Original Editors - Scott BuxtonTop Contributors - Scott Buxton, Kim Jackson, Mariam Hashem, Tony Lowe and Oyemi Sillo
- 1 What is Manual Therapy?
- 2 The Maitland Concept
- 3 Initial Assessment
- 4 Principles of Technique
- 4.1 Decisions Which Need to be Made
- 4.2 How to Choose the Direction
- 4.2.1 Different Types of Mobilisation: How Many Glides?
- 4.2.2 Each joint has a different movement arc in a different direction to other joints and therefore care needs to be taken when choosing which direction to manipulate; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:
- 4.2.3 Concave Convex Rule: Up, down, Left or Right?
- 4.3 How to Choose the Grade: How Far into Range and Quickly or Slowly?
- 4.4 Therapeutic Effect: How and Why Does This Work; Mechanisms of Action
- 4.5 Descending Inhibition
- 5 Should Manual Therapists Take Blood Pressure?
- 6 Additional Resources
- 7 References
What is Manual Therapy?
Manual therapy can be broadly defined as
"...the use of hands in a curative and healing manner or a hands-on technique with therapeutic intent...".
There is a wide range of disciplines which use manual therapeutic methods to treat and manage pathology and dysfunction as a primary treatment method or in conjunction with other treatments. Physiotherapists are sometimes considered specialists in manual therapy but other professions such as Osteopaths, Chiropractors and Nurses employ manual therapy in treatment. Manual therapy works through a multitude of different mechanisms to be effective and understanding the physiological, neurological and psychophysiological mechanisms is critical to utilising manual therapy clinically in a competent and safe manner.
From a Physiotherapy perspective manual therapy is an essential and commonly used treatment method for the management of tissue, joint and movement dysfunction. There are several different main stream approaches to manual therapy; arguably the most common form simplistic form manual therapy used by physiotherapists are mobilisations from the Maitland school of thought.
The Maitland Concept
"The Maitland Concept of Manipulative Physiotherapy [as it became to be known], emphasises a specific way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy (“know when, how and which techniques to perform, and adapt these to the individual Patient”) and a total commitment to the patient."The application of the Maitland concept can be on the peripheral or spinal joints, both require technical explanation and differ in technical terms and effects, however the main theoretical approach is similar to both.
- Accessory Movement - Accessory or joint play movements are joint movements which cannot be performed by the individual. These movements include roll, spin and slide which accompany physiological movements of a joint. The accessory movements are examined passively to assess range and symptom response in the open pack position of a joint. Understanding this idea of accessory movements and their dysfunction is essential to applying the Maitland concept clinically.
- Physiological Movement - The movements which can be achieved and performed actively by a person and can be analysed for quality and symptom response.
- Injuring Movement - Making the pain/symptoms 'come on' by moving the joint in a particular direction during the clinical assessment.
- Overpressure - 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.
The Maitland concept is a fantastic tool for approaching an initial assessment as it can be used to form a logical and deduced hypothesis about the nature of the origins of the movement disorder or pain. It is worth considering using mobilisations in your assessment process and reading the Initial Assessment section in Maitlands book Peripheral Manipulation.
As with any treatment decision a competent and effective assessment is crucial to any patient interaction. The Subjective Assessment is necessary for determining whether or not mobilisations are suitable for this patient or if they are contraindicated by looking for red flags such as cancer, recent fracture, open wound or active bleeding, infective arthritis, joint fusion and more.
The Objective Assessment is an area which the versatile nature of mobilisations becomes clear. Additionally to being a treatment method they are available to the therapist to assess a patients joints and tissues by analysing their extensibility, pain reproduction, bony blocks or abnormal end feels.
Principles of Technique
Decisions Which Need to be Made
- The Direction - of the mobilisation needs to be clinically reasoned by the therapist and needs to be appropriate for the diagnosis made. Not all directions will be effective for any dysfunction.
- The Desired Effect - what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness?
- The Starting Position - of the patient and the therapist to make the treatment effective and comfortable. This also involves thinking about how the forces from the therapists hands will be placed to have a localised effect.
- The Method of Application - The position, range, amplitude, rhythm and duration of the technique.
- The Expected Response - Should the patient be pain-free, have an increased range or have reduced soreness?
- How Might the Technique be Progressed - Duration, frequency or rhythm?
How to Choose the Direction
To make sure you settle on appropriate mobilisations it is important to get the type of glide, the direction and speed correct.
Different Types of Mobilisation: How Many Glides?
