MANUAL THERAPY

Dr. Amna Haider

Lecturer ZIHS
 Manual Therapy
• Manual therapy, manipulative therapy, or
manual & manipulative therapy focuses on
the treatment of health ailment of various
etiologies through passive movement
techniques
• Skilful handling with the hands to give a
therapeutic effect
• To work with one's hands
 Manual Therapy
• Manual therapy uses hands-on techniques to improve ROM
in restricted joints.
• It is also used to stimulate the function of muscles, nerves,
joints, and ligaments.
• This type of therapy includes care from physical therapists,
chiropractors and other rehabilitation team members.
• Chiropractors defined manual therapy as "Procedures by
which the hands directly contact the body to treat the
articulations and/or soft tissues."
 Manual Therapy

• Manual therapy may be defined differently

(according to the profession describing it for
legal purposes) to state what is permitted
within a practitioners scope of practice.
 Manual Therapy
• Within the physical therapy profession, manual therapy is defined as a
clinical approach utilizing skilled, specific hands-on techniques, including
but not limited to manipulation/mobilization, used by the physical
therapist to diagnose and treat soft tissues and joint structures for the
purpose of modulating pain; increasing range of motion (ROM); reducing
or eliminating soft tissue inflammation; inducing relaxation; improving
contractile and non-contractile tissue repair, extensibility, and/or
stability; facilitating movement; and improving function.
 Manual Therapy
• PT Guide to Practice:
Mobilization/Manipulation = “A manual
therapy technique comprised of a continuum
of skilled passive movements to joints and/or
related soft tissues that are applied at varying
speeds and amplitudes, including a small
amplitude/high velocity therapeutic
movement”
 IFOMT definition of OMT
• Orthopaedic Manual Therapy is a specialized area
of physiotherapy / physical therapy for the
management of neuro-musculo-skeletal
conditions, based on clinical reasoning, using
highly specific treatment approaches including
manual techniques and therapeutic exercises.
• Orthopaedic Manual Therapy also includes, and is
determined by, the available scientific and clinical
evidence and the biopsychosocial framework of
each individual patient.
 History of Manipulation
• Hippocrates, Father of
Medicine
– 460-355 B.C.
– Wrote “On Setting Joints by
Leverage”
– Spinal Traction
– Reduction of dislocated
shoulders
• Hippocrates influence was still
evident in 200 AD when Galen
described a method of
manipulation for dislocated
discs while the patient was in
traction.
History of Manipulation
 History of Manipulation
• Avicenna (also known as the doctor of doctors) from
Baghdad (980–1037 CE) included descriptions of
Hippocrates’ techniques in his medical text The Book
of Healing
• In 1580 Pare, the famous French military surgeon
who served four successive kings of France, advised
the use of manipulation in the treatment of spinal
curvature
History of Manipulation
 History of Manipulation

Bone Setters
• Friar Thomas
– published, “The Complete
Bone-Setter”, 1656
• Bone setting flourished in
Europe during the period of
1600-early 1900‟s
– No formal training
– Techniques passed down
within families
– Clicking sounds thought to be
due to moving bones back into
place
 History of Manipulation
• By the 18th century physicians and surgeons tended
to abandon the general acceptance of spinal
manipulation
• James Paget, one of the most famous surgeons of
the 19th century, suggested that doctors would do
well to observe bonesetters and learn from them
what is good and avoid what is bad
 History of Manipulation

• Wharton Hood
– 1871, “On Bone-setting”
• first such book by an orthodox
medical practitioner
• Hood thought snapping sound was
due to breaking adhesions
– In 1887, PTs were given official
registration by Sweden's
National Board of Health and
Welfare
– 1894 Chartered Society of
Physiotherapy founded in
England
 Schools of Thought

• Osteopathy
• McKenzie
• Williams
• James Cyriax
• Geoffrey Maitland
• Ola Grimsby
• James Mennel
• Brian Mulligan
• Kaltenborn
• Evjenth
• Stanley Paris
 History of Manipulation

