History of Manual Therapy and Arthrology


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A brief history of manual therapy followed by a review of the classification of joints.

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  • First recorded description and illustration of manipulation and traction techniques Wrote 3 works including ‘setting joints by leverage’
  • Famous Italian surgeon Quoted Hippocrates in many of his works
  • Law of the Artery
  • Law of the Nerve Most modern chiropractors mix techniques and include modern physical therapy rehabilitation techniques In many states they can state that the perform physical therapy but can not claim to be PTs
  • arthrokinematics
  • Synchondrosis – primarily growth mechanisms…most go on to fuse = synostosis Symphyses – all are median
  • Talocrural calcaneocuboid
  • History of Manual Therapy and Arthrology

    1. 1. History of Manual Therapy
    2. 2. Hippocrates <ul><li>460-355 BC </li></ul>
    3. 3. Claudius Galen <ul><li>131-202 AD </li></ul>
    4. 4. Bone Setting <ul><li>Britain 17 th and 18 th centuries </li></ul><ul><li>practice passed from father to son </li></ul><ul><li>along with barber surgeons were the forerunners to orthopedics and surgery in the UK </li></ul><ul><li>Mid 20 th century bone setting dies out and is replaced by physical therapy and osteopathy </li></ul>
    5. 5. Osteopathic Medicine <ul><li>Andrew Taylor Still – 1874 </li></ul><ul><li>DO Doctor of Osteopathy in the USA –1928 </li></ul><ul><ul><li>Osteopathic Physicians </li></ul></ul><ul><ul><li>gained equal rights with MD’s </li></ul></ul><ul><ul><ul><li>In all states by 1970 </li></ul></ul></ul><ul><li>William Garner Sutherland – 1966 </li></ul><ul><ul><li>offshoot of osteopathy </li></ul></ul><ul><ul><ul><li>cranial osteopathy </li></ul></ul></ul><ul><ul><ul><ul><li>cranialsacral technique </li></ul></ul></ul></ul>
    6. 6. Chiropractic <ul><li>Daniel David Palmer – 1895 </li></ul><ul><ul><li>founder of chiropractic – credits it to medicine </li></ul></ul><ul><ul><li>claims to be the first to reposition vertebrae by using the spinous and transverse processes as balance levers </li></ul></ul>
    7. 7. Manipulation in Medicine <ul><li>medicine created physical therapy to aid in rehabilitation </li></ul><ul><li>physicians trained aids who later became physical therapist </li></ul><ul><li>1899 physiotherapy founded in England </li></ul><ul><ul><li>James and John Mennell – 1 st to use term MT </li></ul></ul><ul><ul><li>Edger and James Cyriax </li></ul></ul>
    8. 8. Physical Therapy <ul><li>1921 physical therapy est. in USA </li></ul><ul><ul><li>American Women’s Physical Therapeutic Association </li></ul></ul><ul><ul><li>need to use medically trained women after WW1 </li></ul></ul><ul><li>1927 – ‘Arthrokinematics’ - used in Gray’s Anatomy </li></ul>
    9. 9. Physical Therapy <ul><li>1957 – James Cyriax </li></ul><ul><ul><li>Textbook of Orthopaedic Medicine </li></ul></ul><ul><ul><ul><li>3 rd edition </li></ul></ul></ul><ul><ul><li>Soft Tissue Differentiation </li></ul></ul><ul><ul><li>popularized the term ‘end-feel’ </li></ul></ul><ul><ul><li>trained physiotherapists </li></ul></ul><ul><ul><li>pleaded for emphasis first on </li></ul></ul><ul><ul><li>evaluation and then on treatment </li></ul></ul>
    10. 10. Freddy Kaltenborn <ul><li>1961 – Kaltenborn – Norway </li></ul><ul><ul><li>Extremity Joint Manipulation </li></ul></ul><ul><ul><li>After 1971 began instructing </li></ul></ul><ul><ul><li>physical therapists worldwide </li></ul></ul><ul><ul><li>Olaf Evjenth </li></ul></ul>
    11. 11. Paris - Maitland <ul><li>1963 – Stanley Paris (USA) –PT </li></ul><ul><ul><li>while in NZ </li></ul></ul><ul><ul><li>The Theory and Technique of Specific Manipulation </li></ul></ul><ul><li>1964 – Geoffrey Maitland (AUST) – PT </li></ul><ul><ul><li>Vertebral Manipulation </li></ul></ul>
