Therapeutic Exercise I:

Manual Therapy – Part 1

Prepared By:
John Lynyrd A. Dela Cruz,
PTRP
 Topic Outline
I. History
II. Role of Musculoskeletal System in
Health and Disease
III. Structural Diagnosis
IV. Barrier Concepts
V. Manipulative Prescription
VI. Recall of Normal Vertebral Motion
VII.Vertebral Motion Dysfunction
 Topic Outline
VIII.Different Manual Therapy
Techniques
A. Soft Tissue Mobilization with Impulse
(Articulatory) Technique
B. Muscle Energy Technique
C. Mobilization with Impulse (High Velocity,
Low Amplitude Thrust) Technique
D. Functional (Indirect) Technique
E. Myofascial Release
F. Craniosacral Technique
History
History
History
History
History
History
History
The Goal of Manipulation

The Goal of Manipulation

 The Goal of Manipulation

The goal of manipulation is to restore

maximal, pain-free movement of the
musculoskeletal system in postural
balance.
The Role of Musculoskeletal
System in Health and
The Role of
Musculoskeletal System in
Health and Disease
 The Role of Musculoskeletal
System in Health and Disease
The field of manual medicine looks at
the musculoskeletal system in a much
broader context, particularly as an
integral and interrelated part of the
total human organism.
 The Role of Musculoskeletal
System in Health and Disease
Concepts:
2. Holism
3. Neurological control
4. Circulatory function
5. Energy expenditure
6. Self-regulation
Structural Diagnosis

Structural Diagnosis
 Somatic Dysfunction
Itrefers to impaired or altered
function of related components of the
somatic system; skeletal, arthrodial,
and myofascial structures; and related
vascular, lymphatic, and neural
elements.
 Somatic Dysfunction
Three Classical Diagnostic Criteria:
A – asymmetry
R – range of motion abnormality
T – tissue texture abnormality
 Essentials of Structural
Diagnosis
Hand-eye Coordination
Layer Palpation
Motion Sense
Screening Examination
Scanning Examination
 Hand-eye Coordination
Coordination between the palpating
hands and the observing eyes.
It is important to use the dominant
eye during observation.
The dominant eye should be midway
between the two anatomical parts
being observed or palpated.
 Layer Palpation

Let’s Practice!
 Motion Sense
Static versus Dynamic Palpation
In static palpation:
• Skin temperature
• Smoothness
• Thickness
• Tissue tone
• Other tissue state
 Motion Sense
 In dynamic palpation:
• Compression
• Shear movements
• Range of movement
• Quality of movement
• End-feel
 Motion sense is an essential component
of the palpatory art in structural
diagnosis.
 Hypermobility
 Compensatory Hypermobility
 Screening Examination
 Evaluation of the total musculoskeletal
system as part of the evaluation.
 Follow the 12-step procedure:
1. Gait analysis in multiple directions.
2. Observation of static posture and palpable
assessment of paired anatomical
landmarks.
3. Dynamic trunk sidebending.
4. Standing flexion test.
5. Stork test.
6. Seated flexion test.
 Screening Examination
7. Screening test of upper extremities.
8. Trunk rotation.
9. Trunk sidebending.
10.Head and neck mobility.
11.Respiration of thoracic cage.
12.Lower extremity screening
 Scanning Examination
SkinRolling Test
Segmental Definition
 Skin Rolling Test
A fold of skin between thumb and
index finger is grasped and rolled.
Assessment of tissue texture.
Provocation of pain.
 Segmental Definition
Identify a specific vertebral segment
or peripheral joint that is
dysfunctional.
Used to determine the specific motion
restriction involved.
Joint-play assessment.
Passive Accessory Intervertebral
Movements (PAIVMs)
Passive Physiologic Intervertebral
Movements (PPIVMs)
Barrier Concepts

Barrier Concepts
Physiologic
Barrier Barrier Concepts Physiologic
Barrier

Bind Bind

Ease Ease

Range
Range
Total Range
of
ofPassive
Active
of
Motion
Motion
Motion

Elastic Elastic
Barrier Midline Barrier
Anatomic Neutral Anatomic
Barrier Barrier
 Barrier Concepts
Active Motion
Movement of an articulation between
the physiological barriers limited to
the range produced voluntarily by the
patient.
 Barrier Concepts
Anatomical Barrier
The bone contour and/or soft tissues,
especially ligaments, that serve as the
final limit to motion in an articulation
beyond which tissue damage occurs.
 Barrier Concepts
Barrier
An obstruction; a factor that tends to
restrict free movement.
 Barrier Concepts
Elastic Barrier
The resistance felt at the end of
passive range of motion when the
slack has been taken out.
 Barrier Concepts
Paraphysiological Space
That sensation of a sudden “give”
beyond the elastic barrier of
resistance, usually accompanied by a
“cracking” sound with a slight amount
of movement beyond the usual
physiologic limit but within the
anatomical barrier.
 Barrier Concepts
Motion
Movement, act, process, or instance of
changing places
 Barrier Concepts
Passive Motion
Movement induced in an articulation
by the operator.
This includes the range of active
motion as well as the movement
between the physiological and
anatomical barriers permitted by soft
tissue resiliency that the patient
cannot do voluntarily.
 Barrier Concepts
Physiological Barrier
The soft tissue tension accumulation
that limits the voluntary motion of an
articulation.
Further motion on the anatomical
barrier can be induced passively.
 Barrier Concepts
Restrictive Barrier
An impediment or obstacle to
movement within the physiological
limits of an articulation that reduces
the active motion range.
 Barrier Concepts
Restrictive barrier can be one of the
following tissues:
• Skin
• Fascia
• Muscle
• Ligaments
• Joint capsule and surfaces
Manipulative Prescription

