DEFINITIONS
Manual therapy is a clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.
HISTORY (Fig. 1.1)
- Acharya Susrutha (600 BC) in his book Susrutha Samhita explained 107 marma points in the body that can be treated with the finger pressure.
- Hippocrates (460–355 BC) explained traction and few other manual therapy techniques.
- Galen (131–202 AD) explained few manual therapy techniques for cervical vertebrae, as well as the upper and lower extremities.
- John Hunter (1728–1793) recommended stretching and joint movements in the cases of stiffness and adhesion.
- Bone setting flourished in Britain during the 17th and 18th centuries.
- Sir James Paget (1814–1899) suggested the medical community to learn bone setting to imitate what is good and avoid what is bad.
- Andrew Taylor Still (1828–1917) founded osteopathy in 1874 in the USA.
- Daniel David Palmer founded Chiropractic in 1895.
- Edgar and James Cyriax, and James & John Mennell taught manual therapy to the physiotherapists in beginning of the 19th century.
- Edgar Cyriax published a paper Manual Treatment of the Cervical Sympathetics in 1917.
- Walmsley coined the term Arthrokinametics in 1927.
- James Mennell wrote a book “Manual Therapy” and got published in 1951.
- James Cyriax published a book “Textbook of Orthopaedic Medicine” in 1954. His book made the term End Feel popular.
- John Mennell used the term Joint Play for the first time in his book “Joint Pain” published in 1960.
- Kaltenborn linked the arthrokinematics with the manual therapy and published his book “Extremity Joint Manipulation” in 1961.
- Stanley V Paris published “Theory and Technique of Specific Spinal Manipulation” in 1963.
- Geoffrey Maitland published his book “Vertebral Manipulation” in 1964.
- In 1966, Kaltenborn, Paris, Grieve, and Maitland held a meeting which resulted into the foundation of Federation of Orthopaedic Manual Therapy (IFOMT).
- In the late 1970s, McKenzie introduced his own concept.
TYPES OF MANUAL THERAPY
According to the Application
- Muscle:
- Soft tissue manipulation
- Muscle energy technique, etc.
- Neural structure:
- Neural stretching.
According to the Procedures
- Thrust:
- High velocity thrust technique/manipulation
- Non-thrust:
- Graded oscillations
- Stretching
- Soft tissue manipulation
- Myofascial release
- Muscle energy technique, etc.
EFFECTS OF MANUAL THERAPY
- Biomechanical effects:
- Joint displacement
- Increase in range of motion (ROM) due to passive movements
- Muscular reflexogenic effects:
- Muscular inhibition
- Muscular facilitation
- Neurophysiologic effects:
- Pain inhibition and analgesia
- Pain gate mechanism
- Psychological effects:
- Placebo.
TERMINOLOGY
Mobilization
Mobilization is passive joint movement applied to spinal or peripheral joint in which a rhythmic oscillatory movement within the control of patient is applied at varying speeds and amplitudes using physiologic or accessory motions to increase range of motion (ROM) or decreasing pain.4
Manipulation
Manipulation is passive joint movement applied to a joint in which a sudden, forceful thrust beyond the patient's control is applied to increase range of motion (ROM).
Soft Tissue Manipulation
The soft tissue manipulation techniques involve various forms of deep massage and are used to increase the mobility of adherent or shortened connective tissues.
Muscle Energy Technique
Muscle energy techniques use the concepts of autogenic inhibition, and reciprocal inhibition to relax and then stretch the target muscle. The patient is asked to do isometric/concentric/eccentric contraction in a precisely controlled direction and intensity against a counterforce applied by the therapist.
Neural Stretching
The neural tissues are stretched and mobilized in the cases of adhesion or scar tissue around the nerve root or at the site of injury at the plexus or peripheral nerves after trauma or surgical procedures. Tension placed on the adhesions or scar tissue leads to pain or neurological symptoms.
Graded Oscillation
Graded oscillation was widely promoted by Maitland. Graded oscillation is a form of cyclic loading whereby alternative pressure, on and off, is delivered at different parts of the available range.
Stretching
Stretching is a general terms that describe any therapeutic maneuver that increases the extensibility of restricted soft tissues.
Myofascial Release
Myofascial release techniques focus on relaxing the fascia by applying direct pressure on the body and using slow and sometimes deep pressure to restore the extensibility of the fascia.5
SCHOOLS OF THOUGHT
Though there are various schools of thought in manual therapy, I would like to quote few notables ones.
- Osteopathy:
- The founder of osteopathic medicine was Andrew Taylor Still (1827–1917).
- Still observed through careful study of a patient that when joints are restricted in motion due to mechanical locking or other related causes were normalized, certain disease conditions improved.
- Dr Still made the “Rule of the Artery” which says that if we manipulate to restore blood flow, it will restore body's innate healing ability.
- According to osteopathy:
- The body is a unit; structure and function are reciprocally interrelated.
- The body possesses self-regulatory mechanisms for rational therapies based on an understanding of the body unity, the self-regulatory mechanisms.
- There is interrelation of structure and function.
- Chiropractic:
- Founded in 1895 by DD Palmer (1845–1913).
- In Chiropractic “Subluxation” of the spine is a causal factor in disease and the revelation that adjustments can restore the body's innate healing abilities.
