????:Greenman PE. Principles of Manual Medicine. 2nd., William

1
??????

• ?????????????
• ??????????
• ???????
• ????Greenman PE. Principles of Manual Medicine.
  2nd., William Wilkins, Baltimore, 1996.

2
Manual Therapy

• Mobilization, manipulation of soft tissues,
  massage
• A systematic method of evaluating and treating
  dysfunctions of the neuromusculoskeletal system
  in order to relieve pain, increase or decrease
  mobility, and in general normalize function

3
History of Manual Therapy

• Hippocrates (460-380 BC)
• Galen (131-202 AD)
• Bone-setter (England)
• .Stiffness and pain in joints were immobilized
  for a long period of time after fractures,
  dislocations, or sprains
• .Stiffness and pain resulting from disuse after
  soft tissue injuries
• .Internal deragements after rupture of the
  meniscus
• .Subluxations of small bones of the hands and
  feet
• .Ganglion development around the wrist
• .Treatment of neck and back disorders
• Graham (1884-1918)
• Massage
• any procedure done by the hands (friction
  manipulation)

4
William Merrell (1853-1912)

• A scientific mode of treating certain forms of
  disease by scientific manipulation, including
  passive range of motion, mobilization, and
  manipulation

5
Osteopaths Andrew Taylor Still (1828-1917)

• The body as a unit had the ability to fight off
  all disease and that the cause of all disease was
  mechanical pressure on blood vessels and nerves
  produced by dislocated bone, abnormal ligaments,
  or contracted muscles in the back(osteopathic
  lesion)

6
Chiropractors Daniel David Palmer (1845-1914)

• To put bones back into place
• .Straights
• .Mixers

7
Medical Manipulators for Physical therapist

• Mennell
• NAAMM merged with AAOM (American Association of
  Orthopaedics Medicine)
• Cyriax

8
Practice of Manual Medicine

• the functional capacity of the human organism
• dynamic processes of disease
• musculoskeletal system comprises over 60 of the
  human organism
• Structural diagnosis
• to evaluate the musculoskeletal system for its
  particular disease and dysfunctions
• to evaluate the somatic manifestations of disease
  and derangement of the internal viscera.
• to increase mobility in restricted areas of
  musculoskeletal system
• to reduce pain

9
Goals of Manipulation

• To restore maximal, pain-free movement of the
  musculoskeletal system in postural balance (1983)

10
Concepts
11
A.     Holism

• the musculoskeletal system deserves thoughtful
  and complete evaluation (treat patients, not to
  treat disease

12
B.     Neurological control (fig)

• 1.        somaticosomatic reflex pathways
• 2.        viscerovisceral reflex arc
• 3.        sympathetic reflex pathways
• 4.        ANS
• a)       parasympathetic
• b)       sympathetic
• (1)     above diaphragm T5
• (2)     below diaphragm T5
• (3)     musculoskeletal system
• 5.        endocrine system neuroendocrine
  control

13
B.       Circulatory function

• 1.        Arterial system2.        venous
  system3.        lymphatic system4.       
  muscular activity5.        diaphragm
• C.      Energy expenditure musculoskeletal
  activity

14
D.      Self-regulation

• 1.        homeostatic mechanism2.       
  iatrogenic diseasel       

15
Manipulable lesion

• osteopathic lesion,
• chiropractic subluxation ,
• joint blockage,
• loss of joint play,
• joint dysfunction
• current somatic dysfunction

16
Manipulable lesion

• A.   defined as impaired or altered function of
  related components of the somatic (body
  framework) system skeletal, arthrodial, and
  myofascial structures and related vascular,
  lymphatic, and neural elementsB.   emphasized is
  on altered function of the musculoskeletal
  systemC.  The art of structural diagnosis is to
  define the presence of somatic dysfunction(s) and
  determine any significance to the patients
  complaint or disease process presenting at the
  time.

