Download Principles of Manual Medicine

Jack Dolbin, DC CSCS
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Much of this module is the result of study
references, books, tapes and personal
conversations with Dr. Philip Greenman, DO.
His work has guided me and given me a
rationale for the diagnosis, treatment and
now teaching of manual medicine for
athletes.
I strongly recommend his work as the gold
standard for any manual medicine
intervention.
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When properly utilized, manipulative
procedures have been noted to reduce pain,
Increase the level of wellness, and in helping
the patient with a myriad of disease
processes.
Philip Greenman DO, Professor of
Biomechanics
Michigan State University School of
Osteopathy Medicine
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The goal of manual medicine is to restore
maximal, pain free movement of the
musculoskeletal system in postural balance.
Dvorak J, Dvorak V,Schneider W : Manual
Medicine 1984,
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1. Holistic man
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2. Neurologic man
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3. Circulatory man
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4. Energy-expending man
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5. Self-regulating man
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The musculoskeletal system comprises most
of the human skeleton and alterations within
it influence the rest of the human organism.
Our role as physicians is to treat patients and
not disease.
Deep Fascia
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Most highly developed nervous system in the
animal kingdom.
All functions of the human body are under some
form of neurologic control.
Control of all glandular and vascular activity is
under the control of the ANS.
Neuroendocrine Control: Substance P,
endorphines, enkephalines, and
neurotransmitters can be altered by
biomechanical alterations
Alterations in neurothropin transmission can be
detrimental to the health of target cells.
Formed by lower motor neurons in the lateral
horns of C2-C4
Ascends through the foramen magnum,
receives fibers from the nucleus ambiguous
and decends along the jugular foramen.
Sends branches to the Vagus Nerve
Has SVE and GSE. Thoracic branches matched
to vagus innervation of the embryonic heart.
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Anything that interfered with with
sympathetic autonomic nervous system
outflow, segmentally mediated, can influence
vasomotor tone to the target end organ.
Maximal function of the musculoskeletal is
important to the efficiency of the circulatory
system and maintainance of a normal cellular
milieu.
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Restriction of one major joint in the lower
extremity increase the energy expenditure in
walking by 40%, two major joints in the same
extremity 300%.
Multiple minor restriction of movement,
especially in the lower extremity gait can have
a detrimental effect on the total body
function
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The goal of the physician should be to
enhance all the body’s self regulating
mechanisms to assist in the recovery from
disease. ( injury).
One in seven hospital days are the result of
adverse reactions to pharmaceuticals.
Anything placed with in the body alter the
self regulating mechanism.
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Primary goal is to determine the specific
spinal motion segment that is dysfunctional,
determine the direction of altered motion,
and determine the tissue involved in the
restrictive motion.
Primary emphysis is placed on motion loss
and its characteristics
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Directed toward restoring maximal motion to
all joints, symmetry of length and strength to
all muscles and ligaments, and symmetry of
tension within fascial elements throughout
the body.
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Maximum function in postural balance
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Top down or bottom up.
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Asymmetry
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Range of motion
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Tissue texture
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Pelvic unleveling: Effect on lower extremity
function. Shoulder function.
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Scapular Winging:
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Anterior Shoulder posture: TOS, entrapment
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Pronation
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1. Range of movement
2. Quality of movement
3. End feel
In the spine: Goal is to determine which
specific vertebra is dysfunctional
Which joint within that segment is
dysfunctional
The direction of altered motion
Tissue involved in the restricted movement.
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Passive: note end feel. Hard or mushy
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Active: Neuromuscular Control
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Motion loss and its characteristics are more
important diagnostic criterion that the
presence of pain and the provocation of pain
by movement.
Greenman: Michigan State University School
of Osteopathic Medicine.
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The most important element in the postural
model has been the restoration of maximum
pelvic mechanics in the walking cycle.
The Pelvis from below to above must be
considered to achieve the symmetrical
movement.
Pelvis is the cornerstone
Shoulder Injuries
Hamstring strains
Knee, ankle, foot injuries
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Check Pelvic leveling in the standing position.
If unlevel: does it level in the sitting position.
If so check leg length. Look for structural or
functional short leg.
If functional check SI joints and pronation.
If Structural: broken leg or past injuries.
Equestrian Illustration: Broken Femur leading
to shoulder entrapment.
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Spasm
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Contracture: Hypertonicity
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Shortening: Chronic adaptation
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Adhesions: Scar Tissue
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Temperature: Inflammation
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Alteration in the characteristics of the soft
tissues of the musculoskeletal system.
Skin
Fascia
Muscle
Ligament
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Most tissue texture abnormalities result from
altered nervous system function with
increased alpha motor neuron activity
maintaining increased muscular hypertonicity
and altered sympathetic nervous system
function.
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Lateral chain ganglia in the thoracic region
are bound by the deep fascia to the posterior
chest wall and overlie the rib heads.
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It would seem reasonable to attempt to
reduce aberrant afferent stimulation to
hyperirritable sections of the sympathetic
nervous system to reduce hyperactivity to the
target end organs.
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The physiological process where cells sense
and respond to mechanical loads.
Various forms of exercise and or movement
prescription promote repair and remodeling
of tendon, muscle, articular cartilage and
bone.
Mechanotransduction: Maintains normal
musculoskeletal structure in the absence of
injury. Homeostasis
Mechanotherapy: Treatment of injuries using
exercise prescription or manual therapy
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The process where the body converts
mechanical loading into cellular response.
Three phases:
A. Mechanicalcoupling: Trigger
B. Cell-Cell communication:communication
throughout a tissue to distribuite the loading
message.
