History of Manual Therapy

Hippocrates

• 460-355 BC

Claudius Galen

• 131-202 AD

Bone Setting

• Britain 17th and 18th centuries

• practice passed from father to son

• along with barber surgeons were the forerunners to orthopedics and surgery in the UK

• Mid 20th century bone setting dies out and is replaced by physical therapy and osteopathy

Osteopathic Medicine

• Andrew Taylor Still – 1874

• DO Doctor of Osteopathy in the USA –1928– Osteopathic Physicians– gained equal rights with MD’s

• In all states by 1970

• William Garner Sutherland – 1966– offshoot of osteopathy

• cranial osteopathy– cranialsacral technique

Chiropractic

• Daniel David Palmer – 1895– founder of chiropractic – credits it to medicine– claims to be the first to reposition vertebrae by

using the spinous and transverse processes as balance levers

Manipulation in Medicine

• medicine created physical therapy to aid in rehabilitation

• physicians trained aids who later became physical therapist

• 1899 physiotherapy founded in England– James and John Mennell – 1st to use term MT– Edger and James Cyriax

Physical Therapy

• 1921 physical therapy est. in USA– American Women’s Physical Therapeutic

Association– need to use medically trained women after

WW1

• 1927 – ‘Arthrokinematics’ - used in Gray’s Anatomy

Physical Therapy

• 1957 – James Cyriax– Textbook of Orthopaedic Medicine

• 3rd edition

– Soft Tissue Differentiation– popularized the term ‘end-feel’– trained physiotherapists– pleaded for emphasis first on

evaluation and then on treatment

Freddy Kaltenborn

• 1961 – Kaltenborn – Norway– Extremity Joint Manipulation– After 1971 began instructing

physical therapists worldwide

Olaf Evjenth

Paris - Maitland

• 1963 – Stanley Paris (USA) –PT– while in NZ– The Theory and Technique of Specific

Manipulation

• 1964 – Geoffrey Maitland (AUST) – PT– Vertebral Manipulation

IFOMT

• 1966 – Paris, Grieve, Maitland, Kaltenborn– met with others to discuss setting up an

international body• 8 years later IFOMT (Montréal)

Robin McKenzie

• late 1970’s

• popularized the concept of

spinal extension for

treatment of LBP– ‘centralization theory’

Brian Mulligan

• 1990’s – Brian Mulligan (NZ)– MWM’s

Current Manual Therapy

• practice by physiotherapist is quite eclectic• no single philosophy dominating• rarely used in isolation, but with:

– therapeutic exercise– patient education– supportive modalities

• most use:– mechanical– muscle energy– oscillatory

Arthrology

Arthrology

• Outline:– joint classification– shapes of articular surfaces– planes and axes– degrees of motion/freedom– arthrokinematics– osteokinematics

Arthrology

Joints(Arthroses)

Solid Joints Cavitated Joints

(Synarthroses) (Diarthroses)

Fibrous Cartilaginous Synovial

Fibrous Joints

1. Sutures

2. Gomphoses (peg and socket- teeth)

3. Syndesmoses– has interosseus ligament

• eg. inferior tibiofibular ligament

Cartilaginous Joints

Synchondroses (primary cartilaginous joints)hyaline growth cartilage (function = growth mechanism)

- sternales, xiphosternalisSymphyses (secondary cartilaginous joints)

hyaline growth cartilage, bonded by fibrocarilaginous disc

- pubis, intervertrebrales, manubriosternalis **

Synovial Joints

• Typical features:– freely moveable– articular surface predominantly hyaline

cartilage, sometimes fibrocartilage– fibrous joint capsule– synovial membrane– synovial fluid– disc or meniscus– joint space

Synovial Joints

Complexity1. Simple

• one pair of articulating surfaces:• convex• concave

2. Compound• more than one articulating pair in a single capsule• neither will articulate with the surface that belongs to the

other

3. Complex• has an articular disc

Shapes of Articular Surfaces

1. Ovoid

2. Sellar

Ovoid

• concave or convex in all planes• degree of curvature will vary in all planes• egg shaped rather than spherical1. Unmodified ovoid

– shape is spherical enough to allow 3 degrees of motion (Hip)

2. Modified ovoid– degree of curvature is more marked in one plane than

the other– allows only 2 degrees of motion (MCP)

Sellar

• saddle shape• predominantly concave in one plane and and convex at right

angles to this• stable and efficient, requires fewer ligaments as surface is

more congruent1. Unmodified Sellar

– joint surfaces are purely concave in one plane and purely convex in the other (perpendicular to each other)

– allows for 2 degrees of motion (1st CMC)

2. Modified Sellar– joint surfaces have both a concave and a convex portion in the same

plane (not perpendicular to each other)– allows for only 1 degree of motion (TCJ, HUJ)

Planes and Axes

PLANE AXIS

median/sagittal transverse

(divides R/L) (runs M/L)

frontal/coronal sagittal

(divides A/P) (runs A/P)

transverse/horizontal vertical

(divides S/I) (runs C/C)

Degrees of Motion

• The number of planes through which a bone can be voluntarily (actively) moved around (3max)

Mechanical Axis– a line passing through the bone perpendicular to the

joint surface

– line of reference for osteokinematic motion

Axis of Movement– bone moves around this point

– perpendicular to the plane of motion

One Degree of Motion

• uniaxial– hinge joints (ulnohumeral)