17
Diagnostic triad for somatic dysfunction

• ART through observation or palpation
• 1.        A Asymmetry
• 2.        R Range of motion of a joint, several
  joints or regions of musculoskeletal system
• a)       Active or passive movement
• b)       Hypermobility or Hypomobility
• 3.        T Tissue texture abnormality of soft
  tissue of the musculoskeletal system for
  location, status (acute, or chronic), prognosis,
  treatment response

18
Relief of nerve-root pressure- reacting only to
the spine

• A.       Specific- chiropractors recommend the
  movement of one specific vertebra on another.
• B.       Nonspecific- Cyriax recommends general
  manipulation with traction       

19
Relief of pain- relating to the spine or
extremities

• A.       Graded oscillations- Maitland believes
  in mobilizations subthreshold to pain
• B.       Contrary movement- Mainge recommends
  therapeutic movement in a direction exactly
  opposite to that which cause pain

20
Normalization of joint mobility- relating to the
spine or extremities

• A.       Osteopathy- osteopaths advocate specific
  techniques for mobilizing the spine and
  extremities
• B.       Treatment of stiffness- Kaltenborn
  advocates the use of arthrokinematic principles
  to regain mobility without regard to pain
• C.      Paris a concept of facet disorder as the
  primary cause of spine dysfunction
• D.      The cause of the dysfunction and
  treatment of pain

21
Joint mobilization

• Passive exercise
• Physiologic movement
• the creation of motion within a joint by an
  outside force taking the body part through all or
  part of its range of motion
• Accessory movement
• movement that occurs between the articulating
  surfaces of a joint that is involved in a
  physiological motion, either active or passive.

22
Accessory movement

• glide, spine, roll
• Accessory movement cannot be produced actively
• Component motion
• the motion occurring in a related joint that
  allows the primary joint to function normally

23
Joint play

• the motion that occurs within the joint but only
  as a response to an outside force and not as a
  result of voluntary movement

24
Joint Mobilization

• the attempt to improve joint mobility or decrease
  pain originating in joint structure by the use of
  selected grades of accessory movement

25
Classification of synovial joints

• Simple
• one joint space with two surfaces ( one concave
  and one convex) and a single capsule
  (metacarpophalangeal joint)
• Compound
• one joint has more than two joint articulating
  surfaces within a single capsule (elbow)
• Complex
• an anatomically compound joint with meniscus or
  intracapsulaar disk (knee)

26
structural forms of joint-articulating surfaces

• Unmodified ovoid-
• ball-and-socket articulation, spheroid, (3 axes
  and 3 degree of freedom) (hip, shoulder)
• Modified ovoid-
• ellipsoid and sellar, (2 axes and 2 degree of
  freedom), (metacarpophalangeal joint) (2 axes and
  2 degree of freedom)

27
structural forms of joint-articulating surfaces

• Unmodified sellar- saddle,
• the surfaces are convex and concave at right
  angles (2 axes and 2 degree of freedom)( 1st
  metacarpal joint)
• Modified sellar-
• a hinge, ginglymus, or trochoid joint( one axes,
  one degree of freedom) (interphalangeal joint,
  the ulnohumeral joint, and knee)

28
Joint Positions Congruence

• Loose-packed position
• any other position of the joint aside from the
  closed-packed position.
• The maximal loose-packed position resting
  position (the optimal position for mobilization)
• elbow flexed to 70 degrees and supination
• the knee in 30 degrees of flexion with a slight
  external rotation of the tibia

• Close-packed position
• occurs when the joint surface are most congruent
• a testing position but never used for
  mobilization because there are no degrees of
  freedom of movement

29
Osteokinematics

• the study of movements of the bone
• Spin a pure rotation around a mechanical axis,
  clockwise or counterclockwise, (the head of
  femur, humerus, and radius), not simultaneous
  with a spin, transverses the shortest route
  between two points
• Swing any movement other than pure spine
• pure or cardinal swing
• impure or arcuate swing

30
Arthrokinematics

• the study of the joint
• Grays anatomy
• Gliding (translation) an arc surface simply
  slides over another surfacewithout adding a
  component of angulation or rotation
• Angular movement
• Circumdution conical outline
• Rotation movement around a longitudinal axis

