INTRODUCTION TO MANUAL THERAPY

V.Bhavani
Manipulative Physiotherapist.(Austr)
Med.Edu.USM
THE TOOLBOX OF MANUAL THERAPY
 LEARNING OUTCOMES
By the end of this lecture students should be able to:
1. Explain the concept of manual therapy and its indications and
contraindications
2. Describe the different schools of thoughts that exist in manual therapy
and its rationale
3. Identify and select manual therapy in clinical decision making with
regards to clinical problems
4. Discuss clinical reasoning underpinn manual therapy
5. Describe the grades in Maitland’s mobilization and it principles of
application.
6. Describe the implication of McKenzie as treatment repertoire.
7.Outline the various mobilization for peripheral joints.
MANUAL THERAPY

• The decision on which manual technique to use is based on the

clinician’s belief, their level of expertise, and their decision-making

processes.
MOBILIZATION AND MANIPULATION
• Mobilization – is a manual therapy intervention, a type of passive
movement of a skeletal joint.

• Manipulation - high velocity low amplitude (HVLA) thrust is often

used interchangeably with manipulation.
INDICATIONS FOR MANUAL THERAPY
CONTRAINDICATIONS TO MANUAL THERAPY
CONTRAINDICATIONS TO MANUAL THERAPY
CONTRAINDICATIONS TO MANUAL THERAPY
CONTRAINDICATIONS TO MANUAL THERAPY
 SOFT TISSUE TECHNIQUES-CYRIAX
• Transverse Friction Massage
• A technique devised by Cyriax whereby repeated cross-grain
massage is applied to muscle, tendons, tendon sheaths, and
ligaments.

• Contraindicated for acute inflammation, hematomas,

debilitated or open skin, peripheral nerves, and with patients
who have diminished sensation in the area
James Cyriax Use selective tension techniques to identify
faulty structures in the examination.

•Emphasizes the need for soft tissue massage

and frequently uses injection of muscle trigger
points.

•Believes the disc is the primary cause of low

back pain and uses non-specific spinal
techniques designed to move the disc to relive
nerve root pressure
•Started to use the term cross friction
•Also known for the term end feel.
• Transverse Friction Massage
• The tissue undergoing TFM should, whenever possible, be put on a
moderate, but not painful stretch.

• The exception to this rule is when applying TFM to a muscle belly,

which is usually positioned in its relaxed position

• The time length of the frictions is usually gauged by when the

desensitization occurs, normally within 3 to 5 minutes.
• Tissues that do not desensitize within 3 to 5 minutes should be
treated using some other form of intervention
• Augmented soft tissue mobilization (ASTM)
• A process that uses specially designed hand-held devices to assist the
clinician in the mobilization of poorly organized scar tissue in and
around muscles, tendons and myofascial planes.

• Myofascial Release
• A series of techniques designed to release restrictions in the
myofascial tissue that are used for the treatment of soft tissue
dysfunction that has not responded to other interventions.
• Massage
• The systematic, therapeutic, and functional stroking and kneading of
the body
 MUSCLE ENERGY

• Can be used to mobilize joints, strengthen weakened muscles,

and to stretch adaptively shortened muscles and fascia
 STRAIN-COUNTERSTRAIN (POSITIONAL RELEASE)
• Involve a gentle, simple indirect manipulative approach for the
treatment of somatic dysfunction, using passive positioning of the
body in a position of ease (rather than into the motion restriction) to
evoke a therapeutic effect .

• Effective in treating chronic and sub acute muscle spasm and pain &
disability that is associated with it.

• Functional Techniques :’
• Functional techniques are indirect techniques using positional
placement away from the restrictive barrier, similar to those
techniques described under Strain-Counterstrain
RATIONALE
• Protective muscle spasm due injury and 2° inflammation result in
neuromuscular patterns associated with ‘guarding', poor posture,
favoring an injured area and immobilization.

• Chronic spasm –its level inappropriate for level of injury…ongoing

limited disability, pain and poor biomechanics well after injury healed.
 RATIONALE
• Chronic spasm – changes in normal fascial,neuromuscular and other
connective tissue relationship.

• Prolonged hypertonicity prolongs inflammation, causes

ischaemia,reduces lymphatic drainage & increases concentration of
metabolites in tissues.

