Lecture Note Theory and Practice of Manipulative Therapy MRH 432 PDF

THEORY AND PRACTICE OF MANIPULATIVE THERAPY (MRH 432) Manipulative therapy. Spinal manipulation and peripheral manipulation. Surface and radiological anatomy. History of joint manipulative techniques for joint and soft tissues. Introduction to the techniques of the various schools of thought in spi...

THEORY AND PRACTICE OF MANIPULATIVE THERAPY (MRH 432) Manipulative therapy. Spinal manipulation and peripheral manipulation. Surface and radiological anatomy. History of joint manipulative techniques for joint and soft tissues. Introduction to the techniques of the various schools of thought in spinal manipulation e.g. Cyriax, Maitland, Nwuga, Kaltenborn, etc. Introduction to the techniques of the McKenzie approach. Prolonged stretching of tissues to correct deformity. Myofascial Release. Manipulative Therapy Manipulative therapy is defined in different ways by diverse professions practicing the act to state what is permissible within the scope of practice of the individual profession. Some professions and authors alike use the term manipulative therapy, manual therapy or manual manipulative therapy interchangeably. It is generally described as a passive technique where the therapist applies a specifically directed manual impulse, or thrust, to a joint, at or near the end of the passive range of motion. This is often accompanied by an audible 'crack'. Within the physiotherapy profession, manipulative therapy is defined as a clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation and mobilization, used by the physiotherapist to diagnose and treat soft tissues and joint structures. By this definition, the purpose of manipulative therapy are to: -modulate pain -increase range of motion (ROM) -reduce or eliminate soft tissue inflammation -induce relaxation -improve contractile and non-contractile tissue repair, extensibility, and/or stability -facilitate movement -improve function. Prior to the application of manipulative therapy technique, it is very vital to understand the anatomy of the structure or part of the body being manipulated. Understanding the anatomy will assist the therapist in the examination/assessment of that body part or structure. Therefore, firsthand knowledge of anatomy in the examination of the spine and other peripheral joints before application of MT is very essential. Normal radiographic anatomy of the regions of the spine The normal radiographic anatomy of the regions of the spine comprises five regions, easily remembered by this phrase: Can This Little Servant Cook? That is cervical, thoracic, lumbar, sacral and coccyx. Each region consists of a specific number of vertebrae aggregating together to 33 in number connected by the intervertebral discs, except the last two that are fused together. The vertebrae in each region have some features which distinguish them from others, but there 1 are certain vertebrae in the cervical, thoracic and lumbar regions that possess common features such as body, spinous and transverse processes, facet joints, intervertebral foramen, etc. The structures shown on radiographs of the under listed regions in different projections/views combined may include: Cervical spine: anterior arch of the atlas, axis, body of vertebra, facet joint, dens of axis, transverse foramen, inferior articular process, intervertebral disc and foramen, lamina of vertebral arch, lateral atlantoaxial joint, lateral mass of atlas, pedicle, posterior arch of atlas, spinous process, transverse process, superior articular process, uncovertebral joint (joint of Luschka). Thoracic spine: body of vertebra, facet joint, costotransverse joint, costovertebral joint, pedicle, inferior articular process, intervertebral disc and foramen, spinous process, transverse process, superior articular process, ribs. Lumbar spine: body of vertebra, facet joint, pedicle, inferior articular process, intervertebral disc and foramen, spinous process, transverse process, superior articular process, lamina of vertebral arch, sacroiliac joint. Sacrum: coccyx, intervertebral disc and foramen, sacroiliac joint, spinous process. SURFACE AND RADIOLOGICAL ANATOMY OF THE SPINE The spine, also known as the vertebral column, is a complex structure that plays a crucial role in supporting the body and protecting the spinal cord. Understanding its surface and radiological anatomy is essential for medical professionals, particularly in fields such as orthopedics, neurology, and radiology. Surface Anatomy of the Spine Cervical Spine (Neck Region) C1 (Atlas) and C2 (Axis): These vertebrae are located at the base of the skull and are not easily palpable. C1 supports the skull, and C2 allows for head rotation. C7 (Vertebra Prominens): This is the most prominent spinous process at the base of the neck and is easily palpable. Thoracic Spine (Upper and Mid Back) T1-T12 (D1-D12): The thoracic vertebrae are located in the upper and mid-back, corresponding to the rib cage. The spinous processes are palpable but less prominent than in the cervical and lumbar regions. T7 is approximately at the level of the inferior angle of the scapula, whilst D4 is almost at the level spine of the scapula. 