Professional Documents
Culture Documents
Bill Vicenzino
Professor in Sports Physiotherapy Head of Division of Physiotherapy
http://www.optp.com/
www.us.elsevierhealth.com
Manipulation
1. Low Velocity Techniques
Passive Mob
Under control of client Passive active or functional components* Includes soft tissue, joints, nerual
Brodeur R 1995 The audible release associated with joint manipulation JMPT 18: 155-64
Audible release caused through cavitation mechanism that is responsible for: Initiating reflex effects Producing forces in target tissues without damaging muscle
Gross et al (2010) Manipulation or Mobilization for Neck Pain: Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD004249.pub3
Gross et al (2010) Manipulation or Mobilization for Neck Pain: Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD004249.pub3
Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. Journal of Orthopaedic & Sports Physical Therapy. 2007 Mar;37(3):100-7.
Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan mobilization with movement technique on ROM ad pressure pain threshold in pain-limited shoulders. Manual Therapy (2008) 13: 37-42.
MWM versus Sham versus Control 11 male & 13 female mean age 46.1 SD 9.86 yrs
Pre
Post
Green, Refshauge, Crosbie, Adams (2001) A RCT of a passive accessory joint mobilization on acute ankle inversion sprains Phys Ther 81:984-94
Acute ankle sprain (<72 hrs); n = 38 Random assignment to control (RICE) or AP mobs (no pain) + RICE. All had home program. Treatment every 2 days for max. 2 weeks or D/C. D/C criterion = no difference in DF side to side Outcomes = number of treatments, pain free dorsiflexion (nonWB), 3 gait variables (stride speed, step length and single support time)
Green, Refshauge, Crosbie, Adams (2001) A RCT of a passive accessory joint mobilization on acute ankle inversion sprains Phys Ther 81:984-94
13/19 (68%) subjects discharged at 4th treatment in PA mob group compared to 3/19 DF improved earlier in treatment group (11 compared to 6 from baseline to treatment 2) Gait variable improvements tended to favour the treatment group
Collins N, Teys P, Vicenzino B, The Initial Effects of a Mulligans MWM Technique on DF & Pain in Subacute Ankle Sprains, Manual Therapy (2004) 9: 77-82
N = 14, grade II ankle sprain (4024 days old) WB DF, PPT and TPT (heat and cold) Deficit only on:
WB DF = 42 mm PPT (ATFL) = 58 kPa
Collins N, Teys P, Vicenzino B, The Initial Effects of a Mulligans MWM Technique on DF & Pain in Subacute Ankle Sprains, Manual Therapy (2004) 9: 77-82
Initial effect of Mulligan MWM on ankle DF in normals: Weight bearing versus non-weight bearing techniques. Vicenzino B, Prangley I, Martin D
(SMA website)
[N=27 (18-27yr)]
% Dorsiflexion Improvement
0 1 2 3 4 5 6 7 8 9 10
* *
Nansel et al (1990) Time course considerations for the effects of unilateral lower cervical adjustments with respect to the amelioration of cervical lateral flexion passive end range asymmetry, JMPT 13: 297-304.
16 traumatic & 16 non-traumatic subjects with > 10 of unilateral side flexion restriction Thrust manipulation applied to side of restriction Measurement of ROM @ 0.5, 4, 24 & 48 hrs 12 improvement @ 0.5 & 4 hours Improvement not evident at 48 hours
McCollam & Benson 1993 Effects of P-A mobilisation on lumbar extension and flexion, JM&MT 1: 134-141.
PA mobilisation to L3, 4 & 5 spinous process for 9 minutes in 65 asymptomatic participants Compared to prone lying for 9 minutes 7.1% improvement in Ext for PA Not present @ 1 week post treatment
Spinal manual therapy is efficacious Need for more peripheral manual therapy studies Short term effects are shown for a number of joints
Does it work?
yes!
