Principles of Manual Medicine

1. Principles of Manual Medicine Jack Dolbin, DC CSCS

2. Dr. Philip Greenman, DO, FAAO

3. References • Much of this module is the result of study references, books, tapes and personal conversations with Dr. Philip Greenman, DO. His work has guided me and given me a rationale for the diagnosis, treatment and now teaching of manual medicine for athletes. • I strongly recommend his work as the gold standard for any manual medicine intervention.

4. Thirty one dollar seminar

5. When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping the patient with a myriad of disease processes. • Philip Greenman DO, Professor of Biomechanics • Michigan State University School of Osteopathy Medicine

6. Goal of manual medicine • The goal of manual medicine is to restore maximal, pain free movement of the musculoskeletal system in postural balance. • Dvorak J, Dvorak V,Schneider W : Manual Medicine 1984,

7. Role of the musculoskeletal System in Health and Disease • 1. Holistic man • 2. Neurologic man • 3. Circulatory man • 4. Energy-expending man • 5. Self-regulating man

8. Holistic Man • The musculoskeletal system comprises most of the human skeleton and alterations within it influence the rest of the human organism. • Our role as physicians is to treat patients and not disease. • Deep Fascia

9. Neurologic Man • Most highly developed nervous system in the animal kingdom. • All functions of the human body are under some form of neurologic control. • Control of all glandular and vascular activity is under the control of the ANS. • Neuroendocrine Control: Substance P, endorphines, enkephalines, and neurotransmitters can be altered by biomechanical alterations • Alterations in neurothropin transmission can be detrimental to the health of target cells.

10. Spinal Accessory Nerve Formed by lower motor neurons in the lateral horns of C2-C4 Ascends through the foramen magnum, receives fibers from the nucleus ambiguous and decends along the jugular foramen. Sends branches to the Vagus Nerve Has SVE and GSE. Thoracic branches matched to vagusinnervation of the embryonic heart.

11. Circulatory man • Anything that interfered with with sympathetic autonomic nervous system outflow, segmentally mediated, can influence vasomotor tone to the target end organ. • Maximal function of the musculoskeletal is important to the efficiency of the circulatory system and maintainance of a normal cellular milieu.

12. Energy expending man • Restriction of one major joint in the lower extremity increase the energy expenditure in walking by 40%, two major joints in the same extremity 300%. • Multiple minor restriction of movement, especially in the lower extremity gait can have a detrimental effect on the total body function

13. Self-Regulating Man • The goal of the physician should be to enhance all the body’s self regulating mechanisms to assist in the recovery from disease. ( injury). • One in seven hospital days are the result of adverse reactions to pharmaceuticals. • Anything placed with in the body alter the self regulating mechanism.

14. Manipulatible Lesion • Primary goal is to determine the specific spinal motion segment that is dysfunctional, determine the direction of altered motion, and determine the tissue involved in the restrictive motion. • Primary emphysis is placed on motion loss and its characteristics

15. Manual Medicine Treatment • Directed toward restoring maximal motion to all joints, symmetry of length and strength to all muscles and ligaments, and symmetry of tension within fascial elements throughout the body. • Maximum function in postural balance • Top down or bottom up.

16. In manual medicine it is just as important to know the nature, location and type of somatic dysfunction before a therapeutic intervention is prescribed.

17. A R T • Asymmetry • Range of motion • Tissue texture

18. Asymetry • Pelvic unleveling: Effect on lower extremity function. Shoulder function. • Scapular Winging: • Anterior Shoulder posture: TOS, entrapment • Pronation

19. Pelvic Unleveling

21. Range of Motion • 1. Range of movement • 2. Quality of movement • 3. End feel • In the spine: Goal is to determine which specific vertebra is dysfunctional • Which joint within that segment is dysfunctional • The direction of altered motion • Tissue involved in the restricted movement.

22. Range of Motion • Passive: note end feel. Hard or mushy • Active: Neuromuscular Control

23. Motion loss and its characteristics are more important diagnostic criterion that the presence of pain and the provocation of pain by movement. • Greenman: Michigan State University School of Osteopathic Medicine.

24. Greenman • The most important element in the postural model has been the restoration of maximum pelvic mechanics in the walking cycle. • The Pelvis from below to above must be considered to achieve the symmetrical movement. • Pelvis is the cornerstone • Shoulder Injuries • Hamstring strains • Knee, ankle, foot injuries

25. Evaluation of symmetry • Check Pelvic leveling in the standing position. • If unlevel: does it level in the sitting position. • If so check leg length. Look for structural or functional short leg. • If functional check SI joints and pronation. • If Structural: broken leg or past injuries. • Equestrian Illustration: Broken Femur leading to shoulder entrapment.

