How Manipulation Works

CHRISTOPHER SO

Physiotherapist, Manipulative Therapist

GATE CONTROL SYSTEM

action system

nociceptors Fig. 1 Gate Control Theory `how manipulation works' in terms of neurophysiology and Introduction biomechanics . Manipulation is an ancient art dating back to the time of Hippocrates, and use of it by the medical profession to relieve 1 . The Effect of Manipulative Procedures with Reference to pain, swelling and muscle spasm, and to restore the functional Neurophysiology use of impaired joints, has waxed and waned (Lomax, 1978). Various schools of thought have been developed to explain how manipulation works, but despite its long-standing history, a. The Gate Control Theory (Fig. 1). there are still many contending ideas regarding its use . WatsonJones has written that there is no place for manipulation in orthopaedic practice related to spines (Mennell, 1975), whereas Melzack and Wall (1965) put forward the "Gate Contro Wiles has suggested that manipulation should always be tried Theory" . They specified that the site of sensory interaction before any surgery on back problems (Mennell, 1975). After is in the substantia gelatinosa (SG), which acts as a gate for reviewing the available literature and research, many noted pain transmission . Afferent input through the large fibres physicians and scientists have come to the conclusion that tends to close the gate and input through the small fibre "There is no justification for the use of manipulative therapy" tends to open it, therefore modulating pain transmission, (Nachemson, 1975; Pearce and Moll, 1967; Sham, 1974). The output from the target cell (T) is influenced by the On the other hand, practitioners of manipulation feel that passage of these impulses through the SG. Melzack and Wall their clinical results are positive and their treatments effective also suggested the mechanism of presynaptic inhibition (Gitelman, 1975 ; Maitland, 1977 ; Mennell, 1960) . In view of whereby if the T cell's output exceeds a certain threshold these contradictions, I would like to attempt to explain it will activate the action system and pain will be perceived 30
The Journal of The Hong Kong Physiotherapy Association

The gate system is also connected to the Central Nervous System (CNS), whose activities may influence the output of the system. As more research was done, Melzack (i973) and Wall (1978) admitted the shortcomings of the theory and recognised that modifications would be necessary . They also discovered the existence of a postsynaptic inhibition mechanism in addition to their postulated presynaptic inhibition mechanism . b. Articular Neurology Wyke (1980) stated that "articular neurology is one of the fundamental sciences of manipulative therapy ." The following is the classification used for receptors in synovial joints and their function . i. Type I Mechanoreceptors are : numerous in the outer layers of capsular tissues of all limb joints and apophyseal joints . more densely distributed in the proximal joints and cervical apophyseal joints. 6 to 9 u in diameter. subject to static and dynamic response to changes of joint position, pressure, direction, amplitude and velocity of active or passive joint movement. slow in adapting; their frequency of resting discharge rises in proportion to the degree of change in joint capsule tension. ii. Type II Mechanoreceptors are : - embedded in the deeper layers of fibrous joint capsules. - relatively more numerous in distal joints . - 9 to 12 u in diameter. - inactive in immobile joints. - fast adapting, with a dynamic response to acceleration or deceleration of joint movements. iii. Type III Mechanoreceptors are : present in joint ligaments (both extrinsic and intrinsic), but absent in the ligaments of the vertebral column . active, when considerable stress is applied towards the extremes of active or passive movement or by a high traction force. 13 to 17 u in diameter . They have a high threshold to mechanical pressure with a slowly adapting response . iv. Type IV Painreceptors are :

