbooks referenced Hippocrates' work.
• In 1892, Andrew Taylor Still established the American Osteopathic College, believing manipulation could cure disease by improving blood flow to the "disturbed artery".
• Daniel David Palmer developed chiropractic medicine, focusing on vertebral subluxations affecting nerve impulses and leading to disease.
• James Henry Cyriax published a textbook of orthopedic medicine in 1954, creating a logical and clinically reasoned method for differential diagnosis, known as "selective tissue tension testing."
• Maitland popularized mobilizations as an alternative to manipulation, developing grades I-V for mobilization.
• The International Federation for Orthopedic Manual Therapy (IFOMT) was established in 1970, and the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in 1992.
• Manual therapy is now recognized as an integral part of physical therapy.

Mechanisms of Manual Therapy

• Manual therapy involves a chain of neurophysiological responses initiated by a mechanical force.
• This can result in transient biomechanical effects, including short-term improvements in joint mobility.
• There's no evidence for long-lasting positional changes resulting from manual therapy.
• The precision of specific techniques is limited, as force is dissipated over a large area, with poor validity and reliability in palpating specific structures.
• The choice of technique doesn't seem to significantly affect outcomes for most patients.
• Finding patients who respond to manual therapy is more important than the technique used.
• Manual therapy can reduce cytokines and release opioids (beta-endorphin, serotonin, cannabinoids) in the periphery. This has the effect of decreasing nerve ending sensitivity and nociceptive load in the pain processing regions of the brain, leading to less temporal and spatial summation.
• Neuron activation occurs reducing activity in the dorsal horn.
• This occurs through descending inhibitory pathways and through the gate control theory, which reduces activity in pain processing regions of the brain.

What Manual Therapy Can and Cannot Do

• Can: Transient biomechanical effects, decrease activation of supraspinal regions, reduce cytokines, release endogenous cannabinoids, decreased spinal activity, and increased dopamine production.
• Cannot: Detect the precise cause of pain, lengthen all tissues, adjust joints, fully restore normal function.

Joint Kinematics

• Joint motion combines rolling, sliding, and spinning to produce movement.
• Arthrokinematics describes movements at joint surfaces (roll, slide/glide, spin), differentiating from osteokinematics (bone movement).
• Convex moving on concave; roll and glide are opposite.
• Concave moving on convex; roll and glide are the same.

Joint Mobilization

• Mobilization focuses on the glide/slide portions of joint arthrokinematics to improve motion and modulate pain.
• Convex/concave rules are not always strictly followed.
• The direction of glide is less important than the mechanical stimulus.

Indications, Contraindications, and Precautions

• Indications*: Pain, muscle guarding/spasm, ROM limitations, functional immobility
• Contraindications*: Malignancy, osteopenia/osteoporosis, manipulation on unhealed fractures/fusions, acute injury with uncertain severity of damage, patient refusal
• Precautions*: Hyperalgesia/Allodynia, hypermobility, weakened connective tissue, long-term corticosteroid use, immediately after surgery, disuse, Rheumatoid arthritis

Manipulation

• Cyriax defines manipulation as passive joint movement with a therapeutic purpose, using the hands.
• Maitland defines manipulation as a small amplitude, high-velocity movement, often at the limit of range of motion.
• Mobilization and manipulation are sometimes used interchangeably. Manipulation is often used for high-velocity low-amplitude thrusts (particularly in relation to the spine).