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Principles of Manual Therapy (A Manual Therapy Approach to Musculoskeletal Dysfunction)
Deepak Sebastian
SECTION 1: GENERAL ASPECTS
1:
Introduction
2:
Evolution of the Practice of Manual Therapy
BEGINNING
MIDDLE AGES AND RENAISSANCE
BEGINNING OF CONTEMPORARY MANUAL MEDICINE
BONE SETTING
OSTEOPATHY
CHIROPRACTIC
MANIPULATION BY PHYSICIANS AND PHYSICAL THERAPISTS
3:
Manipulation: Definition and Types
MANIPULATION
Thrust
Non-thrust
Graded Oscillation
Progressive Loading/Stretch
Sustained Loading/Stretch
Soft Tissue Mobilization
Myofascial Release
Neuromuscular Therapies
4:
Understanding Mechanical Dysfunction
JOINT RESTRICTION
MUSCLE WEAKNESS
5:
Principles of Management of Mechanical Dysfunction
ALIGNMENT
STRENGTH/STABILITY/LENGTH (Relevant to Alignment)
CARE DURING FUNCTION
6:
Palpation
PRINCIPLES
Asymmetry
Restriction of Mobility
Tissue Texture Abnormality
PALPATION LAB
Base of Skull, Cervical and Thoracic Spine
External Occipital Protuberance and Nuchal Line
Mastoid Process
Transverse Process of C1
Spinous Process of C2
Spinous Process of C7
Transverse Processes/Articular Pillars of C3 to C7
Angle of First Rib
Spinous Process of Third Thoracic Spine (T3)
Spinous Process of Seventh Thoracic Spine (T7)
Shoulder
Spine of Scapula
Inferior Angle of Scapula
Acromion
Greater Tuberosity of Humerus
Coracoid Process
Elbow
Olecranon
Radial Head
Wrist and Hand
Radial Styloid
Ulnar Styloid
Capitate
Lunate
Scaphoid
Trapezium
Triquetrium
Pisiform
Hook of Hammate
Lumbar Spine, Pelvis, and Hip
Iliac Crest
Anterior Superior Iliac Spine (ASIS)
Posterior Superior Iliac Spine (PSIS)
Ischial Tuberosity
Spinous Process of L4
Spinous Process of L5
Spinous Process of S2
Base of the Sacrum
Inferior Lateral Angle of the Sacrum (ILA)
Pubic Tubercle
Greater Trochanter
Knee
Lateral Condyle and Medial Condyle of Femur
Head of Fibula
Lateral Tibial Condyle
Medial Tibial Condyle
Ankle and Foot
Talus
Navicular
Medial Cueniform
Cuboid
7:
Principles of Diagnosis
THE SPINE
Forward-bending
Backward-bending
Rotation and Side-bending
POSITIONAL FAULTS
Palpation
Dysfunction
MOVEMENT FAULTS
Palpation
Dysfunction
ERS
FRS
CLINICAL IMPLICATION
EXTREMITIES
Ovoid
Sellar (Saddle)
MACCONNAIL'S CLASSIFICATION OF JOINTS
Rotation
Roll-gliding
Translation
Traction
Compression
Gliding
Muscle and Tendon
SELECTIVE TISSUE TENSION TESTING (STT)
CAPSULE
BURSA
LIGAMENT
NERVE
Hypothetical Somatic Concept of Nerve Dysfunction
SECTION 2: REGIONAL APPLICATION (SPINAL MANIPULATION)
8:
Cervical Spine
RELEVANT ANATOMY1
MID-CERVICAL SPINE
Osseous Anatomy
Ligamentous Anatomy
Anterior Longitudinal Ligament (ALL) and Atlanto Occipital Membrane
Posterior Longitudinal Ligament (PLL) and Tectorial Membrane
Ligamentum Nuchae and Supraspinous Ligament
Ligamentum Flavum
Muscular Anatomy
Postural
Phasic
SUB-CRANIAL SPINE
Osseous Anatomy
Atlas
Axis
Ligamentous Anatomy
Alar Ligaments
Transverse Ligament
Vascular Anatomy
Vertebral Artery
Muscular Anatomy
Sub-occipital Triangle
COMBINED MECHANICS OF THE UPPER AND MID-CERVICAL SPINE3
