Principles, Effectiveness, and Classification of Manual Therapy PDF

MPTY03.1 Prof. Dr. Firas MOURAD PRINCIPLES, EFFECTIVENESS AND CLASSIFICATION OF MANUAL THERAPY 1 HISTORICAL TIMELINE OF THE DEVELOPMENT OF MANUAL THERAPY M...

MPTY03.1 Prof. Dr. Firas MOURAD PRINCIPLES, EFFECTIVENESS AND CLASSIFICATION OF MANUAL THERAPY 1 HISTORICAL TIMELINE OF THE DEVELOPMENT OF MANUAL THERAPY MacDonald et al, 2019 2 HISTORICAL TIMELINE OF THE DEVELOPMENT OF MANUAL THERAPY The Chartered Society of Physiotherapy was founded as the Society of Trained Masseuses in 1894 by 4 nurses. By 1900 the Society had acquired the legal and public status of a professional organisation and became the Incorporated Society of Trained Masseuses. In 1920, the Society was granted its Royal Charter. 3 THE BIRTH OF IFOMPT The inaugural meeting of the International Federation of Orthopaedic Manipulative Therapists (IFOMT) was hosted in Montreal, Canada in 1974. This meeting provided the first international forum for this specialist area of physical therapy following a period of growth and dissemination of Orthopaedic Manipulative Therapy through courses throughout the world by a group of eminent physical therapists. 4 BIOMECHANICAL APPROACH Kahanov & Kato, 2007 5 BIOMECHANICAL APPROACH Farrell & Jensen, 1992 6 MANUAL THERAPY REVOLUTION Sacket, 1996; Djulbegovic & Guyatt, 2017; Engel, 1977 7 MANUAL THERAPY REVOLUTION The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model This model suggests that a mechanical force from MT initiates a cascade of neurophysiological responses from the peripheral and central nervous system which are then responsible for the clinical outcomes. Bialosky et al, 2009 8 MANUAL THERAPY REVOLUTION Manual Therapy is an effective treatment contributing to the recovery of functional capabilities, but it should be included within a multimodal approach targeting the functional recovery of the patient. Current evidence is suggesting that a multimodal approach, including manual therapy, exercise and education, seems to provide better outcomes than manual therapy alone. A genuine multimodal approach should include not only physical management but a consideration of the psychological and psychosocial aspects of the patient's unique pain experience. Bishop et al, 2015 9 MANUAL THERAPY REVOLUTION https://guide.apta.org/search 10 MANUAL THERAPY REVOLUTION Since 1998, APTA’s Guide to Physical Therapist Practice has defined mobilization/manipulation as “a manual therapy technique comprised of a continuum of skilled passive movements that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement.” To achieve a common language for describing this area of the physical therapist’s scope of practice, the terms “thrust” and “nonthrust” manipulation were established to replace the previous terms “manipulation” and “mobilization,” respectively. The APTA Manipulation Education Manual for Physical Therapist Professional Degree Programs further defines thrust manipulation as a “high velocity, low amplitude therapeutic movement within or at the end range of motion” and nonthrust as manipulations that do not involve thrust. https://www.okmedicalboard.org/physical_therapists/download/766/APTA+PTs+and+Direction+of+Mobilization+and+Manipulation.September+2013.pdf 11 MANUAL THERAPY REVOLUTION Manual therapy (MT) is a passive, skilled movement applied by clinicians that directly or indirectly targets a variety of anatomical structures or systems, which is utilized with the intent to create beneficial changes in some aspect of the patient pain experience. Collectively, the process of MT is grounded on clinical reasoning to enhance patient management for musculoskeletal pain by influencing factors from a multidimensional perspective that have potential to positively impact clinical outcomes. The influence of biomechanical, neurophysiological, psychological and nonspecific patient factors as treatment mediators and/or moderators provides additional information related to the process and potential mechanisms by which MT may be effective. As healthcare delivery advances toward personalized approaches there is a crucial need to advance our understanding of the underlying mechanisms associated with MT effectiveness. Bishop et al, 2005 12 MANUAL THERAPY REVOLUTION Passive intervention, defined as health-promoting material that does not require human involvement for delivery 169 