This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.

1. INTRODUCTION TO
MANUAL THERAPY
Schools of thought
BPT Third Year
Saurab Sharma, MPT
Lecturer, KUSMS

2. Objectives of class
At the end of the class, students should
be able to:
 List out various Manual Therapy
schools of thoughts
 Describe types of passive movements
 Explain core elements of Maitland’s
concept

3. Objectives of class (contd..)
At the end of the class, students should
be able to:
 Explain grades of mobilization
 Explain principles of treatment by
Maitland

4. History Of Manual Therapy
 Manual therapy is as old as the
science and art of medicine.
 Time of Hippocrates

5.  17th and 18th centuries:
 Bone-setters vs. physicians
 19th century:
 Osteopathy –Andrew Still - 1874 AD
 Chiropract – Daniel P - 1895 AD
History Of Manual Therapy

6. Manual Medicine
 Manual medicine deals with the
identification of the lesions, which
can be manipulated with the
appropriate use of manual therapy
procedure to resolve the condition.
 Treatment by “hand”

7. Shift from hands on to hands-
off
Pain
Social
BIO
Psycho
Treatment
Manual
Therapy

8. Schools of thought (1)
 McKenzie Technique
 Mulligan Technique
 Maitland Concept
 Muscle Energy Technique
 Cyriax’s Technique
 Craniosacral Therapy

9. Schools of thought (2)
 Butlers- neural mobilization
 Shacklock’s Neurodynamics
 Kaltenborn technique
 Myofasical release
 Positional release technique
 Strain-counterstrain technique

10. Introduction to
Maitland’s Concept

11.  Introduced by G.D. Maitland in the
1950’s.
 It mainly deals with the concept of
examination, treatment and
assessment by passive
movement.
Introduction:

12. Passive movement?
 Movement of any part of the body
performed by an external force may it
be another person or equipment.
 Relieves pain
 Restores full range pain free functional
movements

13. Passive movement: Types
 Physiological movement
 Accessory movement
Mobilization vs Manipulation

14. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
17

15. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
18

16. 1. Patient centered approach
 Patient driven model
 Listening (active) vs hearing (passive)
 Believe the patient
 At the same time questioning
19

17. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
20

18. 2. Brickwall analogy-
“Mode of Thinking”
1. Theoretical Clinical
21

19. 2. Brickwall analogy
 Know the history, symptoms and
signs very clearly
 Medical Diagnosis vs physiotherapy
diagnosis
 Use of words:
 hip joint pain vs pain in hip area
22

20. 2. Brickwall analogy
 Selection of treatment technique:
 Related to patient’s signs and
symptoms (physical therapy diagnosis)
rather than the diagnostic title
 Demands logical reasoning
23

21. 2. Brickwall analogy
 Apply Clinical Reasoning
1. Dysfunction
2. Pathobiological mechanisms
3. Sources and causes of the symptoms
4. Contributing factors
5. Precautions and contraindications
6. Prognosis
7. Management
24
Mark Jones, 2005

22. 2. Brickwall analogy
Clinical Reasoning
1. Dysfunction

23. 2. Brickwall analogy
Clinical Reasoning
2. Pathobiological mechanism

24. 2. Brickwall analogy
Clinical Reasoning
3. Sources of symptoms

25. 2. Brickwall analogy
Clinical Reasoning
4. Contributing factors

26. 2. Brickwall analogy
Clinical Reasoning
5. Precautions and contraindications

27. 2. Brickwall analogy
Clinical Reasoning
6. Prognosis

28. 2. Brickwall analogy
Clinical Reasoning
7. Treatment

29. Clinical reasoning process (Jones,
Rivett 2005)
32

30. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing
movement potential
4. Science and art of assessment
33

31. 3. Identifying and maximizing
movement potential
Key stones-
 Assessment
 Symptom response to movement and
position

32. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
35

33. 4. Science and art of assessment
 Cornerstone of the concept
 Clinical proof of whether treatment
is working or not
36

34. a) Analytical assessment at first
consultation
 Establish and test working hypothesis
b)Pre-treatment assessment
 Effects on comparable signs should be
analyzed
37
4. Science and art of assessment

35. c) Assessment and reassessment during
and immediately after each treatment
session
d) Progressive assessment: after 3-4 sessions
e) Retrospective assessment: after break
f) Final analytical assessment: prognosis
38
4. Science and art of assessment

36. Subjective Examination
 The patient’s story
 Provides most (about 80%) of the
information needed to clarify the cause
or establish a hypothesis
39

37. Subjective examination – aims
 To identify how the patient is affected by
the disorder
 To establish the extent of physical
examination and desired effect of
treatment based on SIN
 To generate hypothesis
40

38. Subjective examination
1. Kind of disorder
2. Area of symptoms: Body chart
3. Intensity of pain
4. Behaviour of symptoms/ pain
5. Relationship of pain, stiffness, spasm
6. History
7. Special questions (to rule out flags)
41

39. Subjective Examination:
Components
 Patient profile
 Chief complaint
 Body chart
 AGG/Ease factors
 24-hour behavior
 Special questions
 Present episode
 Past history
42

40. Variables needed for assessing pain
 Position in range where pain is
expressed (P1, P2)
 Extent of range through which pain is
experienced
 Severity of pain at the limit of
movement (L)
43

41. Develop a body chart
 Get a clear picture of the problem
 Prioritizes complaints, pain P1, P2…
 Many times leads you to diagnosis
44

