Principles of Manual Medicine

Jack Dolbin, DC CSCS

Dr. Philip Greenman, DO, FAAO

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.

References

Thirty one dollar seminar

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

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,

Goal of manual medicine

1. Holistic man

2. Neurologic man

3. Circulatory man

4. Energy-expending man

5. Self-regulating man

Role of the musculoskeletal System in Health and Disease

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

Holistic Man

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.

Neurologic Man

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.

Spinal Accessory Nerve

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.

Circulatory man

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

Energy expending man

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.

Self-Regulating Man

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

Manipulatible Lesion

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.

Maximum function in postural balance

Top down or bottom up.

Manual Medicine Treatment

In manual medicine it is just as important to know

the nature, location and type of somatic

dysfunction before a therapeutic intervention

is prescribed.

Asymmetry

Range of motion

Tissue texture

A R T

Pelvic unleveling: Effect on lower extremity function. Shoulder function.

Scapular Winging:

Anterior Shoulder posture: TOS, entrapment

Pronation

Asymetry

Pelvic Unleveling

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.

Range of Motion

Passive: note end feel. Hard or mushy

Active: Neuromuscular Control

Range of Motion

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.

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

Greenman

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.

Evaluation of symmetry

Spasm

Contracture: Hypertonicity

Shortening: Chronic adaptation

Adhesions: Scar Tissue

Temperature: Inflammation

Tissue Texture

Alteration in the characteristics of the soft tissues of the musculoskeletal system.

Skin Fascia Muscle Ligament

Tissue Texture

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.

Lateral chain ganglia in the thoracic region are bound by the deep fascia to the posterior chest wall and overlie the rib heads.

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.

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

Mechanotherapy

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.

Mechanotherapy

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.

Mechanocoupling

Tendon:Up regulation of IGF-I and cytokines . Associated with cellular proliferation and

remodeling within the tendon.

Tendons can respond favorably to controlled loading after an injury.

Clinical Studies

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.

Muscles

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%

Cartilage

Doing the same thing over and over and expecting a different result.

Einstein on Insanity

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

Evidence Based Protocols

Weak stimuli increases physiological activity while strong stimuli inhibits or abolishes physiological activity.

Arnt-Schultz Principle

Gentle and precise manipulation elicits an internal sensory feed back response designed to stimulate the body’s self correcting mechanism.

Proprioceptive System

Muscle Energy

Impulse Adjusting

High Velosity/ Low amplitude

Indirect Function technique: Sherringtons Law

Myofascial Release: Cyriax Crossfiber

Balance and Hold

Techniques

Mobilize Scar tissue

Breakdown Adhesions

Allows muscle to broaden

Controlled Inflammation: Prolotherapy research

Pain modulation 1. Right Location 2. Right amount of pressure

Cyriax Crossfiber

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.

Cyriax: Continue

Lateral Ankle Sprain

Rotator Cuff Tendonitis

Muscle Energy Technique 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

Isometric Contraction of shortened muscle. Improves resting length Increase Joint movement Improves overall range of motion. Inhalation/Exhalation as activating force

Muscle energy

Achilles Tendon Injury

Quadraceps Injury

Percussion cadencee: Seguin 1838 Manual Vibrations: Kellgren mid 1900 Janse, Wells, Howser 1947 Repetitive Thrusts: Maitland 1964 Fuhr: Activator Colluca-Keller: Impulse Adjusting

Impulse Adjusting

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.

Reset Neurological bed. Bone and muscle belly

Activates mechanoreceptors:

Can be alternative treatment to myofascial release.

Impulse Adjusting

Pacinian Corpusles

Sunderland Balanced ligamentous tension/ Ligamentous

articular strain Techniques1. All joints are balanced ligamentous

articular mechanisms.2. 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

BLT/LAS 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.

Strain/Counterstrain 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 JointsImproves Range of Motion in Dysfunctional

segmments.Activates mechanoreceptor in Joints: Pacinian

and Ruffini corpucles.Allows for normalization of afferent

proprioceptionEffect on Visceral Function ??

Joint Mobilization/Manipulation

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.

Myofascial Release

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.

Deep Fascia

History: 7 Point History MinimumObservation of injured partInspection of Injured partExamination: Palpation, Range of MotionProvocative tests.Evaluation of motion deficits in the kinetic

chain.

Treatment: Manual Medicine Prescription

Procedure For Sports Injury

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.

Post-Check

Getting the restricted joint released Releasing tight muscles Deep fascial work to wake up the

neuromuscular system Functional rehab to retrain muscles

Always look for immediate functional change

Break the inhibition cycle.

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 a reeval and change plan.

Transition to active care: Usually concurrent with your manual therapy

Volume: Maximum of 30-35 patients per day.

A goal of developing a volume based practice is antithetical to the practice of manual medicine

A Must Read !!

Not everyone gets well