Transcript Mechanisms of Manual Therapy

Mechanisms of Manual
Therapy
Manual Therapy
• Physical treatment delivered by a practitioner
• Most commonly delivered by the hands but not
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Deep soft tissue massage
Graston
Instrument Assisted Soft Tissue Massage
Dry Needling
Joint Manipulation
Joint Mobilisations
Acupressure
Craniosacral therapy
Muscle energy techniques
Myofascial release
Traction
Etc etc etc …
Manual Therapy - Theories
1. Biomechanical
1. Joint Realignment
2. Breaking fibrosis
2. Neurophysiological
1. Peripheral
2. Spinal
3. Supraspinal
(Bialosky et al., 2009)
Biomechanical Model
• Old school: not supported by the
literature…
Joint Realignment Theory
• Palpation of joint position and
movement is unreliable
(Seffinger et al., 2004, Walker et al., 2015)
• Techniques are not level specific as
many other segments move
(Dunning et al., 2013, Ross et al., 2004)
Biomechanical Model
• Technique choice or direction may not
make a difference on outcome
• however specific cervical mobilisations
appear to be more effective than non
specific techniques
(Slaven et al., 2013)
• Signs and symptoms away from the
site of application change
• e.g skin temperature, elbow ROM during
ULTT after cervical mobilisation
(Chu et al., 2014)
Biomechanical Model
Breaking fibrosis: Soft Tissue Theory
• Takes approx. 850 - 925kg
perpendicular force and approx.
420 - 460kg parallel force to
deform plantar fascia/ fascia lata
1% (using a mathematical model)
(Chaudhry et al., 2008)
• Surgeons use a knife to cut fibrosis
• We don’t understand stretching
(Weppler and Magnusson, 2010)
Manual Therapy - Theories
1. Biomechanical
1. Joint Realignment
2. Breaking fibrosis
2. Neurophysiological
1. Peripheral
2. Spinal
3. Supraspinal
(Bialosky et al., 2009)
Peripheral Mechanisms
= affecting the tissue locally
How evidence suggests there is a Peripheral Mechanism to Manual Therapy:
• Reduction blood and serum level inflammatory mediators
• Altering nociception or inflammatory markers locally
(Roy et al., 2010, Teodorczyk-Injeyan et al., 2006)
• Cells respond to mechanical load or force through mechanotransduction
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Fibroblast activity changes in response to internal and external forces applied to cells
Fibroblast activity controls the make up of a tissue (collagen formation, extracellular matrix)
Tissue responds and adapts to the force and stress applied to it
This process takes a long time and repeated stress is required
(Langevin et al., 2011)
Peripheral Mechanisms
(Malfait & Shnitzer, 2013)
Spinal Mechanisms
= alters processes that occur at the level of the spinal cord
How evidence suggests there is a Spinal Mechanism to Manual
Therapy:
• Decreased activation of the dorsal horn
• Changes in muscle activity at spinal level
• Change in pain pressure thresholds or even temperature at the spinal level
(Bialosky et al., 2009)
Spinal Mechanisms
(Malfait & Shnitzer, 2013)
Supraspinal Mechanisms
= changes within the brain
How evidence suggests there is a Supraspinal Mechanism to Manual
Therapy:
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Decreased activation of areas of the brain responsible for central pain
Various autonomic responses to manual therapy
Activation of descending inhibition of the periadequctal grey matter
Improvement in psychological outcomes
Improvement in somatosensory processing within the cortex
Release of opioids
(Bialosky et al., 2009, Savva et al., 2014, Zafereo and Deschenes, 2015)
Supraspinal Mechanisms
(Malfait & Shnitzer, 2013)
Neurophysiological Theories
(Bialosky et al., 2009)
Placebo Response to Manual Therapy
• Placebo responses occur in manual
therapy
• Patient therapist interaction
• Patient environment interaction
• Literature suggests placebo can have a
hypoalgesic effect
• Mechanisms
• Expectation
• Conditioning
(Bialosky et al., 2011)
Placebo Physiology
• Principles are similar to the proposed
neurophysiological responses
• Peripheral Mechanisms
• Spinal Mechanisms
• Supraspinal Mechanisms
• Be cautious with patients that have a
desire for pain relief; have fear of pain
or are anxious:
• Negative correlation to placebo related
hypoalgesia
(Bialosky et al., 2011)
From Literature to Practice
• Manual Therapy can be used to decrease pain
and increase range of movement
• Transient, short lived effects (approx. 5 mins)
• Manual Therapy techniques should be selected
based upon:
• Patient preference
• Practitioner comfort
• Type of intervention/technique does not seem
to affect the outcome.
