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How Manipulation Works

CHRISTOPHER SO

Physiotherapist, Manipulative Therapist

GATE CONTROL SYSTEM

action system

nociceptors Fig. 1 Gate Control Theory `how manipulation works' in terms of neurophysiology and Introduction biomechanics . Manipulation is an ancient art dating back to the time of Hippocrates, and use of it by the medical profession to relieve 1 . The Effect of Manipulative Procedures with Reference to pain, swelling and muscle spasm, and to restore the functional Neurophysiology use of impaired joints, has waxed and waned (Lomax, 1978). Various schools of thought have been developed to explain how manipulation works, but despite its long-standing history, a. The Gate Control Theory (Fig. 1). there are still many contending ideas regarding its use . WatsonJones has written that there is no place for manipulation in orthopaedic practice related to spines (Mennell, 1975), whereas Melzack and Wall (1965) put forward the "Gate Contro Wiles has suggested that manipulation should always be tried Theory" . They specified that the site of sensory interaction before any surgery on back problems (Mennell, 1975). After is in the substantia gelatinosa (SG), which acts as a gate for reviewing the available literature and research, many noted pain transmission . Afferent input through the large fibres physicians and scientists have come to the conclusion that tends to close the gate and input through the small fibre "There is no justification for the use of manipulative therapy" tends to open it, therefore modulating pain transmission, (Nachemson, 1975; Pearce and Moll, 1967; Sham, 1974). The output from the target cell (T) is influenced by the On the other hand, practitioners of manipulation feel that passage of these impulses through the SG. Melzack and Wall their clinical results are positive and their treatments effective also suggested the mechanism of presynaptic inhibition (Gitelman, 1975 ; Maitland, 1977 ; Mennell, 1960) . In view of whereby if the T cell's output exceeds a certain threshold these contradictions, I would like to attempt to explain it will activate the action system and pain will be perceived 30
The Journal of The Hong Kong Physiotherapy Association

Melzack (i973) and Wall (1978) admitted the shortcomings of the theory and recognised that modifications would be necessary . At a later stage following disuse. i. absent in synovial tissue. resistance experienced on passive movement of the affected joint is probably due to voluntary and involuntary muscle spasm. with a dynamic response to acceleration or deceleration of joint movements. as a result of a loss of the normal amount of lubricating synovial fluid between them. The cause of joint pathology is controversial . As more research was done. spasm and fatigue . In the early stage of injury. How Manipulation Works The essential prerequisite for evoking pain is transmission of nociceptive afferent activity . . Type IV Painreceptors are : 2 to 5 u in rnyelinated fibres and less than 2 u in unmyelinated fibres . fat pads and advential sheaths of the articular blood vessels . Type II Mechanoreceptors are : . 6 to 9 u in diameter. c. If this spasm is strong enough.fast adapting. entirely inactive under normal circumstances. iv. Type III Mechanoreceptors are : present in joint ligaments (both extrinsic and intrinsic). Type I Mechanoreceptors are : numerous in the outer layers of capsular tissues of all limb joints and apophyseal joints . the joint can be immobilised by it. three things invariably occur : pain. 1980). thereby giving rise to abnormal reflexes in such muscles (Wyke.relatively more numerous in distal joints . They also discovered the existence of a postsynaptic inhibition mechanism in addition to their postulated presynaptic inhibition mechanism . Trauma leads to excitation of the Type IV nociceptive system. different structures around the joint are affected to a varying extent . Muscle spasm may be set up by nociceptive afferents from Type IV receptor systems in joint tissues . intraarticular menisci. However. This may be of a protective nature .The gate system is also connected to the Central Nervous System (CNS). subject to static and dynamic response to changes of joint position. (1960) provided us with a concise clinical explanation ofjoint trauma . pressure. Joint Trauma Mennell J. all tissues around the joint can be affected . which may cause further spasm and more pain. having a rich nerve supply. direction. when considerable stress is applied towards the extremes of active or passive movement or by a high traction force. whose activities may influence the output of the system. . . ii. spasm and loss of function (decrease in range of movement or increased resistance to movement).inactive in immobile joints. This often results in locking of the joint . In minor injury. Spasm initiates fatigue. b. their frequency of resting discharge rises in proportion to the degree of change in joint capsule tension. 1986. bradykinin or 5HT) changes in the tissue . Articular Neurology Wyke (1980) stated that "articular neurology is one of the fundamental sciences of manipulative therapy . d. They have a high threshold to mechanical pressure with a slowly adapting response . adjacent periosteum. Both the capsule and the ligaments of a joint are extremely sensitive structures. active. more densely distributed in the proximal joints and cervical apophyseal joints. only active when irritated by the development of abnormal mechanical or chemical (histamine." The following is the classification used for receptors in synovial joints and their function . . .embedded in the deeper layers of fibrous joint capsules. amplitude and velocity of active or passive joint movement. They project polysynaptically to alpha motoneurones in the motoneurone pools of the muscles related to the joint in question. 13 to 17 u in diameter . In severe cases the bone may be fractured and ligaments may be torn incorporating bony avulsion. articular cartilage and intervertebral discs. Attempted movement gives rise to pain and sets off a vicious circle of pain.9 to 12 u in diameter. iii. slow in adapting. a plexus of unmyelinated nerve fibres that weaves in three dimensions throughout the fibrous capsule. and even minor assaults on their integrity can be very painful. but absent in the ligaments of the vertebral column . The reflex action to capsular pain is spasm . This arises from the irritated Type IV receptor system and travels through the gateway or 31 Volume 8. In traumatic cases. the articular surfaces seize up. pain is perceived and muscle spasm occurs and this produces resistance to movement . individual free unmyelinated nerve endings that weave between the fibres of ligament .

