Manual therapy

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Manual therapy is a system of manual diagnostic and therapeutic methods to correct neurological, orthopedic, visceral and other disorders caused by diseases or pathological changes of the spine, joints, muscular or ligament apparatus.
Contradictions for the use of manual therapy are diseases of the spine and joints of extremities in which manual therapeutic treatment gives an accentuated positive effect making it possible to reduce the dose of medical drugs in many cases or completely refuse them. In combination with other remedial measures (physical exercises, massages, correction with position, physiotherapeutic procedures, etc.) manual therapy accelerates the elimination of pathological syndromes, normalization of the functions of the spine and joints of extremities as well as recovery of working capacities of patients.
The purpose of manual therapy is to remove disorders in the biomechanics of the spine and joints of extremities, recover normal mobility of motor segments, joints and the musculoskeletal apparatus as a whole, reconstruct the dynamic stereotype.
It is known that the impaired tone in some groups of muscles causes functional blockades in extremity joints. This restricts the mobility of not only the joint itself but also the muscle, cartilages and ligaments that surround it. Step by step dystrophic changes increase, trophics worsens, which leads to shortening of damaged muscles. Contractures appear in joints, at first these contractures are functional that can be removed by active treatment, but in severe cases they are organic when the joint totally loses its motor functions. To restore barrier functions of the damaged links of the motor system, correct the musculoskeletal imbalance, improve the trophics with further normalization of the motion stereotype mobilization techniques are used.

mitri.az Formation of blockades in the neighbouring segments. This complication is accompanied with increased painfulness in the area of blocked segments, and an unskilled physician can consider this fact as a failure to mobilize the blocked segment. In fact, due to absence of overloading and the vulnerability of the neighbouring segment by means of locking, permitting the blockade in the damaged segment the manipulation impact caused the blockade of the neighbouring segment. Hypermobility of the damaged spinal-disc segment appears when manipulations are frequently repeated, especially when the spine is generally hypermobile. In these cases soft technique or rhythmic mobilization are preferable. Fractures of osseous elements of the skeleton (rib, vertebral appendices, arch of atlas, vertebral body) are not common and appear in case of aggressive interference with the use of a shock, thrusting technique, as well as an extension technique. Of course, reduction of mechanical stability in case of different diseases of the osseous system increases the frequency of pathological fractures.
mitri.az Having emerged as an individual sphere of medicine that includes its techniques of diagnosing, treating and prevention measures, manual therapy has at first been aimed at the unblocking of spinal and other joints blocked as a result of an entrapment of meniscoids, i.e. at the recovery of mobility in the joint. For that purpose articular surfaces are extended to achieve the gaping of the articular crack or displacement of articular surfaces. Then indications to the treatment with this method caused a need to relax muscles, remove muscle spasms in the spine and joints adjacent to the damaged ones. The main methods of manipulation therapy are fixing (“locking”) of the neighboring, often basic, sections for further mobilization of the blocked joint. Then the manipulation itself is performed: from the position of the joint achieved after mobilization at the moment of relaxation of the patient the joint is suddenly unblocked by means of a peculiar thrust. After that, the motion stereotype should be normalized which would prevent recurrence of blockade. It should be taken into account that it is very dangerous to try to treat using manipulation and having no deep knowledge of medicine and special skills. Very often manipulation nuances are not less important than the main action. It is impossible to study manual therapy from books, however elementary methods of manual relaxation can be used by patients on their own. The method includes relaxation of muscles after their volitional toughening without changing the distance between muscle fixation points, i.e. after isometric toughening. The toughened shortened muscle with painful knots is extended to painless limits and the patient is asked to contract it despite the resistance of the physician. After 7–10 seconds of this isometric tension the patient relaxes, and the physician again stretches the same muscle which already stretches more. These exercises should be repeated 4–5 times at a time. If required, the procedures can be performed several days running.
mitri.az Increased painfulness after performed relaxation. It often occurs after a procedure performed extremely actively with great force or in case of repeated exercises. In this case not only muscle relaxation occurs, but also all elements of the musculotendinous apparatus energetically extend, which significantly distorts the functions of the whole system. Here the contractive activity of the muscle significantly suffers. While after correctly performed relaxation the strength of muscles increases by 15-20 %, in these cases it decreases by the same percentage. Increased contractility of a muscle, i.e. its spasm. This undesirable event occurs in case of insufficiently active relaxation that did not cause functional reconstruction of the nervous apparatus, as a result the qualitative reconstruction of the spinal cord apparatus did not occur, and the appeared changes, on the contrary, activated spastic systems. Increased painfulness in the local muscular hardening occurs in case of continuous strain. Correct manipulations weaken the muscles surrounding the damaged section, without their relaxation. In these cases the point where healthy and damaged sections of a muscle meet is a very active zone that is capable of destabilizing the mechanisms of tone and pain control in the spinal cord apparatus. In principle, many joints can be compressed. This method is especially useful in mobilization of spinal joints – the diagnostic method of thrusting palpation can be used as therapeutic. Rhythmic compression of the sacroiliac joint is the most popular. This method is widely used in mobilization of small joints of the hand and foot when compressive efforts are made in reverse directions – “scissors like” movements with the “shear” plane in the joint projection.