• Positional release technique (PRT) act on muscle spindle mechanism

& reflex mechanism to promote normal firing of spindle and normal
tension in muscle.
 PRT

Muscle spindle

Reduce hyperactivity of myotatic reflex

PRT sets the stage for normal processes to occur efficiently.

Reduce spasm ,increase range, decrease pain,

normal circulation & lymph drainage.
 INDICATION
• Patient with history of trauma
• Limited ROM
• Hypertonicity

Contraindication
• Open wounds
• Hematoma
• Hypersensitive
• Sutures
• Healing fracture
 OTHER CONSIDERATION
• Comfort of patient is paramount
• Goal is relaxation of affected body part and body in general.

• Constant communication –vital

 PROCEDURE
• Evaluate patient’s need via- • Multiple tenderness---treat the
medical Hx,Px and etc. most tender first

• Position patient comfortably, • Palpate selected tender point

often lying down (TP) – instruct the patient to
relax the area.

• Palpate affected area and • Passively move the appropriate

areas that may be associated body part to release tension at
due to referred pain . the TP.

• Multiple tender points, treat the • Stop motion when the pain
most severe first stops and patient only feels
pressure. Communicate!
 PROCEDURE • Point to remember: your
knowledge of anatomy ,referred
• Release the pressure –but pain patterns, muscle action
maintain light contact over TP to and biomechanics is important.
monitor response.

• Anterior TP are usually treated

• Maintain position 90 seconds. in flexion
Hold longer if patient is feeling a
therapeutic pulse, tissue tension
changes or movement. • Lateral to midline TP –rotation
or side bending sterior TP are
usually treated in extension.
• Encourage the patient to relax…
slowly return to neutral position.
• TP in the extremities are often
• Recheck the TP – except 70% found on the opposite side of
improvement in pain level and pain
reduced tension
JOINT MOBILIZATIONS

• Joint mobilization techniques include a broad spectrum, from the

general passive motions performed in the physiologic cardinal
planes at any point in the joint range, to the semi-specific and
specific accessory (arthrokinematic) joint glides, or joint
distractions, initiated from the open-packed position of the joint.
 Geoffrey Maitland
Uses primarily passive accessory movements to restore function
•Relies on an extensive assessment based on information from the patient's
subjective examination (history) and the evaluator's objective assessment.

•The movements are oscillations, the techniques are specific and the goals is what
he terms „reproducible signs‟.

•The Maitland Concept is referred to as a‟ concept‟ and not as a „technique‟.

Emphasis is placed not on the technique of

treatment but on a basic philosophy-a thought and
decision making process, involving analytical
examination and assessment on which treatment
decisions are based
JOINT MOBILIZATIONS-MAITLANDS

• Australian Techniques
• Under this system, the range of motion is defined as the
available range, not the full range, and is usually in one
direction only
• Each joint has an anatomical limit (AL) which is determined by
the configuration of the joint surfaces and the surrounding soft
tissues
• The point of limitation (PL) is that point in the range which is
short of the anatomical limit and which is reduced by either
pain or tissue resistance
The importance of a thorough evaluation
The concept is very simple here; without a complete and
detailed evaluation, you cannot develop an appropriate
exercise program.

•This evaluation is ongoing and does not stop after the “

initial evaluation” (there is a reason for that name…)

•Understanding the true dysfunction and understanding why

that dysfunction exists will put the clinician in the position to
address the dysfunction effectively.

•Treat dysfunction/function, not just a symptom such as pain

Grades I & II –often used before & after
treatment with grades III & IV
Grades of mobilization

Grade I -Activates Type I mechanoreceptors with a low threshold and which

respond to very small increments of tension.

Activates cutaneous mechanoreceptors. Oscillatory motion will selectively

activate the dynamic, rapidly adapting receptors, ie. Meissner'sand Pacinian
Corpuscles .

The former respond to the rate of skin indentation and the latter respond to
the acceleration and retraction of that indentation.

Grade II -Similar effect as Grade I.

By virtue of the large amplitude movement it will affect Type II
mechanoreceptors to a greater extent.
Mobilization Grade III -Similar to Grade II. Selectively activates
more of the muscle and joint mechanoreceptors as it goes into
resistance, and less of the cutaneous ones as the slack of the
subcutaneous tissues is taken up.

