don’t just recover. conquer. how manual therapy works and why it matters the integration of manual...
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DON’T JUST RECOVER. CONQUER.
How Manual Therapy Works and
Why it MattersThe Integration of Manual Therapy into Sports Medicine
Thomas R. Denninger, DPT, OCS, FAAOMPT2015 Steadman Hawkins Clinic of the Carolinas
Sports Medicine Symposium
June 5th-6th, 2015
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➔ Participants will acquire knowledge of the:o Theoretical basis of manual therapy techniques based
off available scientific literatureo Centering on the proposed model by Bialosky.
➔ Participants will demonstrate application of manual therapy for common sports medicine injuries at the:o Shouldero Foot/ankle
• Based upon recent systematic reviews and randomized controlled trials comparing treatment including manual therapy vs. standard of care.
Course Objectives
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What is Manual Therapy?
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➔ Accupressure➔ Anma➔ Bodywork➔ Bone setting➔ Dom method➔ Joint manipulation➔ Joint mobilization➔ Spinal manipulation➔ Spinal mobilization➔ Massage therapy➔ Manual lymphatic drainage
➔ Medical acupuncture➔ Muscle energy technique➔ Myofascial release➔ Narapathy➔ Osteopathic manipulative
medicine➔ Rolfing➔ Seitai➔ Sotai➔ Shiatsu➔ Traction➔ Tui Pa
What is Manual Therapy?
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Years 1958-2015
Number of
Indexed Articles
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“Manual therapy techniques consist of a broad group of passive interventions in which clinicians use their hands to administer skilled movements designed to modulate pain; increase range of motion, reduce or eliminate soft tissue swelling; inflammation; or restriction; induce relaxation; improve contractile and non-contractile tissue extensibility; and improve pulmonary function. These interventions involve a variety of techniques, such as the application of graded forces.”
APTA/AAOMPT Definition
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➔ A physiologic force applied therapeuticallyo Joint Basedo Muscle Basedo Nerve Based
Our Definition
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How Manual Therapy Is Often Assumed to Work
Manual Therapy Mechanical Effect Clinical Benefit
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➔ Biomechanical Evidence Summaryo Joint biomechanics are variable especially in
pathologic jointso Clinical benefits often not consistent with
biomechanical theoryo Studies demonstrate biomechanical changes are • Short lasting• Non-specific• Do not change alignment or position
However
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DON’T JUST RECOVER. CONQUER.**
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NOT How Manual Therapy Works
Manual Therapy Mechanical Effect Clinical Benefit
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“When the scientific literature is considered, attributing
successful (manual therapy) outcomes solely to the
identification and correction of biomechanical faults makes as much sense as crediting a beard for winning a hockey
playoff”
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Something is Missing
Manual Therapy Clinical Benefit
Mechanical Effect
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The Black Box
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It’s Much Messier
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Let’s Simplify a Bit
Non-Specific Effects
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➔ Peripheral Nervous System➔ Central Nervous System➔ Supra-Spinal➔ Psychosocial
Define Non-Specific Effects
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➔ Manual Therapy has been demonstrated to:o Significantly reduce pain
biomarkers o Increase in PEA
Peripheral Nervous System
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➔ Neuromuscular Responseso Motorneuron Poolingo Afferent Dischargeo Muscle Activity
➔ Hypoalgesiao Temporal Summationo Selective blocking of
neurotransmitters
Central Nervous System
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➔ Injection causes activation primarily in dorsal horn of spinal cord
➔ Less activation in rats given knee mobilizations
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Supraspinal and Psychosocial Domains
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Peripheral Nervous System-Changes in local pain biomarkers
Central Nervous System-Muscle relaxation and excitation-Ascending Pain Inhibition
Supra-Spinal Pathways-Endogenous Opioids-Changes in neural processing of
nociceptive information-Autonomic Changes
Psychosocial Components-Placebo-Changes in fear
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Less This
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More This
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In Fact
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Why Should We Use Manual Therapy?
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Manual Therapy for the Shoulder Impingement
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Manual Therapy and Exercise
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➔ Randomized Controlled Trial (Pilot)➔ N=14➔ Outcomes= Pain, Function, Change AROM➔ Interventions= 3x week for 3 weeks
o Supervised Exercise• Stretching, Rotator Cuff Strengthening, Scapular
Strengtheningo Supervised Exercise and Joint Mobilization• As above with addition of Glenohumeral mobilization
Conroy, 1998
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➔ Results
Conroy, 1998
*
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➔ Randomized Controlled Trial➔ N= 52➔ Outcomes= Strength, function, pain➔ Intervention: 6 sessions over 3-4 weeks
o Exercise Group• Stretching, Rotator Cuff Strengthening, Scapular
Strengtheningo Manual Therapy and Exercise Group
• Manual therapy to the upper quarter, stretching, strengthening
Bang, 2000
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➔ Results
Bang, 2000
*
*
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➔ Results
Bang, 2000
*
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Ankle Sprain
*Consistent short term improvements in swelling, range of motion, function, and pain as compared to standard treatment (RICE, AROM, controlled weight bearing)
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Cleland, 2013
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Cleland, 2013
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Cleland, 2013
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Truloys, 2013
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➔ Resultso Pain (0-10): • 1.5 point greater reduction with STM
o Function (100): • 16.6 point greater reduction with STM
o Range of Motion• Significant differences for plantar flexion and
dorsiflexiono Pressure Pain Thresholds• Significant change favoring STM group
Truloys, 2013
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Truloys, 2013
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Plantar Heel Pain
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Cleland, 2009
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➔ Randomized Controlled Trial➔ n=60➔ Outcomes= Function, Pain, Global Rating of
Change➔ Intervention=6 visits over 4 weekso Standard Care
• Calf and PF stretch, intrinsic muscle strengthening, US, Ionto, Ice
o Manual Therapy and Exercise• Soft tissue mobilization, eversion mobilization, manual
therapy LE complex
Cleland, 2009
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Cleland, 2009
LEFS
NPRS
FAAM
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➔ Randomized Controlled Trial➔ n=60➔ Outcomes= SF-36, PPT➔ Interventions
o Self Stretching Groupo Self Stretching and STM
Renin-Ordine, 2011
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Renin-Ordine, 2011
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➔ Resultso Significant between group differences for • SF-36
• Overall• Physical Function• Bodily Pain• General Health• Emotional Role
• Pressure Pain Threshold• Gastrocnemius, Soleus, Calcaneus
Renin-Ordine, 2011
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Thank You