2 Lumbar Spine (Lower Back) L1-L5: The lumbar vertebrae are larger and located in the lower back. The spinous processes are more prominent, with L4 often being at the level of the iliac crest. L5 can be palpated just above the sacrum. Sacrum and Coccyx Sacrum: Located at the base of the spine, the sacrum is fused with the pelvis. The sacral promontory and sacral hiatus are palpable landmarks. Coccyx: The tailbone, or coccyx, is a small, triangular bone at the very end of the vertebral column and can be felt through the skin. Radiological Anatomy of the Spine Radiological imaging is essential for visualizing the spine's structure and diagnosing conditions such as fractures, degenerative diseases, and spinal deformities. Common imaging modalities include X-rays, CT scans, and MRI. Cervical Spine X-rays: AP (anteroposterior) and lateral views are common, showing the alignment, vertebral bodies, and intervertebral discs. The odontoid view (open mouth) is used to visualize C1 and C2. MRI: Provides detailed images of the soft tissues, spinal cord, and intervertebral discs, useful for diagnosing herniated discs and spinal cord compression. CT Scan: Offers detailed bony anatomy, useful for assessing fractures and bony abnormalities. Thoracic Spine X-rays: AP and lateral views are standard, allowing for the assessment of vertebral alignment and rib articulation. MRI: Useful for visualizing soft tissue structures, including intervertebral discs and the spinal cord, and identifying conditions such as tumors and infections. CT Scan: Helps in detailed assessment of vertebral fractures, bony lesions, and deformities. Lumbar Spine 3 X-rays: AP and lateral views are common, often with oblique views to visualize the pars interarticularis (commonly assessed in cases of spondylolysis). MRI: Highly detailed images of the intervertebral discs, nerve roots, and spinal cord, crucial for diagnosing conditions like lumbar disc herniation and spinal stenosis. CT Scan: Used to assess bony structures, including fractures, and to plan for surgical interventions. Sacrum and Coccyx X-rays: Lateral views are typically used to assess the alignment and any potential fractures. MRI: Useful for evaluating soft tissue injuries, tumors, and infections in the sacral region. CT Scan: Provides detailed imaging of the sacrum and coccyx, useful in trauma cases to assess fractures. Key Points Cervical Spine: C7 is a palpable landmark, and imaging focuses on vertebral alignment and soft tissue structures. Thoracic Spine: The vertebrae align with the rib cage, and imaging evaluates both the bony and soft tissue anatomy. Lumbar Spine: L4 is aligned with the iliac crest, and imaging is crucial for diagnosing common lower back issues. Sacrum and Coccyx: These are more static regions, with imaging focusing on trauma and degenerative changes. Understanding both the surface landmarks and radiological appearances of the spine is vital for accurate diagnosis and effective treatment planning. SURFACE AND RADIOLOGICAL ANATOMY OF THE JOINTS OF THE LIMBS The joints of the limbs are crucial for movement and function. Understanding their surface and radiological anatomy is essential for diagnosing and treating conditions related to musculoskeletal health. Surface Anatomy of the Joints of the Limbs (peripheral/appendicular joints 4 Upper Limb Joints Shoulder Joint (Glenohumeral Joint) Surface Anatomy: The shoulder joint is located where the head of the humerus meets the glenoid cavity of the scapula. The acromion, a bony prominence of the scapula, is palpable at the top of the shoulder. The clavicle is easily palpable along its length, and the coracoid process can be felt deep in the deltopectoral groove. Key Landmarks: Acromion, clavicle, coracoid process. Elbow Joint Surface Anatomy: The elbow is formed by the articulation of the humerus with the ulna and radius. The