Manual therapy theory Flashcards
Professionalism
Introduce yourself
Greet patient
Ask about patient
Explain what your doing and why
Ask about Consent and comfort constantly
Patient being appropriately undressed and instructed on bed
Nociceptors
specialised nerve endings that are
activated by a biological stimulus of sufficient intensity
to threaten tissue damage.
Acute pain
- Pain that lasts for a short time and
occurs following surgery or trauma or other condition
Sub-acute pain
- Pain that is progressing towards chronic pain, but this progression may be prevented.
- This is known as the transition phase.
Recurrent pain
Pain that occurs on a cyclical basis,
- EG: a migraine or pelvic pain
Chronic pain
Pain that lasts beyond the time expected for healing following surgery or trauma
Pain gate theory (1965)
- This theory suggests that the spinal cord has a “gate” mechanism that can inhibit or allow the transmission of pain signals to the brain.
- If someone experiences a painful stimulus, the application of a non-noxious (soothing or light rubbing) stimulus can help activate the gate control mechanism, and reduce the pain by closing the gate
- This helps explain the immediate pain-relieving effect of joint mobilisations.
The gate part of the theory
The ‘gate’ is the mechanism where pain signals can be let through or restricted.
One of two things can happen, the gate can be ‘open’ or the gate can be ‘closed’
Open gate
If the gate is open, pain signals can pass through and will be sent to the brain to perceive the pain
Closed gate
If the gate is closed, pain signals will be restricted from travelling up to the brain, and the sensation of pain won’t be perceived
Gate mechanism neurons
- A-β fibres
- A-δ fibres
- C fibers
A-β fibers (Alpha-Beta)
- large diameter fibers,
- have a quick transmission of impulses, due to their myelination
- these type of fibers are activated by light touch, pressure, and hair movement
- Inhibit transmission of A-δ fibers and C fibers and close the gate
Myelination
Material surrounding nerve cells to insulate them and increase rate at which electrical impulses pass along the axon
A-δ fibers (Alpha-Delta)
- smaller diameter fiber
- they are thinly myelinated, and are stimulated by pain and temperature, specifically sharp, intense, tingling sensations
- Responsible for sharp pains received at the time of injury
C fibers
- have the slowest transmission of impulse since they are not myelinated
- these type of fibers are activated by pain and temperature, namely prolonged burning sensations
- Result in dull longer lasting pain
How rubbing and manual therapy helps pain in terms of fibers
When manual therapy is applied in terms of rubbing the skin the A-β fibers, produce an inhibitory response stopping the other fibers from sending pain signals sent to the brain, and in this instance the ‘pain gate’ is closed an
This helps sooth and reduce the pain.
Opioid use in medical
The main intended use is to reduce pain perception by closing the pain gate and giving feelings of euphoria and pleasure instead.
This also releases endorphins.
EG: Morphine, codeine, fentanyl.
Glide test
involves the application of passive gliding movements in all achievable directions
helps find out in which directions joint gliding is reduced
What does Mulligan mobilization allow
- allows the patients to perform the offending movements in a functional position, hence, leading to a rewarding outcome
3 key factors of Maitland mobilization
- Accessory movements
- Physiological movements
- Overpressure
Flexion
the action of bending or the condition of being bent, especially the bending of a limb or joint
Extension
straightening a joint. This occurs when the angle of a joint increases
Abduction
movement away from the midline of the body.
This occurs at the hip and shoulder joints during a jumping jack movement.
Adduction
movement towards the midline of the body
Jumping jack putting hands back to normal
Plantar flexion
– pointing the toes
Dorsiflexion
the foot moves towards the shin as if you are pulling your toes up.
internal rotation
a rotational movement towards the midline
external rotation
is a rotating movement away from the midline
Elevation
refers to movement in a superior direction
(e.g. shoulder shrug)
Depression
depression refers to movement in an inferior direction.
Medial (internal)
towards the midline
eg : The nose is medial to the ears.
Lateral (external)
away from the midline
eg: The eye is lateral to the nose
Anterior
refers to the ‘front’,
Posterior
refers to the ‘back’.
Superior
Higher
inferior
Lower
Proximal
proximal means closer to its origin,
eg: The knee joint is proximal to the ankle joint
Distal
distal means further away.
eg: The wrist joint is distal to the elbow joint.
Pronation
Putting something in prone position
eg: putting hand palm down
Supination
Putting something in supine position
eg: putting palm up
Inversion
involves the movement of the sole in a medial direction
Eversion
involves the movement of the sole in a lateral direction
Opposition
brings the thumb and little finger together.
Reposition
a movement that moves the thumb and the little finger away from each other, effectively reversing opposition.
Protraction
Moves the scapula forward (anteriorly) and toward the side of the body (laterally).
Retraction
Causes the shoulder blades to move back (posteriorly) and toward the body’s midline (medially)
Psychological and Emotional Benefits of manual therapy
Manual therapy reduces pain which improves an individual’s psychological state.
It helps in relieving muscle tension
Reduces cortisol levels (stress)
Oxytocin can be released giving a relaxed feel(relax hormones)
Decrease in Nociceptive Input to lower pain sensation
Overpressure (Maitland)
Each joint has a passive range of movement which exceeds its available active range.