Forward-bending
Backward-bending
Side-bending (e.g. right side-bending)
Rotation (e.g. right rotation)
MECHANISM OF DYSFUNCTION
Components of the Forward Head Posture
Trauma
EXAMINATION
Mid-cervical Spine
Active Movement
Passive Movement
MID-CERVICAL SPINE SOMATIC DIAGNOSIS
ERS
FRS
SUB-CRANIAL SPINE
Active Movement
Forward-bending
Backward-bending
Rotation
Passive Movement Tests
Alar Ligament
Transverse Ligament
VERTEBRAL ARTERY
SUB-CRANIAL SPINE SOMATIC DIAGNOSIS
C0, C1 (OA Dysfunctions)
C0, C1 Forward-bending Restriction
C0, C1 Backward-bending Restriction
C0, C1 Side-bending Restriction
C1, C2 (AA Dysfunctions)
Rotation Restriction
Tissue Texture
TREATMENT
Sub-cranial Spine
Soft Tissue Inhibition
Inhibitive Distraction of the Sub-cranial Spine (sub-occipital release) (Figure 8.29)
Forward Nodding
Backward Nodding
Side-bending
C1, C2 (AA Dysfunctions)
Rotation Restriction
Mid-cervical Spine
Soft Tissue Inhibition
Technique to Free an FRS Restriction (Figure 8.37)
REFERENCES
9:
Thoracic Spine
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
MUSCULAR ANATOMY
MECHANICS
MECHANISM OF DYSFUNCTION
EXAMINATION
Thoracic Spine Somatic Diagnosis
Elevated First Rib (Figure 9.2)
ERS (Upper Thoracic Spine) T1-T5 (Figure 9.3)
FRS (Upper Thoracic Spine) T1 to T5 (Figure 9.4)
ERS (Mid and Lower Thoracic Spine) T6-T12 (Figure 9.5)
FRS (Mid and Lower Thoracic Spine) T6-T12 (Figure 9.6)
TREATMENT
Soft Tissue Inhibition (Figure 9.7)
Elevated First Rib (Figure 9.8)
ERS (Upper Thoracic Spine) T1-T5 (Figures 9.9 and 9.10)
FRS (Upper Thoracic Spine) T1-T5 (Figure 9.11)
ERS (Mid and Lower Thoracic Spine) T6-T12 (Figure 9.12)
FRS (Mid and Lower Thoracic Spine) T6-T12 (Figure 9.14)
PROPHYLAXIS
Cervico Thoracic Complex
Exercise Prescription
MYOFASCIAL TENDER POINTS: CERVICOTHORACIC POSTERIOR/ANTERIOR (Figures 9.15 and 9.16)
10:
Lumbar Spine
OSSEOUS ANATOMY
Typical Lumber Vertebra (Figure 10.1)
Intervertebral Disc
Facet Joints
LIGAMENTOUS ANATOMY11
Multisegmental Ligaments
Anterior Longitudinal Ligament (ALL)
Posterior Longitudinal Ligament (PLL)
Supraspinous Ligament
Segmental Ligaments
Interspinous Ligament
Ligamentum Flavum
Intertransverse Ligament
Iliolumbar Ligament
MUSCULAR ANATOMY
MECHANICS
MECHANISM OF DYSFUNCTION
EXAMINATION
Lumbar Spine Somatic Diagnosis
ERS (L1-L5) (Figure 10.2)
FRS (L1-L5) (Figure 10.3)
TREATMENT
Soft Tissue Inhibition (Figure 10.4)
Long Axis Tissue Stretch (Figure 10.5)
Technique
ERS Dysfunction (L1 to L5) (Figure 10.6)
Technique
FRS Dysfunction (L1-L5) (Figure 10.7)
Technique
REFERENCES
11:
Pelvic Complex
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
Iliolumbar Ligament
Posterior and Anterior Sacroiliac Ligaments
Sacrotuberous and Sacrospinous Ligaments
MUSCULAR ANATOMY
Phasic
Postural
Phasic Musculature
Abdominals
Gluteus Maximus
Gluteus Medius
Quadriceps
Postural Musculature
Iliopsoas
Erector Spinae (Superficial) 6
Erector Spinae (Deep)
Multifidus
Piriformis
Hip adductors/Quadratus lumborum
Hamstrings
MECHANICS