mitri.az Increased painfulness. This complication is related with forced relaxation with great efforts. In these cases the shortened ligament is extended not in the place of the largest hardening but at the point where normal and shortened sections meet, i.e. at the place of the least resistance. This complication is often observed when pelvic ligaments are relaxed, when wrong impression appears that efforts greater than it is necessary are required. Procedures are usually performed not every day but with an interval from 1 to 7 days. The point is that muscles and ligaments need some time to “pull together” and fix the achieved position. Relaxation of the ligamentous apparatus is not often a complication of manual therapy, while congenital weakness of ligamentous elements darkens the long-term prognosis with regard to the stability of the therapeutic effect.
mitri.az Position mobilization is the basis of mobilization technique. The technique combines manipulation, rhythmic mobilization and relaxation. The technique is performed comparatively slowly and consists in straining the joint towards the blockade (i.e. towards the restriction) to the functional barrier and in maintaining this effort during one or more minutes. As a rule, tension in the segment is accompanied with extension of muscles in the area of joints. Position mobilization is often accompanied with consensual muscle tension that occurs when sight, breathing change, neighbouring muscle activate. As a result, three important processes take place during mobilization:
  • Spatial change in the surfaces of joints as a result of confrontation.
  • Relaxation of the stretched muscles of the joint.
  • Rhythmic slow mobilization of the joint due to the change of its position in time with rhythmic reactions of muscles.
As a result of position mobilization the boundaries of the general anatomic and functional barriers of different tissues extend recovering the functional reserve. Position mobilization can be used not only for joints, but also for all other elements of the motor system. As it has been already mentioned, insistent delicacy as a therapeutic need is fully realized in this technique.
A masseur is stretching a woman's arm This technique has a lot of advantages over manipulation thrusting. They are as follows: safety, easiness, painlessness of the procedure, sufficient effectiveness. Its negative side is impossibility to affect muscles and consequently to correct the changed dynamic stereotype of the local and regional muscles. As a result of rhythmic mobilization the entrapped meniscoid has an opportunity to migrate from the bed and take the previous, normal position. There is stretching, rotating and compressive rhythmic mobilization. Stretching mobilization consists in stretching articular surfaces. It is often used for mobilization of large joints, the whole spinal cord or its sections. The main requirement for rhythmic stretching is to maintain preliminary tension (resilient bearing) even when the stretching effort stops. The effort should not be strong, like all techniques in manual therapy, it should increase when stretching and decrease when returning to the level of preliminary tension. Rhythmic rotating movements are rather useful in case of mobilization of spinal joints in the position of the universal mobilization technique. This technique can also be useful in mobilization of some large joints such as knee, shoulder, elbow joints. Rhythmic movements are performed by combining the fixation of one segment of an extremity (initial or final) and rhythmic rotation of the other section towards the restriction. Of course, maintenance of the preliminary tension is a compulsory condition of the therapeutic technique. The frequency of rotations is 1–2 rotation per second. Rhythmic compression is used for joints when stretching or rotating cannot be used for some reason (strong tension in the surrounding muscles, anatomic peculiarities of the joints).
mitri.az The technique consists in combination of short-term (5-10 seconds) activity of minimum intensity and passive extension of the muscle during further 5–10 seconds. These combinations are repeated 3–6 times. As a result, the muscle firmly relaxes and initial painfulness disappears. The main prerequisites of skeletal muscle relaxation: the active effort of the patient must be of minimum intensity and rather short-term. An effort of medium or especially large intensity causes absolutely other types of changes in muscles; as a result, muscles do not relax. Large time intervals tire out muscles; a too short effort cannot cause spatial reconstructions of the contractive substrate in a muscle which is inefficient from therapeutic point of view. It is considered that the technique of this relaxation is a comparatively new technical version of manual therapy. The apparent easiness of this recommendation is often violated when efforts of medium and large intensity are used, which does not allow achieve relaxation and pain relief of muscles. The main recommendations for skeletal muscle relaxation are as follows. Active resistance of the patient (activity) can be replaced with muscle tension that appears as concurrent movement during an inhale. This phenomenon is observed in basic groups most of all and in terminal muscles least of all. Muscle activity is inferior by its expressiveness to the activity of volitional tension, while the achievable therapeutic effect is the same. During a break passive extension of the muscle is performed until slight painfulness. In this position the muscle is fixed with strain in order to repeat with another initial length.
