2. Why I ChoseThisTopic
Are the techniques that I’ve learned on this rotation relevant
to the neurologic patient population?
Which techniques are applicable?
What are the special considerations that need to be made
when applying these techniques in the neurologic patient
population?
How effective is manual therapy versus other treatments?
3. CommonApplications of Manual
Therapy1
Passive stretching
Mobilization – joint or soft tissue
Manipulation
Muscle energy technique
Passive mobilization with active movement
Associated techniques:
Dry needling
Myofascial release
4. Primary & Secondary Impairments
Associated with Neurologic Dysfunction2
Primary Impairments
Changes in muscle strength
Paralysis or weakness
Changes in muscle tone
Hypotonicity
Hypertonicity-Spasticity
Changes in muscle activation
Inappropriate initiation
Difficulty sequencing
Inappropriate timing of firing
Altered force production
Changes in sensation
Awareness
Interpretation
Proprioception
Secondary Impairments
Changes in alignment and
mobility
Changes in muscle and soft
tissue length
Pain
Edema
Adapted from Box 27-1 “ImpairmentsThat
InterfereWith Functional Movement”, pg.
865, Neurological Rehabilitation, 5th Edition.
5. Effects of ManualTherapy1,3
Biomechanical Effects
Improved movement – gains in
ROM or normalized movement
patterns
Improved position – reduction of
positional faults
Neurophysiological Effects
Spinal cord – diminished sensitivity
to pain, sympathoexcitatory
(changes in blood flow, heart rate,
skin conductance and skin
temperature), decrease in
hypertonicity of muscles
Central mediated – alterations in
pain “experience” in amygdala,
periaqueductal gray, and rostral
ventromedial medulla
Peripheral inflammatory – alteration
of blood levels of inflammatory
mediators
“A mechanical stimulus initiates a
number of potential
neurophysiological effects which
produce the clinical outcomes
associated with MT in the
treatment of musculoskeletal
pain.”
Combined Effects
6. Addressing Primary Impairments
Addressed by medical or
pharmacological
intervention
Anti-spasticity
medications, Baclofen
pump, Botox
Implementation of motor
relearning strategies or
facilitation techniques
PNF
Muscle strength
Muscle tone
Muscle activation
Sensation
7. Addressing Secondary Impairments
Improvement of joint mobility4,5
Smedes F, van der SalmA, Koel G, Oosterveld F. Manual
mobilization of the wrist: A pilot study in rehabilitation of
patients with a chronic hemiplegic hand post-stroke. J Hand
Ther. 2014; Epub.6
Decreased pain3
Peripheral7,8 vs. Spinal9 vs. Supraspinal mechanisms10
Lack of literature specific to neurologic patient population
Increased soft tissue length through soft tissue mobilization and dry
needling
Alignment &
mobility
Muscle & soft
tissue length
Pain Edema
8. Dry Needling
Treatment effects11
Decreased pain
Muscle tension
Improved ROM
Muscle strength
Coordination
No evidence supporting dry needling in the neurologic patient
population
Available evidence regarding the use of acupuncture in the stroke
population12,13,14
However, Ernst & Lee 201015 suggest caution regarding the conclusions of
many of the Chinese studies
Negative results are virtually never produced
Many of the study designs are incapable of generating negative results
9. Case 1: CL
Pre-Treatment: 36° lumbar scoliosis curve
with shortening of R trunk
Treatment:
Soft tissue mobilization: B paraspinals
with focus on L paraspinals, QL, bony
clearance of iliac crest and 12th rib
Joint mobilization: transverse glide to R
T8-L5, grade III-IV; R/L PA to adjacent
ribs with assisted trunk rotation
Neuromuscular reeducation: rolling
from supine<>prone to facilitate
activation of L paraspinals
Passive stretch: sidelying R trunk/pelvic
stretch over therapist thigh
HEP: soft tissue mobilization of
paraspinals, gentle mobilization of
lower thoracic/lumbar spine
Outcomes: decreased assistance with
rolling, maintenance of airways and rib
excursion, family currently seeking
reassessment by physiatrist to formally
assess
Demographics: 21 yo female
Diagnosis: cerebral palsy – spastic
quadriplegia, intractable epilepsy
Medications: Keppra,Topomax, Onfi,
L-Carnitine, Bactropan, Acanya,
Ketoconazole, Lactulose, Vusion
Reason for referral: transitioning
from school-based therapy,
hospitalization following seizure as
well as increased seizure activity
decreasing functional abilities
Impairments: global weakness
throughout trunk & extremities;
fingers, L shoulder; max assist-
dependent for all bed mobility,
transfers, ambulation
10. Case 2: SB
Pre-Treatment:
B + clonus with 5 beats on R
B DF to ~8-10 degrees
R LE: 2+ inver / ever, 4- PF, 3+ DF
L LE: 3+ inver / ever, 4- PF, 4- DF
Treatment:
Soft tissue mobilization: STM to R
gastroc/soleus, peroneals
Neuromuscular reeducation: PNF ankle
diagonals following STM
Dry needling: medial/lateral gastroc/soleus
0.3 x 0.5mm
Functional training: ambulation with focus
on increasing DF following IMT/STM
Modalities: 10’ moist heat following IMT
Outcomes: improved AROM into DF and
eversion following IMT & STM, patient
subjective report of immediate decrease in
tightness of calf following each treatment as
well as decreased tingling in calf at night,
limited translation to functional improvement
Demographics: 58 yo female
Diagnosis: 5 year history of
multiple sclerosis
