L15 - PRINCIPLES, EFFECTIVENESS AND CLASSIFICATION OF MANUAL THERAPY Flashcards
Historical timeline of dvp of MT
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Chartered Society of PT founded as Society of Trained Masseuses in 1894 by 4 nurses
- By 1900 Society had acquired legal & public status of professional organization & became
Incorporated Society of Trained Masseuses
- In 1920, Society was granted its Royal Charter
Birth of IFOMPT
Birth of IFOMPT
- Inaugural meeting of IFOMPT hosted in Canada in 1974
- Meeting provided 1st international forum for specialist area of physical therapy following period of
growth & dissemination of Orthopedic Manipulative Therapy through courses throughout world by
group of eminent physical therapists
Biomechanical approach
Table
Manual therapy revolution
Mechanisms of manual therapy in treatment of MSK pain = comprehensive model
- Suggests that mechanical force from MT initiates cascade of neurophysiological responses from
peripheral & central nervous system which are responsible for clinical outcomes
Manual therapy = effective treatment contributing to recovery of functional capabilities
- Should be included within multimodal approach targeting functional recovery of patient. Current
evidence suggesting that multimodal approach including manual therapy, exercise & education,
seems to provide better outcomes than manual therapy alone
Genuine multimodal approach should include not only physical management but consideration of
psychological & psychosocial aspects of patient’s unique pain experience
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APTA’s guide to physical therapist practice: define mob/manip, thrust manip, non thrust, manual therapy
Defined:
- Mobilization / manipulation = manual therapy technique comprised of continuum of skilled
passive movements, that are applied at varying speeds & amplitudes, including small amplitude /
high velocity (HVSA) therapeutic movement
To achieve common language for describing area if physical therapist’s scope of practice, terms “thrust” &
“nonthrust” manipulation established to replace previous terms “manipulation” & “mobilization”
respectively
APTA Manipulation Education Manual for Physical Therapist Professional Degree Programs further defines:
- Thrust manipulation = high velocity, low amplitude therapeutic movement within or at end of
range of motion
- Nonthrust = manipulation that do not involve thrust
Manual therapy = passive, skilled movement applied by clinicians that directly or indirectly targets variety
of anatomical structures or systems, which is utilized with intent to create beneficial changes in some
aspect of patient pan experience
- Process of MT grounded on clinical reasoning to enhance patient management for MSK pain by
influencing factors from multidimensional perspective that have potential to positively impact
clinical outcomes
- Influence of biomechanical, neurophysiological, psychological & nonspecific patient factors as
treatment mediators and/or moderators provides additional information related to process &
potential mechanisms by which MT may be effective
- As healthcare delivery advances toward personalized approaches, crucial need to advance
understanding of underlying mechanisms associated with MT effectiveness
Passive intervention, defined as health-promoting material does not require human involvement for
delivery
- 1699 unique terms labeled as manual therapy
APTA guide: visceral manip
Visceral manipulation
Poor evidence for efficacy if techniques used in Fascial Therapy targeting visceral system & information
help healthcare professionals in decision-making related to use of Fascial Therapy targeting visceral
system in patients with visceral disorders and/or pain
APTA guide: spinal manipulative therapy
Given evidence from RCTs & SRs of similar pain & function outcomes to other recommended
interventions manual therapy recommended treatment for patients with MSK conditions. Np more
research is warranted
- Spinal manipulation consistently recommended for acute, subacute & chronic across
international Clinical Practice Guidelines
Cost effectiveness of MT
Cost effectiveness
- Many studies support that manual therapy is cost-effective
- No studies supporting that manual therapy is cost-prohibitive
Traditional aspects of MT: end feels
End feel
Endpoint/barrier of ROM of joint described as ‘end-feel’
- When joint actively or passively brought to its physiological limit => definite, but not abrupt endfeel
- When joint brought to its anatomical limit => stiffer sensation
- However, if restriction in normal ROM of joint => pathological barrier evident in active or passive
movement
Normal end-feel:
- SOFT: due to soft tissue approximation (knee flexion) or soft tissue elongation (ankle dorsiflexion)
- ELASTIC: capsular or ligamentous elongation (internal rotation of femur)
- HARD: occurs when bone against bone (elbow extension)
Pathological end-feel
May involve number of presentations as:
- Harder, less elastic sensation when scar tissue restricts movement or when shortened
connective tissue
- Elastic, less soft sensation when increase in muscle tone restricts movement
- Hollow end-feel occurs when patient stops movement (or asks to stop it) before reaching true
end-feel, due to extreme pain or fear/kinesiophobia.
Traditional aspects of MT: joint play
Joint play
= Refers to accessory movements (arthrokinematics), associated with separation (traction) or parallel
movement of joint surfaces (sliding or gliding).
