Basic of Manual Therapy

By
Dr. Paras A. Bhura (PT)
MPT (Ortho), CMT, PhD Scholar
Index (Syllabus)

1. Examination of joint integrity

1. Contractile
2. Non contractile

2. Basic Principles and Indication, Contra indication

1. Maitland
2. Mulligan
3. McKenzie
4. MET
5. MFR
6. Cyriax
7. NDT
 Types of tissue structure

According to james cyriax there are 2 types of

structures.
 Contractile
 Non –contractile or inert
 The contractile structure are Muscle, tendons,
Musculotendinous junction and Tenoperiosteal junction.
 The non contractile structure are Ligaments, Capsule,
Dura, Nerve, Bursa and Intra-articular loose bodies.
 The Contractile problems are identified by Resisted Test
and the non contractile structure problems are identified
by the Passive Test
Resisted Test

 It is used to check integrity of contractile

structure.
 The particular muscle is kept at the mid range
and maximal resistance is applied.
 As the contraction of the muscle is isometric
the method is called Resisted Isometrics Test.
 Strong and painless: Contractile structure is normal
 Strong and painful: Minor tear of contractile structure
 Weak and painless: Neurological condition like
hemiplegia, PPRP
 Weak and painful: Major inflammation or tear of
contractile structure.
DEFINITIONS OF TERMS
Mobilization/Manipulation

 Mobilization and manipulation are two words that have

come to have the same meaning and are therefore inter-
changeable.
 They are passive, skilled manual therapy techniques
applied to joints and related soft tissues at varying
speeds and amplitudes using physiological or accessory
motions for therapeutic purposes.
 The varying speeds and amplitudes could range from a
small-amplitude force applied at high velocity to a large-
amplitude force applied at slow velocity; that is, there is
a continuum of intensities and speeds at which the
technique could be applied
Self-Mobilization (Auto-
mobilization)
 Self-mobilization refers to self-stretching
techniques that Specifically use joint traction
or glides that direct the stretch force to the
joint capsule.
 Self-mobilization techniques are described in
the chapters on specific regions of the body.
Mobilization with Movement

 Mobilization with movement (MWM) is the

concurrent application of sustained accessory
mobilization applied by a therapist and an active
physiological movement to end range applied by
the patient.
 Passive end-of-range overpressure, or stretching, is
then delivered without pain as a barrier.
 The techniques are always applied in a pain-free
direction and are described as correcting joint
tracking from a positional fault.
 Brian Mulligan of New Zealand originally described
these techniques.
Physiological Movements

 Physiological movements are movements the

patient can do voluntarily (e.g., the classic or
traditional movements, such as flexion,
abduction, and rotation).
 The term osteokinematics is used when these
motions of the bones are described.
Accessory Movements

 Accessory movements are movements in the joint and

surrounding tissues that are necessary for normal ROM but
that cannot be actively performed by the patient.
 Terms that relate to accessory movements are component
motions and joint play.
 Component motions are those motions that accompany active
motion but are not under voluntary control. The term is often used
synonymously with accessory movement.
 For example, motions such as upward rotation of the scapula and rotation
of the clavicle, which occur with shoulder flexion, and rotation of the
fibula, which occurs with ankle motions, are component motions.
 Joint play describes the motions that occur
between the joint surfaces and also the
distensibility or “give” in the joint capsule, which
allows the bones to move.
 The movements are necessary for normal joint
functioning through the ROM and can be
demonstrated passively, but they cannot be
performed actively by the patient.
 The movements include distraction, sliding,
compression, rolling, and spinning of the joint
surfaces.
 The term arthrokinematics is used when these
motions of the bone surfaces within the joint are
described.
Thrust

 Thrust is a high-velocity, short-amplitude

motion such that the patient cannot prevent
the motion.
 The motion is performed at the end of the
pathological limit of the joint and is intended to
alter positional relationships, snap adhesions,
or stimulate joint receptors.
 Pathological limit means the end of the
available ROM when there is restriction.
Manipulation Under
Anesthesia
 Manipulation under anesthesia is a medical
procedure used to restore full ROM by breaking
adhesions around a joint while the patient is
anesthetized.
 The technique may be a rapid thrust or a
passive stretch using physiological or
accessory movements.
Muscle Energy

 Muscle energy techniques use active

contraction of deep muscles that attach near
the joint and whose line of pull can cause the
desired accessory motion.
 The technique requires the therapist to provide
stabilization to the segment on which the distal
aspect of the muscle attaches.
 A command for an isometric contraction of the
muscle is given that causes accessory
movement of the joint.
Indication of Manual Therapy

Pain, Muscle Guarding, and Spasm

 Painful joints, reflex muscle guarding, and muscle
spasm can be treated with gentle joint-play
techniques to stimulate neurophysiological and
mechanical effects.