Osteopathy
• Andrew Still founded
Osteopathy in 1874
– 1892 founded the first school of
Osteopathy in Kirksville,
Missouri
– “Rule of the Artery”-Manipulate
the spine to restore blood flow
and restore body's innate
healing ability
– Osteopaths currently licensed to
practice medicine in all states
 Osteopathy

•Still observed through careful study of a patient that

when joints are restricted in motion due to
mechanical locking or other related causes were
normalized, certain disease conditions improved.
•He also made much of the blood and nerve „flow‟.
„The Law of the Artery‟.
•In his mind, bloodstream is key to health so „in order
to successfully solve the disease problem or
deformity of any kind in every case without exception
would find one or more obstructions in some artery
or vein‟.
• In osteopathy: The body is a unit; structure and

function are reciprocally interrelated; the body

possesses self regulatory mechanisms for rational

therapies based on an understanding of the body

unity, the self regulatory mechanisms and the

interrelation of structure and function.

Robin A McKenzie
 McKenzie Method
•In the 1960s, the physical therapist Robin Anthony
McKenzie in New Zealand noted that a subset of his
patients experienced significant pain relief when the
spine was extended as the part of a treatment. Often,
these patients were able to return to normal daily
activities.
•Physical therapists who practiced the methods developed
by McKenzie founded the McKenzie Institute in 1982
•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.
 Robin Anthony McKenzie
•McKenzie system is one of, if not the most, studied
approaches
•The McKenzie Method is not merely extension
exercises.
•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: AssessmentAssessment:

•Includes a comprehensive and logical step-by-step process

to evaluate the patient's problem quickly.
•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 exercisesis 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
 Williams (Flexion)
•Dr. Paul Williams first published his exercise
program in 1937 for patients with chronic low back
pain in response to his clinical observation that the
majority of patients who experienced low back
pain had degenerative vertebrae secondary to
degenerative disk disease (Williams 1937).
•These exercises were developed for men under 50
and women under 40 years of age who had
exaggerated lumbar lordosis, whose x-ray films
showed decreased disc space between lumbar
spine segments (L1-S1), and whose symptoms
were chronic but low grade
 Williams(Flexion)
•The goals of performing Williams exercises are to
reduce pain and provide lower trunk stability by
actively developing the "abdominal, gluteus
maximus, and hamstring muscles as well as..."
passively stretching the hip flexors and lower back
(sacrospinalis) muscles.
•Williams said: "The exercises outlined will
accomplish a proper balance between the flexor
and the extensor groups of postural muscles..."
(Williams 1965, Williams 1937,Blackburn 1981,
Ponte et al.).
 Williams (Flexion)
•Williams‟ flexion exercises have been a cornerstone in
the management of lower back pain for many years for
treating a wide variety of back problems, regardless of
diagnosis or chief complaint.
•In many cases they are used when the disorder‟s cause
or characteristics were not fully understood by the
physician or physical therapist.
•Physical therapists often teach these exercises with their
own modifications.
•Williams suggested that a posterior pelvic-tilt position
was necessary to obtain best results (Williams 1937).
 Williams’ Flexion

•Conceptually, Williams felt that the goal of exercise

was to reduce the lumbar lordosis or to flatten the
back. (what about the C-spine?)
•To do this, he suggested strengthening the
abdominal muscles in order to lift the pelvis from
the front.
•In addition, he felt that strengthening the gluteal
muscles would pull the back of the pelvis down.
•According to Williams, the combination of these
two exercises would accomplish the primary goal
of flattening the lumbar curve.
 William’s Flexion

•Williams had a series of suggestions for the

management of back pain, including what he
referred to as "first aid exercises."
•His general exercise protocol included: 1) partial sit-
ups; 2) knee-to-chest exercises; 3) hamstring
stretches; 4) lunges; 5) seated flexion; and 6) squat
James Cyriax
 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 endfeel.
Geoffrey Maitland
 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‟.
 Geoffrey Maitland