26. Tissue Texture • Spasm • Contracture: Hypertonicity • Shortening: Chronic adaptation • Adhesions: Scar Tissue • Temperature: Inflammation

27. Tissue Texture • Alteration in the characteristics of the soft tissues of the musculoskeletal system. • Skin • Fascia • Muscle • Ligament

28. Most tissue texture abnormalities result from altered nervous system function with increased alpha motor neuron activity maintaining increased muscular hypertonicity and altered sympathetic nervous system function.

29. Lateral chain ganglia in the thoracic region are bound by the deep fascia to the posterior chest wall and overlie the rib heads.

30. It would seem reasonable to attempt to reduce aberrant afferent stimulation to hyperirritable sections of the sympathetic nervous system to reduce hyperactivity to the target end organs.

31. Mechanotherapy • The physiological process where cells sense and respond to mechanical loads. • Various forms of exercise and or movement prescription promote repair and remodeling of tendon, muscle, articular cartilage and bone. • Mechanotransduction: Maintains normal musculoskeletal structure in the absence of injury. Homeostasis • Mechanotherapy: Treatment of injuries using exercise prescription or manual therapy

32. Mechanotherapy • The process where the body converts mechanical loading into cellular response. • Three phases: • A. Mechanicalcoupling: Trigger • B. Cell-Cell communication:communication throughout a tissue to distribuite the loading message. • C. Effectorresponse:Response at the cellular level to effect the response that will produce the necessary materials to correct alignment.

33. Mechanocoupling • Refers to a physical load causing physical perturbations to cells that make up tissue. • Key is the direct or indirect perturbations of the of the cell which is transformed into chemical signals both within and among the cells.

34. Clinical Studies • Tendon:Up regulation of IGF-I and cytokines • . • Associated with cellular proliferation and remodeling within the tendon. • Tendons can respond favorably to controlled loading after an injury.

35. Muscles • Highly responsive to changes in functional demands through the modulation of load induced pathways. • Overload: Upregulation of MGF (mechanogrowth factors) • MGF leads to Muscle hypertrophy • Scar stabilizes-controlled load • Leads to faster more complete regeneration and minimization of atrophy.

36. Cartilage • Populated by mechanoreceptive cells: Chrondrocytes. • Studies: Alfredson and Lorentzon showed that cartilage under continuous passive motion healed much better and faster than those without CPM. • 76% vs. 53%

37. Einstein on Insanity • Doing the same thing over and over and expecting a different result.

38. Evidence Based Protocols • The best available evidence from valid peer reviewed studies combined with clinical experience to develop a treatment plan with an expected outcome. • A. Pubmed • B. 34 years of clinical experience

39. Arnt-Schultz Principle • Weak stimuli increases physiological activity while strong stimuli inhibits or abolishes physiological activity.

40. Proprioceptive System • Gentle and precise manipulation elicits an internal sensory feed back response designed to stimulate the body’s self correcting mechanism.

41. Techniques • Muscle Energy • Impulse Adjusting • High Velosity/ Low amplitude • Indirect Function technique: Sherringtons Law • Myofascial Release: CyriaxCrossfiber • Balance and Hold

42. CyriaxCrossfiber • Mobilize Scar tissue • Breakdown Adhesions • Allows muscle to broaden • Controlled Inflammation: Prolotherapy research • Pain modulation • 1. Right Location • 2. Right amount of pressure

43. Cyriax: Continue • During first 24-48 hours. Light mobilizing maximum of 5 minutes.( usually less) • After 48 hours 5-15 minutes • Muscle Injury: Across the relaxed muscle to facilitate broadening. Followed by eccentric exercise or Faradic. • Tendon/Ligament Injuries: Across the ligament in an elongated position. • Every other day maximum.

44. Lateral Ankle Sprain

45. Rotator Cuff Tendonitis

46. Muscle Energy Technique • Limb is moved into the restrictive barrier. • Patient actively attempts to move the limb with the Physician resisting the movement • Hold 5-7 seconds, 3-5 times. Followed by inspiration/expiration. • As tissue releases move to next barrier • Followed by articular correction if necessary

47. Muscle energy • Isometric Contraction of shortened muscle. • Improves resting length • Increase Joint movement • Improves overall range of motion. • Inhalation/Exhalation as activating force

48. Achilles Tendon Injury

49. Quadraceps Injury