- Some degree of movement is physiological & limited by degree of elasticity of soft tissue
- Any change in length/integrity of these tissues alters joint play
Traditional aspects : Taking out slack
Taking out slack
- Purpose of tissue pull is to take slack out of skin, subcutaneous tissues, & underlying muscle up
to segmental contact point prior to making your contact
- Makes contact with segmental contact point more stable (contact point is not sliding around), & if
done in right direction, its pre-stresses tissue in direction of correction
Mobilization types & parameters
Mobilization
Types
- Traction
- Spin
- Glide
- Angular movement
Parameters
- Velocity
- Amplitude
- Force
How deliver MT: description, goals & variable to consider
How to deliver manual therapy
No standard prescription but should be modulated to singular person within & between sessions in
context of multimodal approach
Goals
- Pain
- Function
Variable to consider
- Stage of condition
- Healing phase
- Loadability
- Comorbidities
- Contraindication
- Patient expectation
- Feedback
Tissue healing: factors influencing & doesn’t hurt anymore
Factors influencing
- Severity of injury: more severe take longer
- Loading: need appropriate load for healing, not overloading
- Movement mechanics: repetitive movement patterns, or altered movements stress injured
tissues
- Hydration: dehydrated tissues heal slower
- Nutrition: increased protein needs during tissue healing
- Inflammation: systemic inflammation from poor nutrition, stress, lack of sleep…
- Sleep: essential for tissue repair & inflammation control
- Cardiovascular health: need adequate circulation
Doesn’t hurt anymore
- Absence or presence of pain not good indicator for healing or tissue remodeling
- Pain usually controlled with manual therapy & altering movements & loading patterns
- Injured tissue still needs time to remodel. Will be at risk of reinjury or recurrence until complete
remodeling occurred
Peripheral neurophysiological mechanism
Effects of manual therapy => transient & attributed to neurophysiological alterations of patient’s
nociceptive system
Table
Oscillatory grading (Maitland)
Oscillatory grading (Maitland)
Grade I: small amplitude movement at beginning of range (pain & spasm)
Grade II: large amplitude movement within midrange of movement (pain & spasm)
Grade III: large amplitude movement at end of range (into restriction)
Grade IV: small amplitude movement at end range when tissue resistance (not pain) limiting
Grade V: small amplitude, quick thrust manipulation at end range
Grading: goals & dosage & stimulus
Table
Description of force
Force
- No recommendations on how much force should be used in each individual therapeutic
maneuver
- Available studies are low quality & often on asymptomatic subjects
- Studies have not been done on all joints and, above all, with variable measurements
- Generally, poor inter-reliability but better intra-reliability.
Difficulty in learning these methods clearly
Description of irritability
Irritability
High irritability > acute inflammatory phase > grade I oscillatory movements > away from stiffness
Moderate irritability > proliferative phase > oscillatory movements grade II > towards stiffness
Low irritability > remodeling phase > oscillatory movements grade III-IV > within stiffness but away from
painful
Application stratégies
Star
S: sensibility changes
T: tissue texture abnormality
A: asymmetry
R: restricted ROM
Tart
T: tissue texture abnormality
A: Asymmetry
R: ROM abnormality
T: tenderness
Cockpit model
Reasoning model for application & adaptation of parameters in manual therapy techniques
Modern MT: clinical reasoning
Clinical reasoning
- Joint mobilization/manipulation = example of intervention that does not easily lend itself to being
segmented into distinct sequential phases of evaluation & implementation
- Clinical judgments about amount of force to apply to create or progress arthrokinematics change
cannot be made on “stop-evaluate-decide-proceed” linear time sequence
- Implementation of procedure, by very nature, produces new findings that must be evaluated
simultaneously as intervention is implemented
- Examination, evaluation, intervention, & clinical decision making are inseparable in performance
of mobilization/manipulation
Mechanisms of MT
Table
Effects of manual therapy: mediating factors for effectiveness & moderating factors
Mediating factors for effectiveness of MT
- Biomechanical
o MT causes measurable movement in targeted tissues
o Some structural changes occur within targeted tissues in response to MT
o Limitations to strictly biomechanical model explaining effectiveness of MT result from
low inter-practitioner reliability of application of technique parameters (force &
magnitude)
- Neurophysiological
Immediate changes in neurophysiological function observed after MT:
o Reduction in inflammatory markers
o Decreased spinal excitability & pain sensitivity
Modification to cortical areas involved in pain processing
o Excitation of sympathetic nervous system
Moderating factors for effectiveness of MT
- Patient & provider expectation, therapeutic alliance & context of
intervention heavily influence clinical outcomes of MT
- Psychological factors (catastrophizing) interact with technique
provision enhancing or reducing benefit
Different level of evidence of effects
High level of evidence
- Pain modulation
- Contextual
- Muscle tone & spindles firing
- Inflammatory processes
Moderate level of evidence
- Immune system
- Vascular system
Low level of evidence
- Physical changes
Myths & facts about MT
Table
Value based care
- Patient centered care
- patient outcomes & experience
- cost effectiveness
- guideline concordant integrated care
Patient’s attitudes & beliefs
Patient’s attitudes & beliefs
- Spinal Manipulative Therapy (SMT) believed to be effective, especially in short term & considered
preferential option for managing LBP
- Patients often believe in biomechanical mechanism of SMT, linking it to their beliefs about causes
& management of LBP
Active approach to treatment: description, supported by & ensuring
Active approach to treatment
Humanistic domains of:
- Safety
- Comfort
- Efficiency
Supported by:
- Communication
- Context
- Person-centered care
Ensuring:
- Empowering
- Biopsychosocial
- Evidence-informed
- Active approach to MSK care
Key points
KEY POINTS
1. Manual therapy = term used to describe range of hands-on interventions used by diverse group of
clinical professionals including osteopaths, osteopathic physicians, chiropractors, massage
therapists, physiotherapists.
2. Manual therapy is one of therapeutic tools available in these professionals’ toolbox & constitutes
form of embodied, hands-on, nonverbal, communication with patients aiming at reassuring &
empowering reengagement with activities that they value.
3. Low to moderate levels of evidence that effect sizes for manual therapy range from small to large
for pain & function in tension headache, cervicogenic headache, fibromyalgia, LBP, NP, knee pain,
and hip pain, with minimal safety concerns.
3. Modern integrated manual therapies are well-suited to fostering person-centered approach to
care & have adapted to challenges presented by contemporary societal challenges effectively