    12. 12. IFOMT <ul><li>1966 – Paris, Grieve, Maitland, Kaltenborn </li></ul><ul><ul><li>met with others to discuss setting up an international body </li></ul></ul><ul><ul><ul><li>8 years later IFOMT (Montréal) </li></ul></ul></ul>
    13. 13. Robin McKenzie <ul><li>late 1970’s </li></ul><ul><li>popularized the concept of </li></ul><ul><li>spinal extension for </li></ul><ul><li>treatment of LBP </li></ul><ul><ul><li>‘ centralization theory’ </li></ul></ul>
    14. 14. Brian Mulligan <ul><li>1990’s – Brian Mulligan (NZ) </li></ul><ul><ul><li>MWM’s </li></ul></ul>
    15. 15. Current Manual Therapy <ul><li>practice by physiotherapist is quite eclectic </li></ul><ul><li>no single philosophy dominating </li></ul><ul><li>rarely used in isolation, but with: </li></ul><ul><ul><li>therapeutic exercise </li></ul></ul><ul><ul><li>patient education </li></ul></ul><ul><ul><li>supportive modalities </li></ul></ul><ul><li>most use: </li></ul><ul><ul><li>mechanical </li></ul></ul><ul><ul><li>muscle energy </li></ul></ul><ul><ul><li>oscillatory </li></ul></ul>
    16. 16. Arthrology
    17. 17. Arthrology <ul><li>Outline: </li></ul><ul><ul><li>joint classification </li></ul></ul><ul><ul><li>shapes of articular surfaces </li></ul></ul><ul><ul><li>planes and axes </li></ul></ul><ul><ul><li>degrees of motion/freedom </li></ul></ul><ul><ul><li>arthrokinematics </li></ul></ul><ul><ul><li>osteokinematics </li></ul></ul>
    18. 18. Arthrology <ul><li>Joints </li></ul><ul><li>(Arthroses) </li></ul><ul><li>Solid Joints Cavitated Joints </li></ul><ul><li>(Synarthroses) (Diarthroses) </li></ul><ul><li>Fibrous Cartilaginous Synovial </li></ul>
    19. 19. Fibrous Joints <ul><li>Sutures </li></ul><ul><li>Gomphoses (peg and socket- teeth) </li></ul><ul><li>Syndesmoses </li></ul><ul><ul><li>has interosseus ligament </li></ul></ul><ul><ul><ul><li>eg. inferior tibiofibular ligament </li></ul></ul></ul>
    20. 20. Cartilaginous Joints <ul><li>Synchondroses (primary cartilaginous joints) </li></ul><ul><li>hyaline growth cartilage (function = growth mechanism) </li></ul><ul><li>- sternales, xiphosternalis </li></ul><ul><li>Symphyses (secondary cartilaginous joints) </li></ul><ul><li>hyaline growth cartilage, bonded by fibrocarilaginous disc </li></ul><ul><li>- pubis, intervertrebrales, manubriosternalis ** </li></ul>
    21. 21. Synovial Joints <ul><li>Typical features: </li></ul><ul><ul><li>freely moveable </li></ul></ul><ul><ul><li>articular surface predominantly hyaline cartilage, sometimes fibrocartilage </li></ul></ul><ul><ul><li>fibrous joint capsule </li></ul></ul><ul><ul><li>synovial membrane </li></ul></ul><ul><ul><li>synovial fluid </li></ul></ul><ul><ul><li>disc or meniscus </li></ul></ul><ul><ul><li>joint space </li></ul></ul>
    22. 22. Synovial Joints <ul><li>Complexity </li></ul><ul><li>Simple </li></ul><ul><ul><li>one pair of articulating surfaces: </li></ul></ul><ul><ul><ul><li>convex </li></ul></ul></ul><ul><ul><ul><li>concave </li></ul></ul></ul><ul><li>Compound </li></ul><ul><ul><li>more than one articulating pair in a single capsule </li></ul></ul><ul><ul><li>neither will articulate with the surface that belongs to the other </li></ul></ul><ul><li>Complex </li></ul><ul><ul><li>has an articular disc </li></ul></ul>
    23. 23. Shapes of Articular Surfaces <ul><li>Ovoid </li></ul><ul><li>Sellar </li></ul>
    24. 24. Ovoid <ul><li>concave or convex in all planes </li></ul><ul><li>degree of curvature will vary in all planes </li></ul><ul><li>egg shaped rather than spherical </li></ul><ul><li>Unmodified ovoid </li></ul><ul><ul><li>shape is spherical enough to allow 3 degrees of motion (Hip) </li></ul></ul><ul><li>Modified ovoid </li></ul><ul><ul><li>degree of curvature is more marked in one plane than the other </li></ul></ul><ul><ul><li>allows only 2 degrees of motion (MCP) </li></ul></ul>
