Intro to Manual Therapy

Question 1

What is manual therapy?

Answer 1

skilled hand movements and skilled passive movements of joints and soft tissue

Question 2

What are the manual theapy techniques?

Answer 2

manual lymphatic drainage, manual traction, massage, mobilization/manipulation, neural tissue mobilization, PROM

Question 3

What are the intentions of manual therapy?

Answer 3

improve tissue extensibility, increase ROM, induce relaxation, mobilize or manipulate soft tissue and joints, modulate pain, reduce soft tissue swelling/inflammation/restriction, enhance health/wellness/fitness, enhance or maintain physical performance, increase the ability to move, improve physical function

Question 4

Manual therapy techniques comprising a continuum of skilled passive movements to joints/soft tissues at varying speeds and amplitudes, including a _amplitude/_velocity therapeutic movement.

Answer 4

small, high

Question 5

What are the six criteria for mobilization/manipulation?

Answer 5

rate of force application, location in range of available movement, direction of force, target of force, relative structural movement, patient position

Question 6

What does the location in range of available movement describe?

Answer 6

whether motion is intended to occur only at the beginning, towards the middle, or at the end point of available range of movement

Question 7

What does the target of force describe?

Answer 7

the location to which therapist intends to apply the force

Question 8

What does the relative structural movement describe?

Answer 8

which structure/region is intended to remain stable and which is intended to move (moving structure is named first then stable segment is named second, separated by “on”)

Question 9

What does the patient position describe?

Answer 9

the position of the patient (supine, prone, recumbent, sidelying) includes premanipulative positioning of a region of the body (such as being positioned in rotation or side bending)

Question 10

What is osteopathic medicine?

Answer 10

D.O. - based on “Law of artery” - body us a unit, function and structure are interrelated and body possesses self-regulatory mechanisms for rational therapies

Question 11

What is chiropractic medicine based on?

Answer 11

Law of the Nerve - a vertebrae becomes subluxed resulting in impingement of other structures passing thru the IV foramen which interferes with function of segment and assoc. structures

Question 12

What are the mechanical mechanisms of manual therapy?

Answer 12

joint motion with at least transient biomechanical effects, no evidence for lasting positional change, forces are dissipated over a large area, difficult to assert specificity of techniques, kinetic parameters vary widely among clinicians performing same technique

Question 13

What are the peripheral neurophysiological mechanisms behind manual therapy?

Answer 13

Interactions between inflammatory mediators and peripheral nociceptors may be affected by MT

Question 14

What are the spinal neurophysiological mechanisms behind manual therapy?

Answer 14

may act as a counter irritant to modulate pain by bombarding CNS with sensory input from proprioceptors, decreased activity dorsal horn of the SC in rates following MT, NMS responses (such as changes in afferent discharge, motoneuron pool activity, and muscle activity), hypoalgesia via inhibition of temporal summation and selective blocking of neurotransmitters

Question 15

What is the supraspinal neurophysiological mechanism behind manual therapy?

Answer 15

placebo analgesia as a response to MT:

decreased activity dorsal horn of the supraspinal regions responsible for the changes in pain processing; 
potential inhibition due to changes in autonomic responses, opioid system, dopamine production, and CNS;
psychological factors (expectation of effectiveness, conditioning);
negative emotions are known to diminish

Question 16

Overall, is neurophysiological mechanisms or mechanical mechanisms better?

Answer 16

neurophysiological

Question 17

What is regional interdependence?

Answer 17

concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint

a patient’s primary MSK symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to primary symptom(s)

Question 18

What are the strategies for implementation regarding the region of primary complaint?

Answer 18

should not be ignored, should be examined initially, treat as indicated in accordance with best current evidence, screen regions directly above and below the area of primary complaint within the first two visits, work to prioritize intervening in these regions during the course of care, in cases of recalcitrant and persistent symptoms - consider that symptoms may be due to assoc functional limitations and impairments in more distant regions as well as other body systems

Question 19

What is the Patient Response-based model?

Answer 19

considers pain reproduction and reduction occurring with positioning or movement

patient response guides selection and progression of treatment parameters (direction, amplitude, force, speed)

Question 20

Describe the implementation of the patient response-based model.

Answer 20

Assess: identify signs and symptoms comparable to pt’s complaints and relevant outcomes (Pt response triggers/asterisk signs)

Treat: provide intervention based on best evidence (watch SINSS!)

Reassess: reassess to determine if any changes can be assoc with administered intervention

Instruct: instruct the patient in activities to promote maintenance of gains attained through MT (consider pt response and adjust accordingly)

Question 21

What are the benefits of the patient response-based model?

Answer 21

adaptability to indiv. pts and symptoms, facilitates specificity of tx, not overly reliant on dx or biomech models, respects dx but guide tx decision making, relatively intuitive and easy to learn, provides framework for integrating evidence into practice

Question 22

What are the limitations of the patient response-based model?

Answer 22

time and energy intensive, initially assumes relevance of all findings and that each has the potential to influence decisions, within-session or even between-session improvements don’t always equate to long term, required concerted and clear communication between clinician and pt

Question 23

What are the contraindication to MT?

Answer 23

multi-level nerve root pathology, worsening neurological function, unremitting/severe/non-mech pain; unremitting night pain (preventing sleep), relevant recent trauma, upper motor neuron lesions, spinal cord damage

Question 24

What are the precautions to MT?

Answer 24

local infection, inflammatory disease, active cancer, Hx of cancer, long-term steroid use, osteoporosis, systemically unwell, hypermobility syndromes, CT disease, recent manipulation

Question 25

What is a grade I mobilization/manipulation?

Answer 25

small-amplitude movement near the starting position of available range (non-thrust)

Question 26

What is a grade II mobilization/manipulation?

Answer 26

large-amplitude movement that carries well into available range but free from resistance (non-thrust)

Question 27

What is a grade III mobilization/maniuplation?

Answer 27

large-amplitude movement that moves into resistance (between R1 and R2) (non-thrust)

Question 28

What is a grade IV mobilization/manipulation?

Answer 28

small-amplitude movement maintained within resistance (between R1 and R2) (non-thrust)

Question 29

What is a grade V mobilization/manipulation?

Answer 29

low-amplitude, high velocity movement usually performed at end of available range (thrust)

Question 30

How do you select a grade of technique?

Answer 30

remain disciplined in consideration of all 3 pillars or EBP paradigm;
consider pt’s overal presentation with respect to SIN;
proceed into manual assessment and intervention with clear intent;
continually monitor pt’s responses;
consider relationship of movement to pain and tissue resistance to clarify and correlate associations between symptoms and perceived tissue resistance;
modify technique based upon continual assessment of pt’s signs and symptoms in conjunction with changes in tissue resistance that may occur

Question 31

What are the things to think about when deciding to thrust or not?

Answer 31

consider best current evidence, consider own clinical judgment and competence, consider values of the pt, consider pt size