• Manual Therapy should be comfortable
• Unless the patient’s expectations and/or
experienced successful outcomes with “painful”
manual therapy
Do some ‘hands on therapy’
From Literature to Practice
• Education on mechanisms of manual therapy is
important
• Placebo response can be maximised by working
with patients expectations and conditioning
• If literature suggests a positive response,
explain this to the patient to help facilitate their
expectations, in turn this increases the
likelihood of a positive response
• Beware of patients with negative mood, desire
for pain relief, fear of pain, anxiety
Do some ‘talking therapy’
Practical Application of Manual
Therapy
Why do we use Manual Therapy?
• There are many theories on how Manual Therapy works…
• But essentially no one really knows!
• We can however utilise these mechanisms in order to:
• Decrease pain temporarily
• Improve ROM temporarily
• Change how a muscle contracts temporarily
Safety in Manual Therapy
• IFOMPT have given guidance on
how to screen suitability for
manual therapy
• Discussed some
contraindications already (CAD)
• If ever in doubt, DO NOT DO
MANUAL THERAPY
• The benefit must ALWAYS
outweigh the risk
(Rushton, Rivett et al. 2014)
Absolute Contraindications
• Bone: any pathology that has led to
significant bone weakening:
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Tumour, e.g. cancer
Infection, e.g. TB
Metabolic, e.g. osteomalacia
Congenital, e.g. dysplasias
Latrogenic, e.g. Long-term steroids
Inflammatory, e.g. severe rheumatoid
arthritis
• Traumatic, e.g. fracture
• Neurological
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Cervical myelopathy
Cord compression
Cauda equina compression
Nerve root compression with
increasing neurological deficit
• Vascular
• Signs of cervical artery dysfunction
• Aortic aneurysm
• Haemophilia
• Lack of Diagnosis
• Lack of consent
Relative Contraindications
• Adverse reaction to previous thrust
manipulation
• Disc herniation or prolapse
• Pregnancy
• Spondylolysis
• Spondylolithesis
• Osteoporosis
• Anticoagulant/long term steroids
• Advanced degenerative joint disease
and spondylosis
• Vertigo
• Arterial calcification
A Suggested Structure for Manual Therapy
• Accept the majority of changes are
temporary and EXPLAIN this to the
client
• Treat it as a “Warm Up” or
“Optimising the Body” ready for
exercise
• Start with superficial structures and
progress deeper throughout
treatment
• Select techniques and aggressiveness
based on each client
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Soft Tissue (Massage Type Techniques)
Joints (Joint Mobs/Manips/Traction)
Nervous System (Neurodynamics)
Manual Therapy – Simplified
• Manual Therapy creates a temporary change in tissue tone or
mechanoreceptor and nocioceptor sensitivity
• Short Term Relief
• Changes TONE of muscle
• Appropriate stress could guide collagen formation and therefore
tissue make up
• Reduces Pain, Increases Range of Movement, Improves how a muscle
contracts, Increases Patient Satisfaction
• ALWAYS used as an adjunct to exercise
References
• Bialosky, J. E., M. D. Bishop, S. Z. George and M. E. Robinson (2011). "Placebo response to manual therapy: something out of
nothing?" J Man Manip Ther 19(1): 11-19.
