Manipulation of Key Joints
George DeFranca
Brett Winchester
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
Acknowledge the benefits of manipulation in the rehabilitation setting.
Recognize the genesis of joint fixation.
Understand that joints move and get restricted in different planes.
Grasp pertinent articular neurology.
List contraindications to manipulative therapy.
Realize the manipulative treatment of key joints commonly involved in disturbance of the locomotor system.
Couple joint palpations with manipulation.
“Have a heart that never hardens, a temper that never tires, a touch that never hurts.
–CHARLES DICKENS
Introduction
This is a very exciting time for practitioners who are utilizing manipulation. The last decade has produced a wealth of research justifying this misunderstood treatment modality. Perhaps we are just beginning to scratch the surface on the neurologic implications of manipulation. Yet, writing a chapter based solely on manipulation carries the risk of having the reader take the information out of context, assuming that treating functional disturbances of the locomotor system only involves manipulating joints. This chapter will present the case for manipulation in the rehabilitation setting. Although manipulation can be a powerful intervention in isolation, coupling manipulation with rehabilitation produces stronger long-standing outcomes.1 Often, these two treatment modalities are not utilized together. Perhaps the reason remains embedded deeply in political and philosophical viewpoints. Observing firsthand the powerful effects of manipulation can seduce one into believing that it is all one needs to do. Indeed, the manipulation and mobilization of joints have captured the interest of a variety of healers, doctors, and therapists in their quest to treat a diversity of musculoskeletal pain syndromes. No doubt many of them have become seduced, if not enamored, by the allure of manipulative therapies’ effectiveness. However, believing only one modality can treat an entity as diverse and complex as the locomotor system can prove shortsighted. Such a belief can prove especially crippling when caring for the chronic pain population. Musculoskeletal pain has physical, neurologic, cognitive, and psycho-emotional mechanisms and manifests in chronic, highly complex conditions involving multiple body systems, such as the immune, endocrine, musculoskeletal, neurologic, and digestive systems.2 Although research and practical experience substantiate manipulation’s effectiveness in treating the abovementioned systems of the body, chronic complex cases typically require a multimodal approach. However, there is mounting evidence to support manipulation in the battery of treatment modalities for chronic pain, not just acute pain,3 which is significant as some practitioners question the utility of manipulation in the treatment of chronic musculoskeletal pain. In this regard, the patient should never become dependent on manual therapy and practitioners should teach patients self-care strategies.
There is no disputing the effectiveness of manipulation in acute pain. More recent research has focused on classifying patients into subgroups for determining the need for manipulation. Flynn et al classified patients into subgroups that would most likely benefit from manipulation. Patients were examined according to the clinical prediction rule criteria (symptom duration, symptom location, fear-avoidance beliefs, lumbar mobility, and hip rotation range of motion). Manipulation effects were greatest in the subgroup of patients who were positive on the rule (at least four of five criteria met); healthcare utilization among this subgroup was decreased at 6 months.4 Overall, this research is favorable for manipulation and establishing its place in evidence-based care. However, the main criteria for manipulation should remain joint restriction. It would be shortsighted to conclude that if a patient did not fall into the abovementioned subgroup that manipulation should not be used.
Manipulation offers an extensive history. Pictures of practitioners performing manipulation date back to 17,500 BC in Point Le Mard France. Hippocrates (460-377 BC) and Galen (129-216 BC) also utilized manipulation. Further, the chiropractic profession’s origins can be traced to Davenport, Iowa, 1895 when Daniel David, or D.D., Palmer, coined the term “chiropractic adjustment” and started the first chiropractic college. Palmer described the vertebrae’s segments that were misaligned as “subluxations.” For years, much debate has occurred regarding this terminology across all disciplines. The benefits of manipulation continue to be extensively studied with an overall favorable response. Bronfort et al have completed the most comprehensive, systematic review of manipulation research applied to various conditions and diagnoses.5
Childs et al used the lumbar spring test (joint play) to determine whether manipulation or stabilization exercises would produce better outcomes. Patients with low back pain (LBP) who had lumbar hypomobility experienced greater benefits from an intervention that included manipulation; those with hypermobility were more likely to benefit from a stabilization exercise program.6 While the outcome of this test does not prove surprising, the skill set required to palpate and feel joint play often alludes most practitioners.
