Many excellent textbooks have been written on the topics of sports medicine and manual medicine. So what is different about this one? The idea behind this book is to integrate the principles of manual medicine with sports medicine, highlighting the natural overlap between them.
A fundamental concept in sports medicine is the use of active rehabilitation techniques that result in the safe and timely return of the injured athlete to participation in his or her sport. Coaches as well as athletes expect sports medicine physicians to use all available clinical tools to effectively rehabilitate the injured athlete. Manual medicine techniques are useful tools that can help in this process and are widely accepted by the athletic community. Consequently, we as sports medicine physicians need to be familiar with the concepts and practice of manual medicine. Even if one chooses not to actively use these therapies, many coaches and athletes have the expectation that a sports medicine physician will be familiar enough with these techniques to refer an athlete for manual medicine therapy when it is appropriate and may be beneficial. This text is designed to serve as a resource to sports medicine clinicians experienced in the practice of manual medicine as well as an introductory text to those interested in learning more about manual medicine techniques and their application in sports medicine.
WHAT IS MANUAL MEDICINE?
Manual medicine is not a single technique or type of therapy; rather, it encompasses a spectrum of therapeutic elements. Many of the techniques traditionally used by physical therapists and athletic trainers fall into the realm of manual medicine. Massage and stretching, for example, are types of manual medicine. When a physician refers a patient to physical therapy, there is a good chance that some type of manual medicine will be part of his or her treatment.
The basic concepts of manual medicine probably represent one of the oldest forms of medical therapy. Early references are found in the writings of Hippocrates (ca. 460-377 B.C.) and in the early Chinese medical literature. More recent developments in manual medicine techniques started after Andrew Taylor Still founded osteopathic medicine in 1874 and started the first college of osteopathy in 1892 (1). Chiropractic practitioners have also contributed to the development of manual medicine since Daniel David Palmer founded the first chiropractic school in 1895. Manual medicine concepts have continued to develop throughout the twentieth century on an international level. Some of the more prominent figures include Cyriax and Mennell (Great Britain), Lewit (Czech Republic), Dvorak (Switzerland), and Greenman (United States).
Manual medicine terminology is not completely standardized and can be confusing. There are, however, categories of manual therapy techniques and general terms that are consistently used by most practitioners. A modification of the categories used by Greenman (2) and Schneider and Dvorak (3), including the techniques most commonly used in sports medicine and, in particular, those techniques described in this text, is outlined below.
Soft tissue techniques. These techniques enhance muscle relaxation, flexibility, and circulation of body fluids. The focus is primarily on restoring physiologic movements
to altered joint mechanics. Techniques covered in this text include massage, stretching, strain-counterstrain, myofascial release, “muscle energy,” “unwinding,” and indirect functional techniques.
Mobilization techniques [also known as mobilization without impulse (the term impulse refers to a quick force of moderate intensity that is applied across a joint) or “articulation” techniques]. In these techniques, the joint is gently carried repeatedly and passively through the normal range of motion. The purpose is to increase the range of motion in a joint where the normal motion has become restricted. Examples used in this text include facilitated positional release and joint play.
Manipulation techniques [also called high-velocity, low-amplitude (HVLA) technique or manipulation with impulse]. These have been developed to restore the symmetry of the movements associated with the vertebral or extremity joints.
A basic concept in manual therapy is that the techniques are on a continuum based on the amount of force needed to perform them. The three categories described differ mainly in the focus of the maneuver (soft tissue versus joint) and the amount and type of force placed on the joint (impulse versus no impulse). Soft tissue techniques require the least force, and manipulation techniques require the most force. The amount of force used in a technique relates not only to the risk of injury to the patient but also to the skill and experience needed by the clinician to perform it effectively and safely. With greater force, there is a greater risk of complications, which requires a highly trained clinician to safely perform the technique. This continuum is illustrated in Figure 1.1.
In general, acute problems respond best to the least forceful techniques, and subacute and chronic problems respond to a combination of techniques. Specific technique(s) chosen depend on the nature of the problem and the training and experience of the clinician.