Manual by what is not seen but

Manual
Therapy (MT) can be defined as a passive, skilled movement applied by
clinicians that directly or indirectly targets a variety of anatomical
structures or systems (Bishop et al, 2015). These manipulations are usually
applied to a skeletal joint passively, in the attempt to achieve a therapeutic
effect. Although there are multiple techniques, Maitland’s Theory will be the
focus in this review. Named after renowned physiotherapist, Geoffrey Maitland,
this theory offers a systematic way of thinking that emphasizes continuous evaluation
and assessment and a total commitment to the patient (Jull, 2010). He developed
a system of graded application which was used to modify pain, (Jull,2010) these
motions are defined as Passive Physiological (PPM) and Passive Accessory
Movements (PAM). PPM Movements are the natural motions that occur at a joint,
while PAM are movements within the joint and surrounding tissue. Maitland
defines passive physiological movement as osteokinematics and passive accessory
as arthrokinematics. The osteokinematics refers to obvious bone motions and the
direction they occur in, whereas arthrokinematics can be defined by what is not
seen but rather felt because the motions occur among the joint capsule where surrounding
ligamentous structures are stretched. Both PP and PA movements can be utilized
to treat specific joints, however a specific amplitude is applied dependent of
the intended outcome. 

Geoffrey
proposes four grades in which joint dysfunction can be rectified and painful
symptoms can be reduced within patients. He instructs that grades I and II can
be used to relieve pain and grades III and IV are generally applied to increase
range of motion within the joint capsule. Manual Therapy has shown to have a
large effect on reduction of pain within patients. In relation to the pain gate
theory, application of Maitland’s mobilizations alters ascending and descending
inhibition and as a result affects pain positively. Another aim of manual
therapy is to permanently affect connective tissue structures by elongating
soft tissues and aponeuroses (Threlkeld,1992). Maitland concurs that due to
grade III being oscillations in resistance from mid to end of range, and grade
IV as smaller oscillations at the end of the range it implicates the stress and
strain curve which is represented graphically. This occurs as bundles of
collagen are placed on stretch that is more than that of the connect tissue’s
tensile strength (Threlkeld, 1992).

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A
sizeable amount of research exists that debates how manual therapy elicits pain
relief. Efficacy of manual therapy techniques on pain can be categorized as
stretching or compression, and include small-amplitude movements of a joint
(Threlkeld, 1992). The purpose of this review will be to focus on Manual
therapy’s effects on pain modulation through research that supports and refutes
Manual Therapy techniques. Maitland’s approach to evaluation and assessment
will be mentioned as alternative theories by which manual therapy influences
pain will be critically examined.

 

Current
literature brings to light multiple mechanisms by which Manual Therapy effects
pain, however there is no consensus on which mediating factors directly impact
the outcome of pain reduction. Evidence exists of Manual Therapy providing a
reduction in pain and overall improvement, but no report of how exactly it does
so. MT is most likely a combination of biomechanical and neurophysiological
mediating factors however the lack in specificity of the mechanism in action may
be responsible for why it is viewed as a less scientific mode of treatment
(Bialosky et al., 2009).

Pain
is defined as an unpleasant sensory and emotional experience associated with
actual or potential tissue damage and is always subjective (Iasp-pain.org,
2017). This definition thus suggests that pain is an individual experience
making it difficult to prescribe the utmost adequate treatment at initial evaluation.
In the past 20 years there has been an evolution in the knowledge of pain. The
pain gate theory proposed by Melzack and Wall in 1965, is a gate control system
that acquires information from sensory nerves or nociceptors before there is a
response sent from the brain. Pain Gate theory states that free nerve endings
at the epidermis, generate impulses that are carried along A-delta and C fibres
among the spinothalamic tract entering the dorsal horn (acting as the gate) to
the pain center, located in the Thalamus (Melzack and Wall, 1965). The gate
theory of pain has been referred to for many years, however new research has
come to light that proposes the gate theory of pain to be oversimplified. The
central nervous system in association with the neuromusculoskeletal system
plays a large role in production of pain and disability (Shacklock,1999). This
psychophysical model of pain has become increasingly popular, providing merit
to the pain gate theory; which incorporates the central nervous system and peripheral
nervous systems (Shacklock, 1999).

