Cervical and thoracic spinal manipulation was found to immediately increase levels of neurotensin, oxytocin, and cortisol in asymptomatic subjects. Neurotensin and oxytocin levels increased significantly with both cervical and thoracic manipulation. Cortisol levels only increased with cervical manipulation. No changes were seen in orexin A levels or 2 hours after the interventions. The study suggests spinal manipulation triggers a biochemical response involving pain modulation markers, though the long term effects are unknown.
A two day workshop presented by Albion Musculoskeletal Therapist Paula Nutting. Paula discusses stretching options for treatment of conditions including headaches, lower back pain, shoulder problems and more. Queensland born Remedial massage therapist Paula Nutting will show you easy effective stretches to help return to normal muscle length which should lead to pain relief.
The professor David Lopez, PT and DC expose about the theorical basis of manual therapy in Osteopathy for extremities. In a short approach inted demonstrate the differences and similarities with other manual therapy concepts
Dr. Richard Chmielewski, DO, FACEP, NMM/OMM gave a lecture on the ins and outs of Osteopathy and Osteopathic Medicine, including various techniques used by the Doctor on a daily basis.
To Compare The Effect Of Proprioceptive Neuromuscular Facilitation Program Ve...IOSR Journals
Abstract: Low back pain has been a matter of concern, affecting up to 90% of population at some point in
their lifetime, up to 50% have more than one episode. People of all age group can be affected by this menace
irrespective to their gender and quality of life. It has become one of the leading causes for the visit to physician
thus also puts a heavy burden on the currency of the country. Physiotherapy is the most widely used form of
treatment adopted for gaining relief from low back pain. The exercises include stretching, strengthening, range
of motion exercises, McKenzie therapy and core stability exercises other techniques like Proprioceptive
neuromuscular facilitation program etc. It has been concluded in various studies core stability exercises and
Proprioceptive neuromuscular facilitation are beneficial in low back pain patients but comparison of their effect
needs to be established to provide early and better relief from the disability. Therefore objective of the study was
to compare the effect of Proprioceptive neuromuscular facilitation program and Core stabilization exercises on
low back pain patients. 40 subjects aged 30 – 50 years with low back pain for more than 4 weeks were made
part of the study based on inclusion and exclusion criteria and were then divided into two groups named A, B.
Group A received Proprioceptive neuromuscular facilitation and group B received Core stabilization exercises
and hot pack given initially for 10-15 minutes to the lower back. The exercise program was given for 4 weeks
with a total of 24 sessions and progression of the activity was made within the tolerance of the patient. Pre and
post treatment readings were taken of pain, Oswestry Disability Questionnaire and Functional Reach Test.
Results were analyzed using paired, unpaired t- test. Results showed that there is significant effect on pain,
Oswestry Disability Questionnaire and Functional Reach Test in the two groups but group A was clinically
more significant than groups B. The study concluded that patients with low back pain are benefitted more by
Proprioceptive neuromuscular facilitation program. So, Proprioceptive neuromuscular facilitation program
should be practiced more.
Keywords: Low Back Pain, Core Stabilization Exercises, Proprioceptive Neuromuscular Facilitation.
A two day workshop presented by Albion Musculoskeletal Therapist Paula Nutting. Paula discusses stretching options for treatment of conditions including headaches, lower back pain, shoulder problems and more. Queensland born Remedial massage therapist Paula Nutting will show you easy effective stretches to help return to normal muscle length which should lead to pain relief.
The professor David Lopez, PT and DC expose about the theorical basis of manual therapy in Osteopathy for extremities. In a short approach inted demonstrate the differences and similarities with other manual therapy concepts
Dr. Richard Chmielewski, DO, FACEP, NMM/OMM gave a lecture on the ins and outs of Osteopathy and Osteopathic Medicine, including various techniques used by the Doctor on a daily basis.
To Compare The Effect Of Proprioceptive Neuromuscular Facilitation Program Ve...IOSR Journals
Abstract: Low back pain has been a matter of concern, affecting up to 90% of population at some point in
their lifetime, up to 50% have more than one episode. People of all age group can be affected by this menace
irrespective to their gender and quality of life. It has become one of the leading causes for the visit to physician
thus also puts a heavy burden on the currency of the country. Physiotherapy is the most widely used form of
treatment adopted for gaining relief from low back pain. The exercises include stretching, strengthening, range
of motion exercises, McKenzie therapy and core stability exercises other techniques like Proprioceptive
neuromuscular facilitation program etc. It has been concluded in various studies core stability exercises and
Proprioceptive neuromuscular facilitation are beneficial in low back pain patients but comparison of their effect
needs to be established to provide early and better relief from the disability. Therefore objective of the study was
to compare the effect of Proprioceptive neuromuscular facilitation program and Core stabilization exercises on
low back pain patients. 40 subjects aged 30 – 50 years with low back pain for more than 4 weeks were made
part of the study based on inclusion and exclusion criteria and were then divided into two groups named A, B.
Group A received Proprioceptive neuromuscular facilitation and group B received Core stabilization exercises
and hot pack given initially for 10-15 minutes to the lower back. The exercise program was given for 4 weeks
with a total of 24 sessions and progression of the activity was made within the tolerance of the patient. Pre and
post treatment readings were taken of pain, Oswestry Disability Questionnaire and Functional Reach Test.
Results were analyzed using paired, unpaired t- test. Results showed that there is significant effect on pain,
Oswestry Disability Questionnaire and Functional Reach Test in the two groups but group A was clinically
more significant than groups B. The study concluded that patients with low back pain are benefitted more by
Proprioceptive neuromuscular facilitation program. So, Proprioceptive neuromuscular facilitation program
should be practiced more.
Keywords: Low Back Pain, Core Stabilization Exercises, Proprioceptive Neuromuscular Facilitation.
In this presentation the author, David Lopez Chiropractor DC and Kinesiologyst (PT) from Chile expose about the different principles under the scope of the osteopathic manipulation of the spine. Dr. Lopez is director of the progran in Chiropractic for healh professional of the "Universidad Central de Chile" and director of the Diplomats in Manual Therapy of the "Universidad Santo Tomas de Chile. The interest is to review the fundamentals to understand the approach of the Osteopathy to the practice of the manual therapy and healthcare. This vision was exposed in Poland in the framework of an international symposium of Physiotherapy.
Effectiveness of Strain Counterstrain Technique on Quadratus Lumborum Trigger...IOSR Journals
Abstract: Quadratus lumborum (QL) myofascial trigger points (MTrP) are well documented in low back pain
(LBP) patients. There is a Growing body of evidence suggesting that Strain counterstrain technique (SCS) is an
effective treatment for the pain associated with MTrP. Literature is sparse regarding the effectiveness of SCS on
MTrP in QL in LBP subjects. We studied the immediate effects of SCS on pain intensity & functional outcome
in subjects having LBP with MTrP in QL. 40 subjects were randomly allocated into two groups. The Control
group (CG) received moist heat, & the Experimental group (EG) received moist heat & SCS technique.