Manipulation
Triano discusses in depth the mechanics of a manipulation and the reader is referred there for an excellent discussion on the topic.7 Basically, joint manipulations are characterized by a sudden, impulse-like movement that takes a joint beyond its para-physiologic
barrier, and they are usually associated with a click noise. The sudden movement is beyond the control of the patient, a situation that necessitates the utmost in patient relaxation and clinician control. Manipulation represents a skillful art that demands much training and experience to become proficient in its use. Mastering manipulation involves two vital and distinct skills: palpation and thrusting. While separate skills, proficiency of both is critical to effectively practice the art of manipulation. In general, mastery of any skill is thought to take approximately 10,000 hours.8 This theory was challenged by Erickson, who believes that mastery is not only about logging hours, but more about deliberate practice.9 The thrust, or force generation, applied during manipulation represents a psychomotor skill, which practitioners can continuously refine throughout their careers. The thrust should match the patient’s tissue tolerance and only be performed on restricted articulations. Although palpation reliability has come into question by some,10,11,12,13 one must consider palpation is a skill that takes time to master. Other studies have shown promise for reliability in palpation.14 Karel Lewit states it perfectly, “There never has been or will be a better palpation device than the human hand.”
barrier, and they are usually associated with a click noise. The sudden movement is beyond the control of the patient, a situation that necessitates the utmost in patient relaxation and clinician control. Manipulation represents a skillful art that demands much training and experience to become proficient in its use. Mastering manipulation involves two vital and distinct skills: palpation and thrusting. While separate skills, proficiency of both is critical to effectively practice the art of manipulation. In general, mastery of any skill is thought to take approximately 10,000 hours.8 This theory was challenged by Erickson, who believes that mastery is not only about logging hours, but more about deliberate practice.9 The thrust, or force generation, applied during manipulation represents a psychomotor skill, which practitioners can continuously refine throughout their careers. The thrust should match the patient’s tissue tolerance and only be performed on restricted articulations. Although palpation reliability has come into question by some,10,11,12,13 one must consider palpation is a skill that takes time to master. Other studies have shown promise for reliability in palpation.14 Karel Lewit states it perfectly, “There never has been or will be a better palpation device than the human hand.”
Manipulation is performed to restore joint play at restricted joints. It is thought to work by: (a) releasing entrapped synovial folds or plica; (b) relaxing hypertonic muscles; and (c) disrupting articular or periarticular adhesions.15 Fibrosis of the periarticular tissues can be a result of trauma and inflammation, immobilization, and degenerative joint disease. Additionally, Herzog has noted a change in muscle tone at the site of manipulation and also in the extremities.16 While often considered a biomechanical event, practitioners can appreciate and audit widespread neurologic changes post-manipulation.
The Sensory System and Articular Neurology
The central function of the nervous system is to receive, organize, and transmit information. Accurate static and dynamic joint positioning can only occur with a healthy articular receptor system. These specialized diverse receptors supply constant input to the brain regarding the articular system’s status. Typically, this information is not volitionally perceived, occurring at a subconscious level. In other words, we are not consciously aware of our joints’ position at a given time.17 In Clinical Rehabilitation, Kolar reminds us that sensory and motor functions are closely interrelated. Correct sensation is the foundation for good quality of any desired movement. Assessment of sensory function remains significant in rehabilitation, and practitioners should retain this assessment as a routine part of a patient’s complete examination.18 The articular system is one part of a complex multisensory afferent network. Joint capsules house mechanoreceptors, which are responsible for overall body perception and proprioception. The muscle’s spindles and Golgi tendon organs (GTOs) send the brain information on stretch and tone that also aids in overall proprioception. The skin’s receptor system involves Merkel discs, Meissner corpuscles, Pacinian corpuscles, and Ruffini endings. Aristotle (384-322 BC) is credited with the classification of the five sense organs (sight, smell, taste, touch, and hearing). All of this afferent information is crucial for proprioception. Obviously, this receptor system is vast and complex. The ability of the brain to sort through this diverse information is called “multisensory integration.” This chapter only refers to the articular component, although there is integration between all sensory modalities.