Walking Cycle Relevant to Pelvic Mechanics8
MECHANISM OF DYSFUNCTION
Symphysis Pubis
Superior Pubis
Inferior Pubis
Sacrum
Unilateral Dysfunctions
Causes13
Causes13
Torsional Dysfunctions
Innominates
Upslip
Downslip
Anterior Rotation
Posterior Rotation
EXAMINATION
Pelvic Complex Somatic Diagnosis
Sitting Flexion Test
Stork Test (Figure 11.7)
Pubis
Sacrum
UNILATERAL DYSFUNCTIONS
Unilateral Flexed Sacrum
Left Unilateral Flexed Sacrum
Unilateral Extension Shear
Right Unilateral Extension Shear
TORSIONAL DYSFUNCTIONS
Left on Left Sacral Torsion
Left on Left Sacral Torsion
Left on Right Sacral Torsion
Left on Right Sacral Torsion
Innominates
Anterior Innominate
Posterior Innominate
Upslip and Downslip of Innominate
TREATMENT
Soft Tissue Inhibition (Figure 11.14)
Symphysis Pubis (Figure 11.15):
Superior and Inferior Pubis (Shotgun Technique)
Sacrum
Unilateral Flexed Sacrum (Figure 11.16)
Unilateral Extension Shear (Figure 11.17)
Left on Left Sacral Torsion (Figure 11.18)
Left on Right Sacral Torsion (Figure 11.19)
Innominates
Posterior Innominate (Figure 11.20)
Anterior Innominate (Figure 11.21)
Upslip (Figure 11.22)
Downslip (Figure 11.23)
PROPHYLAXIS
Lumbopelvic Complex
Exercise Prescription
SECTION 3: REGIONAL APPLICATION (EXTREMITY MANIPULATION)
12:
Ankle and Foot
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
Rearfoot
Midfoot
Forefoot
MUSCULAR ANATOMY
MECHANICS
Heel Contact to Weight Acceptance
Rearfoot
Midfoot
Forefoot
Early Midstance/Midstance/Late Midstance
Rearfoot
Midfoot
Forefoot
Push off and Propulsion
Rearfoot
Midfoot
Forefoot
Fibula Mechanics
MECHANISM OF DYSFUNCTION
Ankle
Foot
Lateral Arch
Medial Arch
Transverse Arch
Metatarsal Arch
Common Pathologies Secondary to Mechanical Dysfunction
Plantar Faciitis
Sprains
Muscle Strain/Tendinitis
Neuromas
Stress Fractures
Nerve Irritation
ANKLE AND FOOT SOMATIC DIAGNOSIS8 (For Specific Somatic Dysfunction)
Subtalar Neutral (Figure 12.1)
Talus Plantar Flexed (Figure 12.2)
Calcaneus Inverted/Everted (Figure 14.3)
Cuboid Pronated/Supinated (Figure 12.4)
Navicula Internally/Externally Rotated (Figure 12.5)
Depressed Cuneiforms (Figure 12.6)
First Ray Plantar Flexed (Figure 12.7)
TREATMENT (For Specific Somatic Dysfunction)
Talus Plantar Flexed (Figure 12.8)
Calcaneus Inverted/Everted
Cuboid Pronated/Supinated (Figures 12.9A and B)
Navicula Internally/Externally Rotated
Depressed Cuneiforms (Figure 12.10)
First Ray Plantar Flexed
Treatment for Overall Improvement in Range of Motion10
Talocrural Joint
Subtalar Joint
Metatarsophalangeal Joints
PIP/DIP Joints
TECHNIQUE10 (To Improve Dorsiflexion)
Distraction of Talus (Figure 12.11)
Anteromedial/Posterior Lateral Glide of Talus (Figure 12.12)
Superior Glide of Fibula (Figure 12.13)
A/P Glide of Fibula Head (Figure 12.14)
Navicular Talus Dorsal (superior)/Ventral (inferior) Glide (Figure 12.15)
Cuneonavicular Dorsal (Superior) Glide (Figure 12.16)
4/5th Metatarsal/Cuboid Dorsal (Superior)/Plantar (Inferior) Glide (Figures 12.17A and B)
Distraction Calcaneus (Figure 12.18)
Inversion/Eversion Calcaneus (Figures 12.19A and B)