Manipulative Prescription
 Manipulative Prescription
Itis common for practitioners to be
lax in their specificity for the
structural diagnosis and prescription
of manual medicine intervention.
Too often a diagnosis is made somatic
dysfunction and manual medicine is
the prescription.

Dx – Somatic Dysfunction
Rx – Manipulative Treatment
 Manipulable Lesion Synonyms
Joint blockage
Joint lock
Chiropractic subluxation
Osteopathic lesion
Loss of joint play
Minor intervertebral derangements
 Clinical Goals for Manipulative
Treatment
Remember our goal!
In achieving this goal, different types
of therapeutic effects can be sought
and these are:
1. Circulatory effects
a. Move body fluids
b. Provide tonic effect
 Clinical Goals for Manipulative
Treatment
2. Neurological effect: modify reflexes
Somato-somatic
Somato-visceral
Viscero-somatic
Viscero-visceral
Viscero-somato-visceral
Somato-viscero-somatic
4. Maintenance therapy for irreversible
conditions
 Clinical Goals for Manipulative
Treatment
Depending on the desired outcome,
the therapeutic outcomes will use
different models of manual medicine.
 Models and Mechanisms of
Manual Medicine Intervention
1. Postural Structural or Biomechanical
Model
2. Neurological Model
a. Autonomic Nervous System Model
b. Pain Model
c. Neuroendocrine Model
 Models and Mechanisms of
Manual Medicine Intervention
3. Respiratory Circulatory Model
4. Bioenergy Model
5. Psychobehavioral Model
Manual Medicine
Armamentarium

