Chapter 11 Manual Therapies. Overview A number of manual therapies have evolved over the years A number of manual therapies have evolved over the years

Chapter 11Chapter 11

Manual TherapiesManual Therapies

OverviewOverview

A number of manual therapies A number of manual therapies have evolved over the yearshave evolved over the years

By their nature, many of these By their nature, many of these techniques are not founded on the techniques are not founded on the same scientific rigor as anatomy same scientific rigor as anatomy and physiology, and much of their and physiology, and much of their use is based on clinical outcomes, use is based on clinical outcomes, rather than evidence-based proofrather than evidence-based proof

Manual TherapyManual Therapy

The decision on which manual The decision on which manual technique to use is based on the technique to use is based on the clinician’s belief, their level of clinician’s belief, their level of expertise, and their decision-expertise, and their decision-making processesmaking processes

ApplicationApplication

There is general agreement on There is general agreement on those criteria that are important those criteria that are important for the correct application of a for the correct application of a manual technique. These include:manual technique. These include:– SpecificitySpecificity– Direction and amount of forceDirection and amount of force– The duration, type, and irritability of The duration, type, and irritability of

symptomssymptoms– Patient and clinician positionPatient and clinician position

Indications for Manual Indications for Manual TherapyTherapy Manual therapy is indicated when Manual therapy is indicated when

there is:there is: – Mild painMild pain – A non-irritable conditionA non-irritable condition– Intermittent musculoskeletal painIntermittent musculoskeletal pain– Pain that is relieved by rest, or by Pain that is relieved by rest, or by

particular motions or positions particular motions or positions

Contraindications to Contraindications to Manual TherapyManual Therapy Absolute Absolute

Bacterial infectionBacterial infection MalignancyMalignancy Systemic localized infectionSystemic localized infection Sutures over the areaSutures over the area Recent fractureRecent fracture CellulitisCellulitis Febrile stateFebrile state HematomaHematoma Acute circulatory conditionAcute circulatory condition An open wound at the treatment siteAn open wound at the treatment site

Contraindications to Contraindications to Manual TherapyManual Therapy AbsoluteAbsolute

OsteomyelitisOsteomyelitis Advanced diabetesAdvanced diabetes Hypersensitivity of the skinHypersensitivity of the skin Inappropriate end feel (spasm, empty, Inappropriate end feel (spasm, empty,

bony)bony) Constant, severe pain, including pain which Constant, severe pain, including pain which

disturbs sleep, indicating that the condition disturbs sleep, indicating that the condition is likely to be in the acute stage of healingis likely to be in the acute stage of healing

Extensive radiation of painExtensive radiation of pain Pain unrelieved by restPain unrelieved by rest

Contraindications to Contraindications to Manual TherapyManual Therapy

RelativeRelative Joint effusion or inflammationJoint effusion or inflammation Rheumatoid arthritisRheumatoid arthritis Presence of neurological signsPresence of neurological signs OsteoporosisOsteoporosis HypermobilityHypermobility PregnancyPregnancy DizzinessDizziness

Soft Tissue TechniquesSoft Tissue Techniques

Transverse Friction MassageTransverse Friction Massage– A technique devised by Cyriax whereby A technique devised by Cyriax whereby

repeated cross-grain massage is repeated cross-grain massage is applied to muscle, tendons, tendon applied to muscle, tendons, tendon sheaths, and ligamentssheaths, and ligaments

– Contraindicated for acute inflammation, Contraindicated for acute inflammation, hematomas, debilitated or open skin, hematomas, debilitated or open skin, peripheral nerves, and with patients peripheral nerves, and with patients who have diminished sensation in the who have diminished sensation in the areaarea


Transverse Friction MassageTransverse Friction Massage – The tissue undergoing TFM should, whenever The tissue undergoing TFM should, whenever

possible, be put on a moderate, but not possible, be put on a moderate, but not painful stretch. The exception to this rule is painful stretch. The exception to this rule is when applying TFM to a muscle belly, which when applying TFM to a muscle belly, which is usually positioned in its relaxed positionis usually positioned in its relaxed position

– The time length of the frictions is usually The time length of the frictions is usually gauged by when the desensitization occurs, gauged by when the desensitization occurs, normally within 3 to 5 minutes. Tissues that normally within 3 to 5 minutes. Tissues that do not desensitize within 3 to 5 minutes do not desensitize within 3 to 5 minutes should be treated using some other form of should be treated using some other form of interventionintervention


Augmented soft tissue Augmented soft tissue mobilization (ASTM) mobilization (ASTM) – A process that uses specially A process that uses specially

designed hand-held devices to assist designed hand-held devices to assist the clinician in the mobilization of the clinician in the mobilization of poorly organized scar tissue in and poorly organized scar tissue in and around muscles, tendons and around muscles, tendons and myofascial planesmyofascial planes


Myofascial ReleaseMyofascial Release– A series of techniques designed to A series of techniques designed to

release restrictions in the myofascial release restrictions in the myofascial tissue that are used for the tissue that are used for the treatment of soft tissue dysfunction treatment of soft tissue dysfunction that has not responded to other that has not responded to other interventions. interventions.


