MANIPULATION THERAPY

MANIPULATION THERAPY

Therapeutic manipulation has been practiced in almost all countries of the world since at least the time of Hippocrates; early references have also been found in Egyptian hieroglyphics and early Chinese medical literature.

Recent times have seen rapid growth of manipulation and manual therapy and an increase in its public use. Some healthcare professionals' opposition to the use of manipulation is explained by the fact that manipulation requires skills significantly different than those acquired in allopathic medical schools.

This difference separates practitioners who possess manipulation skills from those who do not. The techniques used in manipulation also fall outside of the mainstream of allopathic medicine.

Manipulation procedures are used in many ways by a variety of practitioners. The most common goal of a manipulative treatment is to increase the mobility of a particular area or region of the musculoskeletal system where restrictions are encountered.

While some practitioners focus on pain relief as a main outcome measure, others seek enhanced mobility or reduction in restriction of vascular or lymphatic congestion as it relates to the rest of the body.

Most of the 90 million annual manipulations performed in the United States by physicians and other practitioners are for complaints of musculoskeletal back and neck pain.

Manipulation generally is directed at restoration of normal motion and elimination of pain secondary to disturbed biomechanics. The majority of the research on the use of manipulation focuses on its application to the cervical and lumbar spine, as well as on treating painful conditions in these areas with either mobilization or thrust-type maneuvers. 

It is important to realize that there are many other types of manipulative techniques, and which one is chosen should be based on a thorough examination of the patient and on the particular musculoskeletal lesion to be treated. 

DEFINITION

                                        A consensus definition of manipulation is "the use of the hands applied to the patient incorporating the use of instructions and maneuvers to achieve maximal painless movement and posture of the musculoskeletal system."  Most common types of manipulation involve passive mechanical forces applied to specific vertebral segments, regions, or other joint segments of the musculoskeletal system, with a primary goal of restoration of diminished ROM.

TECHNIQUES OF MANIPULATION

This list is limited to techniques that physicians are most likely to encounter.

A brief discussion of direct versus indirect treatment is germane to the understanding of the rationale for choosing a particular technique. 

Once an area of restriction, or somatic dysfunction, is palpated, the means of correction must be chosen.  One can elect to treat in the direction of restriction, or into what is commonly called the "ease of motion," that is, away from the restricted motion. 

A direct technique engages the motion barrier; this means that the practitioner directs forces into and through the motion barrier.  On the other hand, an indirect technique allows the body's inherent neurologic or intrinsic forces to release the restriction, as the practitioner positions the area to be treated opposite the direction of a restriction. 

Example: If pain and reduced motion is elicited by actively rotating a patient's neck to the patient's right side, it can be deduced that the patient's restriction is on the right.  Thereby, if the treatment selected takes the patient's neck further to the right, ie, into the restriction or barrier, this is a direct treatment.  Conversely, if the patient's neck is rotated to the left, or away from the barrier, it is considered an indirect method of treatment.

DIRECT THRUST

                         Direct-thrust (eg, high-velocity/low-amplitude) techniques, including European mobilization with impulse, involve diagnosis of dysfunction of a vertebral segment by identifying position or motion abnormalities or related tissue-texture changes, including tenderness to (1) palpation or (2) induced motion.

The practitioner then rotates, side bends, and either flexes or extends the adjacent vertebral segments, locking the facet so that further motion is limited to the segment in question. The vertebral segment is then moved passively to its limit of motion (or barrier) in order to remove slack motion, and a small force, localized to the specifically identified joint, is applied to hold that position.

Brief, controlled thrust is applied in the direction perceived as limited, and a small motion in the desired direction occurs as the vertebra crosses its barrier.

Forces, duration of actions, acceleration, and displacement values for direct thrusting techniques have been measured. These forces peak in the range of 100-400 Newton over a period of approximately 150 milliseconds.

Direct manipulative techniques featuring forces applied over transverse or spinous processes are short-lever techniques. If force is applied distant to the vertebrae through the locked column, the procedure is considered a long-lever technique. All direct-thrust techniques must have forces well localized and specifically directed, and structural diagnosis must be adequate before their application.