• movement of the bone is limited to movement about a single axis

• motion of a bone is produced by a sliding action within a joint

Two Degrees of Motion

• biaxial– ellipsoidal (MCP, wrist)– pivot

• either a swing or spin

• has spin and swing or two distinct swings

• axes must be perpendicular to each other

Three Degrees of Motion

• multiaxial– spheroidal - ball & socket (hip)– planar joints (AC jt)

• movement about 3 distinct axes which are perpendicular to each other

• has a spin and two distinct swings (near pure)

Degrees of Freedom

• the number of independent axes that a bone can move around (6 max)

• axes are perpendicular to each other

• 3 rotations

• 3 translations

Degrees of Freedom

• 3 rotations

• 3 translations

Degrees of Freedom

Arthrokinematics

• study of the movement of one articular surface on another without regard to the movement of the bone or the forces producing that movement

• in the periphery, movement is named after the direction of motion of the distal bone

• in the spine, movement is named by motion of the superior bone

• describes:1. spin2. rock (concave moving)

roll (convex moving)3. glide (slide)4. traction/compression

Arthrokinematics

Convex/Concave Rule

• the relationship between the shape of articulating joint surfaces and the direction of gliding is defined by the convex/concave rule

• if the concave surface is moving on a stationary convex surface, gliding will occur in the same direction as the rocking motion

• if the convex surface is moving on a stationary concave surface, gliding will occur in an opposite direction to the rolling motion

Arthrokinematics

Arthrokinematics

Osteokinematics

• study and measurement of motion of a bone in space

• study of movement of a bone around its mechanical axis without regard to the motion occurring at the joint

• describes:– rotations

• spins• swings

– translations

Rotation

Spin

• the non-linear motion that occurs either at the joint surface (arthrokinematic spin) or around the mechanical axis of the bone (osteokinematic spin)

• motion of the bone is produced by a twisting action

Swing

• the linear motion that either occurs at the joint surface (arthrokinematic swing) or in the plane of the mechanical axis of the bone (osteokinematic swing)

• motion of the bone is produced by a sliding action within a joint

Pure Swing

• (cardinal or chordal)• shortest distance between two points• swing with no accompanying spin• bone moves in one plane• swing can occur without the bone taking a curved

path• only occurs in joints that have at least 2 degrees of

motion• is functionally abnormal and the exception rather than

the rule

Pure Swing

Impure Swing

• (arcuate)

• Is accompanied by spin (conjunct rotation)

• The bone does not stay in one plane

• Movement of a point on the mechanical axis follows a line (arc) other than the shortest one (chord)

Impure Swing

Translation

• all particles in the body at at given time have the same direction of motion relative to a fixed point

• there is no centre of rotation as the bone moves along a plane instead of through it

Translation

PPM/PAM

• Passive Physiological Movement– links with osteokinematics

• Passive Accessory Movement– links with arthrokinematics

Traction Technique ?

Articular NeurologyArticular Neurology

Wyke (1981) The neurology of jointsWyke (1981) The neurology of joints All joints are provided with similar arrays of All joints are provided with similar arrays of

corpuscular and non-corpuscular receptor corpuscular and non-corpuscular receptor nerve endingsnerve endings

Types I-IVTypes I-IV

Receptor CharacteristicsReceptor Characteristics

FunctionsFunctions

Functionally, the receptor systems Functionally, the receptor systems operate in three spheres:operate in three spheres:

1.1. ReflexogenicReflexogenic

2.2. PerceptualPerceptual

3.3. NociceptiveNociceptive

ReflexogenicReflexogenicMyelinated afferent axons that innervate Myelinated afferent axons that innervate mechanoreceptors in joint capsule and ligaments mechanoreceptors in joint capsule and ligaments enter spinal cord through related dorsal NRs are enter spinal cord through related dorsal NRs are dispersed to spinal and brain stem motoneurone dispersed to spinal and brain stem motoneurone pools, cerebellum, brainstem reticular system and pools, cerebellum, brainstem reticular system and thalamusthalamusIntegrated effects are expressed in coordinated Integrated effects are expressed in coordinated reflexogenic effects on the striated musculature in reflexogenic effects on the striated musculature in many parts of the bodymany parts of the body Arthrostatic – operate in absence of joint movementArthrostatic – operate in absence of joint movement Arthrokinetic – operate during joint movementArthrokinetic – operate during joint movement

PerceptualPerceptual

Articular mechanoreceptor projections Articular mechanoreceptor projections to the paracentral and parietal regions to the paracentral and parietal regions of the cerebral cortex (associated with of the cerebral cortex (associated with postural and kinesthetic sensationpostural and kinesthetic sensation

1.1. Postural sensation - staticPostural sensation - static2.2. Kinesthetic sensation – perception of Kinesthetic sensation – perception of

direction, amplitude, and velocity of direction, amplitude, and velocity of joint movementjoint movement

NociceptiveNociceptive

Free nerve endingsFree nerve endings

Active when there is:Active when there is: Mechanical deformation or tensionMechanical deformation or tension Mechanical or chemical irritationMechanical or chemical irritation

Classification ofClassification ofNerve FibersNerve Fibers

Two classification systems:Two classification systems:

1.1. Conduction velocityConduction velocity1.1. AA

1.1. α, β, γ, δα, β, γ, δ

2.2. BB

3.3. CC

2.2. Axonal diameter (used only for sensory fibers)Axonal diameter (used only for sensory fibers)1.1. Group I-IVGroup I-IV