DON’T JUST RECOVER. CONQUER. How Manual Therapy Works and Why it Matters The Integration of Manual...

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DON’T JUST RECOVER. CONQUER.

How Manual Therapy Works and

Why it MattersThe Integration of Manual Therapy into Sports Medicine

Thomas R. Denninger, DPT, OCS, FAAOMPT2015 Steadman Hawkins Clinic of the Carolinas

Sports Medicine Symposium

June 5th-6th, 2015

➔ Participants will acquire knowledge of the:o Theoretical basis of manual therapy techniques based

off available scientific literatureo Centering on the proposed model by Bialosky.

➔ Participants will demonstrate application of manual therapy for common sports medicine injuries at the:o Shouldero Foot/ankle

• Based upon recent systematic reviews and randomized controlled trials comparing treatment including manual therapy vs. standard of care.

Course Objectives

What is Manual Therapy?

➔ Accupressure➔ Anma➔ Bodywork➔ Bone setting➔ Dom method➔ Joint manipulation➔ Joint mobilization➔ Spinal manipulation➔ Spinal mobilization➔ Massage therapy➔ Manual lymphatic drainage

➔ Medical acupuncture➔ Muscle energy technique➔ Myofascial release➔ Narapathy➔ Osteopathic manipulative

medicine➔ Rolfing➔ Seitai➔ Sotai➔ Shiatsu➔ Traction➔ Tui Pa

What is Manual Therapy?

Years 1958-2015

Number of

Indexed Articles

“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.”

APTA/AAOMPT Definition

➔ A physiologic force applied therapeuticallyo Joint Basedo Muscle Basedo Nerve Based

Our Definition

How Manual Therapy Is Often Assumed to Work

Manual Therapy Mechanical Effect Clinical Benefit

➔ Biomechanical Evidence Summaryo Joint biomechanics are variable especially in

pathologic jointso Clinical benefits often not consistent with

biomechanical theoryo Studies demonstrate biomechanical changes are • Short lasting• Non-specific• Do not change alignment or position

However

DON’T JUST RECOVER. CONQUER.**

NOT How Manual Therapy Works

Manual Therapy Mechanical Effect Clinical Benefit

“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”

Something is Missing

Manual Therapy Clinical Benefit

Mechanical Effect

The Black Box

It’s Much Messier

Let’s Simplify a Bit

Non-Specific Effects

➔ Peripheral Nervous System➔ Central Nervous System➔ Supra-Spinal➔ Psychosocial

Define Non-Specific Effects

➔ Manual Therapy has been demonstrated to:o Significantly reduce pain

biomarkers o Increase in PEA

Peripheral Nervous System

➔ Neuromuscular Responseso Motorneuron Poolingo Afferent Dischargeo Muscle Activity

➔ Hypoalgesiao Temporal Summationo Selective blocking of

neurotransmitters

Central Nervous System

➔ Injection causes activation primarily in dorsal horn of spinal cord

➔ Less activation in rats given knee mobilizations

Supraspinal and Psychosocial Domains

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

Less This

More This

In Fact

Why Should We Use Manual Therapy?

Manual Therapy for the Shoulder Impingement

Manual Therapy and Exercise

➔ 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

Strengtheningo Supervised Exercise and Joint Mobilization• As above with addition of Glenohumeral mobilization

Conroy, 1998

➔ Results

Conroy, 1998

➔ Randomized Controlled Trial➔ N= 52➔ Outcomes= Strength, function, pain➔ Intervention: 6 sessions over 3-4 weeks

o Exercise Group• Stretching, Rotator Cuff Strengthening, Scapular

Strengtheningo Manual Therapy and Exercise Group

• Manual therapy to the upper quarter, stretching, strengthening

Bang, 2000

➔ Results

Bang, 2000

➔ Results

Bang, 2000

Ankle Sprain

*Consistent short term improvements in swelling, range of motion, function, and pain as compared to standard treatment (RICE, AROM, controlled weight bearing)

Cleland, 2013

Truloys, 2013

➔ Resultso 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

dorsiflexiono Pressure Pain Thresholds• Significant change favoring STM group

Truloys, 2013

Plantar Heel Pain

Cleland, 2009

➔ Randomized Controlled Trial➔ n=60➔ Outcomes= Function, Pain, Global Rating of

Change➔ Intervention=6 visits over 4 weekso 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

Cleland, 2009

➔ Randomized Controlled Trial➔ n=60➔ Outcomes= SF-36, PPT➔ Interventions

o Self Stretching Groupo Self Stretching and STM

Renin-Ordine, 2011

➔ Resultso Significant between group differences for • SF-36

• Overall• Physical Function• Bodily Pain• General Health• Emotional Role

• Pressure Pain Threshold• Gastrocnemius, Soleus, Calcaneus

Renin-Ordine, 2011

Thank You

DON’T JUST RECOVER. CONQUER. How Manual Therapy Works and Why it Matters The Integration of Manual...

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