Historically, manipulations with joints are considered to be the basis of manual therapy. Masterly performed manipulations with a distinctive sound phenomenon were and, unfortunately, are still allegedly considered to be a sign of specialist’s skillfulness. Increased mobility, pain relief and muscle relaxation that appear after manipulations makes it possible for this type of therapy to hold the first place among effective techniques even now. It was considered that manipulation removes joint subluxations, makes it possible to set a dropped disc, break osseous tectums. Survivability of these ideas is surprising. These wrong ideas became popular because of two facts: a striking therapeutic effect during a minimum time interval (a second or a minute) and a sound phenomenon (crunching). The truth about the effect of manipulations has now been found. Increased mobility, relaxation of periarthric muscles and painlessness in the area of the joint occur as a result of meniscus release which involves relaxation of muscles that fixed the blockade. It is known that quick extension of a muscle leads to activation of muscle receptors with further reflectory muscle contraction. No matter how attractive this manipulation is, its significance should not be exaggerated. Repeated manipulations cause hypermobility in the joint and susceptibility to repeated blockades, which makes patients repeat the treatment again. Of course, this psychic dependence cannot be considered as favourable therapeutic tactics.
mitri.az Tactile evaluation of the state of joints, muscular tissue, skin is the basis of a functional diagnosis. Numerous techniques used in different fields of medicine, have their peculiarities in manual therapy. The main peculiarity is in the creation of so-called preliminary tension required for further basic palpation and its maintenance during the whole investigation. It is a very important condition that if neglected, especially by beginners, results in diagnostic mistakes. Maintenance of the preliminary tension is also a prerequisite for performing technical therapeutic methods. Preliminary tension consists in creation of passive tension in the investigated tissue, in achievement of a passive limit of movements, a resilient barrier. Further an increase (reserve) in the function to the pathological limit of movements, to the rigid barrier is evaluated with additional efforts. The establishment of this reserve is the main component in the evaluation of joint behaviour, muscle and ligament contraction, skin stretchability. Palpation is performed when the patient lies with his face up or down, or sits (to investigate muscles of the upper arm and neck). Naturally, general comfort is a prerequisite. The size of palpating effort should not be great. First of all, this increases the general tone of the muscle making it difficult to determine the strained section; secondly, when the pressure made by a finger is great the accuracy of the investigation does not increase. Patient’s moaning is a sign of inaccurate investigation rather than an accurate diagnosis. Therefore, vibration irritation technique should not be used to determine the area where the pain shoots up. Simple running along the skin with a hand can be a reference point for making a diagnosis. The objective of the investigation is to determine the general consistence of muscles, to get acquainted with it, which is useful in eliminating estimated reaction of tension. Summarizing this section, typical mistakes of palpation should be mentioned that can be caused by impartial and biased reasons. An important mistake caused by the object of palpation is the so-called palpatory illusion. It consists in the fact that in case of deep palpation of osseous formations of, for example, the ishial tuberosity the uniformity of its evaluation will significantly depend on the state of soft tissues, i.e. on the diagnosed medium. If it is hardened or strongly irritates in response to a mechanical irritant, the palpating hand will naturally feel additional overloading. The investigator will assess this as an increase in the size of the underlying bone, while from an unbiased point of view asymmetric location of testing fingers will be registered. Another type of mistakes is related with incorrect interpretation of obtained data when performing a layer-by-layer investigation. In these cases hardening, scars of superficial tissues can be taken for changes in deep structures. To avoid this type of mistakes a layer-by-layer displacement of palpated tissues should be made. Mistakes that depend on the investigator are mainly caused by incorrect position of the hand. The object of manual therapy is the restriction of the functional reserve of the joint. Naturally, the estimation of its size is important both at the stage of diagnosing and after treatment. It is unacceptable to examine a patient through clothes even the thinnest no matter what the arguments are. The general rules include delicacy, warm hands, concentration of the physician, physical and mental calmness of both the physician and the patient. There is no need to comment these rules.
