Overview of Various Types of Manual Medicine

Central to the application of manual medicine techniques is the barrier concept. This concept recognizes the limitation of motion of a normal joint in which asymmetric motion is present. Motion is relatively free in one direction, with loss of some motion in the other direction. Motion loss occurs within the normal range of movement for that joint (eSlide 16.1) . The barrier concept implies that something is preventing the full range of movement of a joint. The term pathologic barrier was initially used to describe the point at which normal motion is limited. The term currently used is restrictive barrier , which means that no organic pathology can be seen under the microscope; these are functional restrictions. The new neutral position has shifted toward the direction of less restricted motion. This gives rise to positional asymmetry. Manipulation is designed to restore normal motion.

Manual medicine techniques can be classified in different ways. They may be classified as soft tissue, articulatory, or specific joint mobilization techniques. The terms direct and indirect are also used to classify the technique, with several types of technique in each category. Direct technique means that the practitioner moves the body part(s) in the direction of the restrictive barrier. Indirect technique means the practitioner moves the body part away from the restrictive barrier.

Direct techniques include the following:

• 1.
  

  Thrust (impulse, high velocity, low amplitude) : The final activating force is operator force.

  
  
• 2.
  

  Articulation: Low velocity, high amplitude

  
  
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  Muscle energy (direct isometric types): The final activating force is a patient contraction.

  
  
• 4.
  

  Direct myofascial release: Load (stretch) tissues, hold, and wait for release.

Indirect techniques include the following:

• 1.
  

  Strain–counterstrain

  
  
• 2.
  

  Indirect balancing

  
  
• 3.
  

  Multiple names (functional, balanced ligamentous tension)

  
  
• 4.
  

  Indirect myofascial release

  
  
• 5.
  

  Craniosacral

Normal and Abnormal Coupled Spinal Motion

Flexion (forward bending) and extension (backward bending) are sagittal plane motions and are not coupled. However, rotation and side bending are coupled. The amount of pure rotation or pure side bending of spinal joints is limited and varies depending on the site within the spine. Rotation and side bending occur together in normal spinal joints. Fryette stated that when side bending is introduced in the absence of marked flexion or extension (termed neutral ), a group of vertebrae rotate into the produced convexity, with maximum rotation at the apex. Rotation and side bending occur at opposite sides when compared with the original starting position. This is sometimes referred to as neutral mechanics or type 1 dysfunction. Nonneutral mechanics or type 2 dysfunctions involve a component of flexion or extension, with rotation and side bending to the same side. This is usually a single-segment motion, although several segments may be involved.

Somatic Dysfunction

Somatic dysfunction is a diagnostic term defined as impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. Dysfunctions that can be palpated include changes in tissue texture, increased sensitivity to touch (hyperalgesia), altered ease or range of movement, and anatomic asymmetry or positional change. The Glossary of Osteopathic Terminology describes the following three ways of naming somatic dysfunction: Type 1: Where is it or what position is it in (e.g., right rotated)? Type 2: What will it do or what is the direction of free motion (e.g., right strain)? Type 3: What will it not do or what is the direction of restriction (e.g., restriction of left rotation)? A dysfunction should be named in three planes of motion, with the upper segment described in relation to the lower segment.

Physiologic Rationale for Manual Therapies

Increased gamma activity of muscle spindles results in increased alpha motor neuron activity of extrafusal fibers of skeletal muscles causing contraction. However, decreasing gamma gain activity is one mechanism that results in muscle relaxation. If the muscle spindle is stretched, increased activity of the gamma system stimulates muscle activity.

Examination

The mnemonic for a musculoskeletal examination is TART: T , tenderness or sensitivity; A , asymmetry (look); R , restriction of motion (move); and T , tissue texture abnormality (feel). The diagnosis of somatic dysfunction is based on a palpatory examination assessing TART. Terms to describe the “feel” might be ease and bind or freedom and resistance (eSlide 16.2) . Segmental motion can also be tested using pressure applied through the hands, without relying on patient movement for diagnosis (eSlide 16.3) .

Assessment of Fascia

Fascia is three dimensional and can form sleeves to compartmentalize, act as cables, or form diaphragms. Assessment of fascia starts with hand placement to perceive the combined vector force in the tissue. Assessment of an extremity would start with hand placement proximal and distal to the area. Examination of the fascia and myofascial structures may include looking for special “points” or “triggers.” These include counterstrain tender points, myofascial trigger points of Simon and Travell, and acupuncture points.