Outcome measures were Visual Analogue Scale (VAS) & Patient Specific Functional Scale (PSFS).Pain
scores(VAS) Showed Statistically significant differences within the groups (P<0.0001), while clinically
significant improvement was seen only in EG with mean difference (3.75) , 95% confidence interval (4.17,3.04),
PSFS also showed significant improvement in EG.
Keywords: Quadratus lumborum, Myofascial Trigger Point, Pain, Low Back Pain, Strain Counterstrain
Physical Therapy Practice Guidelines: Thoracic manipulation is both safe and effective in treating mechanical neck pain (neck pain with mobility deficits).
The McKenzie method was developed in 1960’s by Robin McKenzie , a physical therapist in new Zealand and A central tenet of McKenzie Method is that self-healing and self-treatment are important for patient’s pain relief and rehabilitation.
Soft Tissue Treatment of Musculoskeletal Disorders Utilizing Functional and Kinetic Treatment with Rehab, Provocation and Motion (FAKTR-PM) by Thomas E. Hyde, DC, DACBSP, CSTI, ICSSD, FRCCSS (Hon).
Osteopathic Manipulation Treatment (OMT) is growing rapidly as a preferred and natural family medicine. As a treatment, osteopathic manipulation attempts to improve joint range of motion and balance tissue and muscle mechanics in order to relieve pain.
Two New Applied Kinesiology Textbooks (the 2nd Editions) -- Just Published IN...DrScottCuthbert
Applied Kinesiology and Evidence-Informed Medicine have been combined in two new textbooks that will vastly improve your working knowledge of AK. These textbooks' images, text, graphics, charts and tables are all in color. Your most updated evidence-base for AK and manual muscle testing looks like a medieval manuscript of beautiful colors! These texts offer practical, comprehensive coverage of the AK approach to holistic health care. Muscle testing -- describing the science and the clinical art is broadly updated -- leading to the importance of structural balance.
Manual and physical therapists use a postural-structural-biomechanical (PSB) model to ascertain the causes of various musculoskeletal conditions.
The most important question is consistently being ignored is can a person’s physical shape/posture/structure/biomechanics be the cause of pain in spine
In this presentation the author, David Lopez Chiropractor DC and Kinesiologyst (PT) from Chile expose about the different principles under the scope of the osteopathic manipulation of the spine. Dr. Lopez is director of the progran in Chiropractic for healh professional of the "Universidad Central de Chile" and director of the Diplomats in Manual Therapy of the "Universidad Santo Tomas de Chile. The interest is to review the fundamentals to understand the approach of the Osteopathy to the practice of the manual therapy and healthcare. This vision was exposed in Poland in the framework of an international symposium of Physiotherapy.
Effectiveness of Strain Counterstrain Technique on Quadratus Lumborum Trigger...IOSR Journals
Abstract: Quadratus lumborum (QL) myofascial trigger points (MTrP) are well documented in low back pain
(LBP) patients. There is a Growing body of evidence suggesting that Strain counterstrain technique (SCS) is an
effective treatment for the pain associated with MTrP. Literature is sparse regarding the effectiveness of SCS on
MTrP in QL in LBP subjects. We studied the immediate effects of SCS on pain intensity & functional outcome
in subjects having LBP with MTrP in QL. 40 subjects were randomly allocated into two groups. The Control
group (CG) received moist heat, & the Experimental group (EG) received moist heat & SCS technique.
Outcome measures were Visual Analogue Scale (VAS) & Patient Specific Functional Scale (PSFS).Pain
scores(VAS) Showed Statistically significant differences within the groups (P<0.0001), while clinically
significant improvement was seen only in EG with mean difference (3.75) , 95% confidence interval (4.17,3.04),
PSFS also showed significant improvement in EG.
Keywords: Quadratus lumborum, Myofascial Trigger Point, Pain, Low Back Pain, Strain Counterstrain
Physical Therapy Practice Guidelines: Thoracic manipulation is both safe and effective in treating mechanical neck pain (neck pain with mobility deficits).
The McKenzie method was developed in 1960’s by Robin McKenzie , a physical therapist in new Zealand and A central tenet of McKenzie Method is that self-healing and self-treatment are important for patient’s pain relief and rehabilitation.
Soft Tissue Treatment of Musculoskeletal Disorders Utilizing Functional and Kinetic Treatment with Rehab, Provocation and Motion (FAKTR-PM) by Thomas E. Hyde, DC, DACBSP, CSTI, ICSSD, FRCCSS (Hon).
Osteopathic Manipulation Treatment (OMT) is growing rapidly as a preferred and natural family medicine. As a treatment, osteopathic manipulation attempts to improve joint range of motion and balance tissue and muscle mechanics in order to relieve pain.
Two New Applied Kinesiology Textbooks (the 2nd Editions) -- Just Published IN...DrScottCuthbert
Applied Kinesiology and Evidence-Informed Medicine have been combined in two new textbooks that will vastly improve your working knowledge of AK. These textbooks' images, text, graphics, charts and tables are all in color. Your most updated evidence-base for AK and manual muscle testing looks like a medieval manuscript of beautiful colors! These texts offer practical, comprehensive coverage of the AK approach to holistic health care. Muscle testing -- describing the science and the clinical art is broadly updated -- leading to the importance of structural balance.
Manual and physical therapists use a postural-structural-biomechanical (PSB) model to ascertain the causes of various musculoskeletal conditions.
The most important question is consistently being ignored is can a person’s physical shape/posture/structure/biomechanics be the cause of pain in spine
Reduced Short- and Long-Latency Afferent Inhibition Following Acute Muscle Pa...Antonio Martinez
Corticomotor output is reduced in re-
sponse to acute muscle pain, yet the mechanisms
that underpin this effect remain unclear. Here the au-
thors investigate the effect of acute muscle pain on
short-latency afferent inhibition, long-latency afferent
inhibition, and long-interval intra-cortical inhibition to
determine whether these mechanisms could plausibly
contribute to reduced motor output in pain.
Transcranial Magnetic Stimulation ( TMS) for Chronic PainDr. Rafael Higashi
Aula sobre avanço no tratamento da dor crônica com o uso de Estimulação Magnética Transcraniana (EMT) ministrada por Dr. Rafael Higashi, médico neurologista, no departamento de tratamento da dor do Centro Médico da Universidade de Nova York, NYU, EUA.
www.estimulacaoneurologica.com.br
Physiotherapy in MND
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
Types of MND
Clinical Features of MND
Diagnostic Procedure
Management: 1) Pharmaceutical
2) Physiotherapy
Motor Neuron Disease
Motor Neuron Disease are a group of neurodegenerative disorders that affects the nerves in the spine and brain to progressively lose its function.
Motor neuron diseases (MND) include a heterogeneous spectrum of inherited and sporadic (no family history) clinical disorders of the upper motor neurons (UMNs), lower motor neurons (LMNs), or a combination of both.
