manual therapy.docx

**Definition, History and Type of Manipulation** Manual therapy is a skilled, specific hands on approach used by clinicians including physical therapists to diagnose and treat soft tissue and joint structures for the purpose of decreasing pain, improving joint range and alignment, improving contrac...

**Definition, History and Type of Manipulation** Manual therapy is a skilled, specific hands on approach used by clinicians including physical therapists to diagnose and treat soft tissue and joint structures for the purpose of decreasing pain, improving joint range and alignment, improving contractile and non contractile tissue repair, improving extensibility and stability and facilitating function. Assisted therapeutic exercise and passive movement most definitely encompass the practice of manual therapy, but manual therapy today has evolved as a science with a greater degree of specificity and broader area of application. Most importantly in the diagnosis of musculoskeletal dysfunction which are usually not visualized by complex imaging procedures. Just like any other treatment philosophy, manual therapy is not a cure at all. It has to be combined with other philosophies as appropriate. When addressing every single component of the neuromusculoskeletal apparatus all appropriate tests and most importantly all standard precautions and contraindications should be considered to avoid unfavorable out comes. This literature review hence intends to enlighten the physical therapy clinician, not only the techniques of application, but also the conceptual basis of why such techniques are incorporated with an emphasis on detection or diagnosis of the dysfunction. It also intends to reinforce the fact ever so often to "treat the cause not the symptom." **History** Two physicians who instructed physical therapists in the art of manipulation were Edgar and James Cyriax, and James and John Mennel, father and son. In 1907, James Mennel associated himself with the Chartered Society of Physiotherapy, and instructed joint and soft tissue manipulation techniques. He encouraged his medical colleagues to send patients to physical therapists by prescription. He may have been the first to use the term "manual therapy" to avoid the confusing array of terms such as articulation, mobilization, leading to manipulation. Manual Therapy was the title of his book in which he exclusively addressed topics of massage, passive, assisted and resisted movement, and joint manipulation. His son John Mennel published his book Joint Pain,in 1960, and described that the principle cause for joint pain and pathology was the synovial joint and not the intervertebral disc. He may also have been the first to use the term "joint play" to describe the quality of motion within a joint. He, like his father, instructed techniques principally to physical therapists Another famous name who worked closely with physical therapy was Edgar Cyriax, who wrote extensively on manual therapeutic methods. In 1917, he published a paper Manual Treatment o th Cervical Sympathetics, in which he outlined the technique of palpating the cervical sympathetic ganglions and treating them by transverse friction in order to stimulate their function. His son James Cyriax did much to promote manipulation among physical therapists. He published the Textbook of Orthopedic Medicine in two volumes which has become a classic and is valuable to this day for its clarity in differentiating between soft tissues on examination. He also popularized the term "end feel" to draw attention to the sense of resistance that can be felt in all joints at the end of the range and he attempted to distinguish between normal and abnormal. He strongly emphasized on evaluation and identification of the problem rather than treatment which is the best piece of instruction for any manual therapist. He trained physical therapists and advocated that they, more than the physician, were the appropriate clinicians, to perform manipulation. The 1930s saw the birth of arthro-kinematics. Movement had been traditionally described as spatial relationships of the limbs and trunk to the axis of the body. Hence, joint movement was described as flexion, extension, etc. In 1927, Walmsley began using a new terminology called 'arthrokinematics' which was later accepted by Gray's anatomy, where he described movements taking place within the joint such as roll, glide and spin. Freddy Kalten born, a physical therapist saw the significance of the concept of arthrokinematics and applied it to joint manipulation some years later, thus developing a whole new approach to manipulation distinctive to physical therapy. In 1955, Steindler, in his work Kinesiology of the Human Body under Normal and Pathologic Conditions, summarized earlier research and added a great deal of additional arthrokinematic knowledge. Kalten born was the first to link manipulation to this new concept of arthrokinematics and in 1961 he published Extremity Joint Manipulation In 1964 Maitland of Australia published Vertebral Manipulation, in which he refined the art of oscillatory manipulation and used it treat reproducible signs. His approach was to identify either an active or a passive movement that was painful, to oscillate that joint and test again. If it hurt less, he continued with the oscillations; if there was no change, he tried a different oscillatory technique that he had observed