This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
2. Objectives of class
At the end of the class, students should
be able to:
List out various Manual Therapy
schools of thoughts
Describe types of passive movements
Explain core elements of Maitland’s
concept
3. Objectives of class (contd..)
At the end of the class, students should
be able to:
Explain grades of mobilization
Explain principles of treatment by
Maitland
4. History Of Manual Therapy
Manual therapy is as old as the
science and art of medicine.
Time of Hippocrates
5. 17th and 18th centuries:
Bone-setters vs. physicians
19th century:
Osteopathy –Andrew Still - 1874 AD
Chiropract – Daniel P - 1895 AD
History Of Manual Therapy
6. Manual Medicine
Manual medicine deals with the
identification of the lesions, which
can be manipulated with the
appropriate use of manual therapy
procedure to resolve the condition.
Treatment by “hand”
7. Shift from hands on to hands-
off
Pain
Social
BIO
Psycho
Treatment
Manual
Therapy
8. Schools of thought (1)
McKenzie Technique
Mulligan Technique
Maitland Concept
Muscle Energy Technique
Cyriax’s Technique
Craniosacral Therapy
11. Introduced by G.D. Maitland in the
1950’s.
It mainly deals with the concept of
examination, treatment and
assessment by passive
movement.
Introduction:
12. Passive movement?
Movement of any part of the body
performed by an external force may it
be another person or equipment.
Relieves pain
Restores full range pain free functional
movements
14. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
17
15. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
18
16. 1. Patient centered approach
Patient driven model
Listening (active) vs hearing (passive)
Believe the patient
At the same time questioning
19
17. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
20
19. 2. Brickwall analogy
Know the history, symptoms and
signs very clearly
Medical Diagnosis vs physiotherapy
diagnosis
Use of words:
hip joint pain vs pain in hip area
22
20. 2. Brickwall analogy
Selection of treatment technique:
Related to patient’s signs and
symptoms (physical therapy diagnosis)
rather than the diagnostic title
Demands logical reasoning
23
21. 2. Brickwall analogy
Apply Clinical Reasoning
1. Dysfunction
2. Pathobiological mechanisms
3. Sources and causes of the symptoms
4. Contributing factors
5. Precautions and contraindications
6. Prognosis
7. Management
24
Mark Jones, 2005
30. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing
movement potential
4. Science and art of assessment
33
31. 3. Identifying and maximizing
movement potential
Key stones-
Assessment
Symptom response to movement and
position
32. The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
35
33. 4. Science and art of assessment
Cornerstone of the concept
Clinical proof of whether treatment
is working or not
36
34. a) Analytical assessment at first
consultation
Establish and test working hypothesis
b)Pre-treatment assessment
Effects on comparable signs should be
analyzed
37
4. Science and art of assessment
35. c) Assessment and reassessment during
and immediately after each treatment
session
d) Progressive assessment: after 3-4 sessions
e) Retrospective assessment: after break
f) Final analytical assessment: prognosis
38
4. Science and art of assessment
36. Subjective Examination
The patient’s story
Provides most (about 80%) of the
information needed to clarify the cause
or establish a hypothesis
39
37. Subjective examination – aims
To identify how the patient is affected by
the disorder
To establish the extent of physical
examination and desired effect of
treatment based on SIN
To generate hypothesis
40
38. Subjective examination
1. Kind of disorder
2. Area of symptoms: Body chart
3. Intensity of pain
4. Behaviour of symptoms/ pain
5. Relationship of pain, stiffness, spasm
6. History
7. Special questions (to rule out flags)
41
39. Subjective Examination:
Components
Patient profile
Chief complaint
Body chart
AGG/Ease factors
24-hour behavior
Special questions
Present episode
Past history
42
40. Variables needed for assessing pain
Position in range where pain is
expressed (P1, P2)
Extent of range through which pain is
experienced
Severity of pain at the limit of
movement (L)
43
41. Develop a body chart
Get a clear picture of the problem
Prioritizes complaints, pain P1, P2…
Many times leads you to diagnosis
44
44. Aggravating & Easing Factors
Aggravating
Bending over*
Crossing my legs*
Getting up from chair*
Rolling over in bed*
Walking 5 minutes*
* Treat the Asterisks *
47
Easing
• Return to standing
• Uncrossing my legs
• Walking 5 minutes
• Comfortable position
• Sit for 5 min
45. Behavior of Symptoms
Establish symptom behavior over a
24 hour period
First thing in the morning
Throughout the day
End of day
Night pain/ sleeping pain
Work day versus non-work day
48
46. Assessment During Initial
Examination
Establishing the SINSS:
Severity, Irritability, Nature,
Stage, Stability
Provides the basis for planning the OE
Structures to be examined
Depth of examination
Which symptoms to reproduce
49
47. Severity
Refers to the intensity of symptoms and the
extent that they limit normal activity
Examples:
Pain scales ->
0-10 Numerical (Pain) Rating Scale
Verbal rating scale,
visual analogue scale,
Faces Pain Rating Scale
50
48. Irritability
Refers to the ease in which symptoms are
produced and the time it takes to settle
Examples:
Symptom onset:
Immediately on movement vs. after sustained
activities
Symptom relief:
“Pain goes away immediately when I stand up
straight”
“Pain persists 10-15 minutes after stand up
straight.”