mitri.az Excessive extension of manual therapy opportunities, like in any other treatment method, inevitably leading to its discredit, should be disapproved. To complete this idea it is necessary to determine the position with regard to indicators. Indicators in manual therapy are determined by the performer of therapeutic techniques, and not by the pathological process. In case of the severest organic pathology of the motor system a thoughtful physician with “smart” hands will identify a list of therapeutic techniques to mitigate the state of the patient by eliminating the functional pathology, while a physician with opposite qualities can cause the most serious complications in case of a simple clinical situation. This article will focus on complications that can be caused by various circumstances. Complications due to actions of physicians mainly occur because of an incorrect estimation of the pathological process and application of inadequate techniques in a specific situation. Not comprehensively examined patients, absence of roentgenograms and general clinical information put a physician into a difficult situation. Information deficiency can only activate fantasies, rather than an analysis of certain factors. It is apparent that a mistake in the diagnosis is accompanied with a mistake in the treatment. There can be objections to this, but it is an assertion. They are usually similar: there are so many therapeutic techniques, some of them being sometimes very energetic, but complications occur rather rarely. The answer is the following: not all complications are registered; there is no further information; the reserve capabilities of the motor system in some way eliminate the results of faulty or numerous therapeutic techniques.
  • Intervertebral disc hernia;
  • Pain that usually appears in case of spinal osteochondrosis;
  • Arthroses;
  • Intercostal neuralgias;
  • Permanent giddiness;
  • Regular head ache;
  • Postural disorders;
  • Muscle pain and sense of strong tension;
  • Impaired mobility of some internal organs;
  • Rehabilitation after traumas or diseases;
  • Chronic tiredness and too frequent stresses.
  • Tumours of the spine, spinal cord and cerebrum, joints, extremities, internal organs;
  • Specific and non-specific infectious processes in the spine and joints (tubecular spondylitis, osteomyelitis, active form of rheumatism);
  • Acute and subacute inflammatory diseases of joints;
  • Acute and subacute inflammatory diseases of the spinal cord and its meninges;
  • Recent traumatic injuries of the spine and joints;
  • State after surgeries on the spine;
  • Bechterew’s disease;
  • Fragments of sequestrated disc hernia (caused by a trauma);
  • Disc myelopathies;
  • Any factors that cause abrupt relaxation of vessels with an avalanche-like increase of permeability of the vessel wall and, as a result, can bleed in the brain (infections, alcohol intoxication, increased blood pressure over 180 mm Hg);
  • Acute diseases of the gastrointestinal tract, thoracic organs, acute disorders of the cerebral and coronary circulation (stroke, infarction, bleeding, acute inflammation, infections, etc.).
Relative contraindications for manual therapy:
  • Vertebrogenic syndromes of spinal osteochondrosis in an acute phase;
  • Stage III instability of spinal segments (spondylolisthesis of more than ⅓ to the underlying vertebra, spondylolis spondylolisthesis). Accentuated abnormal development (nonclosure of vertebral arches, sacralization, lumbolization);
  • Forestier disease (diffuse idiopathic skeletal hyperostosis);
  • Consolidated fractures of the spine and traumatic injuries of intervertebral discs before the formation of osteotylus (6 months on the average);
  • Stage III—IV arthrosis;
  • Congenital abnormal development;
  • Intercurrent diseases;
  • Pregnancy of more than 12 weeks;
  • Osseous osteoporosis.
Nowadays there are quite a lot of myths about manual therapy, however they are not proven and contradict the reality.
  1. Manual therapy is a massage. Manual therapy is a hand activity performed on the osseous skeleton including on the spine and large joints, while according to his/her expertise a massage specialist has the right to work only with soft tissues.
  2. It is not required for a manual therapist to have a higher education degree in medicine. In fact, to be a real professional a manual physician must have the following background: a medical category; relevant courses; advanced training experience; primary specialty in manual therapy.
  3. You should feel pain during a manual therapy session. It is not true. Yes, it is difficult to find enjoyment in the process; however manual therapy is not accompanied with strong pain. If the specialist has a long standing experience, a patient can feel “slight” pain only if he/she are not willing or simply cannot relax during the session. It should be noted that it is fear that makes people feel constrained. A physician will never hurt. People who can relax will even be able to find some enjoyment in the procedures (everything depends on your mood).
  4. A therapist can recover patient’s health almost in ten minutes. It is a misconception. Treatment by professional physicians is performed in courses and can include five to ten sessions on the average. Only systematic treatment performed in courses can give an effective and accurate correction of the damaged spine. If there is anyone who promises you to correct your spine during one procedure, know that you visited a bone-setter and not a manual therapist. You should not entrust your health to a bone-setter.
  5. Manual therapy methods cause a lot of complications. Nowadays many manual therapists offer their services, however not each of them can really treat. Work of a really professional manual therapist gives no complications (masters use soft techniques).
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