Neurophysiological Effects
 Small-amplitude oscillatory and distraction
movements are used to stimulate the
mechanoreceptors that may inhibit the transmission
of nociceptive stimuli at the spinal cord or brain stem
levels.
Mechanical Effects
 Small-amplitude distraction or gliding movements of
the joint are used to cause synovial fluid motion,
which is the vehicle for bringing nutrients to the
avascular portions of the articular cartilage (and
intra-articular fibrocartilagewhen present).
 Gentle joint-play techniques help maintain nutrient
exchange and thus prevent the painful and
degenerating effects of stasis when a joint is swollen
or painful and cannot move through the ROM.
Reversible Joint Hypomobility
 Reversible joint hypomobility can be treated with
progressively vigorous joint-play stretching techniques
to elongate hypomobile capsular and ligamentous
connective tissue.
 Sustained or oscillatory stretch forces are used to
distend the shortened tissue mechanically.
Positional Faults/Subluxations
 Malposition of one bony partner with respect to its
opposing surface may result in limited motion or pain.
 This can occur with a traumatic injury, after periods of
immobility, or with muscle imbalances.
 The malpositioning may be perpetuated with maladapted
neuromuscular control across the joint so whenever
attempting active ROM there is faulty tracking of the
joint surfaces resulting in pain or limited motion.
 MWM techniques attempt to realign the bony partners
while the person actively moves the joint through its
ROM.
 Manipulations are used to reposition an obvious
subluxation, such as a pulled elbow or capitate-lunate
subluxation.
Progressive Limitation
 Diseases that progressively limit movement can be
treated with joint-play techniques to maintain available
motion or retard progressive mechanical restrictions.
 The dosage of distraction or glide is dictated by the
patient’s response to treatment and the state of the
disease.
Functional Immobility
 When a patient cannot functionally move a joint for a
period of time, the joint can be treated with nonstretch
gliding or distraction techniques to maintain available
joint play and prevent the degenerating and restricting
effects of immobility.
CONTRAINDICATIONS
AND PRECAUTIONS
The only true contraindications to stretching techniques are
hypermobility, joint effusion, and inflammation.

Hypermobility
 The joints of patients with potential necrosis of the ligaments or
capsule should not be stretched.
 Patients with painful hypermobile joints may benefit from gentle
joint-play techniques if kept within the limits of motion. Stretching
is not done.

Joint Effusion
 There may be joint swelling (effusion) due to trauma or disease.
 Rapid swelling of a joint usually indicates bleeding in the joint and
may occur with trauma or diseases such as hemophilia.
 Medical intervention is required for aspiration of the blood to
minimize its necrotizing effect on the articular cartilage.
 Slow swelling (more than 4 hours) usually indicates serous
effusion (a buildup of excess synovial fluid) or edema in the
joint due to mild trauma, irritation, or a disease such as
arthritis.
 Do not stretch a swollen joint with mobilization or passive
stretching techniques.
 The capsule is already on a stretch by being distended to
accommodate the extra fluid.
 The limited motion is from the extra fluid and muscle response
to pain, not from shortened fibers.
 Gentle oscillating motions that do not stress or stretch the
capsule may help block the transmission of a pain stimulus so
it is not perceived and may also help improve fluid flow while
maintaining available joint play.
 If the patient’s response to gentle techniques results in
increased pain or joint irritability, the techniques were applied
too vigorously or should not have been done with the current
state of pathology.
Inflammation
 Whenever inflammation is present,
stretching increases pain and muscle
guarding and results in greater tissue
damage.
 Gentle oscillating or distraction motions may
temporarily inhibit the pain response.
 Malignancy
 Bone disease detectable on radiographs
 Unhealed fracture (depends on the site of the fracture
and stabilization provided)
 Excessive pain (determine the cause of pain and modify
treatment accordingly)
 Hypermobility in associated joints (associated joints
must be properly stabilized so the mobilization force is
not transmitted to them)
 Total joint replacements (the mechanism of the
replacement is self-limiting, and therefore the
mobilization gliding techniques may be inappropriate)
 Newly formed or weakened connective tissue such as
immediately after injury, surgery, or disuse or when the
patient is taking certain medications such as corticosteroids
(gentle progressive techniques within the tolerance of the
tissue help align the developing fibrils, but forceful
techniques are destructive)
 Systemic connective tissue diseases such as rheumatoid
arthritis, in which the disease weakens the connective
tissue (gentle techniques may benefit restricted tissue, but
forceful techniques may rupture tissue and result in
instabilities)
 Elderly individuals with weakened connective tissue and
diminished circulation (gentle techniques within the
tolerance of the tissue may be beneficial to increase
mobility)
 Rheumatoid collagen necrosis
 Fracture
 Joint ankylosis
 VBI
 Acute inflammatory or infective arthtitis
Relative contra indication
 Osteoporosis
 Pregnancy
 Malignancy
 Hypermobility
 Dizziness
 Neurological signs
 Spondylolisthesis
Principles
 The joint is preferably placed in resting position (loose pack
position).
 The treatment plane must be determined.
 The direction of mobilization must be established using
concave/convex rule.
 Patient and body part must be well supported.
 Patient and therapist must be relax.
 Mobilizing force should be close to therapist’s COG.
 The involved structure must be compared with the normal.
 One joint at a time one movement at a time.
 Stabilise one bone and mobilise other bone.
 Hands should be close to the joint surface.
 Stop if too painful.
 Assess before and after the treatment.