Each joint has a different movement arc in a different direction to other joints and therefore care needs to be taken when choosing which direction to manipulate; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:
- A-P (Anteroposterior)
- P-A (Posteroanterior)
- Longitudinal Caudad
- Longitudinal Cephalad
- Joint Distraction
- Medial Glide
- Lateral Glide
Due to anatomical position and other physical limitations not all peripheral or spinal joints can be subjected to all of the types of glide. Here are examples of mobilisations of joints of the body:
- Elbow Mobilizations
- Wrist/Hand Mobilizations
- Hip Mobilizations
- Knee Mobilizations
- Ankle and Foot Mobilisations
- Shoulder Mobilizations and Manipulation
- Cervicothoracic Manipulation
Concave Convex Rule: Up, down, Left or Right?
Choosing the direction of the mobilisation is integral to ensuring you are having the desired clinical outcome. This is where a knowledge of Arthrokinematics is important. In summary:
There are two important things to remember:
- When a convex surface (i.e Humeral Head) moves on a stable concave surface (i.e Glenoid Fossa) the sliding of the convex articulating surface occurs in the opposite direction to the motion of the bony lever (i.e the Humerus).
The opposite can be said for
- When a concave surface (i.e Tibia; talocrural joint) is moving on a stable convex surface (i.e Talus) sliding occurs in the same direction of the bony level.
To improve shoulder flexion you would perform an A-P mobilisation due to the way the convex humerus articulates with the concave glenoid fossa.
An easier way to visualise this is to try and show this rule with your hands. (Picture from)
How to Choose the Grade: How Far into Range and Quickly or Slowly?
Grade II – large amplitude movement at within the available range of movement
Grade III – large amplitude movement that reaches the end range of movement
Grade IV – small amplitude movement at the very end range of movement
**A 5th grade is possible but further training will be required to perform safely**
In many places, you are obliged to obtain a written consent from your patient before applying grade 5 manipulation .
- Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN scores).
- Higher grades(III + IV) are used to stretch the joint capsule and passive tissues which support and stabilise the joint so increase range of movement.
The rate of mobilisation should be thought of as an oscillation in a rhythmical fashion at:
- 2Hz - 120 movements per minute
- For 30 seconds - 1 minute
Therapeutic Effect: How and Why Does This Work; Mechanisms of Action
There are a number of complex systems which interact to produce the pain-relieving effects of mobilisations, subsequently there is not a single theory into its mechanism. Therefore this article will outline the basics and evidence for the claims and further links will be added for additional more in-depth information.
Pain Gate Theory
The pain gate theory (PGT) was first proposed in 1965 by Melzack and Wall, and is a commonly used explanation of pain transmission. Thinking of pain theory in this way is very simplified and may not be suitable in some contexts, however when discussing pain with patients this description can be very useful.
- α-Beta fibres - Large diameter and myelinated - touch and pressure - Fast (50m/s)
- α-Delta fibres - Small diameter and myelinated - temperature and pain (well localised, sharp/prickly) - Medium (15m/s)
- C fibres - Small diameter and un-myelinated - pain (dull, poorly localised, persistent) - Slow (1m/s)
The size of the fibres is an important consideration as the bigger a nerve is the quicker the conduction, additionally conduction speed is also increased by the presence of a myelin sheath, subsequently large myelinated nerves are very efficient at conduction. This means that α-Beta fibres are the quickest of the 3 types followed by α-Delta fibres and finally C fibres.
The interplay between these nerves is important but it is not the whole story, as you can see only two of these nerves are pain receptors α-Delta fibres are purely sensory in terms of touch. All of these nerves synapse onto projection cells which travel up the spinothalamic tract of the CNS to the brain where they go via the thalamus to the somatosensory cortex, the limbic system and other areas. In the spinal cord there are also inhibitory interneurons which act as the 'gate keeper'. When there is no sensation from the nerves the inhibitory interneurons stop signals travelling up the spinal cord as there is no important information needing to reach the brain so the gate is 'closed'. When the smaller fibres are stimulated the inhibitory interneurons do not act, so the gate is 'open' and pain is sensed. When the larger α-Delta fibres are stimulated they reach the inhibitory interneurons faster and, as larger fibres inhibit the interneuron from working, 'close' the gate. This is why after you have stubbed your toe, or bumped your head, rubbing it helps as you are stimulating the α-Delta fibres which close the gate.
For an alternate explanation: Pain Gate Theory Article Science Daily Physiotherapy Journal Article: Pain Theory & Physiotherapy
The sensation of pain is subject not only to modulation during its ascending transmission from the periphery to the cortex but also to segmental modulation and descending control from higher centres.
It needs to be thought of as not just a linear process, instead a complex interaction of a multitude of different biochemical and physical factors which must be thoroughly understood to understand the process.