MassageMassage– The systematic, therapeutic, and The systematic, therapeutic, and

functional stroking and kneading of functional stroking and kneading of the bodythe body


AcupressureAcupressure – Involves the application of manual Involves the application of manual

pressure over the body’s pressure over the body’s acupuncture points to improve the acupuncture points to improve the flow of the body’s Energy, known as flow of the body’s Energy, known as ‘Qi’. ‘Qi’.


Muscle EnergyMuscle Energy – Can be used to mobilize joints, Can be used to mobilize joints,

strengthen weakened muscles, and strengthen weakened muscles, and to stretch adaptively shortened to stretch adaptively shortened muscles and fasciamuscles and fascia


Strain-Counterstrain (Positional Strain-Counterstrain (Positional Release)Release) – Involve a gentle, and simple indirect Involve a gentle, and simple indirect

manipulative approach for the manipulative approach for the treatment of somatic dysfunction, treatment of somatic dysfunction, using the passive positioning of the using the passive positioning of the body in a position of ease (rather body in a position of ease (rather than into the motion restriction) to than into the motion restriction) to evoke a therapeutic effectevoke a therapeutic effect


Functional TechniquesFunctional Techniques – Functional techniques are indirect Functional techniques are indirect

techniques using positional techniques using positional placement away from the restrictive placement away from the restrictive barrier, similar to those techniques barrier, similar to those techniques described under Strain-Counterstraindescribed under Strain-Counterstrain

Joint MobilizationsJoint Mobilizations

Joint mobilization techniques include Joint mobilization techniques include a broad spectrum, from the general a broad spectrum, from the general passive motions performed in the passive motions performed in the physiologic cardinal planes at any physiologic cardinal planes at any point in the joint range, to the semi-point in the joint range, to the semi-specific and specific accessory specific and specific accessory (arthrokinematic) joint glides, or (arthrokinematic) joint glides, or joint distractions, initiated from the joint distractions, initiated from the open-packed position of the joint. open-packed position of the joint.


Kaltenborn TechniquesKaltenborn Techniques– According to Kaltenborn, all joint According to Kaltenborn, all joint

mobilizations, when performed mobilizations, when performed correctly should be made parallel, or correctly should be made parallel, or at right angles to this plane of at right angles to this plane of motionmotion

– Kaltenborn’s techniques use a Kaltenborn’s techniques use a combination of traction and combination of traction and mobilization to reduce pain and mobilization to reduce pain and mobilize hypomobile joints mobilize hypomobile joints


Australian TechniquesAustralian Techniques– Under this system, the range of motion is Under this system, the range of motion is

defined as the available range, not the full defined as the available range, not the full range, and is usually in one direction onlyrange, and is usually in one direction only

– Each joint has an anatomical limit (AL) Each joint has an anatomical limit (AL) which is determined by the configuration of which is determined by the configuration of the joint surfaces and the surrounding soft the joint surfaces and the surrounding soft tissuestissues

– The point of limitation (PL) is that point in The point of limitation (PL) is that point in the range which is short of the anatomical the range which is short of the anatomical limit and which is reduced by either pain or limit and which is reduced by either pain or tissue resistancetissue resistance


Mobilisations with MovementsMobilisations with Movements– Mulligan’s mobilization techniques Mulligan’s mobilization techniques

are applied parallel to the plane of are applied parallel to the plane of motion, and are sustained motion, and are sustained throughout the movement until the throughout the movement until the joint returns to its starting position, joint returns to its starting position, with the intention of producing no with the intention of producing no pain when applied pain when applied

Joint ManipulationsJoint Manipulations

Unlike mobilizations, which are Unlike mobilizations, which are applied singularly or repetitively applied singularly or repetitively within, or at the physiological within, or at the physiological range of joint motion, joint range of joint motion, joint manipulations involve a thrust to manipulations involve a thrust to a joint so that the joint is briefly a joint so that the joint is briefly forced beyond the restricted forced beyond the restricted range of motionrange of motion

Neurophysiological Neurophysiological TechniquesTechniques Proprioceptive Neuromuscular Proprioceptive Neuromuscular

FacilitationFacilitation– Techniques useTechniques use active muscular active muscular

relaxation techniques that utilize relaxation techniques that utilize muscle facilitation and inhibition to muscle facilitation and inhibition to hasten the response of the hasten the response of the neurophysiological mechanisms neurophysiological mechanisms involved in the stretch reflexinvolved in the stretch reflex

Neurophysiological Neurophysiological TechniquesTechniques Myofascial Trigger Point (MTrP) TherapyMyofascial Trigger Point (MTrP) Therapy

– The major goal of MTrP therapy is to relieve The major goal of MTrP therapy is to relieve pain and tightness of the involved muscles, pain and tightness of the involved muscles, improve joint motion, improve circulation, improve joint motion, improve circulation, and eliminate perpetuating factorsand eliminate perpetuating factors

– When treating a patient for a specific When treating a patient for a specific muscle syndrome, it is important to explain muscle syndrome, it is important to explain the function of the involved muscle and to the function of the involved muscle and to describe or demonstrate a few of the describe or demonstrate a few of the activities or postures that might over stress activities or postures that might over stress it, so that the patient can avoid such it, so that the patient can avoid such activities or postures activities or postures

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Chapter 11 Manual Therapies. Overview A number of manual therapies have evolved over the years A number of manual therapies have evolved over the years