To achieve this range a stretch is applied to the end of normal passive movement.
This range nearly always has a degree of discomfort and assessment of dislocation or subluxation should be acquired during the subjective assessment
Subluxation
A partial dislocation of a joint
Physiological Movements (Maitland)
The movements which can be achieved and performed actively by a person and can be analysed for quality and symptom response.
Accessory Movement (Maitland)
joint movements which cannot be performed by the individual.
These movements include roll, spin and slide which accompany physiological movements of a joint.
examined passively to assess range and symptom response in the open pack position of a joint
Grade I
small movement at the beginning of the available range of movement. (0 – 30%
Grade II
large movement within the available range of movement (20 – 70%)
Grade III
large movement that reaches the end range of movement
(50 – 100%)
Grade IV
small movement at the very end range of movement
(80 – 100%)
Lower grades (I + II
used to reduce pain and irritability
Higher grades(III + IV
used to stretch the joint capsule and passive tissues which support and stabilise the joint so increase range of movement.
Oscillations
30-60 oscillations per minute
Intraarticular
Inside a joint
periaarticular
Around a joint
Osteoarthritis
- A condition that causes the breakdown of cartilage in the joints, leading to pain and stiffness.
Joint end feel
This is what an examiner feels when the joint is at the end of its passive available range of motion in assessment.
There is two types of end feel - Classic normal end feel
and - abnormal end feel
Classic normal end feels
- Bony end feel
- Soft tissue approximation where tissue meets tissue
- Tissue stretch where their is a firm springy type of movement
Abnormal end feels
- Muscle spasm end feel
- Empty end feel
- Springy block end feel where there is rebound sensation
- Soft or mushy end feel when joint feels mushy
Positive research about manual therapy
Qinguang xu et al found:
- that manual therapy effectively and safely alleviated pain, reduced stiffness and restored physical function in knee osteoarthritis patients.
Mulligan Manual Therapy
- helps to improve function and provides total relief from painful conditions.
-They are used in the spine and the upper and lower extremities with underlying pathologies
-. Mulligan manual therapy involves the usage of painless loading of articular surfaces and combining passive movement with active movements.
Contraindications to manual therapy
- If the area is to be treated as an open wound.
- If the patient has a recent history of fractures.
- If there are skin infections at the treatment site.
- If the patient is suffering from osteoporosis (a condition in which bone becomes weak).
- If the patient has malignant conditions.
- In cases of undiagnosed pain or tumours , manual therapy cannot be done.
- If there is acute inflammation of a joint
Maitland manual therapy
- Maitland manual therapy uses passive rhythmic movements that are painless, and sometimes manipulation is also incorporated along with mobilization.
- Manipulation involves rapid movements. They are used in the spine and the joints of extremities.
- There are five grades in Maitland manual therapy.
Benefits of manual therapy
- Posture and movement can be enhanced through manual therapy.
- Manual therapy can be used in chronic painful conditions like backache, neckache, and leg pain.
- Manual therapy will also help in healing the scar tissue by stretching.
- Manual therapy provides a gentle stretch to the skin that enhances lymph capillary activity.
- Range of motion can be improved through manual therapy.
- Manual therapy helps reduce pain and inflammation.
Risks and Side Effects of Manual Therapy
- Soreness and discomfort
- Bruising and swelling:
- Joint or tissue damage if performed incorrectly
- Nerve damage: if too much pressure put on nerves
- Increased pain:
- Adverse reactions
- Everything is only short term benefits
Hysteresis
- The energy dissipation in tissues when they are cyclically loaded and unloaded, as occurs during joint mobilisation.
- When tissues are mobilised, some energy is absorbed, leading to heat generation and tissue relaxation.
- This reduces tissue stiffness and improves elasticity, allowing the joint to move more freely after the mobilisation is complete.
Manual therapy effects on tissue extensibility
- Enhanced circulation of blood flow to affected area enhances the delivery of oxygen
- and delivers more nutrients to tissues to aid with the healing process, such as fibroblasts and collagen,
- This increases the amount of connective tissue allowing us to stretch it and make it more flexible through mobilisations
- while also helping to remove waste products such as lactic acid.
Passive Physiological Mobilisations
Put joint through flexion,extension,inversion,eversion,rotation,abduction
using grades and oscillations
Accessory Mobilisations
Use posterior or anterior glides
Treatment session Dosage
For example
- Perform grade 3 oscillations for 30 to 60 seconds
- If tolerated can progress to grade 4
- Repeat 2 to 3 times monitoring pain and discomfort
Test-retest process
Make sure to retest passive physiological movements after applying the manual therapy to check for improvements
Lisfranc injury
involve the displacement (or dislocation) of the metatarsal bones from the tarsal bones.
- Swelling, bruising pain
Osteoporosis
A degenerative condition where bone density is heavily reduced
Pollack et al 2018
Found positive short term effects after manual therapy in reducing heel pain
Ikeda et al 2019
Found that 60 seconds of oscillations improved muscle extensibility
Why do Oscillations
To stimulate Alpha Beta fibres within the joint
which limits the transmission of pain perception at the spinal cord