Types of Manual Medicine Techniques

Manual medicine techniques can be classified in different ways, including soft tissue techniques, articulatory techniques, or specific joint mobilization. These are directly or indirectly applied. Combined techniques start with an indirect technique, and once the release has occurred, the practitioner may switch to a direct technique.

Contraindications and Side Effects

Perhaps the most serious complication of cervical manipulation is a stroke associated with vertebrobasilar artery dissection. Most complications are associated with high-velocity thrusting techniques. eSlide 16.9 presents a list of conditions that are contraindications to the thrusting technique.

Types of Traction

Traction can be delivered by several different methods, including manual, mechanized, motorized, hydraulic, or inversion (which uses gravity) methods. Irrespective of the method, the surface resistance must be overcome. The resistance is approximately equal to half the weight of the body segment. The force can be continuous, sustained, or intermittent. Continuous traction uses a low force over a long period, such as 30–40 hours. Continuous traction is typically not well tolerated and is not commonly used. Sustained traction uses a larger force but for a shorter period (typically 30–60 minutes). Although sustained traction remains difficult to tolerate, it is commonly used in the lumbar spine with a split traction or autotraction table. Intermittent traction uses greater forces over shorter periods. The traction force can be increased or decreased during each treatment cycle and the duration of pull can be adjusted. The cycle is usually repeated for 15 to 25 minutes, with the traction phase ranging from 5 to 60 seconds, and the rest phase ranging from 5 to 15 seconds. The magnitude, duration, and direction of the pull can be varied.

Cervical traction is commonly performed using manual, mechanical, or motorized methods (with a head or chin sling) or with the use of a supine posterior distraction unit. The optimal angle of pull ranges between 20 and 30 degrees of flexion while 25 pounds of force are required to reverse the normal cervical lordosis and bring about the earliest distraction of vertebral segments. Mechanical cervical traction can be applied in the supine position, which reduces the weight of the head but increases frictional resistance. This position also allows for better control of the head by the patient and is typically more comfortable (eSlide 16.10) .

Traction in the sitting position allows more accurate positioning for the correct angle of pull, but it usually affords less head control and is less comfortable.

Lumbar traction requires a significantly greater force to create distraction of the vertebral segments than cervical traction. Common traction systems include a thoracic or chest belt with a pelvic belt (eSlide 16.11) , inversion, a split traction table, or an autotraction table. Split traction tables have a mobile half and a stationary half. Autotraction tables allow both segments of the table to move and are controlled by the patient. The patient assumes the most pain-free position and performs active traction by pulling on an overhead bar. The patient then uses his or her feet to activate a bar, which alternates compressive and distracting forces.

Physiologic Effects

Physiologic effects of traction have been extensively evaluated and reported. Traction can stretch muscles and ligaments, tighten the posterior longitudinal ligament to exert a centripetal force on the annulus fibrosis, enlarge the intervertebral space, enlarge the intervertebral foramina, and separate apophyseal joints.

Indications, Goals of Treatment, and Efficacy

There is no consensus on the definitive indications for traction, but the condition with the most support for its use is cervical radiculopathy. The use of traction for lumbar radiculopathy, neck pain, and low back pain is more controversial, with contradictions existing in the literature. In the absence of contraindications, traction can be used to treat any condition in which the physiologic effects of traction would be theoretically beneficial.

Contraindications

Absolute contraindications to traction include malignancy, infection (such as osteomyelitis or diskitis), osteoporosis, inflammatory arthritis, fracture, pregnancy, cord compression, uncontrolled hypertension or cardiovascular disease, and in the setting of a carotid or vertebral artery disease. Caution should also be exercised in the elderly, in the setting of midline disk herniations and in the lumbar region when abdominal problems are present. Inversion traction involves more risks because increases in blood pressure and decreases in heart rate are known to occur, leading to headaches and periorbital petechiae.

Indications and Goals of Treatment

Massage has multiple effects on the body, including mechanical, reflexive, neurologic, and psychological effects. The goals of therapeutic massage are to produce relaxation, relieve muscle tension, reduce pain, increase mobility of soft tissues, and improve circulation.