Manual Therapy
Widespread clinical use
Treatment of pain ( dysfunction)
Complex multifaceted
Total MIA effect
Supraspinal inhibition Segmental inhibition Psychological effects Nociceptor effects Joint repair
Time
Complex multifaceted
Straighten spine (Pare 1958) Unlocking locked joint (Twomey 1992) Boney luxations Shift an IVD fragment (Cyriax 1975) Reversing luxations Reduce annular distortion (Farfan 1973) Stretching, tearing or rupturing adhesions that limit joint or nerve range (Zusman 1986, Chrisman et al 1964) Biomechanical Remove blockage or interference of blood flow (Still 1899), nerve compression (Palmer 1910), sympathetic chain (Kunert 1965), and cerebrospinal fluid circulation (DeJanette 1967)
Correct abnormal somatovisceral reflexes and visceral organ dysfunction (Dhami & DeBoer 1992) Stretch contracted muscles, causing relaxation (Perl 1975) Remove irrtable spinal lesions (Korr 1976) Intense reflex effects (mainly musculature, Lewit 1985) Modulate peripheral nociceptors (Zusman 1987) Inhibition of reflex muscle contraction (Zusman 1987) Activates gating mechanism, neurotransmitters, opioide peptides (Dhami and DeBoer 1992)
Neurophysiological
Proposed mechanism:
Neurophysiological
Biomechanical MT
Proposed mechanism:
Neurophysiological
Biomechanical MT
Subluxations?
Biomechanical MT
Subluxation hypothesis
Subluxation hypothesis
22 20 18 16 14 12
Non-injured (n =11)
Matched
18
19
20
21
22
Hubbard T, Hertel J (2008) Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy, 13: 63-67.
22 20 18 16 14 12
Non-injured (n =11)
Matched
18
19
20
21
22
Hubbard T, Hertel J (2008) Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Manual Therapy, 13: 63-67.
O Brien & Vicenzino (1998) A study of effects of a MWM for lateral ankle pain using a case study design. Manual Therapy 3: 78-84. 4.5 cm PVAS reduction following 1 treatment 7.4 units/day on Kaikkonen scale with treatment over 5 weeks compared to 1.4 units/day with natural resolution
because there is a beneficial therapeutic effect, it does not follow that the proposed (speculated) mechanism underlying the treatment is supported!
Subluxations: may well occur but difficult to measure? Unresolved: does the MT reverse bony luxation?
Biomechanical MT
Biomechanical MT
Biomechanical MT
Gal et al (1997) Movements of vertebrae during manipulative thrusts to unembalmed human cadavers, JMPT 20: 30-40.
Evaluated positional change after unilateral PA T-sp HVT in cadavers using 3D kinematic analysis and force mat Demonstrated that:
< 10 mm linear displacement of vertebra Change in position was short lived - mostly for the duration of the technique Restoration of baseline position within 10 minutes of the treatment application
Hsieh C-Y et al 2002 Mulligans MWM for the thumb: a single case using MRI to evaluate the positional fault hypothesis. Manual Therapy 7: 44-9. R 1st MCP pain with F after hyperabduction injury
Glide reversed positional fault on MRI Post-3 weeks self treatment: pain and function improved but positional fault stayed same
Note: therapist was blind to this finding
BIOMECHANICS
Human studies
MT
Specificity of application?
Transient change in bone position
Direction of force:
Direction of force:
Johnson A, Godges JJ, Zimmerman GJ, Ounanian LL, The effect of anterior versus posterior glide joint mobilisation on external rotation range of motion in patients with shoulder adhesive capsulitis J Orthop Sports Phys Ther 2007;37(3):88-99. doi:10.2519/jospt.2007.2307
3 11
31 7
n = 10
n=8
Specificity of direction:
Manual therapy improves ROM
Direction of force:
Johnson A, Godges JJ, Zimmerman GJ, Ounanian LL, The effect of anterior versus posterior glide joint mobilisation on external rotation range of motion in patients with shoulder adhesive capsulitis J Orthop Sports Phys Ther 2007;37(3):88-99. doi:10.2519/jospt.2007.2307
3 11
31 7
Unresolved issue:
What is the relevance of ROM improvement in ROM in pain (mm VAS) & function outcomes
Direction of force:
Abbott et al, 2001, The initial effects of an elbow MWM technique on grip strength in subjects with LE. Manual Therapy 6: 163-9
Amount of force:
140 patients with non-specific LBP Randomized to therapist selected level or random selected level Both groups showed improved pain Selected level did not seem to be superior to random Low lumbar spine mobilisation was superior to upper
126 patients with non-specific neck pain Randomized to therapist selected level or levels below (4 pain relieving traction) Both groups showed improved pain Selected level did not seem superior was there mechanical/treatment overflow from 3 levels below?