Types of MND
Amyotrophic Lateral Sclerosis
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease, characterized by progressive degeneration of motor neurons in the spinal cord, brain stem, and motor cortex, leading to progressive muscle atrophy and weakness.
Clinical Features
UPPER MOTOR NEURON
Loss of Dexterity
Muscle Weakness
Spasticity
Hyperreflexia
Pathological reflexes
LOWER MOTOR NEURON
Muscle Weakness
Muscle Atrophy
Hypotonicity
Hyporeflexia
Fasciculation
Muscle Cramp
Impairment related to LMN
Other clinical features
Diagnostic Criteria
Diagnostic Procedure
EMG-
It include signs of active denervation, such as fibrillation potentials and positive sharp waves;
Signs of chronic denervation, such as large motor unit potentials (increased duration, increased proportion of polyphasic potentials, increased amplitude)
Unstable motor unit potential
Nerve Conduction Velocity Studies,
Muscle And Nerve Biopsies,
Neuroimaging Studies - MRI
Management- Multidisciplinary Approach
Physical Therapy Examination
Cognition
Pain
Psychosocial Function
Joint integrity, ROM and Muscle strength.
Motor Function: Gross motor and Fine motor
Muscle tone and reflexes
Cranial nerve integrity
Sensations
Gait
Respiratory Function
Physiotherapy goals in MND treatment.
Pain reduction
Prevention for contractures
Maintenance of joint mobility
Regular review of posture
Positioning to relieve discomfort
House Modification and ergonomic advice.
Management of Sialorrhea and Pseudobulbar Affect
Management for Dysphagia
PEG procedure.
A PEG may be recommended as the disease progresses.
A PEG is a type of gastrostomy tube inserted via endoscopic surgery that creates a permanent opening into the stomach for the introduction of food.
Studies have found that PEG insertion may prolong survival. Patients with PEG were found to live 1 to 4 months longer than those individuals who refused it.
Management of Dysphagia
A palatal lift prosthesis may be prescribed for individuals with good articulation but who have a breathy voice quality or decreased loudness because of excessive air loss through the nose.
The device, a dental appliance designed to attach to the existing teeth and to elevate the soft palate, is custom-made by a prosthodontist.
Já conheces a PNF? Neste artigo irás verificar as amplas possibilidades do conceito PNF, nomeadamente no caso de uma paciente com queixas ao nível do ombro.
better Rehabilitation through vibro-acoustic-therapy.pdfmichel582642
Sound vibrations and sound wave therapy and their positive effects on the human body have been extensively researched and sufficiently proven.
These studies on the subject of rehabilitation are intended to illustrate how broadly the spectrum of possible patient groups that could benefit from sound wave therapy can be defined. In addition, this form of therapy could be a so-called game changer for prevention.
Enjoy reading!
Michel Menzel
Founder of THERAPIEGOLD
www.therapiegold.de
Running head: NECK PAIN 1
NECK PAIN 2
NECK PAIN
Bamgbola Abitogun
Grand Canyon University
NRS 433V
April 2nd, 2017
Dosage impacts of spinal manipulative treatment for endless neck torment Comment by Denise Foti: APA: The first line of your paper needs to be your paper title not bold-faced
Neck pain is second most common spinal pain to low back torment among musculoskeletal grievances revealed in the all inclusive community and among those exhibiting to manual treatment suppliers. Ceaseless neck torment (i.e. neck torment enduring longer than 90 days) is a typical purpose behind introducing to a chiropractor's office, and such patients frequently get spinal control or activation. Comment by Denise Foti: Indent
Research question: In adults with chronic neck pain, what is the base measurements of control important to create a clinically vital change in neck pain contrasted with directed practice in 2 months Comment by Denise Foti: You need to revise this. Look at the example I provided the first day of class.
(P)-Population: Adults 18 to 60 years old, with a clinical conclusion of endless mechanical neck pain who have not gotten cervical spinal manipulative therapy in the previous year. Patients with non-mechanical neck agony or contraindications to cervical control will be rejected.
(I)-Intervention: Subjects randomized to have control would get standard rotational or sidelong break enhanced method once, twice, or three times each week over a time of 2, 4, or a month and a half. These subjects would likewise get a similar practice regimen given to the control gathering to take out practice as a moment variable influencing results.
(C)-Comparison-An institutionalized administered practice regimen would be utilized as a dynamic control bunch. All subjects, paying little heed to gathering task, would play out an institutionalized practice administration at every session over a time of a month and a half. Utilizing this methodology, we will have the capacity to limit the non-particular impacts because of going to a facility.
(O)-Outcome- Changes in neck pain, measured utilizing the 100mm VAS for agony.
(T)-Time-The result would be measured week by week for two months
Reference
Vernon, H., & Mior, S. (January 01, 1991). The Neck Disability Index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics, 14, 7, 409-15.
Injuries to the cervical spine, particularly those including the delicate tissues, speak to a huge wellspring of unending handicap. Techniques for appraisal for such inability, particularly those focused at exercises of day by day living which are most influenced by neck agony, are very few. An alteration of the Oswestry Low Back Pain Index was led ...
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
1. Fisioterapia Manual Avanzada
Movilización / Manipulación
MITOS Y REALIDADES
PARADIGMA BIOMECÁNICO
Gustavo
Plaza
Manzano
Fisioterapeuta
Facultad
de
Medicina
Universidad
Complutense
de
Madrid
La forma manual de aplicar un movimiento lento, rítmico y/o sostenido,
con la finalidad de reproducir movimientos accesorios y/o fisiológicos a lo
largo del rango de movilidad pasiva disponible de una articulación.
La forma manual de aplicar un impulso, repentino y preciso, de gran
velocidad y corta amplitud, cerca del final del rango de movilidad
disponible mediante la ejecución de un movimiento fisiológico, un
movimiento accesorio o una combinación de ambos.
Alcanza un espacio libre, “parafisiológico”, que se encuentra más allá del
ROM pasivo disponible.
Se distingue por la reproducción de un sonido, a modo de chasquido,
característico de articulaciones sinoviales con fuerte cohesión entre sus
superficies.
Vernon 2005
MOVILIZACIÓN - MANIPULACIÓN
TENSIÓN
AMPLITUD ARTICULARPN MP LAMA
80% 90%
2%
100%
ZONA NEUTRA ZONA ELÁSTICA
IV
IIIII
I
V
MOVILIZACIÓN - MANIPULACIÓN
2. Los mecanismos de acción de las técnicas de terapia manual no se
conocen por completo, pero se cree que los efectos mecánicos y
neurofisiológicos desempeñan un papel importante en los mismos.
POSIBLES EFECTOS MOVILIZACIÓN - MANIPULACIÓN
Sistemas del Dolor
Sistema Nervioso Simpático
Sistema Motor
Estructurales-Posturales-Biomecánicos
Mecanismo Placebo
Estimulación de los procesos de reparación tisular.
Modificación del entorno químico de los nociceptores
periféricos.
Activación de los mecanismos inhibitorios segmentarios.