• Bialosky, J. E., M. D. Bishop, D. D. Price, M. E. Robinson and S. Z. George (2009). "The Mechanisms of Manual Therapy in the
Treatment of Musculoskeletal Pain: A Comprehensive Model." Man Ther 14(5): 531-538.
• Chaudhry, H., R. Schleip, Z. Ji, B. Bukiet, M. Maney and T. Findley (2008). "Three-dimensional mathematical model for deformation
of human fasciae in manual therapy." J Am Osteopath Assoc 108(8): 379-390.
• Chu, J., D. D. Allen, S. Pawlowsky and B. Smoot (2014). "Peripheral response to cervical or thoracic spinal manual therapy: an
evidence-based review with meta analysis." J Man Manip Ther 22(4): 220-229.
• Dunning, J., F. Mourad, M. Barbero, D. Leoni, C. Cescon and R. Butts (2013). "Bilateral and multiple cavitation sounds during upper
cervical thrust manipulation." BMC Musculoskelet Disord 14: 24.
• Langevin, H. M., N. A. Bouffard, J. R. Fox, B. M. Palmer, J. Wu, J. C. Iatridis, W. D. Barnes, G. J. Badger and A. K. Howe (2011).
"Fibroblast cytoskeletal remodeling contributes to connective tissue tension." J Cell Physiol 226(5): 1166-1175.
• Malfait, A.M. and Schnitzer, T.J., (2013). “Towards a mechanism-based approach to pain management in osteoarthritis”. Nature
Reviews Rheumatology, 9(11): 654-664.
• Ross, J. K., D. E. Bereznick and S. M. McGill (2004). "Determining cavitation location during lumbar and thoracic spinal
manipulation: is spinal manipulation accurate and specific?" Spine (Phila Pa 1976) 29(13): 1452-1457.
References
• Roy, R. A., J. P. Boucher and A. S. Comtois (2010). "Inflammatory response following a short-term course of chiropractic treatment
in subjects with and without chronic low back pain." J Chiropr Med 9(3): 107-114.
• Rushton, A., D. Rivett, L. Carlesso, T. Flynn, W. Hing and R. Kerry (2014). "International framework for examination of the cervical
region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention." Man Ther 19(3): 222-228.
• Savva, C., G. Giakas and M. Efstathiou (2014). "The role of the descending inhibitory pain mechanism in musculoskeletal pain
following high-velocity, low amplitude thrust manipulation: a review of the literature." J Back Musculoskelet Rehabil 27(4): 377382.
• Seffinger, M. A., W. I. Najm, S. I. Mishra, A. Adams, V. M. Dickerson, L. S. Murphy and S. Reinsch (2004). "Reliability of spinal
palpation for diagnosis of back and neck pain: a systematic review of the literature." Spine (Phila Pa 1976) 29(19): E413-425.
• Slaven, E. J., A. P. Goode, R. A. Coronado, C. Poole and E. J. Hegedus (2013). "The relative effectiveness of segment specific level
and non-specific level spinal joint mobilization on pain and range of motion: results of a systematic review and meta-analysis." J
Man Manip Ther 21(1): 7-17.
• Teodorczyk-Injeyan, J. A., H. S. Injeyan and R. Ruegg (2006). "Spinal manipulative therapy reduces inflammatory cytokines but not
substance P production in normal subjects." J Manipulative Physiol Ther 29(1): 14-21.
• Walker, B. F., S. L. Koppenhaver, N. J. Stomski and J. J. Hebert (2015). "Interrater Reliability of Motion Palpation in the Thoracic
Spine." Evid Based Complement Alternat Med 2015: 815407.
• Weppler, C. H. and S. P. Magnusson (2010). "Increasing muscle extensibility: a matter of increasing length or modifying sensation?"
Phys Ther 90(3): 438-449.
• Zafereo, J. A. and B. K. Deschenes (2015). "The Role of Spinal Manipulation in Modifying Central Sensitization." Journal of Applied
Biobehavioural Research 20(2).