Week 6 : Manipulation Flashcards
definition of manipulation
skilled therapeutic use of a passive movement designed to restore motion/function
High velocity, small amplitude movement often associated with an audible crack/click
what is a cavitation
crack/click/pop
the audible release is caused by a cavitation process whereby a sudden decrease in intracapsular pressure causes dissolved gasses in the synovial fluid to be released into the joint cavity
Gas remains in the joint for how long after manipulation
20-30mins
What is the affect on the joint post cavitation
the force displacement changes and the ROM of the joint is increased
The gases released from the synovial fluid make up what percentage of the joint volume and consist of what
15% synovial fluid
80%Co2
Grade V HVT define
Manipulation is defined as a form of manual therapy, which involves movement of a joint passed its usual end of range of motion (physiological), but not passed it’s anatomic range of motion
Type of manipulation
general (regional) indirect non - contact long lever soft tissue mobilisation localised (specific) direct contact short lever joint HVT grade V
indications for manipulation
only after thorough clinical assessment
grade V HVT should be primarily considered as a progression of mobilisation to a grade V
in some cases, can be considered as first treatment of choice. for example an acute locked back/neck or thoracic spine manipulation
- Spinal motion restriction/dysfunction (of mechanical origin)
- Responded to mechanical treatment and Rx has plateaued with mobilisations
- Shorter pain duration (<12 weeks) = more evidence
- No contraindications to manipulation
absolute contraindications to manipulation
neoplasia: benign or malignant active infection or inflammation RA neurologic changes cord compression cauda equina compression instability following trauma
Relative contraindications to manipulation
VBI spondylolisthesis anticoagulation drugs Hx of stroke drop attacks Osteoporosis Bone maldevelopment marked foraminal encroachment severe disc protrusion acute nerve irritation
Care contraindications
pregnancy dizziness elderly patient trivial back pain psychogenic pain undiagnosed pain severe pain hypermobility post laminectomy post spinal fusion
Use of a HVLA technique requires looking for signs of specific spinal dysfunction
ARTT
A relates to asymmetry (facet on palpation)
R relates to range of motion
T relates to tissue texture changes
T relates to tissue tenderness
Method of manipulation
localise thrust to a single facet jt
spinal segments above and below should be locked
Short, Sharp thrust given (speed and direction more important than force)
Mechanical effect of manipulation
effects on motion segments (disk/facet/muscle)
Neurophysiological effect of manipulation
effects on pain mechanisms
Effect of manipulation is either on the
mechanical
or
neurophysiological
How does manipulation increase range of motion
stretching of capsular/ligamentous adhesions, scar tissue
Reflex inhibition of muscle spasm/increased tone
Unlocking of entrapped meniscus (synovial folds)
Reduction in intra-articular pressure
Enhancement of joint nutrition/hydrodynamics
previous theories
- four main hypotheses for lesions that respond to Manipulation
1 - release of entrapped synovial folds or plica
2 - relaxation of hypertonic muscle by sudden stretching
3- disruption of articular or periarticular adhesions
4- unbuckling of motion segments that have undergone disproportionate displacements
4th theory - unbuckling of motion segments that have undergone disproportionate displacements
Vague heading refers to either realignment of the joint ‘subluxation’, ‘realignment’ or ‘replacement’
The theory is the oldest and possibly due to the audible ‘clicking’
The profession of the “Bone setters”
manipulation and the effect on muscle spindles
Changes in paraspinal muscle activity noted after SMT
Suggested that it is as a result of stimulation of muscle spindles (Ia fibres)
Decreased muscle tonicity and increased ROM seen after SMT
neurologically based mechanisms of manipulation
– Pain gate-control theory (via stimulation of large diameter sensory mechanoreceptors)
– decrease in joint afferent activity (via stimulation of muscle spindles and decrease in GT activity)
– descending pain inhibitory systems (via PAG and DAG) / similar to mechanisms for TENS
– autonomic nervous system effects – increase in pain threshold levels
psychological benefits of manipulation
unknown mechanisms behind the perceived influence but appears to be related to the audible “click”
mechanisms of HVT manipulation
- The precise mechanism(s) whereby manipulation decreases pain is still unclear
- Proposed mechanisms may be selective to the source of the pain which remains difficult to isolate
efficacy of manipulation
• Acute low back pain
– moderate evidence of the short term efficacy
• SMT
– inconclusive evidence for long-term efficacy
• Chronic low back pain
– moderate evidence of the short term efficacy
• SMT +MOB
– inconclusive evidence for long-term efficacy
side effects/complications
benign transient muscle and joint soreness
how to make it feel better
- massage
- heat
- gentle mobilisations
- pain killers
- support
reversible serious complications associated with manipulation
vertigo/dizziness (cspine) rib fracture (Tx) Progression of neurological deficits TIA (Cx) misdiagnosis - cancer
Irreversible complications associated with manipulations
cauda equina syndrome (1/100 million)
Cerebrovascular injuries/paralysis (1/1million)
Death
Monitor for red flags
cauda equina compression persistent or progressive neuro deficit intractable pain serious spine pathology inflammatory disorders (ankylosing spondylitis & related disorders)
Practicum
Lumbar spine rotation (million dollar roll) Thoracic spine (PA thrust + crossed pisiform) Cervical spine (mid cervical upslope) Talocrural joint (longitudinal) Wrist (capitate flick)