Plantar Flexion/Dorsiflexion Calcaneus (Figures 12.20A and B)
METATARSOPHALANGEAL JOINTS
Distraction (Figure 12.21)
Plantar/Dorsal Glide (Figure 12.22)
Medial/Lateral Glide (Figure 12.23)
Long Axis Rotation (Figure 12.24)
PIP/DIP JOINTS
Distraction (Figure 12.25)
Plantar/Dorsal Glide (Figure 12.26)
Medial/Lateral Glide (Figure 12.27)
PROPHYLAXIS
13:
Knee
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
Primary Ligaments
Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (PCL)
Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)
MUSCULAR ANATOMY
MECHANICS
MECHANISM OF DYSFUNCTION
Common Pathologies Secondary to Mechanical Dysfunction
Patellar Compression
Patellar Tracking
Pes Anserine Bursitis
Iliotibial Band Friction Syndrome
Medial Ligament Strain
Lateral Ligament Strain
Anterior Cruciate Ligament (ACL)
Nerve Compression
KNEE JOINT SOMATIC DIAGNOSIS
Tibial Internal/External (Figure 13.1)
Fibula Anterior/Posterior (Figure 13.2)
Femoral Head Posterolateral
Patella Superolateral (Figure 13.3)
Foot Pronation/Supination
TREATMENT
For Specific Somatic Dysfunction
Tibial Internal/External (Figure 13.4)
Fibula Anterior/Posterior
Femoral Head Posterolateral
Patella Superolateral
Foot Pronation/Supination
For Overall Improvement in Range of Motion10
Functional joint Basics
TECHNIQUE
Patella Superior Glide (Figure 13.6)
Patella Inferior Glide (Figure 13.7)
Patella Medial/lateral Glide (Figure 13.8)
Patella Medial/lateral Tilt (Figure 13.9)
Patella Superior/inferior Tilt (Figure 13.10)
Tibia Distraction (Figure 13.11)
Tibia Posterior Glide Medial Condyle (Figure 13.12)
Tibia Anterior Glide Medial Condyle (Figure 13.13)
Tibia Anterior Tilt (Figure 13.14)
Fibula Anterolateral Glide/Posteromedial Glide (Figure 13.15)
Fibula Superior Glide (Figure 13.16)
PROPHYLAXIS
14:
Hip
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
MUSCULAR ANATOMY
Initial Contact
Midstance
Terminal Stance
Late Stance and Preswing
Terminal Swing
MECHANICS
Initial Contact
Loading Response
Midstance
Terminal Stance
Preswing
Initial Swing
Midswing
Terminal Swing
MECHANISM OF DYSFUNCTION
COMMON PATHOLOGIES SECONDARY TO MECHANICAL DYSFUNCTION
Soft Tissue Strains
Adductors
Iliopsoas
Piriformis
Nerve Irritation
HIP JOINT SOMATIC DIAGNOSIS
Sacral Torsion
Innominate Anterior/Posterior
Superior/Inferior Pubis
Femoral Head Posterolateral (Figure 14.1)
Hip Abduction Firing Pattern (Figure 14.2)
TREATMENT
For Specific Somatic Dysfunction
Femoral Head Posterolateral (Figure 14.3)
Sacral Torsion
Innominate Anterior/Posterior
Pubis Superior/Inferior
Hip Abduction Firing Pattern
For Overall Improvement in Range of Motion11
Functional Joint Basics
TECHNIQUE
Distraction (Figure 14.4)
Posterior Glide
Anterior Glide (Figure 14.6)
Medial Glide (Figure 14.7)
Lateral Glide (Figure 14.8)
PROPHYLAXIS
15:
Shoulder
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
Sternoclavicular Joint
Acromioclavicular Joint
Glenohumeral Joint
Scapulothoracic Joint
MUSCULAR ANATOMY
Axioscapular
Axiohumeral
Scapulohumeral