unique terms labeled as manual therapy Rhon & Deyle, 2021; Minnucci et al, 2023; Wenger et al, 2023 13 VISCERAL MANIPULATION Poor evidence for the efficacy of the techniques used in Fascial Therapy targeting the visceral system, and this information can help healthcare professionals in decision-making related to the use of Fascial Therapy targeting the visceral system in patients with visceral disorders and/or pain. da Silva et al, 2023 14 SPINAL MANIPULATIVE THERAPY Given the evidence from RCTs and SRs of similar pain & function outcomes to other recommended interventions, manual therapy is a recommended treatment for patients with MSK conditions. No more research is warranted. Nim et al. Chiropractic & Manual Therapies (2023) 31:14 Chiropractic & https://doi.org/10.1186/s12998-023-00487-z Manual Therapies STUDY PROTOCOL Open Access The effectiveness of spinal manipulative therapy procedures for spine pain: protocol for a systematic review and network meta-analysis Casper G. Nim1,2,3* , Sasha L. Aspinall4, Chad E. Cook5,6,7, Leticia A. Corrêa8, Megan Donaldson9, Aron S. Downie8, Steen Harsted1,3, Jan Hartvigsen3,10, Hazel J. Jenkins8, David McNaughton11, Luana Nyirö12, Stephen M. Perle4,13, Eric J. Roseen14, James J. Young3,15, Anika Young8, Gong-He Zhao3,16 and Carsten B. Juhl3,17 Abstract Prof. Nadine Foster, NIHR Senior Investigator – EMCT 23 Conference comunication; Nim et al, 2024 15 Background Spinal manipulative therapy (SMT) is a guideline-recommended treatment option for spinal pain. The recommendation is based on multiple systematic reviews. However, these reviews fail to consider that clinical effects may depend on SMT “application procedures” (i.e., how and where SMT is applied). Using network meta-analyses, we aim to investigate which SMT “application procedures” have the greatest magnitude of clinical effectiveness for reduc- ing pain and disability, for any spinal complaint, at short-term and long-term follow-up. We will compare application procedural parameters by classifying the thrust application technique and the application site (patient positioning, assisted, vertebral target, region target, Technique name, forces, and vectors, application site selection approach and rationale) against: 1. Waiting list/no treatment; 2. Sham interventions not resembling SMT (e.g., detuned ultrasound); COST-EFFECTIVENESS Many studies support that Manual Therapy is cost-effective. NO studies supporting that Manual Therapy is cost-prohibitive. Michaleff et al, 2012; Whedon et al, 2021; Leininger et al, 2016; Andronis et al, 2016; 16 Tsertsvadze et al, 2014; Korthals-de Bos et al, 2003; Dagenais et al, 2013 CLINICAL PRACTICE GUIDELINES Spinal manipulation consistently recommended for acute, subacute, and chronic across international CPGs. Zhou et al. BMC Musculoskeletal Disorders (2024) 25:344 BMC Musculoskeletal https://doi.org/10.1186/s12891-024-07468-0 Disorders RESEARCH Open Access Recent clinical practice guidelines for the management of low back pain: a global comparison Tianyu$Zhou1* , David$Salman1,2 and Alison. H.$McGregor1 Abstract Background Low back pain (LBP) is a signi!cant health problem worldwide, with a lifetime prevalence of 84% in the Zhou et al, 2024; WHO, 2023 17 general adult population. To rationalise the management of LBP, clinical practice guidelines (CPGs) have been issued in various countries around the world. This study aims to identify and compare the recommendations of recent CPGs for the management of LBP across the world. Methods MEDLINE, EMBASE, CINAHL, PEDro, and major guideline databases were searched from 2017 to 2022 to identify CPGs. CPGs focusing on information regarding the management and/or treatment of non-speci!c LBP were considered eligible. The quality of included guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Results Our analysis identi!ed a total of 22 CPGs that met the inclusion criteria, and were of middle and high methodological quality as assessed by the AGREE II tool. The guidelines exhibited heterogeneity in their recommendations, particularly in the approach to di"erent stages of LBP. For acute LBP, the guidelines recommended the use of non-steroidal anti-in#ammatory drugs (NSAIDs), therapeutic exercise, staying active, and spinal MPTY03.1 Prof. Dr. Firas MOURAD TRADITIONAL ASPECTS OF MANUAL THERAPY 18 END FEEL The endpoint/barrier of the ROM of a joint can be