Manipulation/Techniques of Manipulation

Author: J Michael Wieting, DO, MEd; Chief Editor: Consuelo T Lorenzo, MD

Therapeutic manipulation has been practiced in almost all countries of the world since at least the time of Hippocrates; early references have also been found in Egyptian hieroglyphics and early Chinese medical literature. Recent times have seen rapid growth of manipulation and manual therapy and an increase in its public use. Some healthcare professionals' opposition to the use of manipulation is explained by the fact that manipulation requires skills significantly different than those acquired in allopathic medical schools. This difference separates practitioners who possess manipulation skills from those who do not. The techniques used in manipulation also fall outside of the mainstream of allopathic medicine.

Manipulation procedures are used in many ways by a variety of practitioners. The most common goal of a manipulative treatment is to increase the mobility of a particular area or region of the musculoskeletal system where restrictions are encountered. While some practitioners focus on pain relief as a main outcome measure, others seek enhanced mobility or reduction in restriction of vascular or lymphatic congestion as it relates to the rest of the body.

Most of the 90 million annual manipulations performed in the United States by physicians and other practitioners are for complaints of musculoskeletal back and neck pain. Manipulation generally is directed at restoration of normal motion and elimination of pain secondary to disturbed biomechanics. The majority of the research on the use of manipulation focuses on its application to the cervical and lumbar spine, as well as on treating painful conditions in these areas with either mobilization or thrust-type maneuvers. It is important to realize that there are many other types of manipulative techniques, and which one is chosen should be based on a thorough examination of the patient and on the particular musculoskeletal lesion to be treated.

Definition

A consensus definition of manipulation is "the use of the hands applied to the patient incorporating the use of instructions and maneuvers to achieve maximal painless movement and posture of the musculoskeletal system." Most common types of manipulation involve passive mechanical forces applied to specific vertebral segments, regions, or other joint segments of the musculoskeletal system, with a primary goal of restoration of diminished ROM

Techniques of Manipulation

Introductions to the most common techniques of manipulation presently used in the United States are presented in the below text. This list is limited to techniques that physicians are most likely to encounter.

A brief discussion of direct versus indirect treatment is germane to the understanding of the rationale for choosing a particular technique. Once an area of restriction, or somatic dysfunction, is palpated, the means of correction must be chosen. One can elect to treat in the direction of restriction, or into what is commonly called the "ease of motion," that is, away from the restricted motion. A direct technique engages the motion barrier; this means that the practitioner directs forces into and through the motion barrier. On the other hand, an indirect technique allows the body’s inherent neurologic or intrinsic forces to release the restriction, as the practitioner positions the area to be treated opposite the direction of a restriction. For example, if pain and reduced motion is elicited by actively rotating a patient’s neck to the patient’s right side, it can be deduced that the patient’s restriction is on the right. Thereby, if the treatment selected takes thepatient’s neck further to the right, ie, into the restriction or barrier, this is a direct treatment. Conversely, if the patient’s neck is rotated to the left, or away from the barrier, it is considered an indirect method of treatment.

Direct thrust

Direct-thrust (eg, high-velocity/low-amplitude) techniques, including European mobilization with impulse, involve diagnosis of dysfunction of a vertebral segment by identifying position or motion abnormalities or related tissue-texture changes, including tenderness to (1) palpation or (2) induced motion. The practitioner then rotates, side bends, and either flexes or extends the adjacent vertebral segments, locking the facet so that further motion is limited to the segment in question. The vertebral segment is then moved passively to its limit of motion (or barrier) in order to remove slack motion, and a small force, localized to the specifically identified joint, is applied to hold that position. Brief, controlled thrust is applied in the direction perceived as limited, and a small motion in the desired direction occurs as the vertebra crosses its barrier. Forces, duration of actions, acceleration, and displacement values for direct thrusting techniques have been measured. These forces peak in the range of100-400 Newtons over a period of approximately 150 milliseconds. Direct manipulative techniques featuring forces applied over transverse or spinous processes are short-lever techniques. If force is applied distant to the vertebrae through the locked column, the procedure is considered a long-lever technique. All direct-thrust techniques must have forces well localized and specifically directed, and structural diagnosis must be adequate before their application.