ARTICULATORY TECHNIQUE

Articulatory technique also referred to as low velocity, high amplitude, involves passive movement of a vertebral joint within reduced ROM (defined by its resting position and dysfunctional limitation of motion).

Extent of motion at its end point may vary, but the ultimate end point and dysfunctional barrier become the same, with the barrier becoming attenuated with repeated motion.

The quality or feel of induced motion, in addition to the quantity of force and excursion, are normalized by this procedure. A small amount of additional force occasionally may take the vertebra through its barrier or restriction.

INDIRECT POSITIONAL TECHNIQUES

Indirect positional techniques (eg, Counterstrain and functional techniques) are based on the underlying principle that somatic dysfunction or hypo mobility is caused by an inappropriately firing muscle group, rather than by shortened, passive tissue, such as joint capsule, ligament, or fascia.

Thrust, articulation, and muscle energy techniques employ forces that could be expected to lengthen shortened, passive tissues, whereas these positional techniques change an inappropriate engram of muscle behavior.

COUNTERSTRAIN

Developed by Jones, Counterstrain is an indirect myofascial technique that shares with functional technique an emphasis on relative positioning of a joint or body part as an essential component of treatment.

Counterstrain- treatment involves placing a joint or body parts into position of maximal ease or comfort, thereby relaxing ligamentous and myofascial soft tissue. This relaxation allows inappropriately shortened muscles to reset their spindles, which then normalizes proprioceptive input into the spinal cord.

The restricting muscle generally is shortened excessively by this positioning (eg, counterstrained), and its antagonist muscle is overstretched (eg, strained) gently in the process. 

The optimal treatment position is found by minimizing pain associated with palpatory pressure over a tender point and, once this position of maximum ease is found, it is held for approximately 90-120 seconds, with concurrent tender-point monitoring.

During this time, tenderness should fade to no more than 20-30% of its initial value. Occasional small, fine-tuning, passive positioning movements with verbal feedback from the patient may be needed.

Tenderness is part of this feedback system; therefore, the patient must respond to the practitioner's questions.  The patient is slowly returned to a neutral position in 1 plane of motion at a time to prevent recurrence of inappropriate muscle firing.

Counterstrain is considered an indirect technique, because positioning is always in a direction away from the restricted motion. If multiple tender points are encountered, they are treated in order of decreasing tenderness. The areas of the highest accumulation of tender points (first proximally, and then distally) are then addressed.

Tender points are found beneath the skin through palpatory examination over shortened and restricted muscles or over related anatomic structures (eg, tendons, muscles, ligaments).

Tender points generally do not coincide with trigger points or points associated with fibromyalgia. Counterstrain tender points usually are small, fibrotic, discrete areas thought to be manifestations of distal somatic dysfunction and are not associated with other signs of fibromyalgia, nor are they paired.

Counterstrain tender points are distributed widely in generally reproducible locations, depending on the nature and location of associated somatic dysfunctions. Those associations are not based on known neurophysiologic or neuroanatomic referral patterns.

Counterstrain is considered safe, effective, gentle, and atraumatic, so it is a very useful technique for the older, hospitalized, or immune-compromised patient, as well as for apprehensive patients and children.

Counterstrain techniques are easy to perform, forgiving for the novice learner, and easily incorporated by the patient into a prescribed home exercise program.

FUNCTIONAL TECHNIQUES

Functional techniques, as well as Counterstrain, have a methodologic approach oriented to resetting inappropriate afferent impulses from nociceptors and mechanoreceptors, resulting in efferent alpha motor activity to the skeletal muscle, by placing the joint or body part into a position of maximum ease.

Unlike Counterstrain, however, the position is found and monitored by the practitioner, sensing either increased resistance to trials of small, induced motions or increased tissue tension of the nearby tissue when motion is induced. The most relaxed position is held in this balanced state.