described as ‘end-feel’. - When a joint is actively or passively brought to its physiological limit, there is usually a definite, but not abrupt end-feel. - When the joint is brought to its anatomical limit, there is a stiffer sensation. - However, if there is a restriction in the normal ROM of a joint, then there is a pathological barrier evident in active or passive movement. Normal end-feel: - SOFT: due to soft tissue approximation (knee flexion) or soft tissue elongation (ankle dorsiflexion). - ELASTIC: capsular or ligamentous elongation (internal rotation of the femur). - HARD: occurs when bone against bone (elbow extension) Pathological end-feel may involve a number of presentation such as: - a harder, less elastic sensation when scar tissue restricts movement or when there is shortened connective tissue - an elastic, less soft sensation when an increase in muscle tone restricts movement - a hollow end-feel occurs when the patient stops movement (or asks to stop it) before reaching a true end-feel, due to extreme pain or fear/kinesiophobia. Kaltenborn, 1985 19 END FEEL Kaltenborn, 1985 20 JOINT PLAY It refers to the accessory movements (arthrokinematics), associated with separation (traction) or parallel movement of joint surfaces (sliding or gliding). Some degree of such movement is physiological and is limited by the degree of elasticity of the soft tissue. Any change in the length/integrity of these tissues alters the joint play. Kaltenborn, 1985 21 JOINT PLAY Kaltenborn, 1985 22 TAKING OUT THE SLACK The purpose of tissue pull is to take the slack out of the skin, subcutaneous tissues, and underlying muscle up to the segmental contact point prior to making your contact. This makes the contact with the segmental contact point more stable (your contact point is not sliding around), and if done in the right direction, it pre-stresses the tissue in the direction of correction. Kaltenborn, 1985 23 BARRIER Pain Physiologic ROM Physiologic barrier Elastic barrier Plastic barrier Anatomical barrier Petracca & Di Giacomo, 2017 24 MOBILIZATION TYPES: Traction Spin Glide Angular movement PARAMETERS: Velocity Amplitude Force Maitland, 1991 25 HOW TO DELIVER MANUAL THERAPY No standard prescription but should be modulated to the singular person within and between sessions in the context of a multimodal approach. GOAL: PAIN & FUNCTION. Variable to consider: Stage of the condition, Healing phase, Loadibility, Comorbities, Contraindication, Patient expectation and feedback da Silva et al, 2023 26 TISSUE HEALING 27 PERIPHERAL NEUROPHYSIOLOGICAL MECHANISM The effects of manual therapy are transient and can be attributed to neurophysiological alterations of the patient's nociceptive system 28 NEUROPHYSIOLOGICAL MECHANISMS Kahanov & Kato, 2007 29 OSCILLATORY GRADING Maitland, 1991 30 THE MOBILE GRADING Pain I II III IV Physiologic ROM Physiologic barrier Elastic barrier Plastic barrier Anatomical barrier Maitland, 1991 31 GRADING Technique Goal Dosage Stimulus Oscillatory Pain reduction 60-120/min Mechanoreceptors type 1-5 sets of 30-60sec II Prolonged hold Applied to end-range to 5-30 sec Mechanoreceptors type reduce stiffnes 1-5 reps I and III 32 FORCE To date, there are no recommendations on how much force should be used in each individual therapeutic manoeuvre. The available studies are of low quality and often on asymptomatic subjects. Studies have not been done on all joints and, above all, with variable measurements. Generally, poor inter-reliability but better intra-reliability. Because of these points there is a difficulty in learning these methods clearly. Gorgos et al, 2014 33 IRRITABILITY High irritability > acute inflammatory phase > grade I oscillatory movements > away from stiffness Moderate irritability > proliferative phase > oscillatory movements grade II > towards stiffness Low irritability > remodelling phase > oscillatory movements grade III-IV > within the stiffness but away from painful 34 APPLICATION STRATEGIES 35 APPLICATION STRATEGIES COCKPIT MODEL Reasoning model for the application and adaptation of parameters in manual therapy techniques. Rhythm Amplitude Direction Joint position Mobilization technique Components Repetitions Intensity Force 36 CASE STUDY Matthew, footballer, suffers an ankle sprain in inversion 3 days ago. Walk with crutches, no weight-bearing on affected foot, swollen and warm ankle, active ROM limited due to pain in all planes of motion. What parameters to set the techniques in the first session? 