Grade IV -Similar to Grade III. With its more sustained movement

at the end of range will activate the static, slow adapting, Type I
mechanoreceptors, whose resting discharge rises in proportion to
the degree of change in joint capsule tension.

Grade V -This is the same as joint manipulation. Use of the term

'Grade V' is only valid if the joint is positioned near to its end range
of motion during joint manipulation.
Maitland Joint Mobilization/Oscillations
Grading Scale
Grading based on amplitude of movement & where within available
ROM the force is applied.

Grade I
Small amplitude movement at the beginning of the range of movement
Used to manage pain and spasm

Grade II
Large amplitude movement within midrange of movement
Utilize when quick oscillation induces spasm or when slowly increasing
pain restricts movement halfway into range
Grade III Large amplitude movement up to point of
limitation (PL) in the range of movement.

Used when pain and resistance from spasm, inert tissue

tension or tissue compression limit movement near end of
range.

Grade IV Small amplitude movement at very end of range.

Used when resistance limits movement in absence of pain

Distraction Classifications Grade I: Where the
joint surfaces are barely un-weighed.

Grade II: Where the slack of the capsule is taken up

Grade III: Where the capsule and ligaments are

stretched

Manual Rhythmic: Series of distraction motions,

altered with periods of rest
Positional: Most usefull in spine to relive nerve root
pressure
Accessory Movements
•Movements which are essential to normal full range and pain free function
and accompany the classical movements.

•A Joint Play Motions: Movements not under voluntary control which

occur only in response to an outside force.

Example: Forward glide of the distal tibia and fibula on the talus during
heel strike.
•Use: To detect the joint's ability to relieve and absorb extrinsic forces
When the convex surface is fixed and the concave surface
moves on it, the concave surface rolls and glides in the same
direction

•When the concave surface is fixed and the convex surface

moves on it, the convex surface rolls and glides
 Rules for mobilization/manipulation

•Patient relaxed with the joint supported

•Examiner must appear relaxed
•Locate the joint line
•One hand stabilizes
•One hand manipulates
•Bunch up skin when feasible
•Do not squeeze or block
•One joint at a time, into one direction
•Manipulate in accessory motion, not classical
•Position/start in LPP
•Manipulate parallel or perpendicular
•No forceful movement
Indications for Manual
therapy/Mobilization

Any painful joint to provoke neurophysiological effects (reduce

pain/protective muscle splinting)

•Any stiff joint for the mechanical benefits

•These are the only two indications for manual therapy

Indication for manual therapy
/Mobilization
Technique selection

•High Tissue Reactivity: Pain before resistance -Oscillations, no

stretching

•Moderate Tissue Reactivity: Pain synchronous with

resistanceOscillations, stretches, oscillations

•Low Tissue Reactivity: resistance before painstretches and/or

thrust
Contra Indications for Manual
therapy/Mobilization

Mobilization

There are no absolute contra-indications, but

techniques selection is rather important, especially for

high velocity thrust techniques.

 Precautions
Certain disease states
•Hemarthrosis, especially when Precautions Prior to Manipulation:
you are not sure whether you •Adequate evaluation
are dealing with a synovitisor a •Identify the direction of the restriction
hemarthrosis •Prepare the soft tissues
•Muscle holding •Protect any neighboring hypermobility
•When in doubt, don‟t
•Hypermobility Structural inspection of posture and bony
•Acute inflammation (gout) position/landmarks are key prior to
•Joint replacement determining the cause of the restriction
•Anti-coagulant therapy
 End feel

Quality of resistance that limit ROM

•End feel will be different per joint, depending on the structure restricting the

ROM

•PROM is always greater than AROM

•Compare to the other side if possible

•To restore normal classical movement, normal end feel should be restored as

well

•Types include soft tissue, muscular, ligamentous, cartilaginous, capsular

Biomechanical effects:
•Stretch restrictions within the capsule

•Stretch or snap adhesions between capsule and bone ends

Chemical effects:

•Release of endorphins following multiple level thrust manipulations

•Type III receptor activation (GTO) results in muscle relaxation

•The Pop (Nitrogen in vacuum

 Arthrokinematics

ArthrokinematicsClosed packed position

•Joint surfaces are incongruous except in one special

position
•Locked and screwed
•Statically efficient for load bearing
•Dynamically dangerous
Loose packed position
•Opposite of CPP
•Capsule and ligaments are at their slackest
•Unlocked
•Statically inefficient for load bearing
•Dynamically safe
 Convex –Concave considerations

Joint motion is either a roll a slide or a long –axis

rotation and often a combination

•I.e.: when the knee moves into extension, the

femur rolls and slides on the tibia.