Functional technique practitioners feel that inherent body motions (eg, respiration) allow the firing pattern of the afferent muscles to reset so that they are normalized in a neutral position. This approach, also unlike Counterstrain, does not make use of tender points and may be somewhat more objective, because practitioner's palpatory findings determine positions of balance.

The practitioner puts the patient through a sequence of positions, with the goal of progressing toward anatomic neutral as the position of maximum ease or balance.

Functional techniques are useful in acute and chronic conditions, because they focus on the quality, rather than the quantity, of motion, with restoration of normal function implying normal quality and ROM. Functional techniques require significant experience on the part of the practitioner.

MUSCLE ENERGY

Muscle energy is a direct, non-thrusting technique (also known in the United States as isometrics and in Europe as mobilization) and has a strong relationship to proprioceptive neuromuscular facilitation.

The physician positions the patient and removes slack as in direct thrust procedures and subsequently prevent active motion of the affected vertebral segment away from its barrier.

The patient then exerts minimal to moderate isometric force against resistance offered by the physician for approximately 5-10 seconds and subsequently relaxes. The physician then finds that the barrier has been displaced and that the affected segment moves beyond its original barrier. This procedure is repeated 2-3 times, with diminishing gains and increased ROM.

SOFT-TISSUE TECHNIQUE

Soft-tissue technique uses mechanical stretch of skin, muscle, and fascia to increase motion. Lateral and linear stretch and deep inhibitory pressure are the most common procedures used. Soft-tissue techniques are useful in virtually all patients and may function as the first step in manipulative treatment involving multiple techniques.

Soft-tissue techniques are very valuable in encouraging circulation and enhancing venous and lymphatic flow. The overall purpose of soft-tissue techniques is to relieve fascial and superficial muscle tension. Soft-tissue techniques are easily learned and can be incorporated into clinical practice with virtually no difficulty.

MYOFASCIAL RELEASE

Myofascial release techniques are directed at vertebral, segmental, or generalized hypo mobility. Myofascial release can be indirect (ie, when a restricted area is placed into a position of little resistance until subsequent relaxation occurs) or direct (ie, when the affected area is placed against a restrictive barrier with constant force until fascial release occurs).

All the myo-fasciae of the body are interconnected, and when one area is tight or restricted, diminished movement occurs not only locally but (potentially) in distant, related areas.

Myofascial release practitioners palpate to assess tissue response and adjust applied forces of stretch, pressure, twist, or traction until affected tissues change toward normal. This progression may occur over a short period of time and is referred to as release.

The mechanism of release may be biomechanical or neuroreflexive; however, fascial resistance to forces applied should be symmetric, and the tissue should be relatively mobile and responsive to force being applied.

In myofascial release, the mechanical approaches of direct thrust, articulatory technique, and muscle energy are combined with the neuroreflexive approaches of Counterstrain, functional technique, and soft-tissue technique.

Effective use of myofascial release requires considerable palpatory skill and experience, and training time is relatively long compared with that for other manipulative approaches.

CRANIOSACRAL

Craniosacral manipulation is based on the concept of a primary respiratory mechanism (ie, a cyclic, palpable, rhythmic wave of inherent motion appreciated most easily in the cranial and sacral areas). This wave may represent a continuous state of flux in the cerebrospinal fluid (CSF).

This primary mechanism may entail inherent mobility of the central nervous system (CNS), CSF fluctuation, cranial bone articular mobility, involuntary motion between the sacrum and ilia, and mobility of interspinal and intercranial membranes.

The craniosacral practitioner palpates the head and/or sacrum to feel pulsations of the wave motion, occurring in the range of 8-12 pulses per minute, as well as to evaluate symmetry, regularity, frequency, and amplitude of the wave. When abnormalities are found, general pressure is applied to the skull and sacral areas to restore the wave to normal symmetry rhythm and amplitude.

While this technique is considered somewhat controversial among nonpractitioners, its largest subset of potential patients may be infants with failure to thrive, birth defects, or head injuries, as well as adults with neurologic or CNS pathology. 

The growth in popularity of this manipulative approach requires physicians to have at least passing familiarity with it. Proficiency with craniosacral manipulation requires considerable training and experience.