    25. 25. Sellar <ul><li>saddle shape </li></ul><ul><li>predominantly concave in one plane and and convex at right angles to this </li></ul><ul><li>stable and efficient, requires fewer ligaments as surface is more congruent </li></ul><ul><li>Unmodified Sellar </li></ul><ul><ul><li>joint surfaces are purely concave in one plane and purely convex in the other (perpendicular to each other) </li></ul></ul><ul><ul><li>allows for 2 degrees of motion (1 st CMC) </li></ul></ul><ul><li>Modified Sellar </li></ul><ul><ul><li>joint surfaces have both a concave and a convex portion in the same plane (not perpendicular to each other) </li></ul></ul><ul><ul><li>allows for only 1 degree of motion (TCJ, HUJ) </li></ul></ul>
    26. 26. Planes and Axes <ul><li>PLANE AXIS </li></ul><ul><li>median/sagittal transverse </li></ul><ul><li>(divides R/L) (runs M/L) </li></ul><ul><li>frontal/coronal sagittal </li></ul><ul><li>(divides A/P) (runs A/P) </li></ul><ul><li>transverse/horizontal vertical </li></ul><ul><li>(divides S/I) (runs C/C) </li></ul>
    27. 28. Degrees of Motion <ul><li>The number of planes through which a bone can be voluntarily (actively) moved around (3max) </li></ul><ul><li>Mechanical Axis </li></ul><ul><ul><li>a line passing through the bone perpendicular to the joint surface </li></ul></ul><ul><ul><li>line of reference for osteokinematic motion </li></ul></ul><ul><ul><li>Axis of Movement </li></ul></ul><ul><ul><li>bone moves around this point </li></ul></ul><ul><ul><li>perpendicular to the plane of motion </li></ul></ul>
    28. 29. One Degree of Motion <ul><li>uniaxial </li></ul><ul><ul><li>hinge joints (ulnohumeral) </li></ul></ul><ul><li>movement of the bone is limited to movement about a single axis </li></ul><ul><li>motion of a bone is produced by a sliding action within a joint </li></ul>
    29. 30. Two Degrees of Motion <ul><li>biaxial </li></ul><ul><ul><li>ellipsoidal (MCP, wrist) </li></ul></ul><ul><ul><li>pivot </li></ul></ul><ul><li>either a swing or spin </li></ul><ul><li>has spin and swing or two distinct swings </li></ul><ul><li>axes must be perpendicular to each other </li></ul>
    30. 31. Three Degrees of Motion <ul><li>multiaxial </li></ul><ul><ul><li>spheroidal - ball & socket (hip) </li></ul></ul><ul><ul><li>planar joints (AC jt) </li></ul></ul><ul><li>movement about 3 distinct axes which are perpendicular to each other </li></ul><ul><li>has a spin and two distinct swings (near pure) </li></ul>
    31. 32. Degrees of Freedom <ul><li>the number of independent axes that a bone can move around (6 max) </li></ul><ul><li>axes are perpendicular to each other </li></ul><ul><li>3 rotations </li></ul><ul><li>3 translations </li></ul>
    32. 33. Degrees of Freedom <ul><li>3 rotations </li></ul><ul><li>3 translations </li></ul>
    33. 34. Degrees of Freedom
    34. 35. Arthrokinematics <ul><li>study of the movement of one articular surface on another without regard to the movement of the bone or the forces producing that movement </li></ul><ul><li>in the periphery, movement is named after the direction of motion of the distal bone </li></ul><ul><li>in the spine, movement is named by motion of the superior bone </li></ul><ul><li>describes: </li></ul><ul><ul><li>1. spin </li></ul></ul><ul><ul><li>2. rock (concave moving) </li></ul></ul><ul><ul><li>roll (convex moving) </li></ul></ul><ul><ul><li>glide (slide) </li></ul></ul><ul><ul><li>traction/compression </li></ul></ul>
    35. 36. Arthrokinematics
    36. 37. Convex/Concave Rule <ul><li>the relationship between the shape of articulating joint surfaces and the direction of gliding is defined by the convex/concave rule </li></ul><ul><li>if the concave surface is moving on a stationary convex surface, gliding will occur in the same direction as the rocking motion </li></ul><ul><li>if the convex surface is moving on a stationary concave surface, gliding will occur in an opposite direction to the rolling motion </li></ul>
    37. 38. Arthrokinematics
    38. 39. Arthrokinematics
    39. 40. Osteokinematics <ul><li>study and measurement of motion of a bone in space </li></ul><ul><li>study of movement of a bone around its mechanical axis without regard to the motion occurring at the joint </li></ul><ul><li>describes: </li></ul><ul><ul><li>rotations </li></ul></ul><ul><ul><ul><li>spins </li></ul></ul></ul><ul><ul><ul><li>swings </li></ul></ul></ul><ul><ul><li>translations </li></ul></ul>