2 to 5 u in rnyelinated fibres and less than 2 u in unmyelinated fibres . a plexus of unmyelinated nerve fibres that weaves in three dimensions throughout the fibrous capsule, adjacent periosteum, fat pads and advential sheaths of the articular blood vessels . individual free unmyelinated nerve endings that weave between the fibres of ligament . entirely inactive under normal circumstances. only active when irritated by the development of abnormal mechanical or chemical (histamine, bradykinin or 5HT) changes in the tissue . absent in synovial tissue, intraarticular menisci, articular cartilage and intervertebral discs. c. Joint Trauma Mennell J. (1960) provided us with a concise clinical explanation ofjoint trauma . Both the capsule and the ligaments of a joint are extremely sensitive structures, having a rich nerve supply, and even minor assaults on their integrity can be very painful. The reflex action to capsular pain is spasm . If this spasm is strong enough, the joint can be immobilised by it. Spasm initiates fatigue, which may cause further spasm and more pain. At a later stage following disuse, the articular surfaces seize up, as a result of a loss of the normal amount of lubricating synovial fluid between them. Attempted movement gives rise to pain and sets off a vicious circle of pain, spasm and fatigue . This often results in locking of the joint . The cause of joint pathology is controversial . In traumatic cases, all tissues around the joint can be affected . In severe cases the bone may be fractured and ligaments may be torn incorporating bony avulsion. In minor injury, different structures around the joint are affected to a varying extent . However, three things invariably occur : pain, spasm and loss of function (decrease in range of movement or increased resistance to movement). In the early stage of injury, resistance experienced on passive movement of the affected joint is probably due to voluntary and involuntary muscle spasm. Muscle spasm may be set up by nociceptive afferents from Type IV receptor systems in joint tissues . They project polysynaptically to alpha motoneurones in the motoneurone pools of the muscles related to the joint in question, thereby giving rise to abnormal reflexes in such muscles (Wyke, 1980). This may be of a protective nature . Trauma leads to excitation of the Type IV nociceptive system, pain is perceived and muscle spasm occurs and this produces resistance to movement . d. How Manipulation Works The essential prerequisite for evoking pain is transmission of nociceptive afferent activity . This arises from the irritated Type IV receptor system and travels through the gateway or 31

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collateral branches which synapse in the basal spinal nucleus. This is transmitted up to the brain via the anterolateral spinal tracts . This transmission can be modulated by all peripheral mechanoreceptors (not just the articular mechanoreceptors). They synapse on the apical spinal nucleus whose axons run anteriorly into the basal spinal nucleus, wherein they terminate in axo-axonic synapses on the presynaptic terminals of nociceptive afferents that are subtended upon the basal nuclear neurones . Activation of peripheral mechanoreceptors by joint or soft tissue manipulation will produce presynaptic inhibition of nociceptive afferent activity and lead to pain suppression or reduction. Different grades of mobilisation according to Maitland's concept (Maitland, 1977) will produce selective activation of different mechanoreceptors : i. Mobilisation Grade I : activates Type I mechanoreceptors with a low threshold and which respond to very small increments of tension activates cutaneous mechanoreceptors oscillatory motion will selectively activate the dynamic, rapidly adapting receptors, ie . Meissner's and Pacinian Corpuscles . The former respond to the rate of skin indentation and the latter respond to the acceleration and retraction of that indentation . Grade II : similar effect as Grade I by virtue of the large amplitude movement it will affect Type II mechanoreceptors to a greater extent .

the cutaneous mechanoreceptors, project polysynaptically to - fusimotor (not alpha) neurone pools within the central nervous system, thus contributing to the continuous modulation of activity flowing around all the fusimotor muscle spindle loop systems. They exert reflexogenic influences on muscle tone . Fisk (1978) attributed the immediate decrease in pain after manipulation to a reflex decrease of muscle spasm . 2. The Effect of Manipulative Procedures with Reference to Biomechanics . a. Joint Mechanics Joint mobilisation is primarily indicated for reversible joint hypomobility, but is also useful for maintaining mobility, delaying progressive stiffness and relieving pain . The degree of freedom of a joint depends on its configuration In a normal ball and socket joint, there are six degrees of freedom namely flexion, extension, abduction, adduction, internal and external rotation . These directions of movement can be carried out by the patients . Their range of movement is large. They are termed as gross, voluntary, or angular movements (Fig . 2) .