MANIPULATION RISKS, BENEFITS, AND PATIENT SELECTION

RISKS AND BENEFITS OF MANIPULATION

Few risks are involved in manipulative care. Complications from isometric or articulatory treatments have not been reported. The number of reports of complications from direct-thrust manipulation actually is quite small, considering the number of manipulations performed annually.

Evidence for the benefits of manipulation is mounting. Proponents report excellent results in treating acute, as well as chronic, musculoskeletal problems. Empirically, these outcomes are comparable to those achieved with more conventional treatments, many of which carry no proof of efficacy.

Manipulative care has been shown to decrease use of medication and physical therapy, to be superior to conventional treatment and placebo manual care, and to be most efficacious in persons with noncomplicated acute low back pain.

Manipulation results in less disability and faster recovery, as well as in greater improvement in pain and activity tolerance, and is a valuable adjunct to an ongoing exercise program.

Manipulation has been shown to be useful in the treatment of upper, middle, and peri-respiratory infections, as well as advanced cardiopulmonary disease, headache, and neck pain.

MANIPULATIVE CARE IN PHYSIATRIC PRACTICE

The physiatrist usually is able to identify, through focused musculoskeletal examination, patients who are most likely to benefit from manipulative care.

Although some manipulation techniques have applicability to hospitalized patients, most persons for whom manipulation is considered appropriate are encountered in the outpatient setting. This constituency includes patients with structural problems (eg, vertebral rotations, pelvic asymmetries, sacral torsions, other entities in which diagnosis relies on palpatory skill). 

SELECTION OF PATIENTS

Perform a general physiatric examination on each patient. Identify and treat any underlying pathology, including fractures, herniated disks, sprains, strains, hematomas, joint injuries, and peripheral and central neurologic injuries.

Use additional diagnostic studies as needed. The physiatrist contemplating manipulative intervention performs a focused, detailed history and structural examination in areas suggested by symptoms or by the general examination.

This involves observation, active gross- and fine-motion assessment, and general palpatory/motion examination. Success of manipulative therapy often depends upon accurate palpatory diagnosis. Palpatory and segmental autonomic changes may be significant components of structural diagnosis.

Generally included in evaluation of vertebral / segmental levels are:

1)     Bony structure asymmetry;

2)     Restricted vertebral motion relative to adjacent vertebrae in flexion, extension, side bending, and rotation;

3)     Tissue-texture changes;

4)     Local tolerance to palpation or induced motion; and

5)     Tenderness elicited over vertebral processes or by induced motion. Evaluate passive motion for range, symmetry, and amount of force needed to achieve full range, which is assessed in terms of quality or end field of motion. Evaluate combinations of vertebral motion as well (eg, flexion, rotation).

Springing of the vertebrae and examination of tenderness or local pressure on interspinous ligaments often are useful techniques in determining musculoskeletal function and loss of joint mobility.

Subcutaneous tissue-texture changes, such as edema or fibrosis, may be noted by palpation and may indicate musculoskeletal pathology with associated segmental autonomic changes. Include an examination of the ribs, occiput, and pelvis in the structural examination.

Hypermobile musculoskeletal segments may not be amenable to manipulative intervention but may indicate the presence of hypomobile segments in other locations and, if nontender, may be amenable to successful manipulation to resolve distant hypermobility.

Thorough structural examinations, as described, may add 5-10 minutes to an initial visit and less than 5 minutes to subsequent patient examinations. Taking the time to perform a thorough structural examination will usually allow the physician to most appropriately focus his or her treatment on the area of most need. 

By localizing the main area of restriction, the treating physician often can minimize the dose and frequency of the manipulative intervention. The physiatrist choosing manipulation should possess a relatively high degree of basic palpatory skills so that referral to another physician or manipulative practitioner includes specific identification of structural dysfunction.

Additionally, palpatory examination allows the physiatrist to determine which areas need manipulative treatment and to establish a potential end point of manual care.

