Spine mobilization and manipulation 1


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Spine mobilization and manipulation 1

  1. 1. Spine Mobilization and Manipulation Prepared By Mohammad Bin Afsar Jan BSPT, MSPT,GCRS,MAPA,MNPA
  2. 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. 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. 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. 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. 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. 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. 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. 9. Question?
  10. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. Discussion