Vertebral manipulation (2)

Spine Mobilization and Manipulation

PreparedBy

Mohammad Bin Afsar JanBSPT, MSPT,GCRS,MAPA,MNPA

Mobilization & Manipulation– It’s a skilled passive movement of joint and related soft tissues applied

at varying speed and amplitudes– Manipulation and mobilization are both used as manual therapy

technique– Manipulation is a high velocity, low amplitude therapeutic movement– Divided in to four grades I,II,III,IV

• Grade I,II are used for neurophysiological effects• Grade III,IV are used for neurophysiological effect and to restore

mobility

Mobilization & Manipulation – Oscillations are graded as

• Grade 1: is a small amplitude movement near the starting position of the range

• Grade 2: is a large amplitude movement which carries well in to range

• Grade 3: is also large amplitude movement but one that does move in to stiffness and muscle spasm

• Grade 4: is a small amplitude movement stretching in to stiffness or muscle spasm

Isometric manipulation (MET)

• Isometric manipulation (MET)– Active movement against specific counter force, direction

holding in controlled position– Similar to hold –relax-stretch technique– Joint is positioned to point of barrier– Isometric manipulation uses local muscles to stretch the joint

at the desired segment and reflexively inhibit the tone for manipulation

Effects of manipulation– Mechanical effect

– Restoration of tissue extensibility– Range of motion of hypomobile joint

• Connective tissues are made of collagen and elastin fibers• tissue's that transmit load i.e. tendons or restrain joint

displacement i.e. ligament/ joint capsule - framework is almost exclusively collagen

• if elasticity is needed i.e. ligamentum flavum - the tissue is made up of elastin

Effects of manipulation• prolonged immobilization results in loss of extracellular molecules

and water in the ground substance• Gradual increase in load/stress elongates tissue

– Toe phase• initial elongation in the tissue occurs with low load and is created

by the straightening of the collagen crimp or waviness of the fibers

– Elastic phase• Once the fibers are straightened and oriented in the direction of

the stress, an increase in load is needed to create a proportional lengthening of the tissue

Effects of manipulation• if a stretch is applied to a tissue with just enough force to elongate

the tissue into the elastic phase, the tissue returns to its original length once the stretch is released without producing a long-term increase in tissue length

– Plastic phase• further increase in intensity of load over time results in micro

failure of collagen • when the load is removed, a proportional increase in tissue resting

length remains• plastic phase must be reached with stretching/mobilizing to create

a long-lasting increase in length of connective tissue

Effects of manipulation– Creep phase

• increase in strain over time reults in progressive failure of collagen bundles

• tissue continues to elongate without needing an increased load• Further stress causes tensile mechanical failure or rupture of the

tissue– For permanent tissue elongation- load should reach the plastic phase– repetition of stretching in elastic range of the tissue- connective tissue

gets stronger and more resistant to microfailure

Neurophysiological Effects of Manipulation

– neurophysiological effect of manipulation result in reduction of pain and influence muscle tone and motor control

– type I mechanoreceptors provide afferent input to the central nervous system regarding static joint position and increase their rate of firing in response to movement

– type II mechanoreceptors remain inactive as long as joints are immobile (when joints are moved actively or passively, they emit brief bursts of impulses)


– type I and II mechanoreceptors are numerous in cervical facet joints/ muscle spindles then thoracic and lumbar spine

– PAG plays an important integrative role for behavioral responses to pain, stress, and other stimuli by coordinating responses of a number of systems, including the nocioceptive system, autonomic nerrvous system, and motor system

– Type I and II mechanoreceptors from joints and muscles project to the PAG

– postmanipulation sympathetic response combined with analgesia


– studies support the concept that manual therapy procedures can produce a hypoalgesic effect both in healthy subjects and patients

– sympathoexcitatory response and the hypoalgesic effect is both local and systemic

– mechanism for the neurophysiological effects of manipulation lies in stimulation of descending pain inhibitory systems of the central nervous system projecting from the midbrain to the spinal cord


– spinal manipulation can inhibit muscle tone, increase muscle tone, or enhance muscle performance

– muscle tone inhibition occurs with a strong end range stretch of a joint from firing type III joint mechanoreceptors- create a reflexive inhibition of the local muscle tone of the muscles overlying the joint

– Speculation also exists that spinal manipulation can increase muscle strength

Muscle Energy Technique– isometric manipulation (MET) helps with treatment of joint

hypomobility– isometric manipulation, similar to a hold relax stretch technique,

causes the golgi tendon organ to fire, which inhibits the antagonistic movement pattern to allow a greater degree of movement into the agonist movement pattern

