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Spine mobilization and manipulation 1

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  • 1. Spine Mobilization and Manipulation Prepared By Mohammad Bin Afsar Jan BSPT, MSPT,GCRS,MAPA,MNPA
  • 2. 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
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. Question?
  • 10. 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)
  • 11. Neurophysiological Effects of Manipulation – 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
  • 12. Neurophysiological Effects of Manipulation – 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
  • 13. Neurophysiological Effects of Manipulation – 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
  • 14. 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
  • 15. Psychological Effects – Effect of touch and reassurance can have powerful effects on easing the patient's fear and anxiety, which can translate into reduced pain and disability
  • 16. 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
  • 17. 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
  • 18. Clinical decision making in use of spinal manipulation – 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 (LlL2, 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
  • 19. Clinical decision making in use of spinal manipulation – 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
  • 20. Clinical decision making in use of spinal manipulation – 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
  • 21. Discussion

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