31
MacConaill and Basmajian

• Spin rotation around a stationary mechanical
  axis
• Gliding or sliding one point on a moving surface
  comes into contact with new points on another
  surface
• pure gliding (involuntary motion)(translation or
  translatory glide
• Rolling when new points on one surface come into
  contact with new points on a second surface
• Rolling and gliding motion are usually found to
  occur simultaneously
• Knee

32
(No Transcript)
33
Kaltenborn

• more gliding---gt nearly congruent
• more rolling---gt nearly incongruent
• The rolling portion of the combined roll-glide
  movement always follows the direction of the bone
  movement
• The gliding portion of the combined roll-glide
  movement

34
Kaltenborn

• whether the moving surface is convex or concave
• If the moving surface is concave---gt both the
  gliding and the bone movement follow the same
  direction
• If the moving surface is convex---gt the gliding
  follows the opposite direction

35
(No Transcript)
36
Traction

• Stage I (grade I) piccolo traction
• which involves neutralizing pressure in the joint
  without actually separating the joint surface
• pain relief and prevent the trauma of grinding
  when performing mobilization techniques

37
Stage II (grade IV)

• to separate the joint surfaces and take up the
  slack in the joint capsule
• slack the amount of looseness or play allowed
  by the capsule and ligaments in a normal joint
• pain relief

38
Stage III (grade IV)

• involves an actual stretching of the soft tissues
• used to increase the mobility in a hypomobile
  joint

39
Mobilization

• Pain relief
• Grade I-II
• Traction
• Vibration and oscillation
• Relaxation
• Grade I-II
• Traction
• Stretch
• Grade III
• Stretch traction
• Stretch-glide
• Rotation

40
(No Transcript)
41
Three-dimensional traction

• spine, positioned relative to all three cardinal
  planes (with relative position such as flexion,
  lateral flexion, and rotation)

42
Translatoric gliding

• used to increase mobility in a hypomobile joint,
  preceded by piccolo traction to eliminate the
  compressive force

43
Maitland

• Grade I
• is a small-amplitude movement conducted from the
  beginning of the available range of motion
• Grade II
• is a large-amplitude movement conducted within
  the range. It does not reach either end of the
  range
• Grade III
• is a large-amplitude movement that does reach
  the end of the range of motion
• Grade IV
• is a small-amplitude movement conducted at the
  very end of the range of motion
• Grade V
• is a high-velocity thrust of small amplitude at
  the end of the available range of motion and
  within is anatomical range.
• Popping, manipulation

44
(No Transcript)
45
General Rules of Mobilization Techniques

• The patient must be relaxed
• The operator must be relaxed
• Do not move into or through the point of pain
• When performing any of the joint mobilization
  techniques, one hand will usually stabilize while
  the other hand performs the movement
• The operator must consider

46
General Rules of Mobilization Techniques

• Direction of movement
• Velocity of movement
• slow stretching for large capsular restriction
• faster oscillation for minor degree of
  restriction
• Amplitude of movement
• graded according to pain, guarding and degree of
  restriction

47
General Rules of Mobilization Techniques

• Compare accessory joint movement to opposite side
  ( extremity), if necessary, to determine presence
  or degree of restriction
• One movement is performed at a time, at one
  joint at a time
• Each technique can be used as
• Examination procedure slack only to see
  accessory movement and pain
• Therapeutic procedure High-velocity,
  small-amplitude thrust or graded oscillation
• Reassessment

48
Indications

• Joint dysfunction
• Restriction of accessory joint motion
• Capsuloligamentous tightening
• Internal derangement
• Reflex muscle guarding
• bony blockage

49
Contraindication

• Relative
• Joint effusion or inflammation
• Arthrosis ( e.g. degenerative joint disease) if
  acute, or if causing a bony block to movement to
  be restored)
• Rheumatoid arthritis
• Osteoporosis
• internal derangement
• General delilitation ( e.g. influenza, pregnancy,
  chronic disease)

• Absolute
• bacterial infection,
• neoplasm,
• recent fracture

50
To increase proprioceptive input

• to the spinal cord to inhibit ongoing nociceptive
  input to anterior horn cells and central
  receiving area
• Grade I-II
• cycles/second

51
(No Transcript)