INDICATIONS FOR MANIPULATION

Manipulation is appropriate for a variety of musculoskeletal problems, especially those of the thorax, rib cage, upper and lower extremities, back, pelvis, and neck. It is also useful when loss of motion or function is encountered or when localized tenderness or pain is noted on induced motion.

Some clinical situations (eg, acute fractures, disk herniations with neurologic signs, tumors, acute inflammation, and joint disease) may not respond to manipulative care because of local conditions that may constitute contraindications or hypermobility.

Remember also to exclude systemic or visceral pathologic conditions, or at least to put them under concurrent care of the practitioner. Some physicians use manipulation for treatment, while others provide it in a more prophylactic manner. 

SIDE EFFECTS OF MANIPULATION

The most commonly reported side effect of manipulation is a transient increase in discomfort lasting approximately 6-72 hours. Minor, temporary autonomic effects (eg, early or increased menses, increased perspiration, vasomotor changes) have been reported.

DURATION OF MANIPULATIVE CARE

Direct techniques (such as high-velocity, low-amplitude thrust) usually have immediate effect, and improvement is seen within a week. Indirect techniques may take longer for the effect to be seen.

Caution must be used to avoid unnecessary continuation of treatment when pain relief does not correlate with biomechanical improvement. If the patient's condition does not improve objectively within 2-4 weeks, reevaluation of the structural diagnosis, manipulative approach, or other therapeutic plan is indicated. Determine the duration of each course of therapy on a case-by-case basis.

CONTRAINDICATIONS FOR MANIPULATION

Different manipulative approaches vary as to the degree of invasiveness. Because of higher forces involved, direct techniques are the most invasive and, therefore, are more likely to be contraindicated.

Absolute contraindications for manipulative care, especially indirect techniques, are very rare. Few relative contraindications exist.

Manipulative care should be performed only for hypomobile vertebral segments or other structural dysfunctions deemed amenable to manipulation. Accurate structural diagnosis is critical. Inadequate practitioner skill is a major contraindication for all types of manipulative care.

Articulatory techniques are contraindicated for patients with vertebral malignancy, infection or inflammation, myelopathy, multiple adjacent radiculopathies, cauda equina syndrome, vertebral bone disease, bony joint instability, and cervical rheumatoid disease.

           Direct manipulation (eg, high-velocity/low-amplitude) is contraindicated in those cases and, additionally, in the presence of

§  Spinal deformity

§  Systemic anticoagulation treatment

§  Severe diabetes or atherosclerotic disease

§  Degenerative joint disease

§  Vertebral basilar disease or insufficiency

§  Spondyloarthropathies

§  Ligamentous joint instability or congenital joint laxity

§  Aseptic necrosis

§  Local aneurysm

§  Osteoporosis

§  Acute disk herniation

§  Osteomalacia

COMPLICATIONS OF MANIPULATION

Complications of manipulation generally arise because of poorly skilled/trained practitioners or due to the performance of contraindicated procedures. No documented or anecdotal reports of complications resulting from articular, isometric, Counterstrain, functional, soft-tissue, or myofascial release exist.

Most reported complications involve direct (eg, high-velocity/low-amplitude) thrusting techniques that generally have been done in the cervical region and, in almost all cases, the neck was extended inappropriately during the procedure.

Extremely serious consequences may occur with very low frequency, estimated to be approximately 1 case in 1-1.5 million manipulations. The Back Letter states that, "As to whether or not healthy patients should be concerned with the risk of cervical manipulation, the risk appears to be quite small.

Risk to the patient is minimized by proper positioning of the individual, with avoidance of extreme positions of flexion, extension, side bending, and rotation. Careful evaluation and treatment of patients with known or suspected osteoporosis or spinal disease also is important.

                       Manipulation, specifically its application to the cervical spine, has been mentioned in the lay press. Associations have been made between cervical, high-velocity thrust techniques and vertebrobasilar artery strokes and stroke like symptoms. 

However, a thorough physical examination, including a neurologic examination and an assessment of the patient's co morbid conditions and risk factors, needs to be conducted before such manipulation is performed. 