Activación de los mecanismos inhibitorios descendentes.
Mecanismo Placebo.
Disminución de la Percepción de Dolor
Wright 2002
¿Qué ocurre en el tejido con el movimiento?
Normalización de la homeostasis del tejido conectivo.
El movimiento favorece el depósito de colágeno en la dirección
adecuada, mantiene el equilibrio entre los constituyentes del
tejido conectivo, refuerza la regeneración vascular normal, y
reduce la formación excesiva de puentes y adherencias.
Existe fuerte evidencia de que la tensión periódica y moderada
es esencial para la nutrición y viabilidad del tejido durante la
curación.
3. Sistema Modulador Descendente
Representado a nivel del tronco cerebral
(SGP, RVM, DLTP), y se encuentran bajo la
influencia del cerebro anterior (corteza y
límbico).
Puede atenuar o aumentar la transmisión
nociceptiva, produciendo analgesia o
hiperalgesia, respectivamente.
Efectos sobre el dolor
Numerosos trabajos estudian su efecto sobre el umbral de
sensibilidad mecánica y térmica al dolor y sobre las respuestas del
sistema nervioso simpático.
Se puede concluir que;
Parecen existir respuestas hipoalgésicas inmediatas, medidas por
el aumento de sensibilidad mecánica al dolor y por la disminución
de los campos de referencia cutánea del mismo.
Estas respuestas no parecen haber influido sobre el umbral de
sensibilidad térmica.
Vicenzino 1998, Vernon 2000, Sterling 2001
No presenta características opioides:
- No afecta a niveles de β-endorfinas.
- No revierte con Naloxona.
- No muestra tolerancia tras aplicaciones repetidas.
- Se atenúa con antagonistas de receptores noradrenérgicos y se
bloquea con antagonistas de receptores serotonérgicos (Skyba
2003).
Considerable evidencia respalda que la movilización articular es un
estímulo suficiente para inducir respuestas excitatorias simpáticas. Parece
existir una correlación entre la rapidez y magnitud de la respuesta
excitatoria simpática con el aumento del umbral de sensibilidad mecánica
al dolor.
Efectos sobre el Dolor y el SNS
Christian 1998, Vicenzino 2000, Souvlis 1999, Paungmali 2003
5. Original article
Immediate effects of spinal manipulation on nitric oxide, substance P
and pain perception
Francisco Molina-Ortega a
, Rafael Lomas-Vega a
, Fidel Hita-Contreras a,*,
Gustavo Plaza Manzano b
, Alexander Achalandabaso a
, Antonio J. Ramos-Morcillo a
,
Antonio Martínez-Amat a
a
Department of Health Sciences, University of Jaén, Campus Las Lagunillas s/n, 23071 Jaén, Spain
b
Department of Physical Medicine and Rehabilitation, Complutense University School of Medicine, Avda. de Séneca, 2. Ciudad Universitaria, 28040 Madrid,
Spain
a r t i c l e i n f o
Article history:
Received 6 September 2013
Received in revised form
15 February 2014
Accepted 23 February 2014
Keywords:
Spinal manipulation
Substance P
Nitric oxide
Pressure pain threshold
a b s t r a c t
Previous studies have analyzed the effects of spinal manipulation on pain sensitivity by using several
sensory modalities, but to our knowledge, no studies have focused on serum biomarkers involved in the
nociceptive pathway after spinal manipulation. Our objectives were to determine the immediate effect of
cervical and dorsal manipulation over the production of nitric oxide and substance P, and establishing
their relationship with changes in pressure pain thresholds in asymptomatic subjects. In this single-blind
randomized controlled trial, 30 asymptomatic subjects (16 men) were randomly distributed into 3
groups (n ¼ 10 per group): control, cervical and dorsal manipulation groups. Blood samples were
extracted to obtain serum. ELISA assay for substance P and chemiluminescence analysis for nitric oxide
determination were performed. Pressure pain thresholds were measured with a pressure algometer at
the C5eC6 joint, the lateral epicondyle and the tibialis anterior muscle. Outcome measures were ob-
tained before intervention, just after intervention and 2 h after intervention. Our results indicated an
increase in substance P plasma level in the cervical manipulation group (70.55%) when compared with
other groups (p < 0.05). This group also showed an elevation in the pressure pain threshold at C5eC6
(26.75%) and lateral epicondyle level (21.63%) immediately after the intervention (p < 0.05). No changes
in nitric oxide production were observed. In conclusion, mechanical stimulus provided by cervical
manipulation increases substance P levels and pressure pain threshold but does not change nitric oxide
concentrations. Part of the hypoalgesic effect of spinal manipulation may be due to the action of sub-
stance P.
Ó 2014 Elsevier Ltd. All rights reserved.
1. Introduction
Manipulation of the spine is a manual therapy technique per-
formed to increase range of motion in a joint with decreased joint
play, with the intention of relieving the pain of patients. Spinal
manipulation (SM) involves a high velocity “impulse” or “thrust” of
short amplitude which is applied to interapophyseal joints. The
effectiveness of SM to treat musculoskeletal pain has been sum-
marized in recent systematic reviews. Overall, evidence suggests
that SM provides greater relief for pain and function than a placebo
or no treatment (Gross et al., 2010; van Middelkoop et al., 2011).
Although SM is widely used in the management of pain, the
physiological basis of its effectiveness remains unknown. It has
been proposed that the mechanical stimuli generated by SM could
activate the liberation of many biochemical mediators from neural
tissue (Skyba et al., 2003).
The perception of pain is clearly a complex process due to the
high number of biochemical mediators involved. Nitric oxide (Ne
O), considered as the major local vasodilator (Takuwa et al., 2010), is
a small molecule with a dual role in cell survival (Cauwels et al.,
2005) and nociception (Millan, 2002). Nitric oxide is a diffusible
gas that rapidly reacts with oxygen to form nitric oxide derivates
such as nitrite and nitrate (Lundberg et al., 2008). Although evi-
dence exists regarding the beneficial effects of the release of small
amounts of NeO during the inhibition of nociceptive pathways
* Corresponding author. Department of Health Sciences (B-3/272), University of
Jaén, Campus Las Lagunillas s/n, 23071 Jaén, Spain. Tel.: þ34 953 212921; fax: þ34
953 211875.
E-mail address: fhita@ujaen.es (F. Hita-Contreras).
Contents lists available at ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
http://dx.doi.org/10.1016/j.math.2014.02.007
1356-689X/Ó 2014 Elsevier Ltd. All rights reserved.