C. Effector response:Response at the cellular
level to effect the response that will produce
the necessary materials to correct alignment.
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Refers to a physical load causing physical
perturbations to cells that make up tissue.
Key is the direct or indirect perturbations of
the of the cell which is transformed into
chemical signals both within and among the
cells.
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Tendon:Up regulation of IGF-I and cytokines
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Associated with cellular proliferation and
remodeling within the tendon.
Tendons can respond favorably to controlled
loading after an injury.
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Highly responsive to changes in functional
demands through the modulation of load
induced pathways.
Overload: Upregulation of MGF
(mechanogrowth factors)
MGF leads to Muscle hypertrophy
Scar stabilizes-controlled load
Leads to faster more complete regeneration
and minimization of atrophy.
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Populated by mechanoreceptive cells:
Chrondrocytes.
Studies: Alfredson and Lorentzon showed
that cartilage under continuous passive
motion healed much better and faster than
those without CPM.
76% vs. 53%
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Doing the same thing over and over and
expecting a different result.
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The best available evidence from valid peer
reviewed studies combined with clinical
experience to develop a treatment plan with
an expected outcome.
A. Pubmed
B. 34 years of clinical experience
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Weak stimuli increases physiological activity
while strong stimuli inhibits or abolishes
physiological activity.
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Gentle and precise manipulation elicits an
internal sensory feed back response designed
to stimulate the body’s self correcting
mechanism.
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Muscle Energy
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Impulse Adjusting
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High Velosity/ Low amplitude
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Indirect Function technique: Sherringtons Law
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Myofascial Release: Cyriax Crossfiber
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Balance and Hold
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Mobilize Scar tissue
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Breakdown Adhesions
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Allows muscle to broaden
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Controlled Inflammation: Prolotherapy research
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Pain modulation
1. Right Location
2. Right amount of pressure
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During first 24-48 hours. Light mobilizing
maximum of 5 minutes.( usually less)
After 48 hours 5-15 minutes
Muscle Injury: Across the relaxed muscle to
facilitate broadening. Followed by eccentric
exercise or Faradic.
Tendon/Ligament Injuries: Across the
ligament in an elongated position.
Every other day maximum.
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Limb is moved into the restrictive barrier.
Patient actively attempts to move the limb
with the Physician resisting the movement
Hold 5-7 seconds, 3-5 times. Followed by
inspiration/expiration.
As tissue releases move to next barrier
Followed by articular correction if necessary
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Isometric Contraction of shortened muscle.
Improves resting length
Increase Joint movement
Improves overall range of motion.
Inhalation/Exhalation as activating force
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Percussion cadencee: Seguin 1838
Manual Vibrations: Kellgren mid 1900
Janse, Wells, Howser 1947
Repetitive Thrusts: Maitland 1964
Fuhr: Activator
Colluca-Keller: Impulse Adjusting
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By Stimulating the Golgi Tendon organs the
shortened muscle lengthens. Myotendinous
Junction.
Pacinian Corpusles: Stimulated when skin is
stimulated rapidly. Respond to high velocity
changes in joint position.
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Reset Neurological bed. Bone and muscle belly
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Activates mechanoreceptors:
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Can be alternative treatment to myofascial
release.
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Balanced ligamentous tension/ Ligamentous
articular strain Techniques
All joints are balanced ligamentous articular
mechanisms.
The ligaments provide propriceptive
information that guides the muscular
response for positioning the joint and the
ligaments themselves guide the motion of
the articular compoments
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Position the joint so all forces within the
articular mechanism converge on one specific
point. This point becomes the fulcrum around
which shift will occur
Use the respiratory mechanism to articulate
the joint.
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Patients somatic dysfunction is treated by
placing the restrictive barrier in a passive
position.
Contact the motor point where the nerve
pierces the fascia and enters the muscle belly.
Hold using respiratory mechanism until
release is felt.
Mobilizes fixated Joints
Improves Range of Motion in Dysfunctional
segmments.
Activates mechanoreceptor in Joints: Pacinian
and Ruffini corpucles.
Allows for normalization of afferent
proprioception
Effect on Visceral Function ??
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Gaining increased attention within the health
care community.
Recent studies at Harvard and U of Vermont
School of Medicine on Cell-Cell
communication within the deep fascial
elements.
Warren Hammer: Soft Tissue the key to the
outcomes we have seen over the years.
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A bodywide communication system
Involved in myofascial force transmission
Fascia is a sensory organ and is relevant in
proprioceptive and nociceptive function and
relevant in shoulder and low back pain and
dysfunction.
History: 7 Point History Minimum
Observation of injured part
Inspection of Injured part
Examination: Palpation, Range of Motion
Provocative tests.
Evaluation of motion deficits in the kinetic
chain.
Treatment: Manual Medicine Prescription
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Evaluate the effect of your treatment
A. Did the muscles get strong
B. Is their gait better
C. Can they lift their arms more easily
D. Can they bend forward or backward with
less pain.
A successful input/adjustment changes
function and breaks the vicious cycle.
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Getting the restricted joint released
Releasing tight muscles
Deep fascial work to wake up the
neuromuscular system
Functional rehab to retrain muscles
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Always look for immediate functional change
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Have a purpose in your treatment. Not
cookbook therapy
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Have a reevaluation process to assess the
effectiveness of your treatment
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A. If not responding do a reeval and change
plan.
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Transition to active care: Usually concurrent
with your manual therapy
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Volume: Maximum of 30-35 patients per day.
A goal of developing a volume based practice
is antithetical to the practice of manual
medicine