Articulatory technique

Articulatory technique, also referred to as low velocity, high amplitude, involves passive movement of a vertebral joint within reduced ROM (defined by its resting position and dysfunctional limitation of motion). Extent of motion at its end point may vary, but the ultimate end point and dysfunctional barrier become the same, with the barrier becoming attenuated with repeated motion. The quality or feel of induced motion, in addition to the quantity of force and excursion, are normalized by this procedure. A small amount of additional force occasionally may take the vertebra through its barrier or restriction.

Indirect positional techniques

Indirect positional techniques (eg, counterstrain and functional techniques) are based on the underlying principle that somatic dysfunction or hypomobility is caused by an inappropriately firing muscle group, rather than by shortened, passive tissue, such as joint capsule, ligament, or fascia. Thrust, articulation, and muscle energy techniques employ forces that could be expected to lengthen shortened, passive tissues, whereas these positional techniques change an inappropriate engram of muscle behavior.

Counterstrain

Developed by Jones, counterstrain is an indirect myofascial technique that shares with functional technique an emphasis on relative positioning of a joint or body part as an essential component of treatment.^{[19, 20]} Counterstrain treatment involves placing a joint or body part into position of maximal ease or comfort, thereby relaxing ligamentous and myofascial soft tissue. This relaxation allows inappropriately shortened muscles to reset their spindles, which then normalizes proprioceptive input into the spinal cord. The restricting muscle generally is shortened excessively by this positioning (eg, counterstrained), and its antagonist muscle is overstretched (eg, strained) gently in the process. The optimal treatment position is found by minimizing pain associated with palpatory pressure over a tender point and, once this position of maximum ease is found, it is held for approximately 90-120 seconds, with concurrent tender-point monitoring. During this time, tenderness should fade to no morethan 20-30% of its initial value. Occasional small, fine-tuning, passive positioning movements with verbal feedback from the patient may be needed. Tenderness is part of this feedback system; therefore, the patient must respond to the practitioner's questions. The patient is slowly returned to a neutral position in 1 plane of motion at a time to prevent recurrence of inappropriate muscle firing.

Counterstrain is considered an indirect technique, because positioning is always in a direction away from the restricted motion. If multiple tender points are encountered, they are treated in order of decreasing tenderness. The areas of the highest accumulation of tender points (first proximally, and then distally) are then addressed.

Tender points are found beneath the skin through palpatory examination over shortened and restricted muscles or over related anatomic structures (eg, tendons, muscles, ligaments). Tender points generally do not coincide with trigger points or points associated with fibromyalgia. Counterstrain tender points usually are small, fibrotic, discrete areas thought to be manifestations of distal somatic dysfunction and are not associated with other signs of fibromyalgia, nor are they paired. Counterstrain tender points are distributed widely in generally reproducible locations, depending on the nature and location of associated somatic dysfunctions. Those associations are not based on known neurophysiologic or neuroanatomic referral patterns.

Counterstrain is considered safe, effective, gentle, and atraumatic, so it is a very useful technique for the older, hospitalized, or immune-compromised patient, as well as for apprehensive patients and children. Counterstrain techniques are easy to perform, forgiving for the novice learner, and easily incorporated by the patient into a prescribed home exercise program.

Functional techniques

Functional techniques, as well as counterstrain, have a methodologic approach oriented to resetting inappropriate afferent impulses from nociceptors and mechanoreceptors, resulting in efferent alpha motor activity to the skeletal muscle, by placing the joint or body part into a position of maximum ease. Unlike counterstrain, however, the position is found and monitored by the practitioner, sensing either increased resistance to trials of small, induced motions or increased tissue tension of the nearby tissue when motion is induced. The most relaxed position is held in this balanced state.