would be the next most likely to succeed In the late 1970s McKenzie began to popularize the concept where he described spinal extension for the treatment of low backpain. He described that the posterior bulging of the disc was much aggravated by flexion due to hydrodynamics of the disc which was compressed anteriorly by the vertebral bodies. He felt that the extension hence compressed the posterior elements, which minimized the risk of the disc moving further posterior towards pain sensitive structures. His methods have gained worldwide acceptance and his school conducts training programs all over the world. The practice of manipulation by physical therapy is quite eclectic or a mixture of philosophies. Most clinicians examine both positional and movement faults and use mechanical, isometric, oscillatory, direct and indirect techniques. Hence the focus of this literature review will be to combine all philosophies taking the most appropriate from each to be able to provide the best of available care. This literature review has been written with a base formed by three existing philosophies, namely Paris, Kalten born and Osteopathy. **Definition and type of Manipulation** Manipulation by definitionis---A skilled passive movement to a joint. Paris,SV (1979). the passive movement thus executed may be of different types, it may be a sustained stretch or range of motion or an oscillation or a high velocity procedure. The type of manipulation is thrustor non-thrust, the area where it is applied is of importance. It can be applied to a very specific area like an individual vertebra or a specific soft tissue, or a general area like several vertebrae or a wider area of soft tissue. Hence, the next differentiation to make is between a general (regional) and a specific (localized) manipulation. MANIPULATION The skilled passive movement to a joint Thrust When a sudden, high velocity short amplitudemotion is delivered at the restricted physio-logical limit of a joint's range of motion. Non-thrust When a joint or soft tissue is taken within orto the limit of the available active or passive range (within physiological limits), andstretched or oscillated. Neuromuscular thera-pies also comprise non-thrust manipulation **Indications and Contraindications** Manual therapy is a therapeutic intervention used to treat musculoskeletal pain and dysfunction through techniques such as mobilization, manipulation, and soft tissue work. However, it's crucial to identify both the indications and contraindications to ensure safe and effective treatment. **Indications for Manual Therapy** 1. Musculoskeletal Pain - Acute and Chronic Pain: Relief of pain from conditions like lower back pain, neck pain, and joint pain. - Myofascial Pain Syndrome: Treatment of pain related to muscle trigger points. 2. Joint Dysfunction - Restricted Range of Motion: Conditions such as adhesive capsulitis (frozen shoulder) or joint stiffness. - Joint Mobilization: To improve movement and function in cases like osteoarthritis or rheumatoid arthritis. 3. Muscle Tightness and Spasms - Muscle Relaxation: Reducing muscle tension and improving flexibility. 4. Post-Surgical Rehabilitation - Improving Mobility: Enhancing recovery post-surgery for conditions like joint replacements or rotator cuff repairs. 5. Sports Injuries - Injury Recovery: Addressing issues such as sprains, strains, and ligament injuries. 6. Neuromuscular Conditions - Improving Function: Conditions such as sciatica or neuropathies where manual therapy can aid in relieving symptoms. 7. Improving Circulation - Enhanced Blood Flow: Techniques can help with conditions that benefit from increased circulation, such as chronic venous insufficiency. 8. Postural and Alignment Issues - Correcting Imbalances: Assisting with issues caused by poor posture or improper body mechanics. **Contraindications for Manual Therapy** 1. Acute Inflammation - Active Infections: Conditions like cellulitis or septic arthritis. - Acute Trauma: Fresh fractures or severe sprains. 2. Bone Conditions - Osteoporosis: Risk of fractures or worsening of the condition. - Paget's Disease: May cause abnormal bone growth or fragility. 3. Vascular Conditions - Deep Vein Thrombosis (DVT): Risk of dislodging a clot. - Severe Varicose Veins: Potential for exacerbating symptoms. 4. Cancer - Malignancy: Particularly if the cancer is active or metastatic, as manual therapy could potentially spread cancerous cells. 5. Neurological Conditions - Acute Neurological Conditions: Such as stroke or spinal cord injury, where manual therapy may worsen symptoms or interfere with recovery. 6. Infectious Diseases - Systemic Infection: Conditions like tuberculosis or HIV/AIDS with active infection could be exacerbated by manual therapy. 7. Recent Surgery - Postoperative Care: Manual therapy may need to be avoided or modified depending on the type of surgery and the stage of recovery. 8. Fractures and Dislocations - Unhealed Fractures: Risk of aggravating the injury or causing further damage. - Dislocations: Treatment should be managed carefully to avoid complications. 9. Severe Spinal Conditions - Severe Disc Herniation: Can be exacerbated by certain manual techniques. - Spinal Instability: Conditions where the spine is unstable and could be worsened by manual manipulation. 10. Psychological Conditions - Severe Mental Health Issues: Such as acute anxiety or psychosis, where manual therapy might not be appropriate.