olecranon process of the ulna is a prominent bony structure that is easily palpable at the back of the elbow. The lateral and medial epicondyles of the humerus are also palpable on either side of the elbow. Key Landmarks: Olecranon process, lateral and medial epicondyles. Wrist Joint (Radiocarpal Joint) Surface Anatomy: The wrist joint is formed where the distal end of the radius meets the carpal bones. The radial styloid process is palpable on the lateral side of the wrist, and the ulnar styloid process on the medial side. The anatomical snuffbox, a depression on the lateral side of the wrist, is a key surface landmark. Key Landmarks: Radial styloid process, ulnar styloid process, anatomical snuffbox. Hand Joints Surface Anatomy: The joints of the hand include the metacarpophalangeal joints (MCP), proximal interphalangeal joints (PIP), and distal interphalangeal joints (DIP). The MCP joints are palpable at the base of each finger, while the PIP and DIP joints are palpable along the fingers. Key Landmarks: MCP joints, PIP joints, DIP joints Lower Limb Joints Hip Joint: 5 Surface Anatomy: The hip joint is formed where the head of the femur meets the acetabulum of the pelvis. The greater trochanter of the femur is a palpable bony prominence on the lateral side of the hip. Key Landmarks: Greater trochanter, anterior superior iliac spine (ASIS). Knee Joint Surface Anatomy: The knee joint is formed by the articulation of the femur, tibia, and patella. The patella (kneecap) is easily palpable on the front of the knee. The tibial tuberosity is a bony prominence below the patella. The joint line, where the femur and tibia meet, can be palpated on either side of the knee. Key Landmarks: Patella, tibial tuberosity, joint line. Ankle Joint (Talocrural Joint) Surface Anatomy: The ankle joint is formed by the distal ends of the tibia and fibula articulating with the talus bone. The medial and lateral malleoli are palpable on either side of the ankle. Key Landmarks: Medial malleolus (tibia), lateral malleolus (fibula), Achilles tendon. Foot Joints Surface Anatomy: The foot includes the subtalar joint, metatarsophalangeal joints (MTP), and interphalangeal joints. The MTP joints are palpable at the base of the toes, while the interphalangeal joints are palpable along the toes. Key Landmarks: MTP joints, interphalangeal joints. Radiological Anatomy of the Joints of the Limbs Upper Limb Joints Shoulder Joint X-rays: AP and lateral views are standard, showing the alignment of the humeral head with the glenoid cavity. The axillary view is used to assess dislocations. MRI: Provides detailed images of the soft tissues, including the rotator cuff, labrum, and biceps tendon. 6 CT Scan: Useful for evaluating complex fractures and bony abnormalities. Elbow Joint X-rays: AP and lateral views are common, focusing on the alignment of the humerus with the radius and ulna. Oblique views may be used for better visualization of the radial head. MRI: Detailed images of ligaments, tendons, and cartilage, used for assessing soft tissue injuries. CT Scan: Helps in assessing complex fractures and joint abnormalities. Wrist Joint X-rays: PA (posteroanterior) and lateral views are standard, showing the alignment of the carpal bones with the radius and ulna. MRI: Provides detailed images of the ligaments, tendons, and cartilage, useful for diagnosing conditions like carpal tunnel syndrome and ligament injuries. CT Scan: Used for assessing fractures and carpal bone alignment. Hand Joints X-rays: AP, oblique, and lateral views are used to visualize the alignment and integrity of the bones and joints of the hand. MRI: Useful for evaluating soft tissue injuries, including ligament tears and tendon injuries. CT Scan: Detailed imaging of bony structures, useful in trauma cases Lower Limb Joints Hip Joint X-rays: AP and lateral views (frog-leg) are standard, showing the alignment of the femoral head with the acetabulum. MRI: Provides detailed images of the soft tissues, including the labrum, ligaments, and cartilage, useful for diagnosing labral tears and avascular necrosis. CT Scan: Useful for evaluating complex fractures and bony abnormalities. 