37 CASE STUDY Matthew, footballer, suffers an ankle sprain in inversion 3 days ago. Walk with crutches, no weight-bearing on affected foot, swollen and warm ankle, active ROM limited due to pain in all planes of motion. What parameters to set the techniques in the first session? Grade 1-2 Traction Single movement Non-end-range Small amplitude Little force Fast oscillations 38 CASE STUDY Matthew, footballer, sprained ankle inversion 30 days ago Walks, runs without pain in straight direction, but has pain (NRS 3/10) on landing from jump and in rapid change of direction Slightly limited active ROM in dorsiflexion What parameters to set the techniques in the first session? 39 CASE STUDY Matthew, footballer, sprained ankle inversion 30 days ago Walks, runs without pain in straight direction, but has pain (NRS 3/10) on landing from jump and in rapid change of direction Slightly limited active ROM in dorsiflexion What parameters to set the techniques in the first session? Grade 3-4 Angular movements Multiple movement End-range Moderate amplitude Moderate force Slow and sustained oscillations 40 MPTY03.1 Prof. Dr. Firas MOURAD MODERN MANUAL THERAPY 41 CLINICAL REASONING Joint mobilization/manipulation is an example of an intervention that does not easily lend itself to being segmented into distinct sequential phases of evaluation and implementation. Clinical judgments about the amount of force to apply to create or progress an arthrokinematic change cannot be made on a “stop-evaluate-decide-proceed” linear time sequence. The implementation of the procedure, by its very nature, produces new findings that must be evaluated simultaneously as the intervention is implemented. Examination, evaluation, intervention, and clinical decision making are inseparable in the performance of mobilization/manipulation. https://www.okmedicalboard.org/physical_therapists/download/766/APTA+PTs+and+Direction+of+Mobilization+and+Manipulation.September+2013.pdf 42 THE IMPORTANCE OF SELECTING THE CORRECT SITE TO APPLY SPINAL MANIPULATION WHEN TREATING SPINAL PAIN: MYTH OR REALITY? The ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of Manual Therapy is in contrast with current evidence. Nim et al, 2021 43 INTEGRATED WITHIN EBP & ICF Gutenbrunner et al., 2007; Sackett & Rosenberg, 1995 44 MECHANISMS Bialosky et al, 2018 45 EFFECTS Bishop, 2005 46 EFFECTS Pain modulation Contextual Muscle tone and spindles firing Inflammatory processes Immune system Vascular system Physical changes Bialosky et al, 2018; Gevers-Montoro et al, 2021; Youg et al, 2024; Cook et al, 2024 47 EFFECTS Coronado & Bialosky, 2017 48 HIGH-VALUE CARE Cook et al, 2021 49 PATIENTS’ ATTITUDES AND BELIEFS «Spinal Manipulative Therapy is believed to be effective (over the short term) and is a preferential option in the management of LBP.» Patients believe in a biomechanical mechanism of SMT which is associated with their beliefs about their LBP Thomas et al, 2023: Dubé et al, 2024 50 HIGH-VALUE MANUL THERAPY Rhon & Deyle, 2021 51 IT IS ABOUT AN ACTIVE APPROACH The humanistic domains of safety, comfort and efficiency and underpinned by the dimensions of communication, context and person-centred care will ensure an empowering, biopsychosocial, evidence-informed, and active approach to MSK care. Kerry et al, 2024 52 KEY POINTS 1. Manual therapy is a term used to describe a range of hands-on interventions used by a diverse group of clinical professionals including osteopaths, osteopathic physicians, chiropractors, massage therapists, physiotherapists. 2. Manual therapy is one of the therapeutic tools available in these professionals’ toolbox, and it constitutes a form of embodied, hands-on, nonverbal, communication with patients aiming at reassuring and empowering reengagement with activities that they value. 3. There is low to moderate levels of evidence that the effect sizes for manual therapy range from small to large for pain and function in tension headache, cervicogenic headache, fibromyalgia, low back pain, neck pain, knee pain, and hip pain, with minimal safety concerns. 4. Modern integrated manual therapies are well-suited to fostering a person-centred approach to care and have adapted to the challenges presented by contemporary societal challenges effectively. Draper-Rodi et al, 2024 53