Manual Therapy xxx (2014) 1e7
Please cite this article in press as: Molina-Ortega F, et al., Immediate effects of spinal manipulation on nitric oxide, substance P and pain
perception, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.02.007
hrust was applied following the
on.
ded to the intervention of the
ures and blood samples were ob-
intervention), immediately just
ention) and 2 h after intervention
acted by venipuncture of the ce-
stem (BectoneDickinson, United
tubes for serum separation (BD
367953). After blood extraction,
mperature for 1 h until the blood
entrifuged for 10 min at 2000 g
USA). Supernatant was collected,
l used.
awed serum aliquots were mixed
buffer (0.5 N NaOH, 10% ZnSO4),
om temperature for 15 min. After
or 5 min at 13,500 rpm and su-
aintained at 4 C until analyzed.
de and NeO derivates was deter-
ocedure described by Braman and
the purge system of Sievers In-
Analytical Instruments, USA). Ni-
ncentrations were calculated by
ns of sodium nitrate. Nitric oxide
rmalized with total protein con-
mined using the Bradford assay
s determined by using LuminexÒ
kit (Milliplex Ref: HNP-35K, Mil-
re normalized with total protein
concentration of each sample calculated by the Bradford method
(Bradford, 1976).
2.3.4. Pressure pain threshold
A pressure algometer (Pain TestÔ FPN 100, Wagner Instruments,
USA) was used to measure PPT. In this study several PPT points
were used to determine the local or regional (C5eC6 zygapophyseal
joint, lateral epicondyle) and global effects (tibialis anterior) of the
spinal manipulation to verify the presence of segmental and/or
central modulation of pain (Urban and Gebhart, 1999; Schaible,
2007). All measurements were carried out by a well-trained expert.
2.4. Statistical analysis
Demographic and experimental data were treated with the
SPSSÒ
19.0 (IBM, USA) and MedCalc 12.3 (MedCalc, Belgium)
cic (n ¼ 10) Cervical (n ¼ 10)
Æ SD Mean Æ SD p-value
Æ 4.52 27.80 Æ 3.99 0.095
Æ 14.33 71.20 Æ 14.19 0.196
Æ 0.06 1.75 Æ 0.12 0.528
Æ 15.83 38.23 Æ 18.34 0.930
Æ 0.03 0.25 Æ 0.17 0.021*
Æ 1.54 3.29 Æ 0.98 0.622
Æ 1.61 4.30 Æ 1.65 0.462
Æ 2.23 7.85 Æ 2.25 0.721
9 Æ 29.44 123.53 Æ 27.07 0.892
hreshold at C5eC6 zygapophyseal joint);
ateral epicondyle); PPT Tib (pressure pain
al protein.
total protein.
Table 2
Test-retest reliability for outcomes variables.
Variable CCI SEM MDC
Substance P 0.679 5.303 10.39
Nitric oxide 0.620 0.012 0.02
PPT C5eC6 0.781 0.239 0.47
PPT Epi 0.736 1.768 3.46
PPT Tib 0.913 0.546 1.07
Abbreviations: CCI (Intraclass Correlation Coefficient); SEM (Standard Error of
Measurement); MDC (Minimal Detectable Change); PPT C5eC6 (pressure pain
threshold at C5eC6 zygapophyseal joint); PPT Epi (pressure pain threshold at right
lateral epicondyle); PPT Tib (pressure pain threshold at tibialis anterior muscle).
Fig. 2. Mean plots for primary measures in each group and each time point.
: Molina-Ortega F, et al., Immediate effects of spinal manipulation on nitric oxide, substance P and pain
4), http://dx.doi.org/10.1016/j.math.2014.02.007
Kingdom). Blood was collected in tubes for serum separation (BD
Vacutainer SST II Advance, ref. 367953). After blood extraction,
tubes were let stand at room temperature for 1 h until the blood
clotted. Afterward, tubes were centrifuged for 10 min at 2000 g
(Avanti J-30I, Beckman Coulter, USA). Supernatant was collected,
aliquoted and kept at À80 C until used.
2.3.2. Nitric oxide determination
To carry out the analysis, the thawed serum aliquots were mixed
in 1/2/2 (w/v/v) deproteinization buffer (0.5 N NaOH, 10% ZnSO4),
briefly shaken and let stand at room temperature for 15 min. After
that, samples were centrifuged for 5 min at 13,500 rpm and su-
pernatants were collected and maintained at 4 C until analyzed.
The total amount of nitric oxide and NeO derivates was deter-
mined by a modification of the procedure described by Braman and
Hendrix (1989) using NOA 280i the purge system of Sievers In-
struments, model NOA 280i (GE Analytical Instruments, USA). Ni-
tric oxide and NeO derivates concentrations were calculated by
comparison with standard solutions of sodium nitrate. Nitric oxide
and NeO derivates data were normalized with total protein con-
centration of each sample determined using the Bradford assay
(Bradford, 1976).
2.3.3. Substance P determination
Plasma determination of SP was determined by using LuminexÒ
technology with a specific ELISA kit (Milliplex Ref: HNP-35K, Mil-
lipore, USA). Substance P data were normalized with total protein
2.3.4. Pressure pain threshold
A pressure algometer (Pain TestÔ FPN 100, Wagner Instruments,
USA) was used to measure PPT. In this study several PPT points
were used to determine the local or regional (C5eC6 zygapophyseal
joint, lateral epicondyle) and global effects (tibialis anterior) of the
spinal manipulation to verify the presence of segmental and/or
central modulation of pain (Urban and Gebhart, 1999; Schaible,
2007). All measurements were carried out by a well-trained expert.
2.4. Statistical analysis
Demographic and experimental data were treated with the
SPSSÒ
19.0 (IBM, USA) and MedCalc 12.3 (MedCalc, Belgium)
Table 1
Baseline characteristics of participants.
Characteristics Control (n ¼ 10) Thoracic (n ¼ 10) Cervical (n ¼ 10)
Mean Æ SD Mean Æ SD Mean Æ SD p-value
Age 25.80 Æ 3.22 29.80 Æ 4.52 27.80 Æ 3.99 0.095
Weight 63.60 Æ 8.47 73.70 Æ 14.33 71.20 Æ 14.19 0.196
Height 1.71 Æ 0.07 1.75 Æ 0.06 1.75 Æ 0.12 0.528
Substance Pa
35.84 Æ 9.36 36.23 Æ 15.83 38.23 Æ 18.34 0.930
Nitric oxideb
0.19 Æ 0.02 0.12 Æ 0.03 0.25 Æ 0.17 0.021*
PPT C5eC6c
3.76 Æ 0.51 3.44 Æ 1.54 3.29 Æ 0.98 0.622
PPT Epic
5.60 Æ 3.44 4.63 Æ 1.61 4.30 Æ 1.65 0.462
PPT Tibc
8.54 Æ 1.85 7.89 Æ 2.23 7.85 Æ 2.25 0.721
Protein
contentd
129.68 Æ 35.84 128.79 Æ 29.44 123.53 Æ 27.07 0.892
*p 0.05.
Abbreviations: PPT C5-C6 (pressure pain threshold at C5eC6 zygapophyseal joint);
PPT Epi (pressure pain threshold at right lateral epicondyle); PPT Tib (pressure pain
threshold at tibialis anterior muscle).
a
Substance P is expressed as pg/mg total protein.
b
Nitric oxide is expressed as mmol/mg total protein.
c
PPTs are expressed as kg/cm2
.
d
Protein content is expressed as mg/ml. Fig. 2. Mean plots for primary measures in each group and each time point.