Humeroscapular
MECHANICS
Acromioclavicular Joint
Flexion
Extension
Abduction
Adduction
External Rotation
Internal Rotation
Sternoclavicular Joint
Flexion
Extension
Abduction
Adduction
External Rotation
Internal Rotation
Scapulothoracic Joint
Glenohumeral Joint
Flexion
Extension
Abduction
External Rotation
Internal Rotation
MECHANISM OF DYSFUNCTION
Impingement/Rotator Cuff Strains
Instability
Common Pathologies Secondary to Mechanical Dysfunction
Faulty Posture (include bicipital and rotator cuff tendinitis)
Subacromial Bursitis
Snapping Scapula
Acromioclavicular Degeneration/Impingement/strain
Nerve Entrapments
SHOULDER JOINT SOMATIC DIAGNOSIS (For specific somatic dysfunction)
Humerus
Anterior (Structural) (Figure 15.2)
Anterior (Dynamic)
Superior (Structural) (Figure 15.3)
Superior (Dynamic)
Medially-rotated (Structural) (Figure 15.4)
Medially-rotated (Dynamic)
Scapula
Winging (Dynamic)
Adducted/Downward rotation:
Abducted/protraction (Structural) (Figures 15.6A and B)
Abducted/protraction (Dynamic)
Acromioclavicular
Inferior Anterior (Figure 15.7)
Sternoclavicular
Superior Posterior (Figure 15.8)
Subcranial Spine/Midcervical Spine
First Rib Elevated
Thoracic Spine
TREATMENT (For Specific Somatic Dysfunction)
Humerus Anterior (Figure 15.9)
Humerus Superior
Humerus Medially Rotated (Figure 15.10)
Scapula Downward-rotated (Figure 15.11)
Protracted (Figure 15.12)
Winged
Acromioclavicular Inferior Anterior
Sternoclavicular Superior Posterior (Figures 15.13A and B)
For Overall Improvement in Range of Motion
Functional Joint Basics
TECHNIQUE
Scapula Distraction (Figure 15.14)
Scapula Upward Rotation (Figure 15.15)
Scapula Downward Rotation (Figure 15.16)
Acromioclavicular Superior Posterior/Inferior Anterior Glide (Figure 15.17)
Sternoclavicular Inferior Anterior Glide (Figure 15.18)
Sternoclavicular Posterior Superior Glide (Figure 15.19)
Glenohumeral Distraction (Figure 15.20)
Glenohumeral Posterior Glide (Figure 15.21)
Glenohumeral Inferior Glide (Figure 15.22)
Glenohumeral Anterior Glide (Figure 15.23)
PROPHYLAXIS
Anterior Humerus
Superior Humerus
Medially-rotated Humerus
Winged Scapula
Downward-rotated Scapula
Protracted Scapula
16:
Elbow
OSSEOUS ANATOMY
LIGAMENTOUS ANATOMY
Ulnar Collateral
Radial Collateral
Annular Ligament
MUSCULAR ANATOMY
Pronator Teres
Supinator Brevis
Flexor Carpi Ulnaris
Extensor Carpi Radialis Longus (ECRL)
Extensor Carpi Radialis Brevis (ECRB)
MECHANICS
MECHANISM OF DYSFUNCTION
Medial Elbow Dysfunction
Throwing
Wrist Flexion
Posterior Elbow Dysfunction
Lateral Elbow Dysfunction
ELBOW JOINT SOMATIC DIAGNOSIS (for specific somatic dysfunction)
Ulna Medial/Lateral (Figure 16.1)
Radial Head Superior/Inferior (Figure 16.2)
Ulnar Variance (Figure 16.3)
Ulnar Styloid Posterior (Figure 16.4)
TREATMENT (For Specific Somatic Dysfunction)
Ulna Medial/Lateral (Figures 16.5A and B)
Radial Head Superior/Inferior
Ulnar Styloid Posterior (Figure 16.7)
Ulnar Variance
For Overall Improvement in Range of Motion8
Functional Joint Basics (Humeroulnar/radial)
