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INTRODUCTION TO
MANUAL THERAPY
Schools of thought
BPT Third Year
Saurab Sharma, MPT
Lecturer, KUSMS
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
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
History Of Manual Therapy
 Manual therapy is as old as the
science and art of medicine.
 Time of Hippocrates
 17th and 18th centuries:
 Bone-setters vs. physicians
 19th century:
 Osteopathy –Andrew Still - 1874 AD
 Chiropract – Daniel P - 1895 AD
History Of Manual Therapy
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”
Shift from hands on to hands-
off
Pain
Social
BIO
Psycho
Treatment
Manual
Therapy
Schools of thought (1)
 McKenzie Technique
 Mulligan Technique
 Maitland Concept
 Muscle Energy Technique
 Cyriax’s Technique
 Craniosacral Therapy
Schools of thought (2)
 Butlers- neural mobilization
 Shacklock’s Neurodynamics
 Kaltenborn technique
 Myofasical release
 Positional release technique
 Strain-counterstrain technique
Introduction to
Maitland’s Concept
 Introduced by G.D. Maitland in the
1950’s.
 It mainly deals with the concept of
examination, treatment and
assessment by passive
movement.
Introduction:
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
Passive movement: Types
 Physiological movement
 Accessory movement
Mobilization vs Manipulation
The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
17
The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
18
1. Patient centered approach
 Patient driven model
 Listening (active) vs hearing (passive)
 Believe the patient
 At the same time questioning
19
The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
20
2. Brickwall analogy-
“Mode of Thinking”
1. Theoretical Clinical
21
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
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
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
2. Brickwall analogy
Clinical Reasoning
1. Dysfunction
2. Brickwall analogy
Clinical Reasoning
2. Pathobiological mechanism
2. Brickwall analogy
Clinical Reasoning
3. Sources of symptoms
2. Brickwall analogy
Clinical Reasoning
4. Contributing factors
2. Brickwall analogy
Clinical Reasoning
5. Precautions and contraindications
2. Brickwall analogy
Clinical Reasoning
6. Prognosis
2. Brickwall analogy
Clinical Reasoning
7. Treatment
Clinical reasoning process (Jones,
Rivett 2005)
32
The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing
movement potential
4. Science and art of assessment
33
3. Identifying and maximizing
movement potential
Key stones-
 Assessment
 Symptom response to movement and
position
The core elements:
1. Patient centered approach
2. Brick wall analogy
3. Identifying and maximizing movement
potential
4. Science and art of assessment
35
4. Science and art of assessment
 Cornerstone of the concept
 Clinical proof of whether treatment
is working or not
36
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
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
Subjective Examination
 The patient’s story
 Provides most (about 80%) of the
information needed to clarify the cause
or establish a hypothesis
39
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
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
Subjective Examination:
Components
 Patient profile
 Chief complaint
 Body chart
 AGG/Ease factors
 24-hour behavior
 Special questions
 Present episode
 Past history
42
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
Develop a body chart
 Get a clear picture of the problem
 Prioritizes complaints, pain P1, P2…
 Many times leads you to diagnosis
44
45
46
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
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
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
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
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
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
Stage and Stability
 Stage: acute, sub-acute, chronic,
acute on chronic
 Stability: how are the symptoms
changing?
Better, worse, the same?
53
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
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
“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
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
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
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
Principle of over pressure
60
Movement diagram
61
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
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
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
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
TREATMENT by
Maitland’s Technique
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
Passive
movement
Physiological
Combined
physiological
Combined
physiological
and
accessory
Accessory
Combined
accessory
68
 Technique is based on the passive
movements that provokes or relieves
patient’s symptoms based on SIN
69
Principles of techniques
Graded oscillations:
accessory
71
72
Graded oscillations: Physiological
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
Based on signs and symptoms
Pain Stiffness
Pain &
Stiffness
Momentary
pain
74
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
References:
 Maitland’s vertebral manipulation.
2005, 7th edition.
 Maitland’s peripheral manipulation.
2004, 4th edition.

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Maitland concept

  • 1. INTRODUCTION TO MANUAL THERAPY Schools of thought BPT Third Year Saurab Sharma, MPT Lecturer, 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
  • 9. Schools of thought (2)  Butlers- neural mobilization  Shacklock’s Neurodynamics  Kaltenborn technique  Myofasical release  Positional release technique  Strain-counterstrain technique
  • 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
  • 13. Passive movement: Types  Physiological movement  Accessory movement Mobilization vs Manipulation
  • 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
  • 18. 2. Brickwall analogy- “Mode of Thinking” 1. Theoretical Clinical 21
  • 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
  • 22. 2. Brickwall analogy Clinical Reasoning 1. Dysfunction
  • 23. 2. Brickwall analogy Clinical Reasoning 2. Pathobiological mechanism
  • 24. 2. Brickwall analogy Clinical Reasoning 3. Sources of symptoms
  • 25. 2. Brickwall analogy Clinical Reasoning 4. Contributing factors
  • 26. 2. Brickwall analogy Clinical Reasoning 5. Precautions and contraindications
  • 27. 2. Brickwall analogy Clinical Reasoning 6. Prognosis
  • 28. 2. Brickwall analogy Clinical Reasoning 7. Treatment
  • 29. Clinical reasoning process (Jones, Rivett 2005) 32
  • 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
  • 42. 45
  • 43. 46
  • 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
  • 57. Principle of over pressure 60
  • 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
  • 66.  Technique is based on the passive movements that provokes or relieves patient’s symptoms based on SIN 69 Principles of techniques
  • 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
  • 72. References:  Maitland’s vertebral manipulation. 2005, 7th edition.  Maitland’s peripheral manipulation. 2004, 4th edition.

Notas do Editor

  1. MT = manual therapy
  2. Many concepts that exist
  3. Many concepts that exist
  4. These oscillatory movements may consist of the joint’s physiological movement e.g. shoulder flexion accessory movements e.g. MCP rotation
  5. 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.
  6. Eg-
  7. Coping with diagnosis and diagnostic titles is difficult and many diagnostic titles are inadequate or even incorrect
  8. Includes all procedures which are undertaken to monitor the therapeutic process throughout all encounters between the physiotherapist and the patient
  9. 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
  10. 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
  11. 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
  12. Features of history fit with behaviour and localization of symptoms
  13. Imagine how the pt can respond to exn, whether a comparable sign can be found or not srtucutures – eg of pain in interscapular region
  14. When examining movement disorders which are related to pain the primary aim is to find a comparable sign at appropriate components
  15. A joint or an active movement can never be stated as normal unless relatively firm overpressure can be applied painlessly
  16. Appropriateness
  17. Ingenuity- inventiveness, cleverness, imagination, originality, creativity
  18. For high SIN- technique that relieves pain, for low SIN- techinques that provokes pain can also be used
  19. example
  20. Eg – severe oa intra articluar disorder
  21. Periarthritis
  22. rest