- “Chiropractors do not manipulate; they do not use the process of manipulating; they adjust.”
- DD Palmer applied an “adjustment” to Harvey Lillard in September 1895 to the T4 vertebra that resulted in restoration of lost hearing.
- Palmer School of Chiropractic founded in 1897 in Davenport, Iowa.
- Williams:
- Dr Paul Williams observed that the majority of patients who experienced low back pain had degenerative vertebrae secondary to degenerative disc disease.
- These exercises were developed for men under 50 and women under 40 years of age:
- Who had exaggerated lumbar lordosis
- Whose X-ray films showed decreased disc space between lumbar spine segments (L1-S1)
- Whose symptoms were chronic but low grade.
- His exercises were flexion biased.
- The goals of performing Williams exercises are to reduce pain and provide lower trunk stability by actively developing the “abdominal, gluteus maximus, and hamstring muscles as well as passively stretching the hip flexors and lower back (sacrospinalis) muscles.
- Williams said: “The exercises outlined will accomplish a proper balance between the flexor and the extensor groups of postural muscles.”
- Conceptually, Williams felt that the goal of exercise was to reduce the lumbar lordosis or to flatten the back.
- To do this, he suggested strengthening the abdominal muscles in order to lift the pelvis from the front.
- In addition, he proposed strengthening the gluteal muscles would pull the back of the pelvis down.
- According to Williams, the combination of these two exercises would accomplish the primary goal of flattening the lumbar curve.
- Mennell:
- Published his book in 1951.
- Felt that ‘joint play’ is key to normal function.
- He emphasized the importance of the small accessory movements as necessary for full movement to occur.
- Techniques are more specific for the extremities than for the spine.
- He was one of the first clinicians to study the intimate mechanics of joints and to adapt mobilizations to his findings.
- He coined the term accessory motion.
- Cyriax:
- Founded by James Cyriax.
- Used selective tension techniques to identify faulty structures in the examination.
- Believed the disc is the primary cause of low back pain and used nonspecific spinal techniques designed to move the disc to relive nerve root pressure.
- Started to use the term cross friction.
- Also known for the term endfeel.
- He published a book “Textbook of Orthopaedic Medicine” in 1954.
- Kaltenborn
- Freddy Kaltenborn is known for his research in arthrokinematics.
- He gave different classification of joints for manual therapists.
- His techniques incorporate the influence of muscle function and soft-tissue changes in the patient's manifestation of loss of function.
- Kaltenborn published his book “Extremity Joint Manipulation” in 1961.
- Maitland:
- Founded by Geoffrey Maitland.
- Used primarily passive accessory movements to restore function.
- Relies on an extensive assessment based on information from the patient's subjective examination (history) and the evaluator's objective assessment.
- The movements are oscillations, the techniques are specific and the goals is what he terms ‘reproducible signs’.
- The Maitland concept is referred to as a ‘concept’ and not as a ‘technique’.
- He published his book “Vertebral Manipulation” in 1964.
- McKenzie:
- Robin Anthony McKenzie noted that a subset of his patients experienced significant pain relief when the spine was extended as the part of a treatment. Often, these patients were able to return to normal daily activities.
- Physical therapists who practiced the methods developed by McKenzie founded the McKenzie Institute in 1982.
- This modality may be used to treat any number of back, spine, muscle, bone, or joint disorders.
- If the pain moves towards the spine or is eliminated, then the patient may be an appropriate candidate for the McKenzie Method®.
- Centralization is the term practitioners of this modality use to describe this movement or elimination of pain.
- Usually, if the patient's pain and spinal-related problems do not have a mechanical origin, the McKenzie Method® may not be a useful treatment for that individual.
- McKenzie is a comprehensive approach to the spine based on sound principles and fundamentals that when understood and followed accordingly are very successful.
- The McKenzie method: Three steps to success:
- Assessment
- Treatment
- Prevention
- Mulligan:
- Developed and founded by Brian Mulligan.
- In 1983 Brian began teaching his techniques.
- For extremities: MWMs (Mobilization with movement)
- For spine: NAGs (Natural apophyseal glides) and SNAGs (Sustained natural apophyseal glides).
- The patient is requested to perform the comparable sign (by performing a classic movement). These signs may be a loss of joint movement, pain associated with movement, or pain associated with specific functional activities.
- A passive accessory joint mobilization is applied. This accessory glide must itself be pain free.
- The comparable sign should now be significantly improved (i.e. increased range of motion, and a significantly decreased or better yet, absence of the original pain).
- The previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.
- Failure to improve the comparable sign would indicate that the therapist has not found the correct contact point, treatment plane, grade or direction of mobilization, spinal segment or that the technique is not indicated.
- Krishna's Kinetikinetic Manual Therapy (KKMT):
- Developed by Dr Krishna N Sharma in 2015.
- Realigns and harmonizes the incongruity and altered states of body, mind, and energy by manipulating the homeostatic kinetic forces and energies.
- The KKMT protocol includes assessment, mobilization, and prevention. Each of these are done separately for three aspects of a human being, i.e. body, mind, and energies.
- Though a therapist can work on any of these three aspect, working on all of them is recommended for better outcome.