Manual Therapy Overview

Manual Therapy

• Manual therapy is the deliberate application of force to body tissue, often with hands, used in treating orthopedic conditions.
• Key figures in manual therapy history include "bone setters", Hippocrates, and multiple physicians who described manipulation and referenced Hippocrates.
• Andrew Taylor Still, in 1892, established the American Osteopathic College, believing manipulation improved function of the disturbed artery.
• Daniel David Palmer developed Chiropractic Medicine, linking vertebral misalignment (subluxation) to nerve impulses and disease.
• James Henry Cyriax, in 1954, published a textbook of orthopedic medicine, laying out a logical method for differential diagnosis.
• Maitland popularized mobilization as an alternative to manipulation and developed grades I-V for mobilization.
• In 1970, the International Federation for Orthopedic Manual Therapy (IFOMT) was established and in 1992 the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) was formed.
• Manual therapy qualifications often include certifications as a Board Certified specialist in Orthopedic Physical Therapy (or similar).
• Manual therapy involves touch-based interventions like mobilization, manipulation, soft tissue mobilization, and neurodynamic movements.
• The mechanisms of manual therapy may include release of endogenous opioids, decreased cytokines, and decreased activity in the dorsal horn via descending inhibitory pathways.
• The mechanisms summed up to initiate a chain of neurophysiological responses which produce the outcomes of manual therapy.

Objectives

• Understand the definition and brief history of manual therapy in treating orthopedic conditions
• Understand the evidence for the mechanisms of pain relief when utilizing manual therapy
• Review joint kinematics with an emphasis on roll/slide movements and convex/concave rules
• Understand the definitions of joint mobilization and manipulation.

Definition

• The deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent

History

• Evidence of manual therapy dates back thousands of years
• Various cultures such as Nepal, Russia, and Norway used "bone setters".
• Hippocrates documented manipulation and traction

Mechanism

• What has been your experience with manual therapy?
• What have you heard described to patients?
• What do you believe is happening?
• Previous diagram summed up: "a mechanical force is necessary to initiate a chain of neurophysiological responses which produce the outcomes associated with MT (manual therapy)".

Transient Biomechanical Effects

• Evidence for short-term improvement in joint mobility
• Limited evidence of lasting joint position change
• Specific techniques lack precision
• Force is dissipated across a large area
• Palpation of specific structures has questionable validity and reliability
• The choice of technique seems less important than finding a patient who responds positively.

Decreased Cytokines, Release of endogenous opioids

• Cytokines are inflammatory substances released after injury
• Endogenous opioids like beta-endorphin, serotonin, and cannabinoids are released.
• These opioids decrease nerve ending sensitivity and the nerve load on pain processing regions.
• This results in decreased temporal and spatial summation.

Neuron Activation

• Neuron activation involves several stages:
• Peak action potential
• Repolarization
• Threshold of excitation
• Hyperpolarization
• Resting potential

Opioid Receptors

• Opioid neurons contain endorphins and are affected by morphine
• Presynaptic and postsynaptic opioid receptors affect pathways like the primary pain pathways.

Decreased Activity at the Dorsal Horn

• Spinal cord activity and decreased activity at the dorsal horn are aspects of manual therapy's mechanism.

Decreased Activation of Pain Processing Regions

• Pain processing occurs in several brain regions.
• These include somatosensory cortex, insular cortex, thalamus, hippocampus, prefrontal cortex, anterior cingulate cortex, amygdala, and others.

What Manual Therapy CAN and CAN'T Do

• Manual therapy CAN produce transient biomechanical effects supporting improved mobility, decrease activation of the spinal areas for central pain processing, and decrease cytokines.
• Manual therapy CAN NOT precisely locate the "cause" of pain, lengthen all specific tissues, or adjust every joint that needs manual therapy.

Joint Kinematics

• Movement at joints involves combined motions.
• Arthrokinematics describes the relative motions of joint surfaces.
• Osteokinematics describes the overall bone movement around the joint.
• Possible movements include the roll, slide/glide, and spin.

Arthrokinematic Rules

• Convex moving on concave (one rounded bone surface moves on another concave surface, and the roll and glide are opposite directions)
• Concave moving on convex(one concave bone surface moved on another convex surface, and the glide and roll are the same direction)

Joint Mobilization

• Mobilizations generally focus on glide/slide aspects of joint arthrokinematics to improve motion and pain modulation.
• Correct direction of glide may be less important than the mechanical stimulus.

Indications

• Pain, muscle guarding/spasm, ROM limitations, and functional immobility.

Contraindications

• Malignancy, osteopenia/osteoporosis, unhealed fractures/fusions, acute injuries with unknown severity, and patient refusal.

Precautions

• Hyperalgesia/allodynia, hypermobility, weakened connective tissue, recent corticosteroid use, recent surgery, disuse, and rheumatoid arthritis.

Mobilization

• Skilled passive manual therapy techniques to joints and related soft tissues.
• Maitland developed a grading system that uses different speeds and amplitudes.

Grades of Mobilization

• Includes low and large amplitude oscillation and movement with different degrees of pain modulation and tissue irritability.

Manipulation

• Defined as passive movement at a joint using hands or tools focused on the therapeutic purpose
• Maitland defines it as a small amplitude rapid movement of a joint, allowing less control from the patient

Questions

• Questions are presented, but no answers are given.