Please cite this article in press as: Molina-Ortega F, et al., Immediate effects of spinal manipulation on nitric oxide, substance P and pain
perception, Manual Therapy (2014), http://dx.doi.org/10.1016/j.math.2014.02.007
Considerable evidencia muestra que
la Movilización / Manipulación es un
estímulo suficiente para inducir
respuestas analgésicas inmediatas.
Movilización / Manipulación
Es muy probable que áreas específicas del cerebro y del
SNC coordinen estas respuestas.
Schmid 2008, Bialosky 2009, Wright 1995
Efectos sobre la actividad motora
Existe suficiente apoyo documental para afirmar que la
movilización/manipulación genera respuestas neuromusculares
reflejas asociadas, con efectos inhibidores y facilitadores.
Existe cierta evidencia para pensar que dichas respuestas están
mediadas por la estimulación mecánica de receptores musculares
y articulares, tanto de bajo como alto umbral. Sin embargo, los
mecanismos neurofisiológicos exactos aún son desconocidos.
Se desconoce la relevancia clínica de dichas respuestas.
Gila 2007, Herzog 1999, Lehman 2001, Murphy 1995
6. El concepto de que la manipulación reposiciona, coloca o mejora la
alineación de las articulaciones es una de las teorías más antiguas
acerca de la misma. Y constituye el principal mito de la Terapia
Manual.
Estudios biomecánicos recientes que examinan el movimiento
vertebral tras una manipulación muestran que esta teoría
“posicional” es falsa.
Simplemente demuestran un movimiento vertebral transitorio y
asociado a la separación de las superficies articulares.
La radiografía, el TAC o la RMN han mostrado ser métodos poco fiables
para el diagnóstico de dolor de espalda. En relación a fuentes de
dolor de espalda, la mal-posición vertebral parece ser un
epifenómeno.
Evans 2002
Paradigma Biomecánico Movilización / Manipulación
Una de la razones para la concepción de esta teoría se relaciona
con la reproducción del ruido articular asociado a la manipulación
y causado por la cavitación, el cuál a menudo convenientemente
coincide con la mejoría inmediata del dolor.
Antes de que el fenómeno de la cavitación fuera aceptado como
el responsable del sonido, los practicantes de la manipulación
asociaban el sonido a la sensación de haber “reposicionado el
hueso en su lugar”.
Muchos pacientes sostienen todavía este concepto de reposición,
y la educación de los mismos para disipar estas creencias es
necesaria.
Evans 2002
Paradigma Biomecánico Movilización / Manipulación
Cramer 2002
Paradigma Biomecánico Movilización / Manipulación
7. Cramer 2002
Paradigma Biomecánico Movilización / Manipulación
Se ha investigado en sujetos con dolor si la manipulación puede
modificar la posición entre el sacro y el ilíaco y si los test
posicionales son válidos para determinar las relaciones espaciales
entre el sacro y el ilíaco.
Los test posicionales se interpretaron como positivos antes de la
manipulación y como negativos tras la misma.
Sin embargo, en los sujetos a estudio la manipulación no modificó
la posición del sacro en relación al ilíaco.
Tullberg 1998
Paradigma Biomecánico Movilización / Manipulación
El concepto de Subluxación Quiropráctica es la base esencial
de la Quiropraxia.
“No se encuentra evidencia que apoye que la subluxación
quiropráctica esté asociada a ningún proceso de enfermedad,
o a crear condiciones subóptimas de salud que requieran
intervención”.
Al demostrarse por imagen que no existían mal-posiciones
vertebrales, se redefinió el término de subluxación quiropráctica:
Mirtz 2009
“Conjunto de cambios patológicos y/o estructurales y/o
funcionales articulares que comprometen la integridad
neural, y que pueden influir en la función de los sistemas,
órganos y en la salud general”.
Paradigma Biomecánico Movilización / Manipulación
8. En los 114 años desde el comienzo de la Quiropraxia nunca se
ha podido demostrar objetivamente la existencia de las
subluxaciones quiroprácticas.
Nunca se ha mostrado que causen interferencia con el
sistema nervioso.
Nunca se ha demostrado que provoquen enfermedades.
Los críticos de la quiropraxia llevan señalando esto desde
hace décadas, pero ahora los mismos quiropractores llegan a
ésta misma conclusión.
Mirtz 2009
Paradigma Biomecánico Movilización / Manipulación
Datos de 367 encuestas a fisioterapeutas especializados en terapia
manual
En relación al examen del movimiento pasivo intervertebral:
El hallazgo clínico más importante a la hora de tomar una
decisión diagnóstica es el cambio en la resistencia percibida al
final del ROM “end feel”.
En menos medida, la provocación o alivio del dolor del paciente
o la resistencia percibida a lo largo del ROM.
Trijffel 2009
Paradigma Biomecánico Movilización / Manipulación
Además,
Consideran que este examen es importante a la hora de tomar
decisiones terapéuticas.
Confían en que las conclusiones del mismo son válidas.
(la investigación de la validez y precisión no permite conclusiones definitivas)
La mayoría confía en poder llegar a la misma conclusión clínica
que otro compañero.
(la evidencia es clara, la fiabilidad inter-examinador es inaceptablemente baja)
Trijffel 2009
Paradigma Biomecánico Movilización / Manipulación
9. Datos de 466 encuestas a fisioterapeutas especializados en terapia
manual Estados Unidos y Nueva Zelanda.
En relación al examen del movimiento pasivo intervertebral:
La mayoría consideraron que es un procedimiento preciso para
estimar la cantidad de movimiento presente en la columna
lumbar.
(restricción de movimiento, movimiento normal o exceso de
movimiento)
Abbott 2009
Paradigma Biomecánico Movilización / Manipulación
Además, la mayoría admite:
Seleccionar diferentes opciones de tratamiento en base, al
menos en parte, a los hallazgos del examen del movimiento
pasivo intervertebral.
Que para determinar la expectativa de movimiento que se
espera en cada segmento compara la respuesta con los
segmentos situados inmediatamente por encima y por
debajo.
Abbott 2009
Paradigma Biomecánico Movilización / Manipulación
¿Qué consideras que estás intentando evaluar cuando realizas un
movimiento intervertebral pasivo fisiológico en la columna lumbar?
Abbott 2009
10. Datos de 118 encuestas a fisioterapeutas especializados en terapia
manual Canadá.
En relación a la indicación o no de la manipulación vertebral:
La mayoría consideró que los hallazgos relacionados con
hipomovilidad eran los más importantes para indicar o no una
manipulación.
- Fijación o bloqueo articular segmentario. 90%.
- Rigidez o limitación de movimiento. 81%
Hurley 2002
Paradigma Biomecánico Movilización / Manipulación
Diferentes disciplinas o líneas de pensamiento en Terapia
Manual hacen uso de sistemas de clasificación del movimiento
intervertebral basados en percepciones subjetivas relacionadas
con la amplitud, calidad o sensación final del movimiento para
la toma de decisiones clínicas.