Manual Medicine
Armamentarium
 Manual Medicine
Armamentarium
1. Soft Tissue Procedures
2. Articulatory Procedures
3. Specific Joint Mobilization
4. Afferent Reduction Procedures
 Soft Tissue Procedures
Force is directed toward specific
influencing tissues of the
musculoskeletal system or, by
peripheral stimulation, enhancing
some form of reflex mechanism that
alters biological function.
Direct procedures include massage,
effleurage, kneading, stretching, and
friction rub.
 Soft Tissue Procedures
Can be a preparatory intervention
prior to additional specific joint
mobilization procedures.
Can be a therapeutic management by
itself.
Therapeutic goals are to overcome
congestion, reduce muscle spasm,
improve tissue mobility, enhance
circulation, and to “tonify” the tissue.
 Articulatory Procedures
Consists primarily of putting the
elements of musculoskeletal system,
particularly the articulations, through
ranges of motion in some graded
fashion.
Its goal is to enhance the quantity and
quality of motion.
 Articulatory Procedures
Therapeutic extension of range of
motion evaluation.
Useful for their tonic and/or circulatory
effects.
 Specific Joint Mobilization
Has 2 common elements:
• Methods
• Activating Forces
 Specific Joint Mobilization
Methods
2. Direct method.
• All direct procedures engage the
restrictive barrier.
• Application of force attempt to move the
restrictive barrier closer to the normal
physiologic barrier to active movement.
 Specific Joint Mobilization
2. Exaggeration method.
• Force is applied against the normal
physiologic barrier in the direction
opposite the motion loss.
• The force is usually a high-velocity low-
amplitude thrust.
 Specific Joint Mobilization
3. Indirect Method.
• The operator moves the segment away from
the restrictive barrier into the range of
“freedom” or “ease” to a point of balanced
tension.
• The segment can be held in that position for
5-90 seconds to relax the tension in the
tissues around the articulation.
• Procedures using this method are termed
functional technique, balance-and-hold
technique, and release-by-positioning
technique.
 Specific Joint Mobilization
4. Combined method.
• Combination of direct, exaggeration, and
indirect methods.
• A combined method series of procedures
is more effective than multiple
applications of the same method.
 Specific Joint Mobilization
5. Physiological response method.
• These procedures apply patient
positioning and movement in response to
position direction to obtain a therapeutic
result.
• Examples are nonneutral mechanics to
restore neutral mechanics of the
musculoskeletal system.
• Another is respiratory effort to affect mobility
of vertebral segments is the spine.
 Specific Joint Mobilization
Activating Forces
Could be extrinsic or intrinsic.
 Specific Joint Mobilization
Extrinsic forces
Forces that are applied from outside of
the patient’s body directly to the
patient.
These are:
1. Operator effort, such as gliding,
springing, and thrust;
2. Adjunctive, such as straps, pads,
traction, and so on;
3. Gravity, which is the weight of the body
part and patient position.
 Specific Joint Mobilization
Intrinsic forces
Forces that occur from within the
patient’s body and are used for their
therapeutic effectiveness.
These are:
1. Inherent force, or nature’s tendency toward
balance and homeostasis;
 Specific Joint Mobilization
2. Respiratory force
a. Inhalation, which straightens curves in
vertebral column and externally rotates
extremities
b. Exhalation, which enhances curves in
vertebral column and internally rotates
extremities
3. Muscle force of the patient
a. Muscle cooperation
b. Muscle energy, especially isometrics
4. Reflex activity
a. Eye movement
b. Muscle activation
Afferent Reduction Procedures
The working hypothesis is that altered
behaviour of the musculoskeletal
system provides aberrant stimulation
to the central nervous system that
alters the programming of
musculoskeletal function.
 Afferent Reduction Procedures
Identifyingthe various positions and
maneuvers that reduce the afferent
bombardment of multiple reflexes at
cord and central levels can provide an
opportunity to restore more normal
behaviour.
Indirect methods work through this
mechanism.
 Manipulation Under
Anesthesia
Indicated for acute and chronic
vertebral dysfunctions that cannot be
managed by nonoperative
conservative means.
For patients who may seem to benefit
from manipulative treatment but
cannot tolerate the maneuver
because of pain.
 Factors Influencing Type of
Manipulative Procedures
1. Age of patient
2. Acuteness or chronicity of the
problem
3. General physical condition of the
patient
4. Operator size and ability
5. Location (office, home, hospital)
6. Effectiveness of previous and/or
present therapy
 Contraindications to Manual
Medicine Procedures
1. The vertebral artery in the cervical
spine
2. Primary joint disease (e.g.
rheumatoid arthritis, infectious
arthritis)
3. Metabolic bone disease (e.g.
osteoporosis)
 Contraindications to Manual
Medicine Procedures
4. Primary or metastatic malignant
bone disease
5. Genetic disorders particularly in the
cervical spine (e.g. Down’s
syndrome)
6. Hypermobility in the involved
segments. This should clearly be
avoided. One should look for
restricted mobility elsewhere in the
presence of hypermobility.
 Complications
Most of the complications involve
vascular and neural structures.
Obvious complications occur when the
procedure is contraindicated.
Cervical spine manipulation, resulting
in insult to vertebral basilar artery
system.
Fractures and dislocations have been
identified as well as spinal cord
injuries.
 Complications
Exaggeration of disc herniation with
radiculopathy after manipulation is
controversial.
Some authors say that mobilization
with impulse as being contraindicated
to patients with disc herniation but
others say it is indicated in certain
conditions if applied appropriately.
 In a Nutshell...
Itis good for the both parties for us to
be knowledgeable about the patient’s
diagnosis, appreciate our own level of
skill and experience, and be
courageous enough to deal with
complications if they occur.
 In a Nutshell...
As manual medicine practitioners, we
should all prescribe our therapy as
precisely as we prescribe any other
therapeutic agent.
Recall of Normal Vertebral
Motion

Recall of Normal Vertebral

Motion
 Normal Biomechanics
Vertebral body
Facet joints
Intervertebral foramina
Intervertebral discs
Ligamentous structures
Muscles
The Fryette’s Law
Vertebral Motion
Dysfunction

Vertebral Motion
Dysfunction
 Theories of Vertebral Motion
Dysfunction
1. Entrapment of synovial material or
synovial meniscoid between the two
opposing joint surfaces.
2. Lack of congruence in the point-to-
point contact of the opposing joint
surfaces.
 Theories of Vertebral Motion
Dysfunction
3. Alteration in the physical and
chemical properties of the synovial
fluid and synovial surfaces
(cavitation phenomena).
4. Altered length and tone of the
muscle.
5. Changes in the biomechanical and
biochemical properties of myofascial
elements of the musculoskeletal
system, capsule, ligamentous
structures, and fascia.
 Diagnosis of Vertebral Motion
Dysfunction
Dysfunctions can be:
1. Single-segment dysfunctions
2. Group dysfunctions
Most common assessment procedures
are the PAIVMs and PPIVMs.
 Single-Segment
Dysfunctions
Alsodescribed as nonneutral
dysfunctions or type II dysfunctions.
The characteristics are:
1. Single vertebral motion unit involved
2. Includes either flexion or extension
restriction component
3. Motion restriction sidebending and rotation
to the same side.
 Neutral (Group)
Dysfunctions
The characteristics are:
1. A group of segments (three or more)
2. Minimal flexion or extension component
of restriction
3. Restriction of the group to sidebending in
one direction and rotation in the opposite
 Hypermobility
Three Types of Hypermobility:
2. Hypermobility due to disease
3. Physiological hypermobility
4. Compensatory hypermobility
 Diagnosing Hypermobility
Again it’s PAIVMs and PPIVMs.
Dysfunction (Hypomobility)
versus Hypermobility

How will you

determine?
 Thought of the Day...

The hallmark of structural diagnosis

of restricted vertebral function is
PRACTICE and EXPERIENCE.
End of Part 1

End of Part 1
Thank you for listening!