Manual Therapy

Original Editor - Finn Gerstell

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Definition

According the the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) Description of Advanced Specialty Practice (DASP), orthopaedic manual physical therapy (OMPT) is defined as:

"OMPT is any “hands-on” treatment provided by the physical therapist. Treatment may include moving joints in specific directions and at different speeds to regain movement (joint mobilization and manipulation), muscle stretching, passive movements of the affected body part, or having the patient move the body part against the therapist’s resistance to improve muscle activation and timing. Selected specific soft tissue techniques may also be used to improve the mobility and function of tissue and muscles."

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) defines manual therapy techniques as:

"Skilled hand movements intended to produce any or all of the following effects: improve tissue extensibility; increase range of motion of the joint complex; mobilize or manipulate soft tissues and joints; induce relaxation; change muscle function; modulate pain; and reduce soft tissue swelling, inflammation or movement restriction."

Terminology

The International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) has offered the following definitions:

Manipulation: A passive, high velocity, low amplitude thrust applied to a joint complex within its anatomical limit* with the intent to restore optimal motion, function, and/ or to reduce pain.

Mobilization: A manual therapy technique comprising a continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small-amplitude/ high velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/ or to reduce pain. 

The terms "Thrust Manipulation" and "Non-Thrust Manipulation" have been used in the literature.  "Thrust Manipulation" is used to describe interventions described as Manipulation by IFOMPT, and "Non-Thrust Manipulation" would be synonymous with the term Mobilization as proposed by IFOMPT.  

The American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) has proposed the following framework for describing manipulative interventions:

1. Rate of force application: Describe the rate at which the force was applied. 

2. Location in range of available movement: Describe whether motion was intended to occur only at the beginning, towards the middle, or at the end point of the available range of movement. The term available range of movement is intended to describe the available movement as perceived by the therapist after the patient has been positioned and at the time the technique is applied. The available movement may or may not be the same as the range of motion available at a particular joint or region under other circumstances. The use of the terms beginning, mid, and end point of available movement are only relevant in the context of describing the particular technique at the time it is applied. The term end point should not be associated with any particular anatomic structures, as many structures have the potential to limit motion depending on the individual patient and technique.

3. Direction of force: Describe the direction in which the therapist imparts the force. This description should be devoid of the “intent” of the technique and, instead, should follow standard anatomical and biomechanical conventions.

4. Target of force: Describe the location where the therapist intended to apply the force. In the case of the spine, force may be directed at a specific level, or more generally across a particular region such as mid lumbar or lower thoracic. The task force suggests that replication of techniques among therapists will be more easily achieved if clearly palpable structures are used as reference points. For most peripheral joints associated with the appendicular skeleton, the target of force may be appropriately described using a specific joint as a reference. It is important to note that the use of a joint, or a particular spinal level, for reference as to where the force is applied is not intended to imply any particular theoretical assumption as to structures affected by a manipulation, but only to provide information about where the force was applied.

5. Relative structural movement: Describe which structure or region was intended to remain stable and which structure or region was intended to move, naming the moving structure or region first and the stable segment second, separated by the word “on.” For example, a “lower lumbar on upper lumbar” technique implies that the clinician intended to move the lower lumbar region while stabilizing the upper lumbar region. Techniques associated with the peripheral joints would be described utilizing the same convention (eg, tibia on femur, humerus on scapular glenoid).

6. Patient position: Describe the position of the patient (eg, supine, prone, recumbent). This would include any premanipulative positioning of a region of the body, such as being positioned in rotation or side bending.

For example, a lumbar technique might be described as, “A high-velocity, end-range, right-rotational force to the lower lumbar spine on the upper lumbar spine in a right side-lying, left lower thoracic lumbar side-bent position.”

Grading Scales

Maitland Joint Mobilization Grading Scale

Grade I - Small amplitude rhythmic oscillating mobilization in early range of movement

Grade II - Large amplitude rhythmic oscillating mobilization in midrange of movement

Grade III - Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement

Grade IV - Small amplitude rhythmic oscillating mobilization at endrange of movement

Grade V (Thrust Manipulation) - Small amplitude, quick thrust at endrange of movement

Kaltenborn Traction Grading Scale

Grade I - Neutralizes joint pressure without separation of joint surfaces

Grade II - Separates articulating surfaces, taking up slack or eliminating play within joint capsule

Grade III - Stretching of soft tissue surrounding joint

Mobilization and Manipulation Techniques

Elbow Mobilizations

Wrist/Hand Mobilizations

Hip Mobilizations

Knee Mobilizations

Ankle/Foot Mobilizations

Spinal_Manipulation

Shoulder Mobilizations and  Manipulation

Cervicothoracic Manipulation

References

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