If a thrusting technique is chosen, the force used should be the minimal necessary to achieve the correction and should be localized as precisely as possible to the restricted segment. Extremes of motion in any direction, but especially cervical extension, should be avoided, because these end ranges have been shown to be the ones most often associated with poor treatment outcomes.

        Manipulation may be used to treat infants and children, as well as adults. Particular care must be taken in the application of manipulative treatments to children, especially with regard to thrust techniques. Some of the serious adverse events in this population that have been documented include death, subarachnoid hemorrhage and tetraplegia.

According to the report, a number of risk factors may predispose a child to an adverse event as a result of spinal manipulative procedures, including "immaturity of the spine, rotational manipulation of the cervical spine, and high-velocity thrust techniques."  Five of the serious adverse-event reports in this study did not specify the type of spinal manipulation used. Two of the 4 that reported such events specified that the practitioner used "rapid and/or strong rotational maneuvers."

It can be inferred from reviews such as this that rotational manipulation of the cervical spine should be used with extreme caution in the pediatric population, and that young patient age may be a relative contraindication for thrusting, especially rotational, maneuvers.  Additional attention to accurate diagnosis and a thorough history and physical examination may prevent such catastrophic outcomes in the pediatric population.

USE OF MANIPULATION BY PHYSIATRISTS

The goals of manipulation are to restore or optimize biomechanical function by improving motion, thereby facilitating mobility, minimizing pain, and increasing the patient's overall level of wellness.

Scientific evidence for the efficacy of manipulation has been mounting. General acceptance of the utility of manipulation in acute low back pain and other forms of musculoskeletal pathology has resulted in recommendations that manipulation be directed toward restoration of normal motion, reduction of pain, and overall increase of physical activity. 

There is also increasing evidence to support the use of manipulation in combination with other modalities to optimize the return of function.

A study by Childs and colleagues compared the use of exercise as a stand-alone therapy with the employment of spinal manipulation in combination with an exercise program, in patients suffering from low back pain.

Improvements in disability and pain were, to a statistically significant degree, greater in the patients who received both therapies than in those in the low-stress aerobic and lumbar spine–stabilizing exercise group.

Subsequent literature reviews examining the use of manipulation in treating pain in the cervical and lumbar regions have also supported its use.  Bronfort and colleagues found moderate evidence to support the use of spinal manipulation and mobilization in the treatment of chronic low back pain, stating that such treatment is "at least as effective as other efficacious and commonly used interventions."

PRESCRIPTION OF MANIPULATION

Referral of a patient to another practitioner for manipulation requires a prescription, the contents of which may be communicated through conversation between the practitioners. Manipulative care also may be included as a portion of a general strengthening, conditioning, and musculoskeletal educational program.

The specific region to be manipulated, potentially suggested techniques, and discussion of any medical issues, considerations, or side effects also must be a part of the prescription.

Include patient age, precautions, diagnosis, treatment recommendations, frequency, duration, and other comments in all prescriptions for manipulation.

Follow-up patient examination is essential. If treatment has been unsuccessful, consider reformulation of the diagnosis or of the therapeutic manipulative approach. If manipulation procedures are producing discomfort lasting more than 8 hours, consider changing to a less invasive, or possibly an indirect, technique.

The manipulative technique used in any intervention is determined by the time course of the problem and the patient's age and general physical condition, as well as past medical history, the presence of any contraindications, and the practitioner's expertise and training.

These considerations underscore the need for a careful history and physical examination, structural examination, and functional diagnosis. A musculoskeletal problem amenable to manipulation must be identified in order for this approach to be effective.

The identification of the source of pain is particularly important for patients with subacute or chronic pain. Note also that complete eradication of pain is rare. This fact may lead patients to become dependent on manipulation.

Having well-defined biomechanical end points of treatment (eg, normal ROM and tissue texture) helps to formulate an effective end to treatment.

Especially in the patient with chronic pain, manipulation should be directed toward obtaining an optimal biomechanical musculoskeletal condition as quickly as possible.