Manual Therapy & Manual Techniques: Their Role in Pain Management Caroline Adrian PT, PhD, CCRP Carrie.Adrian@vca.com Director, Rehabilitation Services VCA Animal Hospitals, Los Angeles, CA, USA VCA Veterinary Specialists of Northern Colorado, Loveland, CO, USA
Objectives Understand the difference between manual therapy vs. manual techniques Recognize the various methods by which various manual therapies/techniques may exerts their effects Understand what implications manual therapy may have on joints, nerves, the spinal cord and higher brain centers Learn several manual therapy methods and techniques as they apply to pain management including joint mobilization (Maitland and Mulligan), TPDN, ischemic compression, IASTM and KT
Manual Therapy (MT) Maitland Founding father of MT Proposed use of PIVMs (passive intervertebral movements) (Maitland, 1986) PAMs passive accessory movements (Maitland, 1986) Identifying end feels (Maitland, 1986) Kaltenborn (Kaltenborn, 1975) Convcave-convex rultes MT eval/tx based on Mulligan (Mulligan, 1995) Mobilization with movement (MWM) Sustained accessory glide/mobilization + concurrent pain free physiological movement Others: McKenzie, Cyriax, Paris
Manual Therapy Insurance coding No soft tissue codes Dumped all hands on into one category 97140 = Manual Therapy PROM Stretching Massage Joint mobilization/manipulation Others IASTM, MFR, TPDN,
Manual Therapy Manual therapy consists of a broad group of passive interventions in which physical therapists use their hands to administer skilled movements designed to: Modulate pain Increase joint range of motion Reduce or eliminate soft tissue inflammation Induce relaxation Improve contractile and noncontractile tissue extensibility Improve pulmonary function limited range of motion APTA, Phys Ther, 2005
Manual Therapy Techniques may include: Range of motion Manual traction Connective tissue massage (MFR) Therapeutic massage *Joint mobilization and manipulation *Soft tissue mobilization and manipulation (stretching, IASTM) *Others (TPDN, KT, etc.) + Management positioning, medications, ther ex, modalities, icing, etc. APTA, Phys Ther, 2005
Manual Therapy: Mobilization/Manipulation Mobilization/manipulation Manual therapy techniques comprised of a continuum of skilled passive movements that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement Interventions employ a variety of techniques, i.e. application of graded forces APTA, Phys Ther, 2005
Manual Therapy: Mobilization/Manipulation (2013) Thrust replaced manipulation High velocity, low amplitude therapeutic movement within or at the end range of motion Nonthrust replaced mobilization Do not involve thrust Emphasis that these procedures are applied on a continuum Requiring ongoing examination and evaluation to determine how to proceed along the continuum Determine the appropriate action - continuing, reducing, or progressing further intervention Modification of speed, amplitude, and direction of forces for optimal clinical outcomes APTA, Phys Ther, 2005
Manual Therapy: Mobilization/Manipulation Interventions requiring immediate and continuous examination and evaluation throughout the intervention - performed exclusively by the physical therapist Such procedural interventions include (but not limited to): Spinal and peripheral joint mobilization (nonthrust manipulation) Spinal and peripheral joint manipulation (thrust manipulation) Due to clinical complexity and the sophistication of judgment required to perform them - precludes delegation to paraprofessionals or others Safe application of mobilization/manipulation requires practitioner to apply advanced understanding of arthrokinematic principles simultaneously with ongoing examination, evaluation, and clinical decision making during the intervention PTAs (CVT/RVT) scope of practice does not include - examination, evaluation, diagnosis, and prognosis APTA, 2013
Manual Therapy Osteokinematic vs. Arthrokinematic Motion
Manual Therapy Osteokinematics Physiologic joint motion Flex/ext Ab/Adduction IR/ER Patients have voluntary control Within PTA/CVT scope of practice Arthrokinematics Accessory joint motion Roll Spin Glide Not under voluntary control of the patient Practitioner produces motion through skilled manual techniques Requires a detailed understanding of joint surface anatomy and kinesiology Requires continuous use of examination with clinical decision making to modulate the technique throughout the treatment session PT/DVM only
Efficacy of Mobilization/Manipulation Shoulder pathologies (Bang and Deyle, JOSPT, 2000; Bergman, et.al., Ann Intern Med, 2004; Vermeulen, et.al., Phys Ther, 2006) Carpal tunnel syndrome (Akalin etal., 2002; Rozmaryn etal., 1998) LBP (Cleland, etl.al, Spine, 2009; Childs, etal, 2004; Licciardone etal., 2003) Knee OA (Deyle, et.al., Ann Intern Med, 2000; Deyle, et.al., Phys Ther, 2005) Hip OA (Hoeksma, et.al., Arthritis and Rheumatism, 2004; MacDonald, etal., 2006) Neck pain (Hoving, et.al., Ann Intern Med, 2002; Walker et.al, Spine, 2008) Lumbar spinal stenosis (Whitman, et.al., Spine, 2006)