Functional technique practitioners feel that inherent body motions (eg, respiration) allow the firing pattern of the afferent muscles to reset so that they are normalized in a neutral position. This approach, also unlike counterstrain, does not make use of tender points and may be somewhat more objective, because practitioner's palpatory findings determine positions of balance.

The practitioner puts the patient through a sequence of positions, with the goal of progressing toward anatomic neutral as the position of maximum ease or balance. Functional techniques are useful in acute and chronic conditions, because they focus on the quality, rather than the quantity, of motion, with restoration of normal function implying normal quality and ROM. Functional techniques require significant experience on the part of the practitioner.

Muscle energy

Muscle energy is a direct, non-thrusting technique (also known in the United States as isometrics and in Europe as mobilization) and has a strong relationship to proprioceptive neuromuscular facilitation. The physician positions the patient and removes slack as in direct thrust procedures and subsequently prevents active motion of the affected vertebral segment away from its barrier. The patient then exerts minimal to moderate isometric force against resistance offered by the physician for approximately 5-10 seconds and subsequently relaxes. The physician then finds that the barrier has been displaced and that the affected segment moves beyond its original barrier. This procedure is repeated 2-3 times, with diminishing gains and increased ROM.

Soft-tissue technique

Soft-tissue technique uses mechanical stretch of skin, muscle, and fascia to increase motion. Lateral and linear stretch and deep inhibitory pressure are the most common procedures used. Soft-tissue techniques are useful in virtually all patients and may function as the first step in manipulative treatment involving multiple techniques. Soft-tissue techniques are very valuable in encouraging circulation and enhancing venous and lymphatic flow. The overall purpose of soft-tissue techniques is to relieve fascial and superficial muscle tension. Soft-tissue techniques are easily learned and can be incorporated into clinical practice with virtually no difficulty.

Myofascial release

Myofascial release techniques are directed at vertebral, segmental, or generalized hypomobility. Myofascial release can be indirect (ie, when a restricted area is placed into a position of little resistance until subsequent relaxation occurs) or direct (ie, when the affected area is placed against a restrictive barrier with constant force until fascial release occurs). All the myofascia of the body are interconnected, and when one area is tight or restricted, diminished movement occurs not only locally but (potentially) in distant, related areas.

Myofascial release practitioners palpate to assess tissue response and adjust applied forces of stretch, pressure, twist, or traction until affected tissues change toward normal. This progression may occur over a short period of time and is referred to as release. The mechanism of release may be biomechanical or neuroreflexive; however, fascial resistance to forces applied should be symmetric, and the tissue should be relatively mobile and responsive to force being applied. In myofascial release, the mechanical approaches of direct thrust, articulatory technique, and muscle energy are combined with the neuroreflexive approaches of counterstrain, functional technique, and soft-tissue technique. Effective use of myofascial release requires considerable palpatory skill and experience, and training time is relatively long compared with that for other manipulative approaches.

Craniosacral

Craniosacral manipulation is based on the concept of a primary respiratory mechanism (ie, a cyclic, palpable, rhythmic wave of inherent motion appreciated most easily in the cranial and sacral areas). This wave may represent a continuous state of flux in the cerebrospinal fluid (CSF). This primary mechanism may entail inherent mobility of the central nervous system (CNS), CSF fluctuation, cranial bone articular mobility, involuntary motion between the sacrum and ilia, and mobility of interspinal and intercranial membranes.

The craniosacral practitioner palpates the head and/or sacrum to feel pulsations of the wave motion, occurring in the range of 8-12 pulses per minute, as well as to evaluate symmetry, regularity, frequency, and amplitude of the wave. When abnormalities are found, general pressure is applied to the skull and sacral areas to restore the wave to normal symmetry rhythm and amplitude.

While this technique is considered somewhat controversial among nonpractitioners, its largest subset of potential patients may be infants with failure to thrive, birth defects, or head injuries, as well as adults with neurologic or CNS pathology. The growth in popularity of this manipulative approach requires physicians to have at least passing familiarity with it. Proficiency with craniosacral manipulation requires considerable training and experience.