Articular neurology has been described in depth by Dr. Barry Wyke and is the branch of the neurologic sciences that concerns itself with the study of the anatomical, physiologic, and clinical features of the joint system’s nerve supply in various parts of the body.19 There are four types of mechanoreceptors: Types 1, 2 and 3 are encapsulated and found in joints and periarticular tissues. Type 4 is a free nerve ending, which is not encapsulated, and is known as a nociceptor. When mechanoreceptors are stimulated through motion, nociceptive signals are inhibited. The types of motion that can stimulate the mechanoreceptors can be active or passive range of motion, exercise, bodywork, and the topic of this chapter, articular manipulation.
There is clear evidence that distortion of the joint’s normal centripetal flow of mechanoreceptor afferent impulses from a joint produces significant impairment of reflex muscular behavior, as well as of kinesthesis.19 Many authors agree that mechanoreceptor stimulation represents a mechanism by which spinal manipulation influences the nervous system.20 Of interest, consider the density of mechanoreceptors in different capsules of joints. The atlanto-occipital articulation has the highest density of mechanoreceptors compared to any other joint. As a result, freely moveable articulations in the upper cervical spine serve as a prerequisite for a healthy nervous system.
The Barrier Concept
One of Karel Lewit’s greatest contributions to the field of manual medicine was the art of palpation. Recognizing the barrier is the first step in becoming an
expert in joint palpation. The quality of the barrier determines whether manipulation, mobilization, soft tissue techniques, or a rehabilitation approach should be implemented. This chapter solely focuses on the articular component of the barrier concept. The first crucial step in palpation requires the practitioner to feel a “barrier” to physiologic movement. When joints are moved beyond their neutral position, a slight resistance can be felt at some point. It was originally described in the osteopathic literature as only pertaining to articular motion. The barrier concept pertains to the normal or abnormal resistance to joint or soft tissue movement within their range of motion. However, the barrier is also observed in the gliding movements of soft tissues such as skin, subcutaneous tissue, fascia, muscle, and periosteal points near bone.
expert in joint palpation. The quality of the barrier determines whether manipulation, mobilization, soft tissue techniques, or a rehabilitation approach should be implemented. This chapter solely focuses on the articular component of the barrier concept. The first crucial step in palpation requires the practitioner to feel a “barrier” to physiologic movement. When joints are moved beyond their neutral position, a slight resistance can be felt at some point. It was originally described in the osteopathic literature as only pertaining to articular motion. The barrier concept pertains to the normal or abnormal resistance to joint or soft tissue movement within their range of motion. However, the barrier is also observed in the gliding movements of soft tissues such as skin, subcutaneous tissue, fascia, muscle, and periosteal points near bone.
The barrier to motion can be physiologic or pathologic. Lewit defines the physiologic barrier as the first normal resistance to motion away from the neutral position of joints or soft tissues.21,22 This phenomenon is common to the movement of all joints and soft tissues. The physiologic barrier is considered subtle, has a slight springy end-feel, and its resistance is sensed gradually rather than abruptly. Further movement into the range of motion will stretch and deform the soft tissue restraints until the anatomic limit of motion is reached, such as capsular-ligamentous structures or bone-on-bone contact. The anatomic limit is not reached during normal active movements and is only engaged with passive overpressure. An elastic barrier is also present, being situated between the passive range and anatomic limit of a joint’s motion. The elastic barrier is transgressed during manipulation, resulting in a click noise as the para-physiologic space is entered.
A pathologic barrier occurs when resistance to movement is felt prematurely in the range. This is usually the case when dysfunction causes joint or soft tissue tension. In addition, a qualitative change in the barrier from a normal gradual springy nature to an abrupt end-feel occurs. Little springing can be felt, whether in a joint or soft tissue structure. Being able to engage and release pathologic barriers in joints and soft tissues is key in assessing and treating locomotor system dysfunctions.
Joint Restriction/Manipulable Lesion: What Characterizes a Manipulable Lesion?