whose resting discharge rises in proportion to the degree of change in joint capsule tension . or angular movements (Fig . delaying progressive stiffness and relieving pain . rapidly adapting receptors. They synapse on the apical spinal nucleus whose axons run anteriorly into the basal spinal nucleus. adduction. they may never return to normal . 1977) will produce selective activation of different mechanoreceptors : i. Their range of movement is large. Meissner's and Pacinian Corpuscles . These movements are termed as involuntary. such movements can only be done by a third party or therapist . and like 32 EXTERNAL ROTATION Voluntary or angular movements of shoulder joint Fig. Type I mechanoreceptors. This is transmitted up to the brain via the anterolateral spinal tracts . Grade IV : similar to Grade III with its more sustained movement at the end of range will activate the static. The degree of freedom of a joint depends on its configuration In a normal ball and socket joint. project polysynaptically to . a. They are termed as gross. extension. This may be due to the stimulation of Type I and Type II mechanoreceptors (Wyke. 2. Grade II : similar effect as Grade I by virtue of the large amplitude movement it will affect Type II mechanoreceptors to a greater extent . there are involuntary movements which cannc be performed by the patient at will . The Effect of Manipulative Procedures with Reference to Biomechanics . Otherwise. Grade V : in the premanipulative position it has the same effect as a sustained grade IV in the snapping action. FLEXION GLENOID CAVITY Grade III : similar to Grade II selectively activates more of the muscle and joint mechanoreceptors as it goes into resistance. thus contributing to the continuous modulation of activity flowing around all the fusimotor muscle spindle loop systems. The Journal of The Hong Kong Physiotherapy Association . They give extra yield to joint movements.collateral branches which synapse in the basal spinal nucleus. slow adapting. abduction. It is these accessory movements which will be affected to a greater extent by trauma and which will be regained last . Fisk (1978) attributed the immediate decrease in pain after manipulation to a reflex decrease of muscle spasm . 3). the cutaneous mechanoreceptors. Different grades of mobilisation according to Maitland's concept (Maitland. Without proper treatment by mobilisation. ie . Clinically. Activation of peripheral mechanoreceptors by joint or soft tissue manipulation will produce presynaptic inhibition of nociceptive afferent activity and lead to pain suppression or reduction. Mobilisation Grade I : activates Type I mechanoreceptors with a low threshold and which respond to very small increments of tension activates cutaneous mechanoreceptors oscillatory motion will selectively activate the dynamic. 2) . They have dynamic and static responses to changes of pressure. accessory or linear movements (Fig . manipulation certainly activates Type II and Type III (high threshold) mechanoreceptors . They exert reflexogenic influences on muscle tone . there are six degrees of freedom namely flexion. resistance due to spasm melts under mobilisation or manipulation . These directions of movement can be carried out by the patients . wherein they terminate in axo-axonic synapses on the presynaptic terminals of nociceptive afferents that are subtended upon the basal nuclear neurones . 1980). They occur as the joins moves. Joint Mechanics Joint mobilisation is primarily indicated for reversible joint hypomobility. and less of the cutaneous ones as the slack of the subcutaneous tissues is taken up . This transmission can be modulated by all peripheral mechanoreceptors (not just the articular mechanoreceptors). internal and external rotation . 2 However.fusimotor (not alpha) neurone pools within the central nervous system. as distinct from the gross or angular movements. voluntary. especially towards the end of range . but is also useful for maintaining mobility. The former respond to the rate of skin indentation and the latter respond to the acceleration and retraction of that indentation .