CLG
PPT
BIOMECHANICS
Human studies
MT
Transient change in bone position & Increase ROM
Potential mechanisms:
Descending Pain Inhibitory Systems (DPIS) Endogenous opioid mechanisms Neurotransmitters (5HT, NA, SP) Spinal mechanisms Gating Theory (Melazack and Wall) Peripheral receptors
NEUROPHYSIOLOGIC
Pain effects human animal Associated systems & modeling
BIOMECHANICS
Human studies
MT
Transient change in bone position & Increase ROM
Zusman M (1987) A theoretical basis for the short term relief of some types of spinal pain with manipulative therapy, Manual Medicine 3: 54-6.
Sustained or repetitive end range mobilisations -> reduction in firing rate (neural hysteresis)
Afferents fail following sustained intense loads, end range positions, repetitive movements in normal animal joints
Clinically manual therapy is not applied to normal joints. Notably, inflamed joint afferents exhibit:
Spontaneous activity in neutral or rest and heightened responses and reduced excitation thresholds to midrange motion
Indicating manual therapy may well provoke pain through this mechanism not alleviate it!
Zusman M (1987) A theoretical basis for the short term relief of some types of spinal pain with manipulative therapy, Manual Medicine 3: 54-6.
Gate control theory (Melzack and Wall 1965) Large diameter input modulating small diameter pain fibres (eg, TENS) Problem with this model for manipulative therapy is that in an inflamed joint otherwise non-painful movements become pain provocative. However, some large diameter fibres are spared (ie, not sensitised) Manual therapists may through their examination target these spared afferents?
Initial manipulation induced hypoalgesia demonstrated in other studies: 45% increase in PPT post HVT of Csp (Vernon et al 1990) 140% increase in cutaneous pain tolerance following T-sp HVT (Terrett and Vernon 1984) 17 & 11% increase in VAS following HVT and mobilisation, respectively (Cassidy et al 1992) 50% increase in VAS following PT manual therapy (Zusman et al 1989)
Manual therapy produces an initial hypoalgesia Treatment effect > placebo/control procedures
Transient change (e.g., Cassidy et al 1992, Paungmali et al 2003, Sterling et al in bone position 2001, Terrett and Vernon 1984, Vernon et & al 1990, Vicenzino
Opioid mechanisms:
Manual therapy produces an initial hypoalgesia Treatment effect > placebo/control procedures
Transient change (e.g., Cassidy et al 1992, Paungmali et al 2003, Sterling et al in bone position 2001, Terrett and Vernon 1984, Vernon et & al 1990, Vicenzino
Manual therapy produces an initial hypoalgesia Treatment effect > placebo/control procedures
Transient change (e.g., Cassidy et al 1992, Paungmali et al 2003, Sterling et al in bone position 2001, Terrett and Vernon 1984, Vernon et & al 1990, Vicenzino
NEUROPHYSIOLOGIC
Pain effects human Animal?
BIOMECHANICS
Human studies
MT
Transient change in bone position & Increase ROM
Skyba et al (2003) Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in spinal cord. Pain 106: 159-68.
Pain
NEUROPHYSIOLOGIC
Pain effects Human Animal
BIOMECHANICS
Human studies
MT
Transient change in bone position & Increase ROM
Are there any other features of manipulation induced hypoalgesia that may add to our understanding of the underlying mechanisms of action?
NEUROPHYSIOLOGIC
Pain effects human animal Associated systems & modeling
* * *
% CHANGE
25 15 5 -5 -15 -25
p < 0.05 N = 24
* *
TREAT
PLACEBO CONTROL
Vicenzino B, Collins D, Benson H & Wright A, An investigation of the interrelationship between manipulative therapy induced hypoalgesia and sympathoexcitation, JMPT, 21 (7), (1998) 448-53.
