Application of Manual Therapy in the Neurologic

Patient PopulationKatie Deaton 4/1/2014

Why I Chose This Topic

Are the techniques that I’ve learned on this rotation relevant to the neurologic patient population?

Which techniques are applicable?

What are the special considerations that need to be made when applying these techniques in the neurologic patient population?

How effective is manual therapy versus other treatments?

Common Applications of Manual Therapy1

Passive stretching

Mobilization – joint or soft tissue

Manipulation

Muscle energy technique

Passive mobilization with active movement

Associated techniques: Dry needling Myofascial release

Primary & Secondary Impairments Associated with Neurologic Dysfunction2

Primary Impairments

Changes in muscle strength Paralysis or weakness

Changes in muscle tone Hypotonicity Hypertonicity-Spasticity

Changes in muscle activation Inappropriate initiation Difficulty sequencing Inappropriate timing of firing Altered force production

Changes in sensation Awareness Interpretation Proprioception

Secondary Impairments

Changes in alignment and mobility

Changes in muscle and soft tissue length

Pain

Edema

Adapted from Box 27-1 “Impairments That Interfere With Functional Movement”, pg. 865, Neurological Rehabilitation, 5th Edition.

Effects of Manual Therapy1,3

Biomechanical Effects Improved movement – gains

in ROM or normalized movement patterns

Improved position – reduction of positional faults

Neurophysiological Effects Spinal cord – diminished

sensitivity to pain, sympathoexcitatory (changes in blood flow, heart rate, skin conductance and skin temperature), decrease in hypertonicity of muscles

Central mediated – alterations in pain “experience” in amygdala, periaqueductal gray, and rostral ventromedial medulla

Peripheral inflammatory – alteration of blood levels of inflammatory mediators

“A mechanical stimulus initiates a number of potential neurophysiological effects which produce the clinical outcomes associated with MT in the treatment of musculoskeletal pain.”

Combined Effects

Addressing Primary Impairments

Addressed by medical or pharmacological intervention Anti-spasticity

medications, Baclofen pump, Botox

Implementation of motor relearning strategies or facilitation techniques PNF

Muscle strength

Muscle tone

Muscle activation

Sensation

Addressing Secondary Impairments

Improvement of joint mobility4,5

Smedes F, van der Salm A, Koel G, Oosterveld F. Manual mobilization of the wrist: A pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke. J Hand Ther. 2014; Epub.6

Decreased pain3

Peripheral7,8 vs. Spinal9 vs. Supraspinal mechanisms10

Lack of literature specific to neurologic patient population Increased soft tissue length through soft tissue mobilization

and dry needling

Alignment & mobility

Muscle & soft

tissue length

Pain Edema

Dry Needling

Treatment effects11

Decreased pain Muscle tension Improved ROM Muscle strength Coordination

No evidence supporting dry needling in the neurologic patient population

Available evidence regarding the use of acupuncture in the stroke population12,13,14

However, Ernst & Lee 201015 suggest caution regarding the conclusions of many of the Chinese studies Negative results are virtually never produced Many of the study designs are incapable of generating

negative results

Case 1: CL

Pre-Treatment: 36° lumbar scoliosis curve with shortening of R trunk

Treatment: Soft tissue mobilization: B

paraspinals with focus on L paraspinals, QL, bony clearance of iliac crest and 12th rib

Joint mobilization: transverse glide to R T8-L5, grade III-IV; R/L PA to adjacent ribs with assisted trunk rotation

Neuromuscular reeducation: rolling from supine<>prone to facilitate activation of L paraspinals

Passive stretch: sidelying R trunk/pelvic stretch over therapist thigh

HEP: soft tissue mobilization of paraspinals, gentle mobilization of lower thoracic/lumbar spine

Outcomes: decreased assistance with rolling, maintenance of airways and rib excursion, family currently seeking reassessment by physiatrist to formally assess

Demographics: 21 yo female

Diagnosis: cerebral palsy – spastic quadriplegia, intractable epilepsy

Medications: Keppra, Topomax, Onfi, L-Carnitine, Bactropan, Acanya, Ketoconazole, Lactulose, Vusion

Reason for referral: transitioning from school-based therapy, hospitalization following seizure as well as increased seizure activity decreasing functional abilities

Impairments: global weakness throughout trunk & extremities; fingers, L shoulder; max assist-dependent for all bed mobility, transfers, ambulation

Case 2: SB

Pre-Treatment: B + clonus with 5 beats on R B DF to ~8-10 degrees R LE: 2+ inver / ever, 4- PF, 3+ DF L LE: 3+ inver / ever, 4- PF, 4- DF

Treatment: Soft tissue mobilization: STM to R

gastroc/soleus, peroneals Neuromuscular reeducation: PNF

ankle diagonals following STM Dry needling: medial/lateral

gastroc/soleus 0.3 x 0.5mm Functional training: ambulation

with focus on increasing DF following IMT/STM

Modalities: 10’ moist heat following IMT

Outcomes: improved AROM into DF and eversion following IMT & STM, patient subjective report of immediate decrease in tightness of calf following each treatment as well as decreased tingling in calf at night, limited translation to functional improvement

Demographics: 58 yo female

Diagnosis: 5 year history of multiple sclerosis

Medications: Baclofen, Cymbalta, Zolpidem tartrate, Rifampin, Ethambutol HCL, Clarithromycin, Ampyra, Tecfidera, Lyrica, Clonazepam