While
the Maitland concept focuses on detailed assessment, clinical reasoning and
reassessment, a major fault is that it does not attempt to consider the anatomy
of structure being assessed. The rules of Geoffrey’s theory can be thought of
as rudimentary in a clinical setting, however every patients pain threshold is
subjective. Manual Therapy therefore is not only the application of technique
but an entire process to ease the patient’s pain (Bishop et al., 2015).
Evaluation of pain based on Maitland’s concept is determined by biomechanical
intervention to correct the noted dysfunction. He instructs, to determine
choice of treatment, there first must be a ‘hand’s on’ approach to decide what
is responsible for the tissue dysfunction. The success of MT thus depends on
the therapist’s attention to theoretical biomechanical constructs (Bishop et
al., 2015). An example of this is the application of the convex-concave rule
which is applied based on the joint articular surfaces’ shapes. With one
surface being concave and the other being convex it aids the therapist in
deciding with direction to perform a glide on the joint in efforts to improve
dysfunction. Although
the convex concave rule deserves merit for being a tool to decide which
direction to apply a mobilization of joints, there is also research to refute
the theory. Neumann 2012 argues that the rules of joint kinematics were not
intended to be a gold standard to decide the direction of application for
manual glides, however it is a helpful aid in determining mobilization
application. In addition, Schomacher 2009 explains that the convex concave
rules describe gliding of joint surfaces but does not take into consideration
the surfaces abilities to roll upon each other. This is seen when taking a
closer look at the anatomy of the GH joint. Although the convex concave rule
prompts us to apply a glide in a specific direction, during abduction the
humeral head in fact translates upwards when performing 90 to 120-degree
shoulder abduction. This is thus a direct conflict with the traditional
opposite roll and slide patter described for the GH joint. Manual Therapy can
also indirectly effect anatomical structures and render similar results as interventions
that target a specific injury (Bishop et al., 2015). These findings thus
promote MT’s overall therapeutic effect in patients and while measurable
biomechanical effects exist, these do not on their own validate observed relief
after application of MT techniques. Finally, Maitland’s theory can be
questioned in being the best form of treatment for pain reduction.

While
biomechanical intervention may result in pain relief, research deems that there
are neurophysiological factors that also play a major role in pain reduction.
Manual Therapy can also affect interaction between inflammatory mediators and
peripheral nociceptors after an injury occurs at tissue (Bishop et al., 2015). Application
of mechanical glides within the joint capsule can stimulate the release of
hormones and chemicals that can promote pain relief. The idea that pain
receptors are found in the skin also support that Manual Therapy techniques
have a placebo effect on patients. This concept can be supported using MT to
treat chronic pain about the pain spasm cycle, in which a patient is continuing
to complain of painful symptoms. Acute injury that becomes chronic allow the
patient to perform protective movements or even compensate because they are
still experiencing deep pain in an area. As Manual Therapy acts through the
central nervous system, it is proposed that by introducing a new and less
threatening stimuli, the therapist can alleviate memories of that stimulus
being uncomfortable or painful (Bishop et al.,2015). Application of treatment
therefore can act as patient re-education in a cognitive or emotional way. Bialosky
(2009, p.532) concludes that a mechanical force is thus necessary to initiate a
chain of neurophysiological responses to deliver positive results through
Manual Therapy application.

Studies
support that applying Maitland’s technique does not always result in
significant pain relief. One study measured the efficacy of anterior-posterior GIII
talus glide in patients with acute and chronic ankle injuries. Thirty-eight
volunteers, men and women, with a mean age of 40.8 years, with subacute and
chronic ankle injuries participated. They were split into two trial groups: EG
and SG, in which EG was treated with anteroposterior mobilization of talus
grade III, and SG was treated with manual contact. Three sets of 30 seconds
reps with 30 second rest in between was conducted. After six sessions and a two
week follow up reassessment they found that Articular grade III mobilization
improved ankle dorsiflexion ROM compared to SG group. As for changes in pain, significant
reduction was noted after the sixth session (F = 12.57, P = .001; power = 0.93)
compared with after the first session in both groups. This improvement was
maintained at follow-up (F = 1.77, P = .19, power = 0.25). Although these
results give confidence to Maitland’s grading scale, where grade III is
supposed to promote range of motion, certain aspects of how the study was
carried out may add bias to the results of the trial. In this study, a goniometer
was used to measure increased or unchanged ROM, in addition to a VAS scale,
confirming that each patients score was subjective. Overall, this study
extrapolates that over time pain reduction will occur with continuous
application of this technique. Although the trials included males and females
all with different ankle injuries it still may not be the best representation
of the public, questioning reliability across other populations (ex. Elderly patients).
These findings give confidence to the idea that Manual therapy is also
dependent on expectations of patient, and other emotional factors.  

Having
surveyed the different ways in which Manual Therapy can modify a patient’s pain
experience, it can be concluded that biomechanical intervention can render
neurophysiological effects. These effects are modified by nonspecific factors
such as the expectation of the patient, the practitioner’s demeanour and placebo
effect. Since results are mediated by several unmeasurable factors, it is
crucial to take all into consideration when approaching treatment of pain.
Rather than focusing on objective markers pre-and post-application, it is necessary
to consider the psychological and psychosocial aspects of the patient’s
personal pain. Bishop et al (2015, p.461) notices that management of chronic pain
through MT seems to correlate with genetic factors related to peripheral and
central neural plasticity as well as environmental events and exposures. Like
the study mentioned above, many study designs do not account for these
nonspecific effects and therefore their standing in a clinical setting is
almost non-existent. It is imperative that future studies account for other
mechanisms such as placebo and patient expectation when collection results to
gain greater acceptance by healthcare providers.