Manual Therapy: Joint Kinematics, Mobilization

• Manual therapy by Adam Squires includes joint kinematics, mobilization and manipulation.
• The objective is to learn manual therapy to treat orthopedic conditions.
• The objective is to understand pain relief mechanisms, and review joint kinematics and definitions.

Definition

• Manual therapy is the deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent (Kerry 2024).
• Touch-based interventions include:
  • Mobilization
  • Manipulation
  • Soft tissue mobilization
  • Neurodynamic movements

History

• Manual therapy has evidence of being used thousands of years ago.
• "Bone setters" existed in Nepal, Russia, Norway, and other countries.
• Hippocrates used manipulation and traction.
• In the 16th-19th century, physicians described manipulation in textbooks, often referring to Hippocrates.
• In 1892, Andrew Taylor Still established the American Osteopathic College.
• Andrew Taylor Still believed manipulation could cure disease through improving function of the "disturbed artery".
• Daniel David Palmer developed Chiropractic Medicine.
• He theorized vertebrae out of alignment (subluxation) affects nerve impulses, leading to disease.
• James Henry Cyriax published Textbook of Orthopedic Medicine, Volume I in 1954.
• James Henry Cyriax laid out a method for logical, clinically reasoned differential diagnosis and called it "selective tissue tension testing".
• Maitland popularized mobilization as an alternative to manipulation, and also developed grades for mobilization I-V.
• In 1970, the International Federation for Orthopedic Manual Therapy (IFOMT) was established.
• In 1992, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) was founded.
  • Completion of an accredited OMPT fellowship can achieve the credential FAAOMPT.
• Manual therapy is recognized as an integral part of the physical therapy scope of practice.

Mechanisms of Manual Therapy

• The previous diagram sums it up that a mechanical force is necessary to initiate a chain of neurophysiological responses which produce the outcomes associated with MT [manual therapy].
• Transient Biomechanical Effects includes
  • Evidence for short-term improvements in joint mobility
  • No evidence for lasting joint position change
  • Precise techniques lack precision
  • Force is dissipated across a large area
  • Palpation of specific structures demonstrates poor validity and reliability
  • Choice of technique does not matter
  • Finding the right patient that will respond is more important
• Manual therapy's effect includes decreased Cytokines and Release of endogenous opioids
  • It happens in the periphery
  • Cytokines are inflammatory chemicals released following injury
  • Endogenous opioids are beta-endorphin, serotonin, and cannabinoids
  • Decreased nerve ending sensitivity and nociceptive load to the pain processing regions of the brain, which means decreased temporal and spatial summation
• Neuron activation is one of the key mechanisms.
• Manual therapy affects Opioid receptors.
• Manual therapy decreases activity at the dorsal horn.
• Manual therapy decreases activity in the dorsal horn via descending inhibitory pathways.
• Manual therapy decreases activation of pain processing regions.
• What manual therapy CAN do:
  • Transient biomechanical effects that supports improved mobility
  • Decreased activation of the supraspinal regions responsible for central pain processing
  • Reduction of cytokines and release of endogenous cannabinoids in the periphery
  • Decreased spinal activity via the dorsal root ganglion
  • Hypoalgesic effect via increased production of dopamine
• What manual therapy CANNOT do:
  • Palpate for positional and movement faults
  • Detect which structure/tissue is the "cause" of pain
  • Lengthen certain tissues such as fascia, muscles, or connective tissue
  • Release muscles
  • Adjust certain joints back into place

Joint Kinematics

• Motion at joints combines rolling, sliding, and/or spinning to produce the desired limb or trunk movement.
• Arthrokinematics defines the movements that happen at the joint surfaces such as roll, slide/glide, and spin.
• Osteokinematics refers to movement of the bones around a joint like Flexion, extension, and abduction.
• Convex moving on concave: roll and glide are opposite.
• Concave moving on convex: roll and glide are same.

Joint Mobilization

• As a general rule, mobilizations focus on the glide/slide portion of the joint arthrokinematics to improve motion and modulate pain.
• Convex/concave rules are not law.
• Evidence suggests the direction of glide is less important than the mechanical stimulus.
• Remember mechanisms discussed previously

Indications and Contraindications/Precautions for Manual Therapy

• Indications:
  • Pain
  • Muscle guarding/spasm
  • ROM limitations
  • Functional Immobility
• Contraindications:
  • Malignancy
  • Osteopenia, osteoporosis
    • Manipulation
  • Unhealed fracture or unhealed fusion
  • Acute njury where there is uncertainty related to the severity of damage
  • Patient doesn't want manual therapy
• Precautions:
  • Hyperalgesia/Allodynia
  • Hypermobility
  • Weakened connective tissue due to:
    • Long-term corticosteroid use
    • Immediately after surgery
    • Disuse
  • Rheumatoid arthritis

Mobilization

• Mobilization Definition: passive, skilled manual therapy techniques applied to joint and related soft tissues at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes.
• Maitland developed a grading system:
  • Grades I-IV
  • Grade V also called manipulation or high-velocity, low-amplitude thrust (HVLAT).

Grades of Mobilization

• Grade I - Low amplitude oscillation at the very beginning of motion, and is used for pain modulation with high symptom irritability.
• Grade II - Large amplitude oscillation within available motion, and is used for pain modulation with high symptom irritability.
• Grade III - Large amplitude osc up to and through tissue resistance.
  • It is used for pain modulation and, theoretically, capsular stretch.
  • It is moderate to low irritability
• Grade IV - small amplitude osc. at and through tissue resistance.
  • Used for pain modulation and, theoretically, capsular stretch with low irritability.
• Kaltenborn Grades

Manipulation

• Cyriax's definition: "simply defined as a passive movement at a joint with a therapeutic purpose, using the hands"
• Maitland's definition: "a small amplitude, rapid movement (not necessarily performed at the limit of a range of movement); which the patient cannot prevent from taking place"
• According to the Guide to Physical Therapist Practice. "Mobilisation/Manipulation is a manual therapy technique comprised of a continuum of skilled passive movements to joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement"
• The terms mobilization and manipulation are often used interchangeably.
• In this class, there is a distinction:
  • mobilization for low speed, oscillatory movements
  • manipulation for high velocity, low amplitude thrust techniques
• Manual therapy is most often directed to the spine, but can be used with peripheral joints as well.

Learn manual therapy techniques for treating orthopedic conditions. Understand pain relief mechanisms and review joint kinematics and definitions. Manual therapy involves applying external force to body tissue, typically with the hands.