42. 45

43. 46

44. Aggravating & Easing Factors
Aggravating
 Bending over*
 Crossing my legs*
 Getting up from chair*
 Rolling over in bed*
 Walking 5 minutes*
* Treat the Asterisks *
47
Easing
• Return to standing
• Uncrossing my legs
• Walking 5 minutes
• Comfortable position
• Sit for 5 min

45. Behavior of Symptoms
 Establish symptom behavior over a
24 hour period
 First thing in the morning
 Throughout the day
 End of day
 Night pain/ sleeping pain
 Work day versus non-work day
48

46. Assessment During Initial
Examination
Establishing the SINSS:
 Severity, Irritability, Nature,
Stage, Stability
 Provides the basis for planning the OE
 Structures to be examined
 Depth of examination
 Which symptoms to reproduce
49

47. Severity
 Refers to the intensity of symptoms and the
extent that they limit normal activity
Examples:
Pain scales ->
 0-10 Numerical (Pain) Rating Scale
 Verbal rating scale,
 visual analogue scale,
 Faces Pain Rating Scale
50

48. Irritability
 Refers to the ease in which symptoms are
produced and the time it takes to settle
Examples:
Symptom onset:
 Immediately on movement vs. after sustained
activities
Symptom relief:
 “Pain goes away immediately when I stand up
straight”
 “Pain persists 10-15 minutes after stand up
straight.”
51

49. Nature
 Refers to the type and extent of injury
Examples:
 Type: aching, throbbing, burning, stabbing,
sharp, dull, deep, superficial, etc.
 Symptom behavior: radiating, referred, local,
etc.
 Tissue and injury: sprain, DJD, fracture,
osteoporosis, multi-tissue trauma, neural
tension
 Degree of injury: 1st-3rd degree, mild-
severe, etc.
52

50. Stage and Stability
 Stage: acute, sub-acute, chronic,
acute on chronic
 Stability: how are the symptoms
changing?
Better, worse, the same?
53

51. Assessment During Treatment
Course
Proves the value of each technique
At beginning of a treatment session:
 Determine effect of last treatment session
(immediate, that evening, next morning)
 Reassess SE* and OE*
 Forms the basis for treatment session
As each technique is performed:
 Be alert to changes on the patient’s
symptoms
 Palpate, observe, and question
54

52. Assessment During Treatment
Course
After each technique is used:
 Determine the immediate effect of a
technique (reassess SE* and OE*)
 Determine how to proceed (repeat, modify,
add, or discontinue the treatment
technique)
At conclusion of a treatment session:
 Determines the effect of the whole
treatment session
55

53. “Making features fit”
 Determine the information obtained fit in
recognizable clinical patterns of
symptom behaviour deriving from
specific sources of impairments
 Link with physical examination
56

54. Planning of physical examination
 Structures need to be examined as the
cause of the disorder
 Extent of examination
 Strength with which the test movements
need to be carried
57

55. Physical examination – aims
 Primary aim is to find a comparable
sign in disorders with pain
 These comparable signs will frequently
serve in reassessment procedures
 Test the hypothesis generated in
subjective examination
58

56. Physical Examination includes
 Observation
 Functional demonstration
 Active movement tests: quality, quantity
of movement, symptom response (pain and
ROM), Over pressure
 Passive movements tests: physiological,
accessory movement, symptom response
 Isometric tests
 Palpation
 Differentiation tests
59

57. Principle of over pressure
60

58. Movement diagram
61

59. Comparable signs
 A comparable sign refers to combination
of pain, stiffness, motor responses
which the examiner discovers on physical
examination and considers to be
comparable with patient’s symptoms as
described in the subjective examination
62

60. Treatment Techniques
 Based on the response to examination
 May relieve or provoke symptoms
 Take into account:
 SINSS
 Worse, same, better
 Vigor of techniques
 Test – retest
 Choose one or two techniques and
compliment with specific home exercise
“A technique is the brainchild of ingenuity.”
– GD Maitland 63

61. Mobilization principles (Maitland
and Greenmann)
 Patient must be completely relaxed
 Operator must be relaxed
 Patient must be comfortable and have
complete confidence in the operator’s grasp
 Embrace the joint to be moved, hold
around the joint to feel movement
64

62. Mobilization principles (Maitland
and Greenmann)
 Move one joint, one motion at one time
 Patient must be confident that the joint will
not be hurt
 Operator’s position must be comfortable
and easy to maintain
 Operator’s position must afford him/her
complete control
65

63. TREATMENT by
Maitland’s Technique

64. Principles of techniques
 Assessment is the key to success -
technique is merely a tool.
 “A technique is a brain child of ingenuity”
 Imagination, originality, creativity
 There are no set techniques; but the
basic techniques must include every
possible movement combinations
67

65. Passive
movement
Physiological
Combined
physiological
Combined
physiological
and
accessory
Accessory
Combined
accessory
68

66.  Technique is based on the passive
movements that provokes or relieves
patient’s symptoms based on SIN
69
Principles of techniques

67. Graded oscillations:
accessory
71

68. 72
Graded oscillations: Physiological

69. Selection of techniques
1. General aspects: based on SIN
2. Aspects of technique itself-
mobilisation vs manipulation, grades
choices
3. Based on symptoms and signs
73

70. Based on signs and symptoms
Pain Stiffness
Pain &
Stiffness
Momentary
pain
74

71. Now are you able to?
 Describe types of passive movements
 Explain core elements of Maitland’s
concept
 Understand a movement diagram
 Explain grades of mobilization
 Explain principles of treatment by
Maitland
80

72. References:
 Maitland’s vertebral manipulation.
2005, 7th edition.
 Maitland’s peripheral manipulation.
2004, 4th edition.