Mechanical and Physiologic Effects

The mechanical pressure created by massage moves fluid from areas of relative stasis (low pressure) to higher pressure areas by creating a hydrostatic pressure gradient. Once fluids leave the cell or interstitial fluid, they can enter the lymphatic or vascular system. Valves within the lymphatic and venous system prevent return of the fluid to the tissue. Massage can also have an immediate effect on cutaneous blood flow, with hyperemia being noticed even with superficial techniques. Deep massage has an effect on the underlying fascia and deep connective tissues. Injuries to these deeper tissues can result in restrictions, adhesions, and scarring. These fascial constrictions can potentially cause restriction of fluid movement within the vasculature, as well as reduction in muscle activity. Deep massage can help release these restrictions, adhesions, and areas of microscarring.

Pain, inactivity, and debilitation result in insufficient muscle movement to mobilize fluids. This hypomobility can result in increased fluid stasis, producing a self-perpetuating positive feedback loop. This can result in the accumulation of not only fluids but also metabolic byproducts. These metabolic byproducts can create an osmotic influence on fluid shifts and result in stimulation of pain fibers. Massage increases the mobility of these metabolic byproducts and the dispersion of accumulated fluids.

Somatic afferent nerve fibers carry information from the somatic system to the spinal cord. Dysfunction within the somatic structures can result in increased afferent neural input. This increased input changes efferent activity at the same spinal cord level through interneurons, which can result in muscle hypertonicity and contraction.

Types of Massage

A vast array of techniques has been used to perform therapeutic massages. These techniques can be categorized by the geographic region of origin as either classic Western (European) or Eastern (Asian) forms of massage. The most common Western (European) techniques are those outlined by the Swedish system. The four basic massage strokes are effleurage, pétrissage, friction massage, and tapotement, as originally described by the French. Several treatment schemes combine massage with other techniques, such as structural reintegration, functional restoration, and movement therapies. Effleurage involves gliding the palms, fingertips, and/or thumbs over the skin in a rhythmic circular pattern with varying degrees of pressure. This stroke is performed by maintaining continuous contact with the skin and stroking from a distal to a proximal position on the extremities, torso, or spine (eSlide 16.12) . This technique is often used as a prelude to more aggressive massage techniques or manipulation. Pétrissage is also known as “kneading massage.” It involves both hands compressing the skin between the thumb and fingers. The tissue is grasped from the underlying skeletal structures, lifted, and massaged. Both hands rhythmically alternate in a rolling motion. Pétrissage (eSlide 16.13) is also considered as a compression massage, and several variations exist, including kneading or picking up, wringing, rolling, or shaking the tissue. Tapotement, or percussion massage (eSlide 16.14) , uses rhythmic alternating contact of varying pressure between the hands and body’s soft tissue. Various techniques are used to produce this type of massage, including hacking, clapping, beating, pounding, and vibration. Friction massage is a circular, longitudinal, or transverse pressure applied by the fingers, thumb, or hypothenar region of the hand to small areas. Cross-friction massage is perpendicular to the fibers. Very little motion occurs at the fingertips overlying the skin. The tissues are massaged by increasing the pressure applied from the superficial to deep tissues. The goal of friction massage is to break down adhesions in scar tissues, loosen ligaments, and disable trigger points. It is often uncomfortable and can even result in some bruising (eSlide 16.15) . Other massage techniques include Tager psychological integration, Alexander and Feldenkrais techniques, “Rolfing” myofascial release, and manual lymphatic drainage. Shiatsu ( shi [“finger”] and atsu [“pressure”]) is a Japanese type of body work based on acupuncture. Pressure is applied in particular meridians similar to acupuncture.

Evidence-Based Use of Massage

At least one large randomized controlled trial supports the use of massage in the treatment of anxiety and stress; arthralgias and various arthritides; fibromyalgia; lymphedema; musculoskeletal disorders, such as whiplash, low back pain, and sports-related injuries; and sleep disorders.

Contraindications

Massage should not be performed over areas of malignancy, cellulitis, or lymphangitis. Massaging these regions can cause mobilization of tumor cells into the vascular lymphatic supply or can cause the spread of infection. Areas of trauma or recent bleeding should not be treated with deep tissue massage. Mobilization of these areas can increase the propensity for rebleeding. Patients taking anticoagulants should be treated with gentler techniques and observed for bruising and ecchymosis. Deep tissue work should be used with extreme caution in people receiving anticoagulants or those who have a bleeding diathesis.

Massage should not be used over areas of known deep venous thrombosis or atherosclerotic plaques. This could dislodge vascular thrombi, resulting in embolic infarcts that affect the pulmonary, cerebral, or peripheral systems.