•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.
Ola Grimsby
 Ola Grimsby
•Seeks a scientific rationale for his clinical skill, but
puts an emphasis on the art of clinical performance.
•In recognition of the need for scientific verification,
it is important to remember that research has little
value to us unless it is clinically applicable.
•Consequently, his course do not offer a finished
product, but offer you instead, the opportunity to
participate in a process of constant development,
fostering the development of a lifelong learner.
 James Mennel

•Feels that „joint play‟ is key to normal function.

•He emphasizes the importance of the small accessory
movements as necessary for full movement to occur.
•Techniques are more specific for the extremities than
for the spine.
•Was one of the first clinicians to study the intimate
mechanics of joints and to adapt mobilizations to his
findings
•E coined the term accessory motion.
Brian Mulligan:
 Brian Mulligan:
•Mobilization with movement: Nags and snags.
•Concept of mobilizations with movement (MWMS) in the
extremities and sustained natural apophysealglides
(SNAGS) in the spine have progressed physical therapist-
applied passive physiological movements and accessory
techniques in the treatment of musculoskeletal injuries.
•The Physiotherapy treatment of musculoskeletal injuries has
progressed from its foundation in remedial gymnastics and
active exercise to therapist-applied passive physiological
movements and on to therapist-applied accessory
techniques.
 Brian Mulligan
•Brian Mulligan's concept of mobilizations with
movement (MWMS) in the extremities and (SNAGS) in
the spine are the logical continuance of this evolution
with the concurrent application of both therapist
applied accessory and patient generated active
physiological movements.
•In the application of manual therapy techniques,
Physical Therapists acknowledge that contraindications
to treatment exist and should be respected at all times.
•Although always guided by the basic rule of never
causing pain, therapist choosing to make use of SNAGS
in the spine and MWMs in the extremities must still
know and abide by the basic rules of application of
manual therapy techniques
 Brian Mulligan
•Specific to the application of MWM and SNAGS in clinical
practice, the following basic principles have been
developed
•During assessment the therapist will identify one or more
comparable signs as described by Maitland.
•These signs may be a loss of joint movement, pain
associated with movement, or pain associated with specific
functional activities (i.e., lateral elbow pain with resisted
wrist extension, adverse neural tension).
•A passive accessory joint mobilization is applied following
the principles of Kaltenborn(i.e., parallel or perpendicular
to the joint plane).
•This accessory glide must itself be pain free.
 Brian Mulligan
•Utilizing his/her knowledge of joint arthrology, the
patient is requested to perform the comparable
sign (by performing a classic movement)
•The comparable sign should now be significantly
improved (i.e., increased range of motion, and a
significantly decreased or better yet, absence of
the original pain).
•Failure to improve the comparable sign would
indicate that the therapist has not found the
correct contact point, treatment plane, grade or
direction of mobilisation, spinal segment or that
the technique is not indicated
 Brian Mulligan
•The previously restricted and/or painful motion or activity is
repeated by the patient while the therapist continues to
maintain the appropriate accessory glide.
•Further gains are expected with repetition during a
treatment session typically involving three sets of ten
repetitions.
•Further gains may be realisedthrough the application of
passive overpressure at the end of available range. It is
expected that this overpressure is again, pain-free.
•Successful MWM and Snags techniques should render the
comparable sign painless while significantly improving
function during the application of the technique.
•Sustained improvements are necessary to justify ongoing
intervention.
Kaltenborn/Evjenth
 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
 Stanley Paris
•Incorporates both chiropractic and osteopathic
orientations in his eclectic approach to
normalization of arthrokinematics, especially joint
play and component motions. As a general rule,
the patient is not used to guide the treatment.
•Stabilize vs. mobilize.
•Founded USA
 History of Manipulation

