Transcript Manual Therapy-Denninger

How Manual Therapy Works
and
Why it Matters
The Integration of Manual Therapy into Sports Medicine
Thomas R. Denninger, DPT, OCS, FAAOMPT
2015 Steadman Hawkins Clinic of the Carolinas
Sports Medicine Symposium
June 5th-6th, 2015
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Course Objectives
➔ Participants
o
o
will acquire knowledge of the:
Theoretical basis of manual therapy techniques based
off available scientific literature
Centering on the proposed model by Bialosky.
➔ Participants
will demonstrate application of
manual therapy for common sports medicine
injuries at the:
o
o
Shoulder
Foot/ankle
• Based upon recent systematic reviews and randomized
controlled trials comparing treatment including manual
therapy vs. standard of care.
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What is Manual Therapy?
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What is Manual Therapy?
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Accupressure
Anma
Bodywork
Bone setting
Dom method
Joint manipulation
Joint mobilization
Spinal manipulation
Spinal mobilization
Massage therapy
Manual lymphatic drainage
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Medical acupuncture
Muscle energy technique
Myofascial release
Narapathy
Osteopathic manipulative
medicine
Rolfing
Seitai
Sotai
Shiatsu
Traction
Tui Pa
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300
250
200
Number
of
Indexed
Articles
150
100
50
0
Years 1958-2015
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APTA/AAOMPT Definition
“Manual therapy techniques consist of a broad
group of passive interventions in which clinicians
use their hands to administer skilled movements
designed to modulate pain; increase range of
motion, reduce or eliminate soft tissue swelling;
inflammation; or restriction; induce relaxation;
improve contractile and non-contractile tissue
extensibility; and improve pulmonary function.
These interventions involve a variety of techniques,
such as the application of graded forces.”
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Our Definition
➔A
physiologic force applied therapeutically
Joint Based
o Muscle Based
o Nerve Based
o
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How Manual Therapy Is Often Assumed to Work
Manual Therapy
Mechanical Effect
Clinical Benefit
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However
➔ Biomechanical
Evidence Summary
Joint biomechanics are variable especially in
pathologic joints
o Clinical benefits often not consistent with
biomechanical theory
o Studies demonstrate biomechanical changes are
o
• Short lasting
• Non-specific
• Do not change alignment or position
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*
*
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NOT How Manual Therapy Works
Manual Therapy
Mechanical Effect
Clinical Benefit
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“When the scientific literature
is considered, attributing
successful (manual therapy)
outcomes solely to the
identification and correction
of biomechanical faults makes
as much sense as crediting a
beard for winning a hockey
playoff”
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Something is Missing
Mechanical Effect
Manual Therapy
Clinical Benefit
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The Black Box
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It’s Much Messier
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Let’s Simplify a Bit
Non-Specific Effects
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Define Non-Specific Effects
➔ Peripheral
Nervous System
➔ Central Nervous System
➔ Supra-Spinal
➔ Psychosocial
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Peripheral Nervous System
➔ Manual
Therapy has been
demonstrated to:
Significantly reduce pain
biomarkers
o Increase in PEA
o
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Central Nervous System
➔ Neuromuscular
Responses
Motorneuron Pooling
o Afferent Discharge
o Muscle Activity
o
➔ Hypoalgesia
Temporal Summation
o Selective blocking of
neurotransmitters
o
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➔ Injection
causes activation primarily in dorsal
horn of spinal cord
➔ Less activation in rats given knee mobilizations
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Supraspinal and Psychosocial Domains
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Peripheral Nervous System
-Changes in local pain biomarkers
Central Nervous System
-Muscle relaxation and excitation
-Ascending Pain Inhibition
Supra-Spinal Pathways
-Endogenous Opioids
-Changes in neural processing of
nociceptive information
-Autonomic Changes
Psychosocial Components
-Placebo
-Changes in fear
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Less This
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More This
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In Fact
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Why Should We Use Manual Therapy?
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Manual Therapy for the Shoulder
Impingement
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Manual Therapy and Exercise
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Conroy, 1998
➔ Randomized
Controlled Trial (Pilot)
➔ N=14
➔ Outcomes=
Pain, Function, Change AROM
➔ Interventions= 3x week for 3 weeks
o
Supervised Exercise
• Stretching, Rotator Cuff Strengthening, Scapular
Strengthening
o
Supervised Exercise and Joint Mobilization
• As above with addition of Glenohumeral mobilization
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Conroy, 1998
➔ Results
*
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Bang, 2000
➔ Randomized
Controlled Trial
➔ N=
52
➔ Outcomes= Strength, function, pain
➔ Intervention: 6 sessions over 3-4 weeks
o
Exercise Group
• Stretching, Rotator Cuff Strengthening, Scapular
Strengthening
o
Manual Therapy and Exercise Group
• Manual therapy to the upper quarter, stretching,
strengthening
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Bang, 2000
➔ Results
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*
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Bang, 2000
➔ Results
*
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Ankle Sprain
*Consistent short term improvements in swelling, range of motion, function, and pain as
compared to standard treatment (RICE, AROM, controlled weight bearing)
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Cleland, 2013
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Cleland, 2013
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Cleland, 2013
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Truloys, 2013
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Truloys, 2013
➔ Results
o
Pain (0-10):
• 1.5 point greater reduction with STM
o
Function (100):
• 16.6 point greater reduction with STM
o
Range of Motion
• Significant differences for plantar flexion and
dorsiflexion
o
Pressure Pain Thresholds
• Significant change favoring STM group
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Truloys, 2013
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Plantar Heel Pain
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Cleland, 2009
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Cleland, 2009
➔ Randomized
Controlled Trial
➔ n=60
➔ Outcomes=
Change
➔
Function, Pain, Global Rating of
Intervention=6 visits over 4 weeks
o Standard Care
• Calf and PF stretch, intrinsic muscle strengthening, US, Ionto,
Ice
o
Manual Therapy and Exercise
• Soft tissue mobilization, eversion mobilization, manual
therapy LE complex
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Cleland, 2009
NPRS
LEFS
FAAM
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Renin-Ordine, 2011
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Randomized Controlled Trial
n=60
Outcomes= SF-36, PPT
Interventions
o
o
Self Stretching Group
Self Stretching and STM
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Renin-Ordine, 2011
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Renin-Ordine, 2011
➔ Results
o
Significant between group differences for
• SF-36
•
•
•
•
•
Overall
Physical Function
Bodily Pain
General Health
Emotional Role
• Pressure Pain Threshold
• Gastrocnemius, Soleus, Calcaneus
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Thank You
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