When the articular system is involved in barrier restriction, practitioners will have a manipulable lesion. Various terms have been used to describe the manipulable lesion. Gatterman discusses more than 100 terms related to spinal manipulable lesions.23 Among these are subluxation, joint dysfunction, somatic dysfunction, fixation, joint blockage, and segmental dyskinesia. Unfortunately, throughout the history of manipulation, a thought or belief existed that vertebrae or bones have come “out of place” and that practitioners of manipulation actually put bones back into place. Lewit, Gillet, Illi, Mennel, Faye, and Kaltenborn were pioneers who devised a new thought process that was more dynamic and functional. They proposed that vertebrae and segments were not malpositioned, but were instead stiff and lacking motion. They referred to these lesions as joint restrictions, or fixations. To date, the research supports this theory. Joint movement typically utilizes three planes of motion: sagittal (flexion and extension), frontal (lateral flexion), and transverse (rotation). Having freely moveable joints requires that all planes of motion are utilized. Therefore, assessment of the three planes of motion is necessary. In reality, joints often move in “coupled” or predictable patterns combining multiple planes of motion. For example, lateral flexing the lumbar spine to the right will produce spinous rotation to the same side.24 These coupled motions can be detected with movement analysis palpation. Also, certain regions of the spine will have more range of motion in specific planes. This is often dictated by facet joint orientation. For example, the occipital atlas joint has vast flexion and extension possibilities and minimal rotation or lateral bending.
Joints become fixated because of either internal or external causes. Internally, if the muscular stabilization strategy is not ideal across joint surfaces, then articular restriction can result. For example, if the patient is not able to utilize correct diaphragmatic respiration and positioning, a predictable joint restriction at the thoracic-lumbar articulation will be found. Although manipulation can, and should, be utilized, we must also address the original cause of dysfunction, which was improper respiration. A visceral somatic reaction represents another example of internal causation. Dysfunction in the viscera and internal organs will often manifest itself in the musculoskeletal system. The asthmatic or chronic obstructive pulmonary disease (COPD) patient, who exhibits chronic fixation in the thoracic spine, costovertebral, and costotransverse joints of the rib cage, provides an example of musculoskeletal system manifestation. Another example of viscerosomatic changes includes observing stiff upper thoracic spinal segments with left-sided painfully indurated paraspinal soft tissues often found in cardiac patients.
Externally, joints can become fixated because of poor posturing, overuse, or trauma. For example, sedentary lifestyles have created an epidemic of cervical and upper thoracic flexion problems. Traumatically, the distal tibia/fibula joint often becomes restricted after an inversion ankle sprain.
Joint restriction can be assessed in three ways: joint play, passive movement assessment, and active movement assessment. In the first instance, John Mennell, MD, coined the term joint play that refers to the ability of the joint to have normal elasticity and springiness. Mennell stated that this should be 1/8 of an inch in depth.25 Physicians will typically have their hands over the joint surface and the spring is created with the hand or closed fist. The spinous process can also be used as a lever to spring. The practitioner must be aware of the inherent plasticity of the spinous process when using this method.26 Mennell also stated, “Exercise programs should not be started until joints have normal end-feel (joint play).” Although there are aspects of this statement that are debatable, there is also merit. Table 28.1 contains other helpful Mennell joint truisms. Second, in passive movement analysis, the segments are moved passively by the practitioner while the palpating hand discerns whether movement is occurring in different planes of motion. Third, in active movement assessment, the practitioner puts his or her hand over the segments being assessed and the patient moves actively. A determination is then made whether or not the correct amount of motion is occurring.
Pre-manipulative Provocative Testing
Prior to any manipulative thrust, a pre-manipulative provocative test should be conducted not only to assess for patient tolerance and pain but also to acquaint the patient with the technique.27 The manipulative technique is set up with complete slack removal, yet a thrust is not delivered. During the technique’s “dry run,” an assessment is made as to patient comfort and the patient’s ability to relax as the joint in question is preloaded. The clinician also assesses the patient’s ability to properly set up the technique and to gain a sense about the appropriate amount of slack. This also gives the clinician a second chance to ensure the palpation proved accurate. If accurate, the clinician should find the fixation felt during palpation or joint play. In cases where the fixation is not felt, the clinician should re-palpate to make sure the initial assessment was correct. If no problems are encountered with this pre-manipulative maneuver, practitioners can then advance to an actual manipulation setup and a thrust safely attempted. Evidence of pain or the inability of the patient to relax mandates the alteration of technique administration.