Medications: Baclofen,
Cymbalta, Zolpidem tartrate,
Rifampin, Ethambutol HCL,
Clarithromycin, Ampyra,
Tecfidera, Lyrica, Clonazepam
Reason for Referral: increasing
extremity weakness leading to
functional decline and falls
Impairments: decreased B LE
strength, increased tone R LE,
gait impairment
11. Case 3: ET
Pre-Treatment: subjective report of
“clicking”, pain of 5/10 in R shoulder
Treatment:
Soft tissue mobilization: upper trap,
subscapularis, lat, supraspinatus,
infraspinatus, pec clearance of bony
contours of clavicle
Joint mobilization: traction, inferior &
posterior glides – grade I-IV
Neuromuscular reeducation: scapular
PNF with PD pattern, prolonged holds
with shoulder ER
Passive stretch: AAROM R pec stretch
Therapeutic exercise: manual
resistance into shoulder ER/IR, supine
shoulder alphabets A-Z
HEP: around the world shoulder
activity
Outcomes: R shoulder flexion ~165 with
mild soreness in anterior shoulder and
continued “clicking”
Demographics: 32 yo female
Diagnosis:TBI s/p MVA June 2009
Medications: Baclofen – ITB pump
Reason for Referral: gait & balance
impairments, R UE ROM &
strength deficits, recurrent B
patellar dislocation
Impairments: postural deficits, R
knee hyperextension, B decreased
hipAROM & strength, gait &
balance deficits – R shoulder not
assessed at initial evaluation
12. Literature Review – ManualTherapy
Lack of studies investigating the effects of manual therapy in
the neurologic patient population
Smedes F, van der SalmA, Koel G, Oosterveld F. Manual
mobilization of the wrist: A pilot study in rehabilitation of
patients with a chronic hemiplegic hand post-stroke. J Hand
Ther. 2014: Epub.6
Statistically significant improvement in active/passive wrist
movement with manual therapy intervention.
Pilot study
13. Literature Review – Dry Needling
Positive results have been achieved in individual studies, but the
level of evidence supporting the effectiveness of dry needling in
various conditions is lacking.
KimTH, Lee CR, ChoiTY, et al. Intramuscular stimulation therapy
for healthcare: a systematic review of randomised controlled trials.
Acupunct Med. 2012; 30(4): 286–90.16
Large, well-designed RCTs are still needed to evaluate the clinical
utility of this technique.
Cagnie B, DewitteV, BarbeT,Timmermans F, Delrue N, Meeus M.
Physiological effects of dry needling. Curr Pain Headache Rep. 2013.
17: 348.11
Lacking evidence for the utility of dry needling overall and for specific
patient populations – ie. neurologic patient population
14. Discussion Points
Experiences with the application of manual therapy with
patients with neurologic dysfunction.What techniques were
utilized? What were the outcomes?
Arguments for/against the application of manual therapy in
the neurologic patient population?
Priority of manual therapy intervention vs. other treatment
techniques
15. References
1. Cook CE. Orthopedic Manual Therapy: An Evidence-Based Approach. 2nd Ed. Pearson: New Jersey. 2012.
2. Umphred DA. Neurological Rehabilitation. 5th Ed. Mosby Elsevier: St. Louis. 2007.
3. Bialosky J, Bishop M, Price D, Robinson M, George S. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009; 14(5): 531-538.
4. Randall T, Portney L, Harris BA. Effects of joint mobilization on joint stiffness and active motion of the metacarpal-phalangeal joint.
5. Hoch M, McKeon P. Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. Journal of Orthopeadic Research. 2011.
6. Smedes F, van der Salm A, Koel G, Oosterveld F. Manual mobilization of the wrist: A pilot study in rehabilitation of patients with a chronic hemiplegichand post-stroke. J Hand Ther. 2014; Epub.
7. McPartland JM, Giuffrida A, King J, Skinner E, Scotter J, Musty RE. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath. 2005; 105: 283-291.
8. Field T, Diego M, Cullen C, Hernandez-Reif M, Sunshine W, Douglas S. Fibromyalgia pain and substance P decrease and sleep improves after massage therapy. J Clin Rheumatol. 2002; 8: 72-76.
9. Malisza KL, Stroman PW, Turner A, Gregorash L, Foniok T, Wright A. A functional MRI of the rat lumbar spinal cord involving painful stimulation and the effect of peripheral joint mobilization. J Magn Reson Imaging. 2003; 18: 152-159.
10. Malisza KL, Gregorash L, Turner A, Foniok T, Stroman PW, Allman AA, Summers R, Wright A. Functional MRI involving painful stimulation of the ankle and the effect of physiotherapy joint mobilization. J Magn Reson Imaging. 2003:
21; 489-496.
11. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Curr Pain Headache Rep. 2013; 17: 348.
12. Yang ZX, Shi XM. Systematic evaluation of the therapeutic effect and safety of Xingnao Kaigiao needling method in treatment of stroke. Zhonggou Zhen Jiu. 2007; 27 (8): 601-8.
13. Hong JB, Sheng PJ, Yuan YQ, Yi SX, Yue ZH. Observation on therapeutic effect of opposingneedling for treatment of poststroke shoulder-hand syndrome. Zhonggou Zhen Jiu. 2009; 29(3): 2005-8.
14. Hai Y, Yu X. Observation on therapeutic effect of acupuncture on spastic dyskinesia due to stroke. Zhonggou Zhen Jiu. 2007; 27(10): 735-7.
15. Ernst E, Lee MS. Acupuncture during stroke rehabilitation. Stroke. 2010; 41(8): e549.
16. Kim TH, Lee CR, Choi TY, et al. Intramuscular stimulation therapy for healthcare: a systematic review of randomised controlled trials. Acupunct Med. 2012; 30(4): 286–90.