McGuiness, J., Vicenzino, B. and Wright, A., The influence of a cervical mobilisation technique on respiratory and cardiovascular function, Manual Therapy, 2, (1997) 216-220. Simon, R., Vicenzino, B. and Wright, A., The influence of an anteroposterior accessory glide of the glenohumeral joint on measures of peripheral sympathetic nervous system function in the upper limb, Manual Therapy; 2(1) (1997) 18-23. Slater, H., Vicenzino, B. and Wright, A., Sympathetic Slump : The effects of a novel manual therapy technique on peripheral sympathetic nervous system function, JMMT, 2, (1994) 156-162. Vicenzino B, Collins D. & Wright A, (1994) Sudomotor Changes Induced by Neural Mobilisation Techniques in Asymptomatic Subjects., Journal of Manual and Manipulative Therapy, 2, 66-74. Vicenzino B, Cartwright T, Collins D & Wright A, (1998) Cardiovascular and respiratory changes produced by lateral glide mobilisation of the cervical spine, Manual Therapy, 3, 67-71.
Sympathoexcitation is:
Treatment technique specific
PA vs CLG vs Symp. Slump (magnitude) HVLA vs mobilisation
Frequency specific
Not present at less than 1 Hz oscillation
Region specific
Osteopathic HVT show differences
Are there any other features of manipulation induced hypoalgesia that may add to our understanding of the underlying mechanisms of action?
NEUROPHYSIOLOGIC
Pain effects human animal Associated systems & modeling
Hypoalgesia
?
BLOOD FLUX
SympathoExcitation
ULTT2b
PFG
PPT
CONDUCTANCE
TEMPERATURE
Vicenzino B, Collins D, Benson H and Wright A, An investigation of the interrelationship between manipulative therapy induced hypoalgesia and sympathoexcitation, JMPT, 21 (7), (1998) 448-53.
0.03
0.57*
0.58* SKNCON
0.48* ELBFLX
HNDTMP
DORSOMEDIAL
DORSOLATERAL
LATERAL
VENTROLATERAL
Dorsal/Lateral PAG
Stimulus
Ventrolateral PAG
(Carrive 1993)
0.03
0.57*
0.58* SKNCON
0.48* ELBFLX
HNDTMP
Dorsal/Lateral PAG
Stimulus
Ventrolateral PAG
Methods N Stress & pain levels before, during and after treatment N Double blind, placebo-controlled, repeated measures (n = 24) Results N No stress or pain was perceived during treatment N Stress was greatest at the first session regardless of treatment condition applied on that day, reducing on day 2 & 3. Conclusion N Stress and pain are not features of the lateral glide
Important to understand: All the techniques we have studied have been non-painful during their application
Are there any other features of manipulation induced hypoalgesia that may add to our understanding of the underlying mechanisms of action?
NEUROPHYSIOLOGIC
Pain effects human animal Associated systems & modeling: motor?
bito effects reported Facilatory and inhibitory unsure if this add adds or detracts! d on deficit? depend
Transient change in bone position & (e.g., Vicenzino et al 2010, Abbot et al 2001) Increase ROM
NEUROPHYSIOLOGIC
Direction Force level Temporal (f, v) Technique Localization? Not the pop! Pain effects human animal Associated systems & modeling
BIOMECHANICS
Human studies
MT
Specificity of application Transient change in bone position & Increase ROM
NEUROPHYSIOLOGIC
Direction Force level Temporal (f, v) Technique Localization? Not the pop! Pain effects human animal Associated systems & modeling
BIOMECHANICS
Human studies
MT
Specificity of application Transient change in bone position & Increase ROM
Complex multifaceted
Psychological effects
Time
Pre-existing beliefs: Injury & damage Catastrophisation Fear-avoidance Expectations: Placebo Practitioner Treatments
Chronic pain = conditioned (learned) phenomenon (Zusman 2004) MWM = a re-conditioning of a pain-movement association [possibly through non-associative learning theory mechanism (Zusman 2004))]
Chronic pain = conditioned (learned) phenomenon (Zusman 2004) MWM = a re-conditioning of a pain-movement association [possibly through non-associative learning theory mechanism (Zusman 2004))]