7 Knee Joint X-rays: AP, lateral, and sunrise (patellar) views are common, focusing on the alignment of the femur, tibia, and patella. MRI: Detailed images of the menisci, ligaments (ACL, PCL, MCL, LCL), and cartilage, used for assessing soft tissue injuries. CT Scan: Useful for evaluating complex fractures and bony abnormalities, especially in trauma cases. Ankle Joint X-rays: AP, lateral, and mortise views are standard, showing the alignment of the tibia, fibula, and talus. MRI: Provides detailed images of the ligaments, tendons, and cartilage, useful for diagnosing soft tissue injuries and ligament tears. CT Scan: Used for assessing fractures, particularly in cases of complex trauma. Foot Joints X-rays: AP, lateral, and oblique views are used to visualize the alignment and integrity of the bones and joints of the foot. MRI: Useful for evaluating soft tissue injuries, including ligament tears, tendon injuries, and plantar fasciitis. CT Scan: Detailed imaging of bony structures, useful in trauma cases and complex fractures. Key Points Upper Limb Joints: Surface anatomy focuses on palpable bony landmarks. Radiological imaging often includes X-rays for bone alignment and MRI for soft tissue evaluation. Lower Limb Joints: Palpable landmarks guide the surface anatomy, while imaging includes X- rays for bony structure and MRI/CT for soft tissue and complex fractures. Understanding both surface and radiological anatomy is critical for accurate diagnosis and effective treatment of joint-related conditions in the limbs. 8 Client's Examination before Application of SPINAL MANIPULATION The ability to observe the client modestly, listen attentively to his complaints, and interpret the signs and symptoms he presents form the basis for a successful treatment. An adequate and detailed pre-treatment examination is required to form an intelligent rationale for plan of management. Importance of examination 1. Examination helps the therapist to select the appropriate technique for treatment, and hence guide the therapist to avoid the choice of wrong technique that may worsen or alter the symptoms the client presented initially. For instance, if a client says that supine or left side lying increases his pain, advising him to continue using these positions, invariably will not improve this symptom. 2. Examination will lead to a fairly accurate prognosis as to how the client will react to manipulation. E.g. a client who presents with a long lasting or chronic back pain will probably stay longer with the therapist than one presenting with recent pain. So also, a client whose SLR is 70° may have a better prognosis than one whose SLR is 30°. In the same vein, a client whose onset of symptoms was sudden and was associated with a particular spinal movement will probably respond better to treatment than whose onset of symptoms was insidious and spontaneous. With these types of information, the examiner will be to set the goals of treatment as well as formulate treatment plan. 3. Findings from examination help to determine whether manipulation is indicated or contraindicated. Some symptoms that present as back disorder may be systemic or referred from the viscera. If an examiner becomes suspicious or the presented case is obscure, discussing with the referral physician for further assessment, is not out of place. Although, it may be assumed that the client might have undergone thorough assessment before being referred, but back pain is a complex phenomenon, and sometimes human error plays out. For instance, a client was referred for acute lumbar disc prolapse; on examination, the articular signs was not in consistent with that kind of picture usually observed in this type of condition. All the possible movements of the spine did not affect the client's pain in anyway. The client was later re-diagnosed as a case of carcinoma of the bronchus which referred the pain to the back. Such cases although not very rampant, but do occur, hence the essence of proper clinical examination and reasoning. 4. A comprehensive clinical examination will establish the pre-treatment picture of the client. A comparison with the post-treatment picture will give the examiner a definite idea whether the presented condition has improved, remain the same, or deteriorated. E.g. if a client presented with a shooting pain which radiated to the gluteal region on coughing and this disappeared after treatment, this is a positive indication that the condition is improving. 