Depending on WB of the knee, roll and glide will

happen in the same or opposite direction

•There are some common rules that you should

understand before you start mobilizing peripheral
joints
If a convex surface is moving relative to a concave
surface, roll and slide must occur in the opposite
direction.

So a manipulation force of slide would be applied in the

opposite direction to the movement of the limb

•If a concave surface moves on a convex surface, roll

and slide occur in the same direction.

So a manipulation force of slide must be applied in the same

direction as the movement of the limb
•These Convex/Concave rules only apply to component
motions and not to joint play
Spine (mobility) tests

Palpation: Condition, Position,

Mobility Cervical Spine: Flexion, Extension, Rotation, Side bending First
rib.

Thoracic Spine: Flexion, Extension, Rotation, Side bending

Lumbar Spine:Flexion, Extension, Rotation, Side bending

C0-C1-C2 Complex Upper cervical spine vs. mid cervical spine

ALWAYS PERFORM VERTEBRAL ARTERY TEST PRIOR TO C-

SPINE MONILIZATIONS
The Hand
MCP Flexion
Metacarpophalangeal joints mobilizations
•Movement: Flexion, extension •Distraction

•LPP: 10-20 degrees flexion •Long Axis Rotation

•VolarGlide
•Component motions:
•Radial Glide
•Dorsal glide
•UlnarGlide
•Volarglide
•Dorsal Tilt
•Radial glide
•UlnarTilt
•Ulnarglide
•Radial Tilt
•Daorsaltilt with flexion beyond 65
MCP PIP and DIP PIP and DIP
flexion
Extension extension
mobilization
mobilizations
•Distraction mobilization
•Distraction
•Volar Glide •Distraction
•Dorsal Glide
•Radial Glide •Four uni-condylar •Dorsal Glide
•UlnarGlide
glides •Four uni-condylar
•Long Axis
•Radial tilt glides
Rotation
•UlnarTilt •Ulnar tilt •Radial tilt
•Radial Tilt
•Ulnar tilt
The Wrist

•Inthis course we will assess the

carpal bones as a distal and
proximal row rather than each
carpal bone by itself

•Movement: Flexion (with ,

extension, adduction, abduction,
supination, pronation

•Component motions: Volar

glides, dorsal glides, distraction

•Capitate is main landmark and is

center of movement
Wrist extension Wrist flexion

•Distal row moves dorsal,

proximal row moves volar up to •The opposite occurs

60 degrees. •There is considerable shift of the

radius moving caudally

•At 60 degrees, hamate,
capitate, trapezoid and scaphoid •Last 30 degrees of flexion is

come into CPP, forcing radial mainly distal row movement

deviation.
•Mobilization; Convex on

•When a blow is taken to the concave, or vv.? Flexion vs.

hand in extension, the force is extension

generally taken via the third
•Distraction: Hand in pronation,
metacarpal to the capitate to
lunate then to the radius volar side down
The Wrist

•Distal row is convex on the

proximal side

•Proximal row is concave at the

distal side and convex on the
proximal side

•The distal aspect of the

radius/ulna are considered concave

•Mobilization; Convex on
concave, or vv.? Flexion vs.
extension.

•Distraction: Hand in pronation,

volar side down
CMC Joint Motion:

Flexion, extension, abduction, adduction

Component motions:
•PalmarGlide Across Palm, parallel to palm (Flexion),

•PalmarGlide into Palm, right angles to palm (Abduction)

•TriquetralVolar Glide (Supination)

•Distal Radius-ulna Volar Glide of Ulna ( Pro/Sup/Ext/Flex

(wrist+Elbow))
Other wrist techniques:

•Radio-carpal Volar Glide: Wrist extension

•Radio-carpal Medial Glide : Wrist abdcution(radial

deviation) (may use wedge)

The Knee Joints:

•Patello-Femoral

•Tibia Femoral

•Tibia Fibula Movements:

•Flexion and extension of tibia on femur

•Medial and lateral rotation of tibia on femur

PFJ: 0-5 degrees

Tib-fib: 10-20 degrees flexion

The Knee Component motions:

•Moving into extension with foot of the ground (open chain)

•Moving into flexion with foot off the ground (open

chain)Joint play motions:

PFJ: transverse axis rock longitudinal axis rock medical lateral

glides
The Knee Joint play motions:

Tibia Femoral Distraction Medial, lateral tilts.