– isometric contraction of the local muscles attached to the targeted spinal facet joint applies a stretch to the joint capsule or corrects slight positional faults by either pulling directly on the joint capsule or moving the adjacent bone

Psychological Effects– effect of touch and reassurance from a medical professional can have

powerful effects on easing the patient's fear and anxiety, which can translate into reduced pain and disability

audible joint ‘POP’– Certain amount of tension result in joint separation with a ‘POP’– partial vacuum occupied by water vapor and blood gases occurs under

reduced pressure– joint surfaces must be close to give the correct preloadding conditions

for cavitation to occur– beneficial effects of manipulation do not appear to be dependent on

the production of a joint sound

Clinical decision making in use of spinal manipulation

– Hypomobile and reactive joint- use adequate depth and force to stretch the joint, but less vigorous techniques (grades I and II) may precede the stretch manipulation procedure to first attempt to inhibit pain

– Thrust technique- successful because speed of technique can proceed the muscle guarding reaction, and if successful, pain reduction and muscle inhibition result at the targeted spinal segment

– Hypermobile joint- stabilization exercises/grade III or IV manipulation techniques may be used at hypomobile regions above or below the hypermobile spinal segment

– PA manipulation forces directed to the spine are less localized but max at the segment applied

– force applied at L2 or Ll, the three most cranial lumbar segments (Ll-L2, L2-L3, and L3-L4) moved toward extension, and the two most caudal segments (L4-L5 and L5-S1) moved toward flexion

– The magnitude of extension motion was greatest at the targeted segment

– if a particular spinal level is painful with PA force application, oscillatory techniques can be applied to adjacent spinal levels to induce some motion at the painful segment

– If mechanical effects are desired - greatest extension movement can be applied by mobilizing at the targeted stiff segment

– If passive motion is contraindicated at a spinal level i.e. recent lumbar fusion- PA glides should not be used at the adjacent spinal segments

– Clinicians should never rely on the results of one assessment to make a clinical decision

– With clinical situations in which the research evidence is not clear, use of a biomechanical impairment-based approach is the foundation of physical therapy treatment of musculoskeletal disorders

– An impairment approach can guide clinical decision making where specific physical impairments i.e. joint stiffness, joint hypermobility, muscle weakness, or tightness are identified

• Principles of Techniques– Learn to sense or feel movement – Physiotherapist body should produce movement– Learn to modify skill– Position joint in mid range between flexion and extension– Compare oscillations to the adjacent joint

– Rhythm• Varies from smooth gentle techniques to sharp staccato

movement or to a sustained position without any oscillation at all• Depends on the objective of technique• Pressure on is always faster even if only fractionally except

– pain is experienced as a consequence of movement in a releasing direction

– When spinous process is abnormally deep set and painful– technique is used as slowly increasing sustained pressure into

either muscle spasm or strong resistance, when the pain provoked by the pressure is quite intense

• When dealing with pain – oscillations should be smooth and even– Pressure-on should be equal to pressure-off– Amplitude of movement must be as large as symptom

response allow– Greater the pain slow and smooth should be movement– Movements can then be altered by increasing amplitude,

moving in to discomfort, increasing speed maintaining smoothness

– When spasms accompany pain then movement must be sustained rather oscillation and stay until spasms release and may take 20 sec to 1 min

– Longer it takes to provoke symptom at the limit of range, longer treatment technique should sustain

– Speed of oscillation should be around 2 oscillation per second– A sudden movement at the limit of range is indicated when

no further improvement is experienced– Manipulating specific joint may follow if there is painless stiff

joint not improving with mobs– If pain radiates on a technique then be careful with amplitude

and assess after 24 hrs

– Duration and frequency of movement• First day mobs should be less• Give warning for increase in symptoms• Second day treatment depends on reaction to first treatment –

more can be done if symptoms reduce however there is always an optimum level i.e 3-4 mobilization per session approx 30 sec each

• Continue with whatever medication or routine patient is in• When no more improvement is gaining then give gap for 7-14 days

• If mobilization is used successfully then there should be marked improvement within 4-5 days

• If not much improvement observed then manipulation is tried• Good break should be given between manipulations• Stiff joints should first be mobilized and then manipulated

Practical Session

Health & Medicine

Vertebral manipulation (2)