Una parte de estas disciplinas atribuyen el hallazgo de rigidez o
hipomovilidad segmentaria como el principal criterio a la hora
de seleccionar la manipulación como una opción de
tratamiento.
Paradigma Biomecánico Movilización / Manipulación
Mediante RMN se compara la movilidad pasiva intervertebral lumbar
entre 45 pacientes con dolor lumbar y 20 sujetos asintomáticos.
Como procedimiento de evaluación se utiliza la movilización PA
lumbar.
El número de sujetos que presentó hipomovilidad fue muy bajo:
4.4% de los pacientes.
10% de los sujetos asintomáticos.
Es más, el 40% de los pacientes presentó hipermovilidad en uno o
más segmentos de la columna.
Kulig 2007
Paradigma Biomecánico Movilización / Manipulación
11. Un experimentado osteópata es capaz de identificar, con buena
fiabilidad, la articulación lumbar con signos de disfunción
segmentaria que se pueda beneficiar de una manipulación
vertebral. Lesión Manipulable.
Sin embargo, en la columna dorsal y sin estar entrenado, el mismo
osteópata tiene moderada a baja fiabilidad en identificar signos de
disfunción segmentaria.
Esto en una muestra de SUJETOS ASINTOMÁTICOS.
Potter 2006
Paradigma Biomecánico Movilización / Manipulación
En relación al examen del movimiento pasivo intervertebral.
Clasificar los hallazgos en base a percepciones subjetivas
relacionadas con la amplitud, calidad, resistencia o sensación
final del movimiento ha demostrado tener poca o ninguna
fiabilidad cuando se compara la concordancia de los resultados
entre diferentes examinadores.
La evidencia es clara en este sentido.
Paradigma Biomecánico Movilización / Manipulación
La evidencia recopilada de los estudios incluidos en esta
revisión sistemática indica que la fiabilidad inter-
examinador, por parte de los terapeutas manuales, del
examen del movimiento pasivo intervertebral de la
columna cervical y lumbar es baja.
Trijffel 2005
Fiabilidad y Validez en la Evaluación del Movimiento Pasivo Intervertebral
12. Más importante que medir el acuerdo de los hallazgos
subjetivos del movimiento entre diferentes evaluadores es:
Medir hasta que punto concuerdan las percepciones
subjetivas del movimiento intervertebral con la evaluación
objetiva del mismo.
Fiabilidad y Validez en la Evaluación del Movimiento Pasivo Intervertebral
A través de una movilización PA lumbar, 2 examinadores
muestran concordancia buena para el nivel vertebral menos
móvil y concordancia mala para el nivel más móvil.
En ningún momento hubo concordancia de estos hallazgos con
la medición del desplazamiento vertebral en RMN dinámica.
Estos resultados ponen en seria duda la validez de estos
procedimientos como método de evaluación del movimiento
intervertebral.
Landel 2008
Fiabilidad y Validez en la Evaluación del Movimiento Pasivo Intervertebral
Los resultados de la investigación ponen en seria duda la validez
de estos procedimientos como método de evaluación del
movimiento intervertebral.
Ninguna de las pruebas de posición y movilidad articular son
útiles si carecen de fiabilidad interexaminador. El mismo paciente
puede ser diagnosticado por un fisioterapeuta en tener
problemas de hipermovilidad y por otro en tener problemas de
hipomovilidad, lo que puede resultar en diferentes estrategias de
tratamiento.
Para que una prueba pueda ser considerada útil como apoyo a
un conjunto o agrupación de pruebas, primero debe mostrar su
validez y fiabilidad.
Fiabilidad y Validez en la Evaluación del Movimiento Pasivo Intervertebral
Johanson 2006
13. La investigación acerca de la aplicación de movilización y
manipulación ha mostrado lo poco específicos que son estos
procedimientos.
La cavitación producida durante la manipulación de la columna
lumbar no se da en el segmento deseado en +50% de los casos y
sólo es específica (cavitación única del nivel deseado) en el 36%
de los casos.
No existe correlación entre la manipulación vertebral específica y
la localización de la cavitación en la columna lumbar y ASI.
Parece que ni siquiera es necesario la reproducción del sonido
para que la misma sea efectiva.
Paradigma Biomecánico Movilización / Manipulación
Ross 2004, Beffa 2004, Flynn 2003
La investigación acerca de la aplicación de movilización y
manipulación ha mostrado lo poco específicos que son estos
procedimientos.
Mediante RMN se ha demostrado que aplicar movilizaciones PA
en la región cervical o lumbar produce movimientos en todos los
segmentos vertebrales de cada región.
Por tanto, no pueden ser consideradas como simples
deslizamientos de una vértebra sobre otra.
Paradigma Biomecánico Movilización / Manipulación
Lee 2005, Powers 2003
En relación al tratamiento por movilización y manipulación
Diferentes formas de movilización y manipulación parecen
tener efectos similares en cuanto a dolor y función
percibida.
Estos efectos no parecen depender de la selección de la
técnica más “apropiada”.
Paradigma Biomecánico Movilización / Manipulación
14. En sujetos con dolor lumbar, se compara el efecto de un tratamiento
específico basado en el examen del paciente (nivel vertebral, tipo
de técnica y forma de aplicarla) con el efecto de un tratamiento
elegido al azar.
Ambos grupos mostraron reducción significativa del dolor y una
mejor función.
Elegir la técnica que parece ser la más apropiada no superó
ningún resultado medido en este estudio.
Chiradejnant 2003
Paradigma Biomecánico Movilización / Manipulación
En pacientes con dolor lumbar crónico se compara el efecto inmediato, en
la intensidad del dolor y en el umbral de dolor a la presión, de una
manipulación lumbar específica (basada en el examen físico) con el
efecto de una manipulación torácica superior.
Ambos grupos mostraron una mejora clara en el dolor y en el UDP.
En pacientes con dolor lumbar crónico, elegir una manipulación lumbar
específica no produce un mejor efecto inmediato sobre el dolor y el
Fernando de Oliveira 2013
Paradigma Biomecánico Movilización / Manipulación
En pacientes con radiculopatía cervical se compara el efecto en dolor,
ROM y función de un set de movilizaciones y ejercicios de estabilización
con el efecto de añadir, al mismo programa, técnicas dirigidos a aumentar
el tamaño del foramen intervertebral.
Ambos grupos mostraron una mejoría clínica y estadísticamente
significativa en el seguimiento a 4 y 8 semanas.
Añadir técnicas dirigidas a aumentar el FIV no produce un mejor efecto
Langevin P 2015
Paradigma Biomecánico Movilización / Manipulación
15. En sujetos con dolor de cuello se compara el efecto de una
manipulación cervical en rotación con el efecto de una
manipulación cervical lateral que fueron asignadas al azar.
No se encontraron diferencias mostrando ambos grupos mejoras
significativas en cuanto a dolor y rango de movimiento después
de 10 sesiones de tratamiento y en el seguimiento a un mes.