Possibilities of pain referred from joints other than those underlying the painful areas are considered. Pain or stiffness of the joint is related to the mechanism of the injury and activities that cause the 33 Fig. assessed and cleared. In the acute phase. swelling. In addition. problems will be caused by the malalignment of joint configuration . There are a few weight-bearing or self resisted exercises which may help in gaining accessory movements. 4 Ankle dorsiflexion with anteroposterior glide Volume 8. 3 f AP Involuntary or linear movements of shoulder joint EXTENSION POSTEROANTERIOR GLIDE PA AP CEP CAUD MED LAT posteroanterior glide anteroposterior glide cephalic glide caudal glide medial glide lateral glide Manipulative procedures constitute various manual or mechanical techniques (Maitland's Peripheral & Vertebral Manipulation. can also lead to joint dysfunction . 1977). In the chronic phase stiffness is a bigger problem as compared to pain . but compared to passive mobilisation they are far from ideal. swelling and spasm . Examples include lunging exercise for ankle dorsiflexion and extension exercises for the wrist (Figs. How Manipulation Works --Related to Biomechanics Manipulative therapy lays stress on treatments to regain both angular and linear movements. adhesions and contractures plus weakness of the supportive joint structures. 4 and 5). Manipulative procedures play a major part in regaining the range of movement or function of the joint. 1986. Exercises help to maintain the range of movement gained from mobilisation . There are a number of pain relieving techniques. namely the ligaments and muscles. ANTEROPOSTEROR GLIDE The signs and symptoms of the patient are analysed before the treatment . as explained previously. Manipulative therapy aims to reduce pain. . In the chronic phase. muscle spasm and malalignment of joint configuration . Their effects on the biomechanics of joints are clear cut and direct.b. Trauma will bring about a loss of function. Other conventional physiotherapy treatments will be beneficial as well. CRUD Fig . 5 Wrist dorsiflexion with posteroanterior glide Fig . Exercises are given mainly to help the patient to regain the gross or angular movements. it may be caused by pain.