5. A methodological examination will lead the therapist to the exact location or source of the client's lesion. By getting to the source of the pain, the client is more likely to be helped 9 maximally, thus avoiding waste of the client's and therapist's time. It is also cost beneficial to the client and reduces his stay with the therapist. Initial questioning and observation Examination of the client begins immediately from the point of entrance to when he eventually enters the examination room/cubicle. The overall pictures which he presents with should be fully noted. Does he have a good posture? A limp? As he tries to sit down, does he perform this simple exercise with ease, or with difficulty accompanied by grimacing or other telltale signs of pain? The attitude which he presents to the treatment area and other nonverbal cues should be well noted and appropriate communication style should be adopted. The client's sociodemographics such as age, sex, occupation, hobbies, sports interest etc. should be noted. Younger clients respond differently to manipulation when compared to their older counterparts. The type of work a client does or his sports activities may give clue to the mechanism of injury to the back. A labourer who spends all day bending, lifting, twisting and shoveling, a farmer who handles heavy equipment, a banker who sits all day long, a mother who lifts and carries her wrongly might give a vital clue on how their respective pain predisposed. When the back is draped, excessive lordosis, thoracic kyphosis, scoliosis and the general spinal posture should be properly observed. These will give the therapist an insight into the mechanical efficiency of the spine and kind of stresses with which the back has to cope with. For instance, an exaggerated thoracic kyphosis will lead to the contractures on the anterior spinal structures, and stretching of the posterior structures. A scoliotic spine will present with increased compression of the structures located at the concavity side. Additionally, there may be osteophitic formation in old cases, ligaments stretching on the concave side, narrowing of joint spaces and sclerosis of bones on the concave side. When examining the general spinal posture for any possible deviation, the furrow which runs down the center of the back may not give an examiner the accurate picture. E.g. some scoliotic conditions have a greater rotatory component than lateral component, thus a cursory view of the spinous processes may not reveal the exact degree of the spinal deformity. However, if the client is asked to flex the spine forward, the symmetry of the two sides of the back can be assessed by a horizontal view or tangential view from above. If a scoliosis is present, one side of the back will demonstrate a greater upward prominence than the other. When the scoliotic condition is structural in nature, it presents the higher side on the convexity of the curve. If a rotatory component is present in the deformity, a rib hump appears as the patient flexes forward. While viewing the back, one may observe a fixed kyphosis which may be indicative of ankylosing spondylitis. Undue prominence of the spinous process of L5 may be due to spondylolisthesis. There may be presence of obliterated normal lordotic curve at the lumbar region, flattening the back or even showing slight flexion with the patient leaning toward or away from side of the pain. The hip and knee knee may be held in flexion on the side of the pain. This is usually a sign of root irritation. In severe cases, the patient holds back rigidly and his movement is deliberate, avoiding any movement in the spinal region. Sitting or standing becomes difficult. 10 With the examiner still looking at the patient's back, the posterior superior iliac spines (PSISs) can be checked for horizontal alignment. In the standing position, the PSIS are indicated by the two dimples in the lower back. During forward bending, the dimples disappear and are replaced by two bony prominences. If a patient has one lower limb shorter than the other, the horizontal alignment which normally exists between the two dimples disappears. The examiner can estimate the relative heights of the dimples by placing his thumbs on them. Leg length discrepancy (LLD) which exceeds 1 cm may require prescribing a shoe raise to restore the natural horizontal alignment between the two dimples. This may be a more permanent means of approaching the condition compared with manipulative treatment, although it can be used initially. A common cause of leg shortening is an old fracture of the femur. LLD can be true or apparent. True LLD is determined by placing the patient's lower limb in comparable positions (i.e. squaring the pelvis), then measuring the distance from the anterior superior iliac spines (ASIS) to the medial malleoli. If the distances measured on both sides are not equal, it indicates one lower limb is shorter than the other. If the test shows that the