Manual Therapy Intro PDF

Manual Therapy Adam Squires PT, DPT, Cert SMT, Cert DN Board Certified Specialist in Orthopedic Physical Therapy  Objectives Understand the definition and a brief history of manual therapy in treating orthopedic conditions. Understand the current evidence on the m...

Manual Therapy Adam Squires PT, DPT, Cert SMT, Cert DN Board Certified Specialist in Orthopedic Physical Therapy  Objectives Understand the definition and a brief history of manual therapy in treating orthopedic conditions. Understand the current evidence on the mechanisms of pain relief when utilizing manual therapy. Review joint kinematics with an emphasis in the roll/slide movements and convex/concave rules Understand definitions of joint mobilization and joint manipulation.  Definition “The deliberate application of externally generated force upon body tissue, typically via the hands, with therapeutic intent” (Kerry 2024) Touch-based interventions Mobilization Manipulation Soft tissue mobilization Neurodynamic movements https://www.olagrimsby.com/courses/mt2-cervical-spine-upper-extremity-manual-therapy/  History Evidence for manual therapy going back thousands of years “Bone setters” Nepal, Russia, Norway, and others Hippocrates Manipulation and traction 16-19th century https://www.twohandsphysiotherapy.ca/Blog/37/Home Multiple physicians describe manipulation in textbooks, often referencing Hippocrates  History In 1892, Andrew Taylor Still established the American Osteopathic College Believed manipulation could cure disease through improving function of the “disturbed artery”. Daniel David Palmer Developed Chiropractic Medicine Vertebrae that are out of alignment (subluxation) affects nerve impulses Leads to disease  History James Henry Cyriax Published Textbook of Orthopedic Medicine, Volume I in 1954 Laid out a method for logical, clinically reasoned differential diagnosis Called “selective tissue tension testing” Maitland Popularized mobilization as an alternative to manipulation Developed grades for mobilization I-V  History In 1970, the International Federation for Orthopedic Manual Therapy (IFOMT) was established In 1992, American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) was founded If you complete an accredited OMPT fellowship, can achieve the credential FAAOMPT Recognized as an integral part of physical therapy scope of practice Mechanisms of Manual Therapy  Mechanisms What has been your experience with manual therapy? What have you heard described to patients? What do you believe is happening? Mechanisms  Mechanisms 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]”  Mechanisms Transient Biomechanical Effects Evidence for short-term improvements in joint mobility No evidence for lasting joint position change Specific techniques lack precision Force is dissipated across a large area Palpation of specific structures demonstrates poor validity and reliability Choice of technique does not seem to matter More important to find the patient that will respond  Mechanisms Decreased Cytokines, Release of endogenous opioids Happens in the periphery Cytokines – inflammatory chemicals released following injury Endogenous opioids – beta-endorphin, serotonin, cannabinoids Has the effect of decreasing nerve ending sensitivity and nociceptive load to the pain processing regions of the brain i.e. decreased temporal and spatial summation  Mechanisms Neuron activation https://organismalbio.biosci.gatech.edu/chemical-and-electrical-signals/neurons/ https://jackwestin.com/resources/mcat-content/nerve-cell/excitatory-and-inhibitory-nerve-fibers-summation-frequency-of-firing  Mechanisms Opioid receptors https://opentext.wsu.edu/biopsychological-effects-alcohol-drugs/chapter/chapter-12-opioids/#12.3  Mechanisms Decreased activity at the dorsal horn https://www.nature.com/articles/nrd3673  Mechanisms Decreased activity in the dorsal horn via descending inhibitory pathways  Mechanisms Decreased activity at the dorsal horn Gate open Gate closed https://www.physio-pedia.com/Gate_Control_Theory_of_Pain https://www.physio-pedia.com/Gate_Control_Theory_of_Pain  Mechanisms Decreased activation of pain processing regions https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2021.628980/full https://aneskey.com/pain-as-a-perceptual-experience/ Mechanisms Joint Kinematics  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 Roll, slide/glide, spin Osteokinematics refers to movement of the bones around a joint Flexion, extension, abduction, etc. Joint Kinematics  Arthrokinematic Rules Convex moving on concave Roll and glide are opposite https://quizlet.com/67367282/osteokinematics-arthrokinematic-flash-cards/  Arthrokinematic Rules Concave moving on convex Roll and glide are same https://clinicalgate.com/knee-5/  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, Contraindications, Precautions  Indications Pain Muscle guarding/spasm ROM limitations Functional Immobility https://elliottphysicaltherapy.com/physical-therapy-treatments/manual-therapy/  Contraindications Malignancy Osteopenia, osteoporosis Manipulation Unhealed fracture or unhealed fusion Acute injury where there is uncertainty related to the severity of damage Patient does not want it  Precautions Hyperalgesia/Allodynia Hypermobility Weakened connective tissue Long-term corticosteroid use Immediately after surgery Disuse https://clipart-library.com/precaution-cliparts.html 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  Grades of Mobilization Grade I – Low amplitude oscillation at beginning of motion Pain modulation – high symptom irritability Grade II – Large amplitude osc within available motion Pain modulation – high symptom irritability Grade III – Large amplitude osc up to and through tissue resistance Pain modulation and, theoretically, capsular stretch – moderate to low irritability Grade IV – small amplitude at and through tissue resistance Pain modulation and, theoretically, capsular stretch – low irritability  Grades of Mobilization Kaltenborn Grades Manipulation  Manipulation Cyriax defined as: “simply defined as a passive movement at a joint with a therapeutic purpose, using the hands” Maitland defined as: “a small amplitude, rapid movement (not necessarily performed at the limit of a range of movement); which the patient cannot prevent from taking place”  Manipulation Guide to Physical Therapist Practice “Mobilisation/Manipulation: 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”  Manipulation Will often see these terms used interchangeably In this class, we will use mobilization for low speed, oscillatory movements and manipulation for high velocity, low amplitude thrust techniques Most often directed to the spine, but can be used with peripheral joints as well  Objectives Understand the definition and a brief history of manual therapy in treating orthopedic conditions. Understand the current evidence on the mechanisms of pain relief when utilizing manual therapy. Review joint kinematics with an emphasis in the roll/slide movements and convex/concave rules Understand definitions of joint mobilization and joint manipulation. Questions