Mechanistic Model of MT? (Bialoskly etal., 2010) Mechanical stimulus transient biomechanical effects Neurophysiologic mechanism interaction of peripheral and central nervous system Peripheral mechanism affects inflammatory process Spinal mechanism effect on the spinal cord Supraspinal mechanism influence of specific supraspinal structures in response to pain
Manual Therapy 14 (2009) 531 538 Contents lists available at ScienceDirect Manual Therapy journal h omepage: www.elsevier.com/math Original Article The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model Joel E. Bialosky a, *, Mark D. Bishop a, Don D. Price b, Michael E. Robinson c, Steven Z. George a 1. Mechanical effects 2. Neurophysiological effects
Biomechanical Effects - Evidence Summary McFadden & Taylor (1990) - Gapping of L4/5 facet joint in a cadaver after incision of the capsule Ianuzzi A, et.al. (2005) successful treatment using manip may not require segmental specificity Fernandez-de-la-Penas C, et.al. (2005) increased CSp intervertebral motion Tullberg T, et.al. (1998) SMT didn t alter sacral position in relation to ilium
Biomechanical Effects - Evidence Summary Fibrous adhesions develop https://classconnection.s3.amazonaws.com/930/flas hcards/619930/jpg/facet-joint1312044979149.jpg Thrust separates Z-joints Breaks up adhesions by gapping Z-joints Z-joints can move normally
Biomechanical Effects - Evidence Summary Evidence that manual therapy causes Increased intervertebral motion Vertebral movement Gapping of facets Not site specific BUT! No changes in alignment/position Changes are not specific Changes don t last long THUS: Unlikely to be solely responsible for clinical benefits
Manual Therapy 14 (2009) 531 538 Contents lists available at ScienceDirect Manual Therapy journal h omepage: www.elsevier.com/math Original Article The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model Joel E. Bialosky a, *, Mark D. Bishop a, Don D. Price b, Michael E. Robinson c, Steven Z. George a 1. Mechanical effects 2. Neurophysiological effects
Neurophysiologic Effects Transient mechanical stimulus to the tissue causes chain of neurophysiological effects Immediate hypoalgesia (Vicenzino et al, 2001; Paungmali et al, 2004; Mohammadian et al, 2004) Bombards the CNS with sensory input from muscle proprioceptors (Pickar & Wheeler, 2001) Counter irritant to spinal cord neurons (Boal & Gillette, 2004) Specific activation of the PAG (Wright, 1995; Sterling et.al, 2001)
Manual Therapy for Pain Management Joint mobilizations Maitland Grades I and II, for pain Mulligan Distraction TPDN Ischemic compression IASTM KT
Joint Mobilizations EVERY movement of the body possesses some form of accessory/arthrokinematic joint motion Restrictions of accessory joint motion Pain Restriction during physiologic motion Capsuloligamentous tightening, internal derangement, bony blockage, reflex mm. guarding, bony subluxation, deformity secondary to pain, dysfunction, postoperative adhesions
Concave Convex Rule Stifle When a concave surface moves on a convex, the gliding occurs in the SAME direction * Femoral condyle convex surface * Tibial plateau concave surface Tibia moving on the femoral condyles produces a glide in the SAME direction To increase stifle flexion, tibia glides caudally (mobilize cranial to caudal = caudal glide) http://balkanvets.com/wpcontent/uploads/2015/08/cranial-cruciate-ligament.jpg
Concave Convex Rule Hip When a convex surface moves on a concave, the gliding occurs in the OPPOSITE direction * Acetabulum concave surface * Head of femur convex surface Femur moving on the acetabulum produces a glide in the OPPOSITE direction To increase hip extension, head of femur glides cranially (Mobilize caudal to cranial = cranial glide) http://www.dog-health-handbook.com/imagefiles/dog_legrear.jpg
Concave Convex Rule Hip When a concave surface moves on a convex, the gliding occurs in the OPPOSITE direction * Acetabulum concave surface * Head of femur convex surface Femur moving in the acetabulum produces a glide in the OPPOSITE direction To increase hip extension, head of femur glides cranially (Mobilize caudal to cranial = cranial glide) http://www.dog-health-handbook.com/imagefiles/dog_legrear.jpg
Cranial glide Distraction Picture Maitland, Grade 1 and 2 Hip OA Example
Concave Convex Rule Elbow Concave? Convex? Direction of glide? To increase flexion? Distraction
Graded Movements End range Mid-range I II III IV V Pain Stiffness
Maitland Grade I and II Neuromodulatory effect Grade I: gentle Light pressure Extremely small amplitude Used for pain and muscle spasms Grade II Larger amplitude PAINFREE range Avoid pain and spasm