    40. 41. Rotation
    41. 42. Spin <ul><li>the non-linear motion that occurs either at the joint surface (arthrokinematic spin) or around the mechanical axis of the bone (osteokinematic spin) </li></ul><ul><li>motion of the bone is produced by a twisting action </li></ul>
    42. 43. Swing <ul><li>the linear motion that either occurs at the joint surface (arthrokinematic swing) or in the plane of the mechanical axis of the bone (osteokinematic swing) </li></ul><ul><li>motion of the bone is produced by a sliding action within a joint </li></ul>
    43. 44. Pure Swing <ul><li>(cardinal or chordal) </li></ul><ul><li>shortest distance between two points </li></ul><ul><li>swing with no accompanying spin </li></ul><ul><li>bone moves in one plane </li></ul><ul><li>swing can occur without the bone taking a curved path </li></ul><ul><li>only occurs in joints that have at least 2 degrees of motion </li></ul><ul><li>is functionally abnormal and the exception rather than the rule </li></ul>
    44. 45. Pure Swing
    45. 46. Impure Swing <ul><li>(arcuate) </li></ul><ul><li>Is accompanied by spin (conjunct rotation) </li></ul><ul><li>The bone does not stay in one plane </li></ul><ul><li>Movement of a point on the mechanical axis follows a line (arc) other than the shortest one (chord) </li></ul>
    46. 47. Impure Swing
    47. 48. Translation <ul><li>all particles in the body at at given time have the same direction of motion relative to a fixed point </li></ul><ul><li>there is no centre of rotation as the bone moves along a plane instead of through it </li></ul>
    48. 49. Translation
    49. 50. PPM/PAM <ul><li>Passive Physiological Movement </li></ul><ul><ul><li>links with osteokinematics </li></ul></ul><ul><li>Passive Accessory Movement </li></ul><ul><ul><li>links with arthrokinematics </li></ul></ul>
    50. 51. Traction Technique ?
    51. 52. Articular Neurology <ul><li>Wyke (1981) The neurology of joints </li></ul><ul><ul><li>All joints are provided with similar arrays of corpuscular and non-corpuscular receptor nerve endings </li></ul></ul><ul><ul><li>Types I-IV </li></ul></ul>
    52. 54. Receptor Characteristics
    53. 55. Functions <ul><li>Functionally, the receptor systems operate in three spheres: </li></ul><ul><li>Reflexogenic </li></ul><ul><li>Perceptual </li></ul><ul><li>Nociceptive </li></ul>
    54. 56. Reflexogenic <ul><li>Myelinated afferent axons that innervate mechanoreceptors in joint capsule and ligaments enter spinal cord through related dorsal NRs are dispersed to spinal and brain stem motoneurone pools, cerebellum, brainstem reticular system and thalamus </li></ul><ul><li>Integrated effects are expressed in coordinated reflexogenic effects on the striated musculature in many parts of the body </li></ul><ul><ul><li>Arthrostatic – operate in absence of joint movement </li></ul></ul><ul><ul><li>Arthrokinetic – operate during joint movement </li></ul></ul>
    55. 57. Perceptual <ul><li>Articular mechanoreceptor projections to the paracentral and parietal regions of the cerebral cortex (associated with postural and kinesthetic sensation </li></ul><ul><li>Postural sensation - static </li></ul><ul><li>Kinesthetic sensation – perception of direction, amplitude, and velocity of joint movement </li></ul>
    56. 58. Nociceptive <ul><li>Free nerve endings </li></ul><ul><li>Active when there is: </li></ul><ul><ul><li>Mechanical deformation or tension </li></ul></ul><ul><ul><li>Mechanical or chemical irritation </li></ul></ul>
    57. 59. Classification of Nerve Fibers <ul><li>Two classification systems: </li></ul><ul><li>Conduction velocity </li></ul><ul><ul><li>A </li></ul></ul><ul><ul><ul><li>α, β, γ, δ </li></ul></ul></ul><ul><ul><li>B </li></ul></ul><ul><ul><li>C </li></ul></ul><ul><li>Axonal diameter (used only for sensory fibers) </li></ul><ul><ul><li>Group I-IV </li></ul></ul>