Manual Therapy – Spinal Vertebra Mobilisation
One physiotherapy modality is fast becoming de rigueur in the treatment of referred pain caused by stiff joints is manual therapy. Manual therapy is the mainstay of modern physiotherapy moving away from the dependency on Electro-Therapy Agents. These include Ultrasound, Short Wave and TENS as the primary treatment modalities.
Referred pain is a very unpleasant sensation localised to an area separate from the site of the causative injury or other painful stimulation. Referred pain often arises when a nerve is compressed or damaged at or near its origin. The territory the nerve serves will feel the sensation of pain. This is even though the damage originates elsewhere.
What Does Manual Therapy Consist Of?
Manual therapy consists of a range of interventions, including hands-on techniques such as joint mobilisation. Joint mobilisation helps maintain or improve the extensibility and tensile strength of the articular tissues. This reduces the effects of mechanical limitations, elongate hypomobile capsular, ligamentous and connective tissue. It also stimulates mechanoreceptors. Therefore, it may be responsible for inhibiting the transmission of nociceptive stimuli and in doing so, reduce pain perception. (Kisner and Colby 2002).
There are two common concepts of manual techniques used for spinal mobilisation in Singapore. They are the Maitland Concept and the Mulligan Concept.
Maitland’s Concepts involve the application of passive and accessory oscillatory movements to spinal and vertebral joints. This helps to treat pain and stiffness of a mechanical nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude.
A small amplitude movement performed below the range of resistance is Grade I. It is suitable for treating highly irritable conditions. Using Grade I enables the slack in collagen to be taken up when the connective tissue is not under load. It can relieve pain by working on neural structures (Threlkeld).
A Grade II mobilisation is wider in amplitude but still below resistance. Use of Grade I and II are appropriate when palpation elicits pain before restriction of movement.
Grade III and IV are used when resistance to movement is encountered before pain. A large amplitude movement performed within resistance and generally used to improve range of motion is when Grade III is used.
A small amplitude movement performed within resistance used for chronic aches of low irritability is Grade IV.
A high velocity thrust used in manipulation is Grade V.
Application of Maitland techniques to the vertebrae is along an anterior-posterior axis or transverse irrespective of the angle of the joint. Peripheral joints are similarly treated with Maitland techniques on planes appropriate to the condition, usually on the plane where there is pain or restriction. These may be anterior- posterior, transverse or longitudinal.
The comparable pain response “is nearly always found with the unphysiological movement rather than the physiological movement” is the argument for Maitland. Conversely, Brian Mulligan applies movement in sympathy with the physiological movement. Mulligan guides towards the restoration of correct physiological tracking by the absence of pain. His techniques are designed to deal with problems of restricted or painful movement. However, they are not highly irritable. These techniques are therefore used for non-acute conditions; when there is an altering of the biomechanics of the joint without inducing pain. Maitland’s criteria of severity, irritation and nature of the condition are used to judge the appropriateness of the technique.
Principle Of Mulligan’s Concept
Mulligan does not prescribe grades of movement or oscillatory movements. He prescribes taking the joint through its full range of movement and this entails taking it into resistance. The physiotherapist superimposes an accessory movement onto the patient’s active physiological movement with the aim of over-riding the obstruction and re-establishing correct alignment. The accessory movement takes the joint through what would be the normal physiological movement of the joint. Reasserting the ‘joint memory’ or prior conditioning of the healthy joint re-establishes the pre-injury joint tracking.
Mulligan’s principle techniques are NAGS, SNAGS and MWMs. Natural Apophyseal accessory Glides refer to NAGS, where it is applied to the cervical spine with the patient passive. Sustained Natural Apophyseal accessory Glides refer to SNAGs, where the patient attempts to actively move a painful or stiff joint through its range of motion whilst the therapist overlays an accessory glide parallel with the treatment plane. Mobilisations With Movement refer to MWMs, and are applied to the peripheral joints.
The underlying principle to MWMs is derived from Kaltenborn (1989 in Exelby 1995) who argued that joint surfaces are not fully congruent, physiological movements are a combination of rotation and glide, and glide is essential to pain free movement. Glide occurs in the direction of bone lever movement where its articulating surface is concave and in the opposite direction when convex.
Treating The Spine Using The Mulligan’s Concept
The treatment plane lies at a ninety-degree angle to the concave articulating surface of the bone and treatment is applied parallel to the treatment plane. The anterior-posterior and posterior-anterior movements used in Maitland’s techniques follow the same planes in peripheral joints.
However, in treating the spine Maitland will follow the planes of the intervertebral body joints whilst Mulligan techniques follow the plane of the zygapophyseal joints.
Exelby argues that the zygapophyseal joints guide the spine and so improving their glide by applying NAGs and SNAGs will improve the range of spinal movement. Applying treatment on the plane of the intervertebral body joints results in compression on the zygapophyseal joints and will not promote glide.