MANUAL THERAPY
What is Manual Therapy?
Within the chartered physiotherapy profession, manual therapy is defined as a clinical approach utilising skilled, specific, hands-on techniques, including but not limited to manipulation/mobilisation. It is used by the physiotherapist to diagnose and treat soft tissues and joint structures for the purpose of:
- modulating pain
- increasing range of motion (ROM)
- reducing or eliminating soft tissue inflammation
- inducing relaxation
- improving contractile and non-contractile tissue repair, extensibility, and/or stability
- facilitating movement
- improving function
Forms of Manual Therapy
The three most notable forms of manual therapy are manipulation, mobilisation and massage.
Manipulation is the artful introduction of a rapid rotational, sheer or distraction force into an articulation. Manipulation is often associated with an audible popping sound caused by the instantaneous breakdown of gas bubbles that form during joint cavitation.
Mobilisation is a slower, more controlled process of articular and soft-tissue (myofascial) stretching intended to improve bio-mechanical elasticity.
Massage is typically the repetitive rubbing, stripping or kneading of myofascial tissues to principally improve interstitial fluid dynamics.
The Maitland Concept
The Maitland Concept of Manipulative Physiotherapy 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”. It emphasises 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.
The concept is named after its pioneer Geoffrey Maitland who was seen as a pioneer of musculoskeletal physiotherapy, along with several of his colleagues.
Key Terms
- 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.
McKenzie Mechanical Diagnosis and Therapy (MDT)
This is an internationally acclaimed method of assessment and treatment for spinal and extremity pain developed by New Zealand Physiotherapist Robin McKenzie. It has been widely used all over the world for more than 30 years.
MDT clinicians are trained to assess and diagnose all areas of the musculoskeletal system. That means that if a problem exists in or around the spine, joint or muscle, an MDT evaluation may be appropriate.
This approach continues to be one of the most researched physical therapy based methods available.
Key Features
The initial assessment is key – a safe and reliable way to reach an accurate diagnosis and only then make the appropriate treatment plan. Expensive tests such as MRI’s are often unnecessary. Certified MDT clinicians are able to rapidly determine whether the method will be effective for each patient. In its truest sense, MDT is a comprehensive approach based on sound principles and fundamentals that, when fully understood and followed, is very successful.
Each syndrome is addressed according to its unique nature, with specific mechanical procedures, including repeated movements and sustained postures. MDT is a comprehensive classification system, and includes a smaller group of patients that cannot be classified into one of the three Syndromes, but are into the ‘Other’ Subgroup which includes serious pathologies, non-mechanical causes, true chronic pain etc.
Using the information from the assessment, the clinician will prescribe specific exercises and advice regarding postures to adopt and postures to temporarily avoid. If your problem has a more difficult mechanical presentation, a qualified MDT clinician may need to add hands-on techniques until you can self-manage. The aim is to be as effective as possible in the least number of sessions. Treatment that you can perform five or six times a day is more likely to be effective in a shorter period of time than treatment administered by the clinician once or twice per week. The emphasis is on you, the patient, being actively involved. This can minimise the number of visits to the clinic. Ultimately, most patients can successfully treat themselves when provided with the necessary knowledge and tools.
Cyriax Orthopaedic Medicine
This is both diagnostic and therapeutic and was developed by Dr James Cyriax. He was the first person in medicine to formulate a comprehensive system of diagnosis and therapy based on current knowledge and evidence of anatomy physiology and biomechanics, bound together by a ruthless application of logic and reasoning.
When he started, there was only procaine for use in diagnosis by local anaesthetic. There was no fluoroscopic or ultrasound guidance, and there was no CT or MRI, only radiographs. Inflammation was acknowledged as the response of the body to healing, but was also considered to be the cause of pain in the musculoskeletal system. It was therefore the enemy.
He was the first medical practitioner to regard physiotherapists as intelligent, autonomous clinicians. He regarded their therapeutic skills very highly and his treatments were largely carried out by the physiotherapists he trained.
Treatments
The treatments were essentially:
- Transverse friction massage. This was a very specific form of massage consisting of to and fro movements transverse to the orientation of tendon, ligament or muscle fibres. His idea was that scar tissue (the inevitable consequence of inflammation) tethered and bound down collagen and muscle fibres causing limitation of movement and pain.
- Cyriax believed that manipulation must be given under strong traction to ensure safety since he regarded most spinal pain to be caused by mechanical disc derangements.
- Cyriax was probably the first clinician to routinely and systematically use local anaesthesia as a diagnostic tool and corticosteroids to treat a wide variety of common painful musculoskeletal conditions. He also developed and devised most of the techniques of injection and used his excellent anatomical knowledge to ensure that injectate was delivered to the anatomical destination intended. His description of techniques was excellent and there are books that provide excellent guidance.
Mullingan’s – NAGS and SNAGS
The Physiotherapy treatment of musculoskeletal injuries has progressed to therapist-applied passive physiological movement and on to therapist-applied accessory techniques. Brian Mulligan’s concept of mobilizations with movement (MWMS) is the logical continuance of this evolution with the concurrent application of both therapist applied accessory and patient generated active physiological movements.
In the application of manual therapy techniques, Physiotherapists acknowledge that contraindications to treatment exist and should be respected at all times. Although always guided by the basic rule of never causing pain, therapist choosing to make use of SNAGS in the spine and MWMs in the extremities must still know and abide by the basic rules of application of manual therapy techniques.
NAGS
In the cervical spine, Mulligan describes an occilatory mid to end range manual therapy technique performed in seated weight bearing. As the therapists gliding force is always performed parallel to the surface of the relevant apophyseal joints under treatment they have been termed “Natural Apophyseal Glides” or “NAGS”.
NAGS provide the therapist with an opportunity to both assess and treat the patient in the closed kinetic chain weight bearing position where most patients experience their symptoms. They are often indicated in the elderly and highly useful in the management of the acute post-injury patient when other manual therapy techniques would be poorly tolerated.
SNAGS
Mulligan’s other spinal manual therapy treatment techniques involve the concurrent application of both therapist applied accessory apophyseal joint gliding and end range active physiological movement on the part of the patient. As these techniques are sustained at the end of available pain-free range and still follow the plane of the apophyseal joints under treatment, they have gained the name “Sustained Natural Apophyseal Glides”. “SNAGS” was of course the acronym of choice.
Peripheral MWMs
Mobilizations with movement in the peripheral joints are also the simultaneous combination of therapist-applied accessory gliding techniques and patient and/or therapist generated physiological movements. They are applicable to most extremity joints and result in immediate and sustained improvement in mobility and function.
Physiotherapists seeking to expand from a basic recipe treatment format to an analytical problem solving approach based on a solid foundation of; anatomy, arthrology and biomechanics will find this system of intervention rewarding to both the patients under their care and to their own professional development.