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Principles of Manual Medicine

Principles of Manual Medicine. Jack Dolbin, DC CSCS. When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping the patient with a myriad of disease processes. Philip Greeman DO, Professor of Biomechanics

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Principles of Manual Medicine

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  1. Principles of Manual Medicine Jack Dolbin, DC CSCS

  2. When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping the patient with a myriad of disease processes. • Philip Greeman DO, Professor of Biomechanics • Michigan State University School of Osteopathy Medicine

  3. Goal of manual medicine • The goal of manual medicine is to restore maximal, pain free movement of the musculoskeletal system in postural balance. • Dvorak J, Dvorak V,Schneider W : Manual Medicine 1984,

  4. Role of the musculoskeletal System in Health and Disease • 1. Holistic man • 2. Neurologic man • 3. Circulatory man • 4. Energy-expending man • 5. Self-regulating man

  5. Holistic Man • The musculoskeletal system comprises most of the human skeleton and alterations within it influence the rest of the human organism. • Our role as physicians is to treat patients and not disease.

  6. Neurologic Man • Most highly developed nervous system in the animal kingdom. • All functions of the human body are under some form of neurologic control. • Control of all glandular and vascular activity is under the control of the ANS. • Neuroendocrine Control: Substabnce P, endorphines, enkephalines, and neurotransmitters can be altered by biomechanical alterations • Alterations in neurothropin transmission can be detrimental to the health of target cells.

  7. Circulatory man • Anything that interfered with with sympathetic autonomic nervous system outflow, segmentally mediated, can influence vasomotor tone to the target end organ. • Maximal function of the musculoskeletal is important to the efficiency of the circulatory system and maintainance of a normal cellular milieu.

  8. Energy expending man • Restriction of one major joint in the lower extremity increase the energy expenditure in walking by 40%, two major joints in the same extremity 300%. • Multiple minor restriction of movement, especially in the lower extremity gait can have a detrimental effect on the total body function

  9. Self-Regulating Man • The goal of the physician should be to enhance all the body’s self regulating mechanisms to assist in the recovery from disease. ( injury). • One in seven hospital days are the result of adverse reactions to pharmaceuticals. • Anything placed with in the body alter the self regulating mechanism.

  10. Manipulatible Lesion • Primary goal is to determine the specific spinal motion segment that is dysfunctional, determine the direction of altered motion, and determine the tissue involved in the restrictive motion. • Primary emphysis is placed on motion loss and its characteristics

  11. A R T • Asymmetry • Range of motion • Tissue texture

  12. Asymetry • Pelvic unleveling: Effect on lower extremity function. Shoulder function. • Scapular Winging: • Anterior Shoulder posture: TOS • Pronation

  13. Pelvic Unleveling

  14. Range of Motion • Passive: note end feel. Hard or mushy • Active: Neuromuscular Control

  15. Tissue Texture • Spasm • Contracture: Hypertonicity • Shortening: Chronic adaptation • Adhesions: Scar Tissue • Temperature: Inflammation

  16. Greenman • The most important element in the postural model has been the restoration of maximum pelvic mechanics in the walking cycle. • The Pelvis from below to above must be considered to achieve the symmetrical movement. • Shoulder Injuries • Hamstring strains • Knee, ankle, foot injuries

  17. Evaluation of symmetry • Check Pelvic leveling in the standing position. • If unlevel: does it level in the sitting position. • If so check leg length. Look for structural or functional short leg. • If functional check SI joints and pronation. • If Structural: broken leg or past injuries. • Equestrian Illustration: Broken Femur leading to shoulder entrapment.

  18. Range of Motion • 1. Range of movement • 2. Quality of movement • 3. End feel • In the spine: Goal is to determine which specific vertebra is dysfunctional • Which joint within that segment is dysfunctional • The direction of altered motion • Tissue involved in the restricted movement.

  19. Motion loss and its characteristics are more important diagnostic criterion that the presence of pain and the provocation of pain by movement. • Greenman: Michigan State University School of Osteopathic Medicine.

  20. Tissue Texture • Alteration in the characteristics of the soft tissues of the musculoskeletal system. • Skin • Fascia • Muscle • Ligament

  21. Techniques • Muscle Energy • Impulse Adjusting • High Velosity/ Low amplitude • Indirect Function technique: Sherringtons Law • Myofascial Release: Cyriax Crossfiber

  22. CyriaxCrossfiber • Mobilize Scar tissue • Breakdown Adhesions • Allows muscle to broaden • Controlled Imflammation • Pain modulation • 1. Right Location • 2. Right amount of pressure

  23. Cyriax: Continue • During first 24-48 hours. Light mobilizing maximum of 5 minutes.( usually less) • After 48 hours 5-15 minutes • Muscle Injury: Across the relaxed muscle to facilitate broadening. Followed by eccentric exercise or Faradic. • Tendon/Ligament Injuries: Across the ligament in an elongated position. • Every other day

  24. Lateral Ankle Sprain

  25. Rotator Cuff Tendonitis

  26. Muscle energy • Isometric Contraction of shortened muscle. • Improves resting length • Increase Joint movement • Improves overall range of motion. • 3-5 repetitions 5-7 seconds. • Inhalation/Exhalation as activating force

  27. Achilles Tendon Injury

  28. Quadraceps Injury

  29. Impulse Adjusting • Percussion cadencee: Seguin 1838 • Manual Vibrations: Kellgren mid 1900 • Janse, Wells, Howser 1947 • Repetitive Thrusts: Maitland 1964 • Fuhr: Activator • Colluca-Keller: Impulse Adjusting

  30. Impulse Adjusting • By Stimulating the Golgi Tendon organs the shortened muscle lengthens. Myotendinous Junction. • Reset Neurological bed. Bone and muscle belly • Activates mechanoreceptors: • Can be alternative treatment to myofascial release: Opinion

  31. Joint Mobilization/Manipulation Mobilizes fixated Joints Improves Range of Motion in Dysfunctional segmments. Activates mechanoreceptor in Joints: Pacinian and Ruffini corpucles. Allows for normalization of afferent proprioception Effect on Visceral Function ??

  32. Procedure For Sports Injury History: 7 Point History Minimum Observation of injured part Inspection of Injured part Examination: Palpation, Range of Motion Provocative tests. Evaluation of motion deficits in the kinetic chain. Treatment: Manual Medicine Prescription

  33. Have a purpose in your treatment. Not cookbook therapy • Have a reevaluation process to assess the effectiveness of your treatment • A. If not responding do revel and change plan. • Transition to active care: Usually concurrent with your manual therapy

  34. Volume: Maximum of 30-35 patients per day. • A goal of developing a volume based practice is antithetical to the practice of manual medicine

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