FLEXION

GLENOID CAVITY

Grade III : similar to Grade II selectively activates more of the muscle and joint mechanoreceptors as it goes into resistance, and less of the cutaneous ones as the slack of the subcutaneous tissues is taken up . Grade IV : similar to Grade III with its more sustained movement at the end of range will activate the static, slow adapting, Type I mechanoreceptors, whose resting discharge rises in proportion to the degree of change in joint capsule tension . Grade V : in the premanipulative position it has the same effect as a sustained grade IV in the snapping action, manipulation certainly activates Type II and Type III (high threshold) mechanoreceptors . Clinically, resistance due to spasm melts under mobilisation or manipulation . This may be due to the stimulation of Type I and Type II mechanoreceptors (Wyke, 1980). They have dynamic and static responses to changes of pressure, and like 32

EXTERNAL ROTATION Voluntary or angular movements of shoulder joint

Fig. 2

However, there are involuntary movements which cannc be performed by the patient at will . They occur as the joins moves, especially towards the end of range . They give extra yield to joint movements. Otherwise, such movements can only be done by a third party or therapist . These movements are termed as involuntary, accessory or linear movements (Fig . 3), as distinct from the gross or angular movements, It is these accessory movements which will be affected to a greater extent by trauma and which will be regained last . Without proper treatment by mobilisation, they may never return to normal .
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b. How Manipulation Works --Related to Biomechanics

Manipulative therapy lays stress on treatments to regain both angular and linear movements. Exercises are given mainly to help the patient to regain the gross or angular movements. There are a few weight-bearing or self resisted exercises which may help in gaining accessory movements, but compared to passive mobilisation they are far from ideal. Examples include lunging exercise for ankle dorsiflexion and extension exercises for the wrist (Figs. 4 and 5).

CRUD Fig . 3

AP

Involuntary or linear movements of shoulder joint

EXTENSION

POSTEROANTERIOR GLIDE PA AP CEP CAUD MED LAT posteroanterior glide anteroposterior glide cephalic glide caudal glide medial glide lateral glide Manipulative procedures constitute various manual or mechanical techniques (Maitland's Peripheral & Vertebral Manipulation, 1977). Their effects on the biomechanics of joints are clear cut and direct, as explained previously. Trauma will bring about a loss of function. In the acute phase, it may be caused by pain, swelling, muscle spasm and malalignment of joint configuration . Manipulative therapy aims to reduce pain, swelling and spasm . There are a number of pain relieving techniques. Other conventional physiotherapy treatments will be beneficial as well. In the chronic phase, problems will be caused by the malalignment of joint configuration . In addition, adhesions and contractures plus weakness of the supportive joint structures, namely the ligaments and muscles, can also lead to joint dysfunction . In the chronic phase stiffness is a bigger problem as compared to pain . Manipulative procedures play a major part in regaining the range of movement or function of the joint. Exercises help to maintain the range of movement gained from mobilisation . ANTEROPOSTEROR GLIDE The signs and symptoms of the patient are analysed before the treatment . Possibilities of pain referred from joints other than those underlying the painful areas are considered, assessed and cleared. Pain or stiffness of the joint is related to the mechanism of the injury and activities that cause the 33 Fig. 5 Wrist dorsiflexion with posteroanterior glide

Fig . 4

Ankle dorsiflexion with anteroposterior glide

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pain. These are termed as 'aggravating activities' . The movement and direction of these activities is analysed according to the anatomy and biomechanics of the joint concerned . Components of soft tissue around the joint that might be affected by such activities are considered . A joint and its surrounding soft tissue cannot be separated functionally. "Normal joint physiology requires that the surrounding muscles and relevant blood vessels, nerves and connective tissues are functioning properly" (Kaltenborn, 1976). Lehto (1985) found that mobilisation seems essential for the quicker resorption of scar tissue and better structural organisation of the healing muscle. The importance of passive mobilisation and manipulation lies in the restoration of gross movements and accessory movements, which cannot be gained by patients through exercises alone, and certainly not by rest. The essence of the approach of manipulation lies in the integration of all the information gained from subjective and objective assessments in order to arrive at a logical conclusion of what structures of the joint are involved and which techniques are best for such joint dysfunction . Nowadays, orthopaedic surgeons and physiotherapists are more 'aggressive' than before . In Australia, the mobilisation of recent fractures (Jull, 1979) and mobilisation of nonuniting fractures (McNair, 1985) has produced good results. (It must be stressed that an 'aggressive' approach does not necessarily mean rough handling.) Recent research has supported the idea of the existence of a meniscus in the spinal apophyseal joints as hypothesised by Wolf (Goldstein, 1975). Moreover, the narrowing of the disc space is found to be the result of subchondral fractures rather than actual thinning of the disc . On the contrary, the disc thickens as it ages (Twomey and Taylor, 1985) . Such knowledge of joint biomechanics helps us to decide which structures within a joint are the more plausible cause of the problem in certain conditions . It also helps the therapist to choose the most appropriate technique for each condition. Summary In conclusion, there seems to be a sound scientific basis for manipulative therapy in the treatment of joint problems. As more knowledge of joint physiology and biomechanics unfolds, the effect of manipulative therapy may become more convincing. Even at this stage, the importance of manipulative therapy for joint problems should not be ignored . References Articles
1. Fisk, J.W. (1978) An Evaluation of Manipulation in the Treatment of the Acute Low Back Pain Syndrome in General Practice . In Approaches to the Validation of Manipulative Therapy. Buerger A.A . & Tobis J.S ., Ed . Charles C. Thomas, p. 236-270. 2. Gitelman, R. (1975) The treatment of pain by spinal manipulation . In : The Research Status of Spinal Manipulative Therapy. Ed . M. Goldstein, NINCDS Monograph No . 15 DHEW, p. 277-285.