lower limbs are equal, a test of apparent LLD which stems from pelvic obliquity may be performed. With the patient lying supine and the lower limb in a neutral position, the examiner measures from the umbilicus to the medial malleolus. An unequal distances on both sides indicate an apparent LLD. Another way of testing for a short lower limb is to ask the patient to bend forward. A careful tangential view will reveal that the lower back on the short side will look lower. The somatotype (body built/type) of the patient may be noted at this stage. If the patient is obese, treatment with manual therapy may be difficult. Patients of this type are usually difficult to palpate accurately and the therapist may even find it difficult to direct manipulative therapy to the desired area because of the interfering fat contents of the tissues. The situation may be worse if the therapist is a frail female. If in addition to the obesity, the patient also presents with protruding fat abdomen, the center of gravity is thrown anteriorly with a compensation hyperextended lumbar spine. In the short stocky type of patient the muscles and ligaments are usually strong and joint movements less than the average. Degenerative changes are more marked in them. Patients with this body type are not also easy to manipulate. Slender patients present with weaker muscles and ligaments. They are easier to palpate since the bony points are more prominent, and layers of muscles and fat considerably less. Intervertebral discs The intervertebral discs (or discs) are fibrocartilages lying between adjacent surfaces of the vertebrae. They form a fibrocartilaginous joint between the vertebral bodies, linking them together. Collectively, the discs make up one quarter to one third of the total spinal column's length, forming an interpose between adjacent vertebrae from the axis (C2) to the sacrum. There are about 23 discs in the spine: 6 cervical, 12 thoracic, and 5 in the lumbar region. The intervertebral discs are approximately 7-10 mm thick and 4 cm in diameter (anterior - posterior plane) in the lumbar region of the spine. It consists of a thick outer ring of fibrous cartilage called the anulus (derived from the Latin word "anus" meaning ring) or annulus (anulus fibrosus disci intervertebralis), which surrounds an inner gel-like centre or more gelatinous core known as the 11 nucleus pulposus (meaning "pulpy interior"). The nucleus pulposus is sandwiched inferiorly and superiorly by cartilage endplates. Structure Anulus fibrosus: The anulus is made up of a series of 15-25 concentric rings, or lamellae, with the collagen fibres lying parallel within each lamella. The fibres are oriented at approximately 60 degrees to the vertical axis, alternating to the left and right of it in adjacent lamellae. Elastin fibres lie between the lamellae, possibly helping the disc to return to its original arrangement following bending (flexion or extension). Cells of the anulus are elongated, thin, and aligned parallel to the collagen fibres. Towards the inner anulus the cells are oval. The anulus is relatively stiff providing greater strength to the disc and withstands compressive force. Nucleus pulposus: The central nucleus pulposus contains collagen fibres which are organized randomly, and elastin fibres which are arranged radially. These fibres are embedded in a highly hydrated aggrecan containing gel. In infant humans, the nucleus contains around 87% water and is translucent. The hydration of the nucleus falls to around 80% in young adults and the nucleus then loses its translucent appearance and becomes whiter, firmer, and less easily distinguishable from the surrounding annulus fibrosus. With age the disc begins to accumulate yellow pigmentation. Endplate: The endplate is the third morphologically distinct part of the intervertebral disc. It is a thin horizontal layer, usually less than 1 mm thick. This structure interfaces the disc and the vertebral body. Collagen fibres within it run horizontally and parallel to the vertebral bodies, and become continuous with the disc. In humans, unlike in most animal species, this endplate acts as the growth plate for the vertebral bodies and has the typical structure of an epiphyseal growth plate. In infancy, this growth plate is thick and occupies a substantial fraction of the disc and is penetrated by cartilage canals and small blood vessels. It thins as growth progresses; the cartilage canals disappear and the endplate loses its vascularity. By maturity, the endplate consists of a thin (