Tibia Fibula anterior/lateral glide

posterior/medial glide superior, inferior glides

Mobilizations to improve Knee flexion PFJ:

Inferior glide Medial glide Lateral glide transverse axis rock

longitudinal axis rock

Tib-Fem: Distraction Posterior glide Anterior glide lateral

condyle

Posterior glide medial condyle

Anterior tilt Medial tilt Lateral tilt

Mobilizations to improve Knee: flexion Tib-Fib
Posterior/medial glide Anterior/lateral glide Inferior
glide Superior Glide

Mobilizations to improve Knee extension

PFJ: Superior glide Medial glide Lateral glide transverse axis rock

longitudinal axis rock

Tib-Fem: Distraction Anterior glide Posterior glide

lateral condyle Anterior glide medial condyle Medial tilt Lateral tilt
Mobilizations to improve Knee flexion
Tib-Fib

Posterior/medial glide Anterior/lateral glide

Inferior glide Superior Glide
 The foot ankle complex

Complex Joints:

•Talo-crural

•Sub-talar

•Mid-tarsal
The foot ankle complex Talocrural

Complex Talocrural: Active movements: Dorsiflexion, plantarflexion

LPP:5-10 degrees plantar-flexion

Component motions: Dorsiflexion:

•
Posterior glide and medial glide of talus

•Superior movement of the fibula

Plantarflexion:

•Anterior glide and lateral glide of talus

•Inferior movement of fibula

Ankle dorsiflexion: Ankle plantar flexion:

Talocrural
•Talocrural •Distraction talus
•Distraction talus
•Posterior glide talus •Anterior glide talus

•Medial glide talus •Lateral glide talus

•Posterior glide distal tibia
•Anterior glide distal tibia
•Inferior motion fibula
•Superior motion fibula •Anterior/lateral glide

•Ant/lat glide fibula head fibula head

•Post/med glide fibula
•Post/med glide fibula head
head
The Hip Active movements:

Flexion, extension, adduction, abduction,

IR/ERLPP:30°flexion, 30°ABD, little ER Component

motions: Posterior glide, anterior glide, inferior glide

Hip Joint Mobilization
Hip Joint Mobilization
Flexion:
Internal rotation:

•Distraction
•Distraction
•Posterior stretch
•Inferior glide beyond
•Posterior stretch
70°flexionExtension:
•Distraction
External rotation:
•Anterior stretch Adduction:
•Distraction
•Distraction
•Lateral stretch Abduction:
•Anterior stretch
•Distraction
•Medial stretch
The Shoulder
For this course we will only discuss the glenohumeral joint

Active movements:

•Sagittal flexion and extension

•Coronal adduction and abduction

•Scapulo-humeral elevation

•Internal, external rotation LPP: 20 degrees scapulohumeral

abduction (20 degrees horizontal abduction
The Shoulder Component
motions: Gleno-humeral mobilizations

Abduction/Flexion
•Inferior & posterior glide with
sagittal flexion •Lateral distraction
•Anterior glide with extension •Inferior glide External Rotation:
•Inferior and anterior glide with
•Lateral distraction
coronal abduction
•Inferior glide with scapulohumeral •Anterior glide Internal Rotation:
elevation •Lateral distraction
•Posterior glide with internal rotation
•Posterior glide Horizontal
•Anterior glide with external rotation
Joint play Motions: adduction:
•Lateral Distraction •Lateral distraction

•Posterior glide
Mobilizations Horizontal
Abduction

•Lateral distraction
•Anterior glide Sagittal Flexion:
•Lateral distraction
•Inferior glide
•Posterior glide Extension:
•Lateral distraction
•Anterior glide Coronal
Abduction:
•Lateral distraction
•Inferior glide
•Anterior glide
 Reasoning behind manual therapy

Sensory Receptors
Type 1 receptors (Merkel’s disk receptors in skin, Ruffini
endings in joint capsule):Present in the superficial layers of the
fibrous joint capsule and skin.