Reason for Referral: increasing extremity weakness leading to functional decline and falls

Impairments: decreased B LE strength, increased tone R LE, gait impairment

Case 3: ET

Pre-Treatment: subjective report of “clicking”, pain of 5/10 in R shoulder

Treatment: Soft tissue mobilization: upper

trap, subscapularis, lat, supraspinatus, infraspinatus, pec clearance of bony contours of clavicle

Joint mobilization: traction, inferior & posterior glides – grade I-IV

Neuromuscular reeducation: scapular PNF with PD pattern, prolonged holds with shoulder ER

Passive stretch: AAROM R pec stretch

Therapeutic exercise: manual resistance into shoulder ER/IR, supine shoulder alphabets A-Z

HEP: around the world shoulder activity

Outcomes: R shoulder flexion ~165 with mild soreness in anterior shoulder and continued “clicking”

Demographics: 32 yo female

Diagnosis: TBI s/p MVA June 2009

Medications: Baclofen – ITB pump

Reason for Referral: gait & balance impairments, R UE ROM & strength deficits, recurrent B patellar dislocation

Impairments: postural deficits, R knee hyperextension, B decreased hip AROM & strength, gait & balance deficits – R shoulder not assessed at initial evaluation

Literature Review – Manual Therapy

Lack of studies investigating the effects of manual therapy in the neurologic patient population Smedes F, van der Salm A, Koel G, Oosterveld F.

Manual mobilization of the wrist: A pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke. J Hand Ther. 2014: Epub.6

Statistically significant improvement in active/passive wrist movement with manual therapy intervention. Pilot study

Literature Review – Dry Needling

Positive results have been achieved in individual studies, but the level of evidence supporting the effectiveness of dry needling in various conditions is lacking. Kim TH, Lee CR, Choi TY, et al. Intramuscular stimulation

therapy for healthcare: a systematic review of randomised controlled trials. Acupunct Med. 2012; 30(4): 286–90.16

Large, well-designed RCTs are still needed to evaluate the clinical utility of this technique. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N,

Meeus M. Physiological effects of dry needling. Curr Pain Headache Rep. 2013. 17: 348.11

Lacking evidence for the utility of dry needling overall and for specific patient populations – ie. neurologic patient population

Discussion Points

Experiences with the application of manual therapy with patients with neurologic dysfunction. What techniques were utilized? What were the outcomes?

Arguments for/against the application of manual therapy in the neurologic patient population?

Priority of manual therapy intervention vs. other treatment techniques

References1. Cook CE. Orthopedic Manual Therapy: An Evidence-Based Approach. 2nd Ed. Pearson: New Jersey. 2012.

2. Umphred DA. Neurological Rehabilitation. 5th Ed. Mosby Elsevier: St. Louis. 2007.

3. Bialosky J, Bishop M, Price D, Robinson M, George S. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009; 14(5): 531-538.

4. Randall T, Portney L, Harris BA. Effects of joint mobilization on joint stiffness and active motion of the metacarpal-phalangeal joint.

5. Hoch M, McKeon P. Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. Journal of Orthopeadic Research. 2011.

6. Smedes F, van der Salm A, Koel G, Oosterveld F. Manual mobilization of the wrist: A pilot study in rehabilitation of patients with a chronic hemiplegic hand post-stroke. J Hand Ther. 2014; Epub.

7. McPartland JM, Giuffrida A, King J, Skinner E, Scotter J, Musty RE. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath. 2005; 105: 283-291.

8. Field T, Diego M, Cullen C, Hernandez-Reif M, Sunshine W, Douglas S. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J Clin Rheumatol. 2002; 8: 72-76.

9. Malisza KL, Stroman PW, Turner A, Gregorash L, Foniok T, Wright A. A functional MRI of the rat lumbar spinal cord involving painful stimulation and the effect of peripheral joint mobilization. J Magn Reson Imaging. 2003; 18: 152-159.

10. Malisza KL, Gregorash L, Turner A, Foniok T, Stroman PW, Allman AA, Summers R, Wright A. Functional MRI involving painful stimulation of the ankle and the effect of physiotherapy joint mobilization. J Magn Reson Imaging. 2003: 21; 489-496.

11. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Curr Pain Headache Rep. 2013; 17: 348.

12. Yang ZX, Shi XM. Systematic evaluation of the therapeutic effect and safety of Xingnao Kaigiao needling method in treatment of stroke. Zhonggou Zhen Jiu. 2007; 27 (8): 601-8.

13. Hong JB, Sheng PJ, Yuan YQ, Yi SX, Yue ZH. Observation on therapeutic effect of opposing needling for treatment of poststroke shoulder-hand syndrome. Zhonggou Zhen Jiu. 2009; 29(3): 2005-8.

14. Hai Y, Yu X. Observation on therapeutic effect of acupuncture on spastic dyskinesia due to stroke. Zhonggou Zhen Jiu. 2007; 27(10): 735-7.

15. Ernst E, Lee MS. Acupuncture during stroke rehabilitation. Stroke. 2010; 41(8): e549.

16. Kim TH, Lee CR, Choi TY, et al. Intramuscular stimulation therapy for healthcare: a systematic review of randomised controlled trials. Acupunct Med. 2012; 30(4): 286–90.