Functional Joint Basics (Superior radioulnar)
Ulna Distraction8 (Figure 16.8)
Superior Movement of the Radius (Figure 16.9)
Anterior/Posterior Glide of Radial Head (Figure 16.10)
Outward Roll of Radius and Ulna (Figure 16.11)
Inferior Movement of the Radius (Figure 16.12)
Anterior Glide of Ulna Styloid (Figure 16.13)
Posterior Glide of Ulna Styloid (Figure 16.14)
MYOFACIAL TENDER POINTS (FIGURES 16.15 AND 16.16)
17:
Wrist and Hand
OSSEOUS ANATOMY
Distal Radioulnar Joint
Radiocarpal
Intercarpal
Midcarpal
Carpometacarpal
Intermetacarpal
Metacarpophalangeal
Interphalangeal
LIGAMENTOUS ANATOMY
Scapholunate/Lunate-capitate
Transverse Carpal
Ulnar Collateral Ligament of Thumb
Collateral Ligament (MCP, IP)
Piso Hamate Ligament
MUSCULAR ANATOMY
Interossei
Extensor Digitorum Communis
Flexor Digitorum Superficialis/Profundus
Abductor Pollicis Longus/Extensor Pollicis Brevis
MECHANICS
Wrist Extension with Radial Deviation
Wrist Flexion with Ulnar Deviation
MECHANISM OF DYSFUNCTION
Common Pathologies Secondary to Mechanical Dysfunction
TFCC (triangular fibrocartilage complex)
de Quervain's Disease
Muscles and Tendons
Ligament Strains
Transverse Carpal
Ulnar Collateral Ligament of Thumb (Gamekeeper's Thumb)
Collateral Ligament (MCP, IP)
Pisohamate Ligament
CMC Arthrosis
Intersection Syndrome
Nerve Entrapments
WRIST AND HAND SOMATIC DIAGNOSIS (For Specific Somatic Dysfunction)
Ulnar Variance (Figure 17.1)
Radial Head Superior/Inferior (Figure 17.2)
Ulna Posterior (Figure 17.3)
Lunate Anterior (Figure 17.4)
Assessment of Restriction of Joint Play
Wrist Extension with Radial Deviation (Figure 17.5)
Wrist Flexion with Ulnar Deviation
TREATMENT (For Specific Somatic Dysfunction)
Radial Head Superior/Inferior
Ulnar Styloid Posterior (Figure 17.7)
Positive Ulnar Variance
Lunate Anterior (Figure 17.8)
Wrist Extension with Radial Deviation
Wrist Flexion with Ulnar Deviation
For Overall Improvement in Range of Motion
Radiocarpal (Wrist Joint)
Metacarpophalangeal Joints
PIP/DIP Joints
Carpometacarpal Joints
TECHNIQUE
Radiocarpal Distraction (Figure 17.13)
Radiocarpal Dorsal Glide (Pisiform, triquetrum, lunate, scaphoid) (Figure 17.14)
Midcarpal Volar Glide (trapezium, trapezoid, capitate, hamate) (Figure 17.15)
Caudal Movement of Radius (Figure 17.16)
Radiocarpal Volar Glide (Pisiform, triquetrum, lunate, scaphoid) (Figure 17.17)
Midcarpal Dorsal Glide (trapezium, trapezoid, capitate, hamate) (Figure 17.18)
Cephalad Movement of Radius (Figure 17.19)
Ulnar/Radial Glide of Proximal Row (Figure 17.20)
METACARPOPHALANGEAL JOINTS (To Improve Flexion)
Distraction (Figure 17.21)
Volar Glide (Figure 17.22)
Medial/lateral Glides (Figure 17.23)
Long Axis Rotation (Figure 17.24)
Dorsal Glide (Figure 17.25)
PIP/DIP JOINTS
Distraction (Figure 17.26)
Volar Glide (Figure 17.27)
Medial/lateral Glides (Figure 17.28)
Dorsal Glide (Figure 17.29)
CARPOMETACARPAL JOINTS
Palmar Glide Parallel to Palm (Figure 17.30)
Palmar Glide at Right Angles to the Palm (Figure 17.31)
PROPHYLAXIS
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