They respond to stretch and pressure within the capsule and

are slow-adapting receptors with a low threshold.

They signal joint position and movement

 Movement Receptors
Vision (information received when moving the head is much greater then when
kept stationary)

•Hearing (ball on a racket, walking surface; example blindness)

•Equilibrium organ (gives information about position head in space, otoconia

moving in semi circular canals indicating speed and direction)

•Joint receptors

•Tendon receptors

•Muscle spindles

•Skin receptors
 Sensory receptors by type:

Type: location: Fired by:

Type I postural capsule oscillations

Dynamic capsule oscillations

Type II
Inhibitive capsule/ stretch or sustained ligament
Type III
pressure

Type IV
Nociceptive most tissues injury and inflammation
Type 2 receptors: (Pacini)
Present in the deep layers of the fibrous capsule.

They respond to rapid movement, pressure change and vibration but

adapt quickly.

They have a low threshold and are inactive when the joint is at rest.
Type 3 receptors: These are present in ligaments. (Comparable with Golgi
tendon receptors)

These receptors inform the central nervous system of ligamentous tension, so

preventing excessive stresses.

The threshold is high and they adapt slowly. They are not active in rest
Type 4 : Free un-encapsulated terminals, also called nocisensors.

These sensors ramify within the fibrous capsule, adjacent fat pads and
around blood vessels.

They are thought to signal excessive joint movements and also to signal
pain; they have a high threshold and are slow-adapting.

The synovial membrane is relatively sensitive to pain due to the absence of

these nerve endings.
•All these receptors influence muscle tone via the spinal reflex arcs

which are formed by the same nerves that supply the muscles

acting on the joint.

Parts of the joint capsule supplied by a given nerve correspond

with the antagonistic muscles.

•Tension given on this part of the capsule produces reflex

contraction of these muscles and prevents overstretching of the

capsule.
In consequence, all receptors have an important function in
stabilizing and protecting the joint.

•After rupture of joint capsule and ligament, perception is

considerably disturbed due to disruption of afferent information.

•For example a sprained ankle shows loss of control of locomotion.

Even months after repair of ligamentous and capsular tissues has

taken place, perception might still be distorted.
THINK-PAIR -SHARE

2 minute Ponder
 Kaltenborn/Evjenth
Freddy Kaltenborn: Known for his research in arthrokinematics.

•His techniques incorporate the influence of muscle function and soft-tissue

changes in the patient‟s manifestation of loss of function.

•The techniques are eclectic and very specific.

 KALTENBORN TECHNIQUES

• Freddy Kaltenborn -Physical educator in Germany in 1945;physical

therapists in Norway in 1949.

• According to Kaltenborn, all joint mobilizations, when performed

correctly should be made parallel, or at right angles to this plane of
motion.

• Kaltenborn’s techniques use a combination of traction and

mobilization to reduce pain and mobilize hypomobile joints
 MC KENZIE

• The McKenzie Method is a philosophy of active patient treatment

that emphasizes intervention and prevention. It provides the
patient with life-long pain management skills.

• Also known as mechanical diagnosis and therapy (MDT),

McKenzie is based upon a consistent "cause and effect"
relationship between mechanical forces and pain response often
accompanied by a change in motion/function.
 McKenzie Method
This modality may be used to treat any number of back, spine, muscle,
bone, or joint disorders.

•In order to determine if the McKenzie Method® will relieve a patient's

pain or improve their mobility or range of motion, the patient attempts
several of the exercises designed to reduce the sensation of pain

•If the pain moves towards the spine or is eliminated, then the patient
may be an appropriate candidate for the McKenzie Method®.

•Centralization is the term practitioners of this modality use to describe

this movement or elimination of pain.
•
The McKenzie Method® classifies musculoskeletal problems that may
benefit from this treatment into three categories.

•Usually, if the patient's pain and spinal-related problems do not have

a mechanical origin, the McKenzie Method® may not be a useful
treatment for that individual.