Mulligan - Mobilization with Movement (MWM) Passive techniques, decrease pain; but dysfunction returns Efficacy is determined by immediate gains in pain-free ROM PRODUCE NO PAIN! Minimum force Repetitions
Mulligan - Mobilization with Movement (MWM) Direction primary direction of accessory glide Location where to apply MWM, based on exam Force minimal force necessary to allow pain-free motion
Mulligan Example - Shoulder
Mobilization (Nonthrust)/Manipulation (Thrust): Negative Responses Worsening and/or peripheralization of symptoms Tissue damage Promotion of inflammation leading to chronic pain and/or proliferation of scar tissue Spinal or joint instability Neurovascular compromise. Failure to properly evaluate responses during the course of examination and/or intervention = result in adverse responses from the intervention Increased pain and deformity Loss of function Death
Intramuscular Manual Therapy (Trigger Point Dry Needling) What s a Myofascial Trigger Point (MTP)? (Simons, etal., 1999) Ever have a knot in your muscle? Hyperirritable/sensitive palpable nodule In taut band of skeletal muscle or muscle fascia Causes sensory, motor, neurologic, and autonomic symptoms Key S/S: (Lavelle, etal., 2007) Local and referred pain Restriced ROM Increased sensitivity to stretching Muscle weakness, due to pain No muscular atrophy
Intramuscular Manual Therapy (Trigger Point Dry Needling) Dry needling, trigger point dry needling, or intramuscular needle TPDN - used to treat myofascial pain (Virginia Board of Physical Therapy Task Force on Dry Needling, 2007) Uses a dry needle No medication Inserted into a trigger point Goal of releasing/inactivating the trigger points Relieving pain Improves pain control Reduces muscle tension Normalizes biochemical and electrical dysfunction of motor endplates Facilitates an accelerated return to active rehabilitation (aaompt.org/members/statements.cfm)
TPDN - Differs From Acupuncture "Acupuncture" Treatment method of moxibustion Use of electrical, thermal, mechanical or magnetic devices With or without needles Stimulate acupuncture points/meridians Induce acupuncture anesthesia/analgesia Only similarity is the tool a 28 gauge needle TPDN - NOT an entry level skill Requires additional training
TPDN
TPDN Common locations: Triceps Infra/supra Rhomboids/traps Quads/hams Sartorius Gracilis
MTP Treatment Ischemic Compression Manual pressure Application of increasing pressure on TPs With thumb/tool Until pain reaches max tolerable level Immediate pain relief Evidence limited for long-term pain relief (Vernon & Schneider, 2009)
Ischemic Compression Palpate, palpate, palpate! Gradual increase in pressure To tolerance! Hold ~30 seconds Repeat 2-3 times Reassess after each treatment
video Ischemic Compression
Instrument Assisted Soft Tissue Manipulation (IASTM) soft tissue technique that enables the therapist to detect and treat myofascial restrictions to improve ROM and decrease pain Indirect changes in soft tissue 1. Stimulate localized inflammatory response 2. Potential reabsorption of fibrotic tissue 3. Facilitates healing process
Instrument Assisted Soft Tissue Manipulation (IASTM) Uses: Limited mobility due to soft tissue restrictions Pain modulation Motor control issues Kinesthetic feedback Painful hands from manual therapy! The Wave Tool Smart Tools Hawkgrips Rockblades The Edge Tool
Instrument Assisted Soft Tissue Manipulation (IASTM) Palpate for aberrant tension Scan area with tool Treat with appropriate techniques Clean the tool! Reassess with palpation and movement Increased tone/tension/pain = long, slow strokes Restrictions = feel gritty, use short, quick strokes
IASTM - Example
Kinesiotaping (KT) Elastic - stretched to up to 120% to 140% of original length Provides pulling force to the skin Supposedly increase the distance between the fascia and the soft tissue KT does not restrict joint movement May increase muscle performance (Firth, etal., 2010; Hammer 2006; Hsu, etal., 2009) Normalize muscle function (Kase, etal., 1996; Williams, etal., 2012) Increase lymphatic and vascular flow Aid in correction of possible articular malalignments Diminish pain
Kinesiotaping (KT) Basic Principles: 1. Inflammation, tissue restrictions, other limitations in soft tissue = increased resistance/decreased space between skin, fascia and muscle 2. Increased resistance = increased limitations 3. Increased limitations = decreased muscle performance Goal: decrease resistance Increase conduction increase function Decrease resistance by: 1. Lift skin 2. Better fluid exchange between the superficial layers 3. Stimulate nervous system - tactile cueing - develop new/proper patterns
Kinesiotaping (KT)
Scraping & Taping Example Gigi
Scraping & Taping Example
Fall in Colorado Photo courtesy of Dr. Amy Komitor