Table 28.1 Manipulation Truisms | ||
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Post-manipulative Side Effects
Post-manipulative side effects are common, but relatively minor, when compared with the more serious, yet rare, complications that can arise from manipulation.28,29 The most common side effects encountered entailed local discomfort, radiating discomfort, headache, and fatigue, especially when the cervical and thoracic spines are manipulated. These side effects are predictable to some degree (see Table 28.2). Senstad et al studied more than 1,000 patients undergoing more than 4,700 treatments and observed some predictors to the more common side effects of spinal manipulation mentioned.29 Uncommon reactions, such as dizziness and nausea, were not associated with any specific predictors. Contraindications to manipulative therapy must always be kept in mind and the reader is referred to Table 28.3.30
Table 28.2 Predictors to Adverse Reactions to Manipulative Therapy | ||
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Table 28.3 Contraindications to Manipulative Therapy | ||
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In their study, Senstad et al found that when the thoracic spine was only manipulated, more patients complained of side effects than when the other spinal regions were solely treated.29 Headache was the most common side effect from cervical and thoracic spine manipulations. The researchers also observed that the number of reactions increased as the number of spinal regions treated was increased from one to three. Younger subjects (27-46 years) were more likely to experience reactions when compared with older subjects (47-64 years). Women reacted adversely more commonly than men and more reactions were observed after the first two treatment sessions, but especially the first. Because of the above observations, one should be careful to limit treatment to one area on the first treatment session, especially in younger women. Len Faye recommends finding the primary (greatest) restriction and manipulating it in all planes of motion that are blocked, leaving the other restrictions alone. “I have found it a clinical advantage to adjust one major at one office visit. However, I attempt multiple adjustments in different ranges of motion in the motion unit selected. Some will produce audible releases, others will effect only a mobilization.”31 Most importantly, force should not be substituted for skill, nor should a practitioner advance on a quest to satisfy the neurotic need to hear an audible click by either clinician or patient. One should keep in mind that 85% of these reactions are only mild to moderate in nature and 74% are transient, disappearing within 24 hours.29 Axen et al showed that LBP patients who demonstrated the most favorable response to chiropractic manipulative treatment were those who reported immediate improvement after the first visit.32 Typically, adverse reactions occur when practitioners have inaccurately palpated. This leads to motion being imparted to joints that are already hypermobile and symptomatic.
Chain Reactions The locomotor system “thinks” in terms of function, and its individual parts are integrated to work in a closed kinematic system. No body part functions in isolation but, rather, is intimately linked to the entire locomotor system. This linkage occurs under the volitional direction of the nervous system or via involuntary reflex mechanisms and is “hard wired” into the kinematic system.
When necessary, every joint will make its contribution to movement. Not surprisingly, when a joint develops stiffness in multiple planes, the areas above and below will have to compensate, such as at the cervical-thoracic junction. We often see cervical disc herniation at predictable levels: C5-C6 and C6-C7. Typically, these patients present with joint restriction at the segments T1-T4. Ironically, these patients usually do not lose overall active range of motion in the cervical spine. Compensation occurs and excessive motion is imparted to the areas of symptomatic disc herniation. In other words, very rarely do practitioners adjust at the level of disc herniation. Over time, the same patient’s spine will typically begin to create osteophytes in an attempt to stabilize this area of hypermobility. The consequence of this process is eventual restriction and spinal stenosis. Radiographs often reveal osteophytes at common sites of disc herniation. This is not coincidental. The reaction of the regional muscles in this example is typically neurologic inhibition of the deep neck flexors and overactivity of the cervical extensors. In this example, upper thoracic manipulation often serves as the starting point in the rehabilitation process. Manipulative therapy of the upper thoracic spine and rib articulations was also shown to improve patients with shoulder dysfunction and pain.33 In another study, shoulder impingement symptoms also improved with only thoracic manipulation.34
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Pain Mechanism Classification System Overview and Focus on the Motor/Autonomic Mechanism
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