Download Principles of Manual Medicine

Jack Dolbin, DC CSCS
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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 Greeman 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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Holistic man
Neurologic man
Circulatory man
Energy-expending man
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.
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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: Substabnce P,
endorphines, enkephalines, and
neurotransmitters can be altered by
biomechanical alterations
Alterations in neurothropin transmission can be
detrimental to the health of target cells.
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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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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
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Pronation
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Passive: note end feel. Hard or mushy
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Active: Neuromuscular Control
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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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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.
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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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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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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Alteration in the characteristics of the soft
tissues of the musculoskeletal system.
Skin
Fascia
Muscle
Ligament
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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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Mobilize Scar tissue
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Breakdown Adhesions
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Allows muscle to broaden
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Controlled Imflammation
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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
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Isometric Contraction of shortened muscle.
Improves resting length
Increase Joint movement
Improves overall range of motion.
3-5 repetitions 5-7 seconds.
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.
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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: Opinion
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 ??
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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Have a purpose in your treatment. Not
cookbook therapy
Have a reevaluation process to assess the
effectiveness of your treatment
A. If not responding do revel and change
plan.
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