En sujetos con dolor cuello, se ha comparado el efecto de una
manipulación específica dirigida al segmento “hipomóvil” con el
efecto de la misma manipulación en un segmento elegido al
azar.
Los resultados no encuentran diferencias entre los grupos
mostrando ambos reducción en el dolor cervical.
Paradigma Biomecánico Movilización / Manipulación
Schalkwyk 2000, Haas 2003
Un metaanálisis compara los resultados de diferentes ensayos
clínicos en los que se elige o no un procedimiento de movilización
y/o manipulación específico para sujetos con dolor lumbar.
En aproximadamente 2/3 de los ensayos, se había elegido un
procedimiento específico.
Sin embargo, no existían diferencias a favor de estos ensayos.
La elección o no de una técnica específica de movilización /
manipulación no parece influir en un mayor efecto de la
Terapia Manual en el dolor lumbar.
Kent 2005
Paradigma Biomecánico Movilización / Manipulación
No se han identificado cambios biomecánicos duraderos.
Los clínicos son incapaces de identificar de forma fiable qué
alteraciones biomecánicas requieren TM.
Las fuerzas asociadas con la TM no son específicas para una
localización determinada y son variables entre los clínicos.
La elección de la técnica que parece ser la más apropiada, en un
análisis biomecánico, no parece que influya en los resultados.
Las respuestas de signos y síntomas se producen en áreas alejadas de la
región de aplicación.
A pesar de estas inconsistencias con el modelo biomecánico, otros
mecanismos adicionales pueden ser pertinentes para entender los
efectos de la TM.
Se sugiere que la fuerza mecánica es necesaria para iniciar una cadena
de respuestas neurofisiológicas que producen los resultados asociados
con la TM.
Bialosky 2009
Mecanismos de la Terapia Manual
16. En relación a las manipulaciones vertebrales en los modelos biomecánicos
tradicionales.
Las manipulaciones vertebrales NO colocan los huesos en su lugar.
Las manipulaciones vertebrales NO producen cambios duraderos en la
posición de las articulaciones.
La investigación ha demostrado que un diagnóstico de mal-posición NO
debe ser un criterio para seleccionar una técnica de manipulación.
En más de la mitad de las veces, la manipulación NO se produce en la
articulación seleccionada y, rara vez, es específica de esa articulación.
Con un análisis de posición o de movilidad vertebral, la elección de un
nivel vertebral hipomóvil o en “bloqueo” NO influye en un mayor efecto
clínico de la manipulación. Además, esta elección, NO supera el efecto
de técnicas elegidas al azar.
Paradigma Biomecánico Movilización / Manipulación
En relación a las pruebas pasivas de posición y movilidad intervertebral:
Carecen de un estándar de comparación válido.
NO permiten medir de forma precisa el movimiento pasivo
intervertebral.
Otro compañero entrenado NO obtiene los mismos resultados, lo que
conduce a categorías diagnósticas y tratamientos diferentes. Incluso el
mismo terapeuta NO concuerda con sus propios resultados en
momentos diferentes.
Las alteraciones de posición y movilidad son tan comunes en la gente
con dolor que sin dolor de espalda. Por tanto, NO se correlacionan con
el dolor y no pueden ser consideradas causas del mismo.
La elección de la técnica que parece ser más apropiada, con este
examen biomecánico, NO produce mayor efecto clínico que las
Paradigma Biomecánico Movilización / Manipulación
Paradigma Biomecánico Movilización / Manipulación
Parece evidente que evaluar el movimiento mediante percepciones
subjetivas no es válido para tomar decisiones terapéuticas. Existe una alta
probabilidad de elegir y aplicar un tratamiento erróneo.
En relación al examen del movimiento intervertebral, ¿existe alguna utilidad
que sea respaldada por la investigación?
Las movilizaciones PA en columna cervical y lumbar han mostrado alto
grado de sensibilidad y especificidad al ser comparadas con bloqueos
anestésicos.
Tienen concordancia alta, inter e intra examinador, para detectar
niveles vertebrales sintomáticos.
Dependen en cierto grado de la comunicación verbal con el paciente
para lograr la concordancia perfecta.
Jull 1988, 1997, Phillips 1996
17. ¿Qué consideras que estás intentando evaluar cuando realizas un
movimiento pasivo accesorio PA central en la columna lumbar?
Abbott 2009
Existe evidencia parcial acerca del efecto de una intervención
por movilización / manipulación seleccionada en base a la
localización de niveles vertebrales sintomáticos.
(Niveles vertebrales en donde el procedimiento manual reproduce
parcial o totalmente el dolor del paciente).
Se ha demostrado que la movilización produce mayor
reducción de dolor cuando ésta se aplica en el nivel vertebral
que el fisioterapeuta identifica como más sintomático y con
mayor capacidad de reproducir el síntoma del paciente.
Chiradejnant 2002
Paradigma Biomecánico Movilización / Manipulación
“La incapacidad de demostrar la superioridad sobre el placebo no
implica falta de eficacia; puede reflejar únicamente similitud de
mecanismos. La comparación de un tratamiento con el placebo no
es, en consecuencia, una comparación de dos mecanismos, sino tan
sólo la comparación de su capacidad de activar el mismo
mecanismo….”. Lawes 2002
Mecanismos cerebrales específicos
parecen mediar la respuesta al placebo.
El grado en que una persona responde a
un placebo está vinculado íntimamente a
la actividad que registre el área del
cerebro destinada a obtener un beneficio
o una recompensa.
Mecanismo Placebo
Lawes 2002, Scott 2007
18. Se ha estudiado el efecto en la percepción de dolor de crear
expectativas positivas, negativas o neutras en cuanto al resultado
de la manipulación.
Expectativa positiva: “la manipulación es un procedimiento muy
efectivo que se utiliza para tratar el dolor lumbar bajo, y
esperamos que reduzca su percepción de dolor”.
Expectativa negativa: “la manipulación es un procedimiento
ineficaz que se utiliza para tratar el dolor lumbar bajo, y
esperamos un empeoramiento temporal de su percepción de
dolor”.
Expectativa neutra: “la manipulación es un procedimiento que
se utiliza para tratar el dolor lumbar bajo y desconocemos sus
efectos en la percepción de dolor”.
Bialosky 2008
Mecanismo Placebo
Los sujetos que reciben la expectativa negativa muestran un aumento
importante en la percepción de dolor en el área corporal donde se
crea la expectativa del resultado, y que parece condicionar el
efecto de hipoalgesia que se atribuye a la manipulación.
La mayor parte de los estudios de investigación en Terapia
Manual concluyen que ésta puede ser efectiva en el alivio
del dolor y en la mejoría de la función en pacientes con
dolor musculoesquelético.
No está claro cómo deben ser aplicadas las diferentes
maniobras en relación al orden de las mismas, intensidad,
frecuencia, tiempo de duración, etc...
Movilización / Manipulación