Chiropractic Founded 1895

• D. D. Palmer (1845 -1913),
founder of Chiropractic. "The
Chiropractor's Adjuster,"
1910.
 History of Manipulation

History of Chiropractic
• DD Palmer applied an “adjustment” to Harvey
Lillard in September 1895 to the T4 vertebra that
resulted in restoration of lost hearing
• Concept of “subluxation” as a causal factor in
disease and the revelation that adjustments can
restore the body’s innate healing abilities
• Palmer School of Chiropractic founded in 1897 in
Davenport, Iowa
 History of Manipulation
Chiropractic Philosophy
• 'Adjustment or manipulation' means the
forceful movement of joints or tissue to
restore joint function, in whole or part, to
increase circulation, to increase motion, or to
reduce interosseous disrelation.
 History of Manipulation
Chiropractic Philosophy
• Belief in body’s innate ability to heal itself
• Presence of a “subtle” energy within the
organism
• “The Law of the Nerve”
– Adjust spinal “subluxations” to restore nerve flow
and facilitate the body’s innate healing ability
 History of Manipulation
Chiropractic Philosophy
• 1904, BJ Palmer (1881-1961) gained operational control of
the School and continued until 1961
• BJ is considered the “Developer” of chiropractic and
defender of “straight” chiropractic
• “Straights” adhere to original philosophy
• “Mixers” incorporate other modalities
 History of Manipulation
• Chiropractors claim to be the first
professionals to develop manipulation
• Chiropractors have a 110+ year history of
practicing and protecting their right to
manipulate
• All other professions are infringing on the
chiropractic scope of practice who wish to use
manipulation
 History of Manipulation
Physical Therapy in Sweden (1813)
• Per Henrik Ling “Father of Swedish
Gymnastics” founded Royal Central
Institute of Gymnastics (RCIG) in 1813
• Medical gymnastics
• Educational gymnastics
• Military gymnastics
• Swedish word for physical therapist is
“sjukgymnast” = “gymnast of the sick”
• Practitioners came from throughout
Europe to learn PT techniques at RCIG
including Jonas H. Kellgren(1837-1916)
(Grandfather to James Cyriax)
 History of Manipulation: US

PTs vision on Manipulation:

• Mary McMillan, 1st president of APTA
(founded 1921)
• The four branches of physiotherapy:
“namely
– manipulation to muscle and joint,
– therapeutic exercise
– electrotherapy and
– Hydrotherapy
 History of Manipulation

• McMillan’s 1921/1925 book is

based on the teachings of Ling
and RCIG in Sweden
– “Medical gymnastics” and
“therapeutic exercise” are
synonymous terms
• McMillan uses the word
“manipulation” throughout her
book to describe techniques
such as effleurage, tapotement,
friction massage, paddle
technique
 History of Manipulation
US PT history
• 1925 –1939: Yearly publications in Physical Therapy
literature on Manipulation and related topics
• By 1928, a council on physical therapy was
established within the American Medical Association
(AMA)
• 1940 –mid 1970‟s: The word “manipulation” is not
widely used in the literature
– Mobilization/articulation used to separate PT from
chiropractic
 History of Manipulation
Key PTs who stood up for
manipulation performed
by PTs
• Freddy Kaltenborn
– The Spine, …Mobilization 1961
– Nordic approach
– First to relate manipulation to
arthrokinematics
• Geoffrey Maitland
– “Vertebral Manipulation”, 1964
– Treats “reproducible signs”
– Oscillatory techniques (Grades I-
V)
 History of Manipulation
• Stanley Paris
– Spinal Lesion, 1965
– Educated PTs in U.S. in manual
therapy
– Founding member of AAOMPT
and first president of the
Orthopaedic Section
– Founder of University of St.
Augustine
• Maitland, Kaltenborn, and Paris
established long term Manual
Therapy education programs
for PTs in the USA and abroad
 History of Manipulation
IFOMPT
• Subgroup WCPT
• Formed in 1974
• IFOMPT sets educational and clinical
standards
• IFOMPT requirements reflect content relating
to manipulative physiotherapy
 History of Manipulation
Where do we go from here
• Evidence Based Practice
• Physical Therapists are the leaders in the diagnosis
and management of “Movement” Disorders
– Evidence shows that manipulation and exercise are PTs
most useful tools
• Professional Associations promote and protect scope
of practice
 History of Manipulation
Summary
• No one profession invented or owns Manipulation
• Traditional Chiropractic is based on unproven
theories
– “Law of the nerve”
– “Subluxation theory”
• Manipulation has been a vital part of the scope of PT
practice since the inception of the profession
 History of Manipulation