Should Manual Therapists Take Blood Pressure?
A controversial and often neglected consideration when performing manual therapy, particularly on the neck, is the impact therapy has on blood pressure and a 2012 article by Taylor and Kerry highlighted this as a professional issue which should be a major concern to physiotherapists everywhere.. The influence manual therapy has on blood pressure can be caused by the central effect on the CNS or local effects caused by the close proximity of the cervical arteries. this can be a serious risk to patients, explain here:
"Because of the proximity of the vertebral artery to the lateral cervical articulations, caution must be used during manipulation of the cervical spine (MCS). It is thought that stroke can be induced as a result of MCS by mechanical compression or excessive stretching of arterial walls but the pathogenesis of ischemia is unknown."
Hypertension ('the silent killer') is common in the developed world due to poor diet, high stress and sedentary lifestyle many people adopt and surprisingly 30% of people may be unaware of its serious consequences. Hypertension is one of the biggest causes of stoke but also can be used as a warning sign for the risk a patient has of having a stroke. Therefore it should be used to ensure there is no risk to a patient by performing cervical manual therapy. Worryingly, Frese et al (2002) surveyed 597 physiotherapists and found 47% of respondents "never measured BP" with 4.4% reporting always checking. The most common reason chosen for the decision not to check BP was that it is "not important for my patient population". This is a concern due to the numbers of people suffering from hypertension, obesity and other known risk factors for hypertension and stroke surely it should be important for any patient population.
- International Maitland teachers Association
- Principles of Mobilisation PDF File
- Princliples of Clinical Reasoning PDF
- Manual Therapy Journal
- Lederman E. The Science and Practice of Manual therapy. 2nd ed. Elsevier: London. (2005)
- International Maitland Teachers association. A tribute to the life and work of G.D.Maitland 1924-2010. Manual Therapy. 2010; 300-301
- http://www.imta.ch/ International Maitland Teachers Association. 2013
- Hengeveld E, Banks K.(ed) Maitland's Peripheral Manipulation. 4th ed. Elsevier: London.(2005)
- Manipulation Association of Chartered Physiotherapists. Tribute to Geoffrey Maitland (1924-2010) Manual therapy. (2010; 298-299)
- Ferguson F, Holdsworth L, Rafferty D. Low back pain and physiotherapy use of red flags: the evidence from Scotland. Physiotherapy (2010:96,4;282-288 DOI: 10.1016/j.physio.2010.01.001)
- Levangie P, Norkin C. Joint Structure and Function. A comprehensive Analysis. 3rd edn. Philadelphia: F.A. Davis company. (2001)
- Cochrane CG. Joint Mobilisation Principles: Considerations for Use in the child with Central Nervous System Dysfunction. Physical therapy. (1987: 1105-1109)
- Convex concave role. Available from:https://www.youtube.com/watch?v=wUUSZWtvB6M
- Kessler RM, Hertling. Management of Common Musculoskeletal Disorders: Physical Therapy, Principles and Methods. Philadelphia: Harper fckLR& Row, Publishers Inc. (1983)
- Melzack R, Wall PD. Pain Mechanisms: A New Theory. Science: New Series 150. (1965:971-979)
- Fields HL and Basbaum AI. Central Nervous System Mechanisms of Pain Modulation. in Wall PD and Melzack R (eds). Textbook of Pain. 1999: 309-330
- van Griensven H, Strong J, Unruh AM (2014). Pain, 2nd ed. Edinburgh: Churchill-Livingstone.
- Jenkins G. Kemnitz C. Tortora G. Anatomy and Physiology: From Science to Life. New Jersey :John Wiley & sons, Inc 2007
- Martini, FH. Nath, JL. Fundamentals of Anatomy & Physiology. (8th edn). San Francisco:Pearson. 2009
- Stamford J. Descending Control of Pain. British Journal of Anaesthesia. 1995;75:217-227
- British Medical Journal. Risk Assessment of Cervical Spine Prior to Manual Therapy. (Online) Available from: http://www.bmj.com/content/344/bmj.e3679
- Di Fabio RP. "Manipulation of the Cervical Spine: Risks and Benefits." Physical Therapy. 1999;79(1):50-65
- The Stroke Association. Millions at risk from 'silent killer'. (Online) available from: www.stroke.org.uk/media_centre/press_releases/millions_at_risk.html (2011)
- Frese EM, Richter RR, Burlis TV. "Self-reported measurement of heart rate and blood pressure in patients by physical therapy clinical instructors". Physical therapy 2002;82(12):1191-1200
- Stephen Spoonemore. Cervical Manipulation Risk vs Reward. 2015