•Because of the immediate assessment procedures that take place in

the first appointment, patients avoid spending money on a procedure
that may not benefit them.
McKenzie is a comprehensive approach to the spine
based on sound principles and fundamentals that
when understood and followed accordingly are very
successful

•The McKenzie Method: Three Steps To Success:

•Assessment
•Treatment
•Prevention
McKenzie Method: Assessment
Assessment:
••This mechanical examination can "classify" most patient conditions by
the level of pain or limitation that results from certain movements or
positions.

•A McKenzie assessment can eliminate the need for expensive and/or

invasive procedures

•Research has shown the initial McKenzie assessment procedures to be

as reliable as costly diagnostic imaging (i.e., X-rays, MRIs) to determine
the source of the problem and quickly identify responders and non-
responders
McKenzie Method:
Treatment
•McKenzie treatment prescribes a series of individualized exercises.

•The emphasis is on active patient involvement, which minimizes the

number of visits to the clinic.

•Ultimately, most patients can successfully treat themselves when

provided the necessary knowledge and tools.

•For patients with more difficult mechanical problems, a certified

McKenzie clinician can provide advanced hands-on techniques until the
patient can self administer
McKenzie Method: Prevention

•By learning how to self-treat the current problem,

patients gain hands-on knowledge on how to minimize
the risk of recurrence and to rapidly deal with
recurrence if it occurs.

•The likelihood of problems persisting can more likely

be prevented through self-maintenance.
McKenzie

•McKenzie back extension exercises have been order by

physicians and prescribed by physical therapists for at least
two decades (McKenzie 1981).

•Robin McKenzie noted that some of his patients reported

lower back pain relief while in an extended position.

•This went against the predominant thinking of Williams

Flexion biased exercises at this period of time.
McKenzie

•The goal of McKenzie exercises is to centralized pain.

•If a patient has pain in the lower back, right buttock, right
posterior thigh, and right calf, then the goal would be to
"centralize" the pain to the lower back, buttock, and
posterior thigh.

•Then, "centralize" the pain to the lower back and buttock,

and finally just the lower back
McKenzie

•McKenzie has developed diagnostic categories that assign

patient to specific treatments.

•Patients evaluated by McKenzie certified therapists are

most likely to be placed into an extension biased exercise
program.

•This is probably why most people think of extension when

talking about McKenzie exercises, or because the original
exercises were in opposition to Williams' flexion exercises.
 MUSCLE ENERGY

Theory

􀂄􀂄 Muscle energy technique is a manual therapy

procedure which involves the voluntary

contraction of a muscle in a precisely

controlled direction at varying levels of

intensity against a distinct counterforce applied

by the operator.
Uses:

• Lengthen a shortened, contractured, or spastic muscle.

• Strengthen a weakened muscle or group of muscles.

• To reduce localized edema.

• Relieve passive congestion.

• To mobilize an articulation with restricted mobility

 Types of Contraction

Isometric

􀂄􀂄 Concentric Isotonic

􀂄􀂄 Eccentric Isotonic

􀂄􀂄 Isolytic
 Principles Employed

Reciprocal Inhibition

Autogenic (post-isometric) Inhibition

 Isometric Contraction

• Primarily reduce the tone in a hypertonic muscle & reestablish its normal

resting length.

• Shortened and hypertonic muscles are frequently identified as the major

component of restricted motion of an articulation.

• Length and tone are governed by the fusiform motor system to the

intrafusal fibers.

• The gamma system is the neurological control for this system.

• Works on a reflex arc.

• Autogenic (post-isometric) Inhibition
• Reciprocal Innervation& Inhibition
• Improved Tone & Performance

• Overall Effect:

1. These muscle contractions affect the surrounding fascia,

2. connective tissue ground substance interstitial fluids, and alter

3. muscle physiology by reflex mechanisms.

4. Fascial length and tone is altered by muscle contraction.

5. Alteration in fascia influences biomechanical function,

6. biochemical, and immunological functions.

7. The contraction produces metabolic processes to occur and the

8. patient may experience soreness within 12-36 hours after

9. treatment.
 ELEMENTS OF MUSCLE ENERGY

• Patient-active contraction

• Controlled Joint Position

• Direction specific muscle contraction

• Operator applied specific counterforce

MINI ASSESSMENT
• Describe the different concept between Maitland’s approach and
McKenzie Approach

• Grades of Joint Mobilization ?

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