• Spinal manipulation is not designated as being under the

exclusive domain of any one specific profession or group
of practitioners.
• Physical therapists, chiropractors, medical doctors, and
osteopathic physicians are all educated and trained to
employ manipulation within the scope of their respective
licenses and in a manner that protects the public's health,
safety and welfare.
• It is inappropriate for one profession to attempt to "own"
a specific technique or dictate clinical practice through
such legislation
Nordic System Orthopedic Manual
Therapy
• Nordic System approch to manual
therapy begins in 1940 by Freddy
kaltenborn
• He developed this concept in
collaboration with Olaf Evjenth also
known as Kaltenborn-Evjenth
approach
Nordic System Orthopedic Manual
Therapy
Freddy Kaltenborn
• Physical educator in Germany
in 1945; Physical therapist in
Norway in 1949
– Became frustrated in treating
spinal disorders
• Massage + mobilization +
manipulation (especially for the
extremities) learned from physical
education along with the active +
passive movements learned from
physical therapy training were
limited in their effectiveness
Nordic System Orthopedic Manual
Therapy
• His major contributions was the use of biomechanical
principles in patient evaluation and treatment
• Promote the use of arthrokinematics and osteokinematics in
both assessment and treatment of articular motion
dysfunctions
– Emphasized the use of
• translatoric joint play movements in relation to a treatment plane for
evaluating and mobilizing joints
• grades of movement
• the convex-concave rule
• pre-positioning for joint movement
• protecting adjacent non-treated joints during procedures
Nordic System Orthopedic Manual
Therapy
• He also introduced the concepts of self-
treatment, ergonomic principles applied to
protect the therapist and trial treatment
 Special Features

• Combination of Techniques

• Biomechanical Approach to Treatment and

Diagnosis

• Ergonomic Principles for the Therapist

• Trial Treatment
 Combination of Techniques
• Multiple treatment techniques approach in one
treatment session.
• Self-treatment instructions which may include
– Auto-mobilization
– Auto-stretching
– Auto-traction
– Strengthening or coordination exercises
• Advice on body mechanics and ergonomics to
maintain improvements gained by therapy and
prevent recurrences
Biomechanical Approach to Treatment
and Diagnosis
• The Nordic approach emphasize the use of biomechanical
principles in the analysis and treatment of musculoskeletal
problems
– Translatoric joint play movements
• Allow safe & effective joint movements
• Can be evaluated by feeling the amount of slack in the movement and
sensing the end-feel
– Grades of movement – to rate the amount of joint play movement
– Joint positioning – direct the force to the point of restriction
– Convex-concave rule – determine the direction for gliding
– Evaluate and treat all combinations of movements, coupled and non-
coupled
– Special tests
 Ergonomic Principles for the
Therapist
• The Nordic System emphasize good therapist
body mechanics.
– In 1950’s the first pneumatic high-low adjustable
treatment table was designed by kaltenborn for
manual therapists.
– Treatment techniques and tools were developed
for efficiency and safety, including fixation belts,
wedges and articulating tables.
 Trial Treatment
• The manual therapist confirms the initial
physical diagnosis with a low-risk trial
treatment as an additional evaluation
procedure
– Subjective markers
– Objective markers