51
49. Nature
Refers to the type and extent of injury
Examples:
Type: aching, throbbing, burning, stabbing,
sharp, dull, deep, superficial, etc.
Symptom behavior: radiating, referred, local,
etc.
Tissue and injury: sprain, DJD, fracture,
osteoporosis, multi-tissue trauma, neural
tension
Degree of injury: 1st-3rd degree, mild-
severe, etc.
52
50. Stage and Stability
Stage: acute, sub-acute, chronic,
acute on chronic
Stability: how are the symptoms
changing?
Better, worse, the same?
53
51. Assessment During Treatment
Course
Proves the value of each technique
At beginning of a treatment session:
Determine effect of last treatment session
(immediate, that evening, next morning)
Reassess SE* and OE*
Forms the basis for treatment session
As each technique is performed:
Be alert to changes on the patient’s
symptoms
Palpate, observe, and question
54
52. Assessment During Treatment
Course
After each technique is used:
Determine the immediate effect of a
technique (reassess SE* and OE*)
Determine how to proceed (repeat, modify,
add, or discontinue the treatment
technique)
At conclusion of a treatment session:
Determines the effect of the whole
treatment session
55
53. “Making features fit”
Determine the information obtained fit in
recognizable clinical patterns of
symptom behaviour deriving from
specific sources of impairments
Link with physical examination
56
54. Planning of physical examination
Structures need to be examined as the
cause of the disorder
Extent of examination
Strength with which the test movements
need to be carried
57
55. Physical examination – aims
Primary aim is to find a comparable
sign in disorders with pain
These comparable signs will frequently
serve in reassessment procedures
Test the hypothesis generated in
subjective examination
58
56. Physical Examination includes
Observation
Functional demonstration
Active movement tests: quality, quantity
of movement, symptom response (pain and
ROM), Over pressure
Passive movements tests: physiological,
accessory movement, symptom response
Isometric tests
Palpation
Differentiation tests
59
59. Comparable signs
A comparable sign refers to combination
of pain, stiffness, motor responses
which the examiner discovers on physical
examination and considers to be
comparable with patient’s symptoms as
described in the subjective examination
62
60. Treatment Techniques
Based on the response to examination
May relieve or provoke symptoms
Take into account:
SINSS
Worse, same, better
Vigor of techniques
Test – retest
Choose one or two techniques and
compliment with specific home exercise
“A technique is the brainchild of ingenuity.”
– GD Maitland 63
61. Mobilization principles (Maitland
and Greenmann)
Patient must be completely relaxed
Operator must be relaxed
Patient must be comfortable and have
complete confidence in the operator’s grasp
Embrace the joint to be moved, hold
around the joint to feel movement
64
62. Mobilization principles (Maitland
and Greenmann)
Move one joint, one motion at one time
Patient must be confident that the joint will
not be hurt
Operator’s position must be comfortable
and easy to maintain
Operator’s position must afford him/her
complete control
65
64. Principles of techniques
Assessment is the key to success -
technique is merely a tool.
“A technique is a brain child of ingenuity”
Imagination, originality, creativity
There are no set techniques; but the
basic techniques must include every
possible movement combinations
67
69. Selection of techniques
1. General aspects: based on SIN
2. Aspects of technique itself-
mobilisation vs manipulation, grades
choices
3. Based on symptoms and signs
73
70. Based on signs and symptoms
Pain Stiffness
Pain &
Stiffness
Momentary
pain
74
71. Now are you able to?
Describe types of passive movements
Explain core elements of Maitland’s
concept
Understand a movement diagram
Explain grades of mobilization
Explain principles of treatment by
Maitland
80
These oscillatory movements may consist of the joint’s
physiological movement e.g. shoulder flexion
accessory movements e.g. MCP rotation
Manipulation under anesthesia is a medical procedure performed under general anesthesia, as a steady and controlled stretch in order to restore full range of motion in a joint by breaking down adhesions.
Eg-
Coping with diagnosis and diagnostic titles is difficult and many diagnostic titles are inadequate or even incorrect
Includes all procedures which are undertaken to monitor the therapeutic process throughout all encounters between the physiotherapist and the patient
Assessment demands a mind that is: agile, open to receive information, plastic and innovative to analyse findings, and disciplined, logical and methodological in its use of information
Progressive assessment is done after 3 0r 4 sessions to gain an overview of rate of improvement
retrospective assessment - After a planned break from treatment to assess whether the disorder is spontaneously recovering or due to treatment
6. final analytical assessment - to establish the future prognosis and possible recurrence of the disorder
Patient may have one disorder but different kinds of pain, overlapping areas of pain from different components of disorder, different pains with different behaviors and histories
Features of history fit with behaviour and localization of symptoms
Imagine how the pt can respond to exn, whether a comparable sign can be found or not srtucutures – eg of pain in interscapular region
When examining movement disorders which are related to pain the primary aim is to find a comparable sign at appropriate components
A joint or an active movement can never be stated as normal unless relatively firm overpressure can be applied painlessly