83-88.Twomey. In : The Research Status ofSpinal Manipulative Therapy. Duance. L.T . Clinical Orthop . p. The essence of the approach of manipulation lies in the integration of all the information gained from subjective and objective assessments in order to arrive at a logical conclusion of what structures of the joint are involved and which techniques are best for such joint dysfunction . J Neurol.. 16 . (1977) Peripheral Manipulation. Lehto (1985) found that mobilisation seems essential for the quicker resorption of scar tissue and better structural organisation of the healing muscle. Vertebral Manipulation. S. Mennell. London. 101 :1-18 . These are termed as 'aggravating activities' . 5. Buerger A. & Tobis J. Sham. p. M. Goldstein. An immunohistological study of the effects of physical activity on the repair of injured gastrocnemius muscle in the rat. Goldstein.) Recent research has supported the idea of the existence of a meniscus in the spinal apophyseal joints as hypothesised by Wolf (Goldstein.. 4th Ed . J. The Journal of Bone and Joint Surgery. Ed. Such knowledge of joint biomechanics helps us to decide which structures within a joint are the more plausible cause of the problem in certain conditions . 2nd Ed . D. Lincoln Institute of Health Sciences.. (1985) Collagen and fibronectin in a healing skeletal muscle injury . G. l0 . (1975) The Research Status of Spinal Manipulative Therapy.. 15 DREW. there seems to be a sound scientific basis for manipulative therapy in the treatment of joint problems. 1975). p. (1967) Conservative treatment and natural history of acute disc lesion.W. p. P. Related Res. 6.M . 277-285. Maitland.D . 31 :3. Summary In conclusion. In Approaches to the Validation of Manipulative Therapy. 67-B(5). (1976) Manual Therapy for the Extremity Joints. R.. Goldstein. Wellington New Zealand. (1985) Vertebral Column Development and its Relation to Adult Pathology. (1960) Back Pain. J. Maitland. The movement and direction of these activities is analysed according to the anatomy and biomechanics of the joint concerned . the effect of manipulative therapy may become more convincing.A . Proceedings of Fourth Biennial Conference .A . In : The Research Status of Spinal Manipulative Therapy. NINCDS Monograph No . Lomax. NINCDS Monograph No. R. B. p. Aust. Physiother. 1979) and mobilisation of nonuniting fractures (McNair. .T.Wall. and Wall. 7. 30 :13-17 . (1978) An Evaluation of Manipulation in the Treatment of the Acute Low Back Pain Syndrome in General Practice . 25 :3 July . Moreover. Thomas. Melzack.C. Jull. Neurosurg. P. In : The Research Status of Spinal Manipulative Therapy. "Normal joint physiology requires that the surrounding muscles and relevant blood vessels.D . Boston. NINCDS Monograph No . On the contrary. A. and certainly not by rest. Gitelman. Nowadays. . Books 1 .pain. the importance of manipulative therapy for joint problems should not be ignored . McNair. 1985) has produced good results.D . orthopaedic surgeons and physiotherapists are more 'aggressive' than before . J Physiother. Brisbane . (1985) Non-uniting Fractures Management by Manual Passive Mobilisation . and Twomey L. 1985) . 101:146-150. M.R . J Physiother. Charles C.. In : Aspects o) Manipulative Therapy. II . 287-293. University Press.M . A joint and its surrounding soft tissue cannot be separated functionally. In Australia. McM. J. Aust. M.. Psychiat .R . J. (1965) Pain mechanisms : a new theory . J. London.W . 4.S. and Moll. NINCDS Monograph No . (1975) The treatment of pain by spinal manipulation . 15 DHEW 4. (1978) Manipulative Therapy: An Historical Perspective . 19-24. 67-72. the narrowing of the disc space is found to be the result of subchondral fractures rather than actual thinning of the disc . the disc thickens as it ages (Twomey and Taylor. (It must be stressed that an 'aggressive' approach does not necessarily mean rough handling. (1980) Articular Neurology and Manipulative Therapy. Fisk. p. 14. G. F. 2. Aust. 12 . Ed . References Articles 1. (1973) The Puzzle of Pain. McM. 15 DHEW. J. and Restall.A . Butterworth. nerves and connective tissues are functioning properly" (Kaltenborn.106-114 . 2.T . Goldstein. 236-270. M. (1975) A critical look at the treatment for low back pain . 31 :3. 9. Kaltenborn. G. 5. R. Ed . E. Melzack. 3. (1975) History of the Development of Medical Manipulative Concepts : Medical Terminology . 8. M. As more knowledge of joint physiology and biomechanics unfolds.D . Little. (1985) Age Changes in the Lumbar Articular Triad.Nachemson. 820-828. 13 . Ed .. Mennell. 1976). The importance of passive mobilisation and manipulation lies in the restoration of gross movements and accessory movements. In : Approaches to the Validation of Manipulative Therapy . Brain. Ed . V. (1974) Manipulation of the lumbosacral spine. and Taylor J. Penguin Education. Idczak.H. J. (1979) The role of passive mobilisation in the immediate management of . R. 205-216.M .M .Taylor. Charles C. Lehto. 3. Components of soft tissue around the joint that might be affected by such activities are considered . Buerger A. Wyke. (1977) Butterworth. (1978) The Gate Control Theory of Pain Mechanisms : a re-examination and re-statement . J. p. Science 150. 971-979.Pearce.. 15 . p. Brown and Co The Journal of The Hong Kong Physiotherapy Association 34 . the mobilisation of recent fractures (Jull. the fractured neck of humerus.A. Even at this stage. which cannot be gained by patients through exercises alone. M.S . & Tobis J. Thomas. Ed . 15 DHEW. It also helps the therapist to choose the most appropriate technique for each condition.