3. Goldstein, M. (1975) The Research Status of Spinal Manipulative Therapy. NINCDS Monograph No . 15 DHEW 4. Jull, G. (1979) The role of passive mobilisation in the immediate management of . the fractured neck of humerus. Aust. J Physiother., 25 :3 July . 5. Lehto, M., Duance, V.C. and Restall, D. (1985) Collagen and fibronectin in a healing skeletal muscle injury . An immunohistological study of the effects of physical activity on the repair of injured gastrocnemius muscle in the rat. The Journal of Bone and Joint Surgery, 67-B(5), p. 820-828. 6. Lomax, E. (1978) Manipulative Therapy: An Historical Perspective . In : Approaches to the Validation of Manipulative Therapy . Buerger A.A . & Tobis J.S. Ed ., Charles C. Thomas, p. 205-216. 7. McNair, J. (1985) Non-uniting Fractures Management by Manual Passive Mobilisation . Proceedings of Fourth Biennial Conference . M.T .A .A. Brisbane . 8. Melzack, R. and Wall, P.D . (1965) Pain mechanisms : a new theory . Science 150, p. 971-979. 9. Mennell, J. McM. (1975) History of the Development of Medical Manipulative Concepts : Medical Terminology . In : The Research Status ofSpinal Manipulative Therapy. Ed . M. Goldstein, NINCDS Monograph No . 15 DREW, p. 19-24. l0 .Nachemson, A. (1975) A critical look at the treatment for low back pain . In : The Research Status of Spinal Manipulative Therapy. Ed. M. Goldstein, NINCDS Monograph No. 15 DHEW, p. 287-293. II .Pearce, J. and Moll, J.M .H. (1967) Conservative treatment and natural history of acute disc lesion. J Neurol. Neurosurg. Psychiat ., 30 :13-17 . . 12 . Sham, S.M . (1974) Manipulation of the lumbosacral spine. Clinical Orthop . Related Res., 101:146-150. 13 .Taylor, J.R . and Twomey L.T. (1985) Vertebral Column Development and its Relation to Adult Pathology. Aust. J. Physiother., 31 :3, 83-88. 14.Twomey, L.T . and Taylor J.R . (1985) Age Changes in the Lumbar Articular Triad. Aust. J Physiother. . 31 :3,106-114 . 15 .Wall, P.W . (1978) The Gate Control Theory of Pain Mechanisms : a re-examination and re-statement . Brain, 101 :1-18 . 16 . Wyke, B.D . (1980) Articular Neurology and Manipulative Therapy. In : Aspects o) Manipulative Therapy. Ed . Idczak, R.M . Lincoln Institute of Health Sciences, p. 67-72.

Books
1 . Kaltenborn, F.M . (1976) Manual Therapy for the Extremity Joints. Wellington New Zealand, University Press. 2. Maitland, G.D . (1977) Butterworth. Vertebral Manipulation, 4th Ed ., London,

3. Maitland, G.D . (1977) Peripheral Manipulation, 2nd Ed ., London, Butterworth. 4. Melzack, R. (1973) The Puzzle of Pain, Penguin Education. 5. Mennell, J. McM. (1960) Back Pain, Boston, Little, Brown and Co The Journal of The Hong Kong Physiotherapy Association

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