history of manual therapy and arthrology
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History of Manual Therapy
Hippocrates
• 460-355 BC
Claudius Galen
• 131-202 AD
Bone Setting
• Britain 17th and 18th centuries
• practice passed from father to son
• along with barber surgeons were the forerunners to orthopedics and surgery in the UK
• Mid 20th century bone setting dies out and is replaced by physical therapy and osteopathy
Osteopathic Medicine
• Andrew Taylor Still – 1874
• DO Doctor of Osteopathy in the USA –1928– Osteopathic Physicians– gained equal rights with MD’s
• In all states by 1970
• William Garner Sutherland – 1966– offshoot of osteopathy
• cranial osteopathy– cranialsacral technique
Chiropractic
• Daniel David Palmer – 1895– founder of chiropractic – credits it to medicine– claims to be the first to reposition vertebrae by
using the spinous and transverse processes as balance levers
Manipulation in Medicine
• medicine created physical therapy to aid in rehabilitation
• physicians trained aids who later became physical therapist
• 1899 physiotherapy founded in England– James and John Mennell – 1st to use term MT– Edger and James Cyriax
Physical Therapy
• 1921 physical therapy est. in USA– American Women’s Physical Therapeutic
Association– need to use medically trained women after
WW1
• 1927 – ‘Arthrokinematics’ - used in Gray’s Anatomy
Physical Therapy
• 1957 – James Cyriax– Textbook of Orthopaedic Medicine
• 3rd edition
– Soft Tissue Differentiation– popularized the term ‘end-feel’– trained physiotherapists– pleaded for emphasis first on
evaluation and then on treatment
Freddy Kaltenborn
• 1961 – Kaltenborn – Norway– Extremity Joint Manipulation– After 1971 began instructing
physical therapists worldwide
Olaf Evjenth
Paris - Maitland
• 1963 – Stanley Paris (USA) –PT– while in NZ– The Theory and Technique of Specific
Manipulation
• 1964 – Geoffrey Maitland (AUST) – PT– Vertebral Manipulation
IFOMT
• 1966 – Paris, Grieve, Maitland, Kaltenborn– met with others to discuss setting up an
international body• 8 years later IFOMT (Montréal)
Robin McKenzie
• late 1970’s
• popularized the concept of
spinal extension for
treatment of LBP– ‘centralization theory’
Brian Mulligan
• 1990’s – Brian Mulligan (NZ)– MWM’s
Current Manual Therapy
• practice by physiotherapist is quite eclectic• no single philosophy dominating• rarely used in isolation, but with:
– therapeutic exercise– patient education– supportive modalities
• most use:– mechanical– muscle energy– oscillatory
Arthrology
Arthrology
• Outline:– joint classification– shapes of articular surfaces– planes and axes– degrees of motion/freedom– arthrokinematics– osteokinematics
Arthrology
Joints(Arthroses)
Solid Joints Cavitated Joints
(Synarthroses) (Diarthroses)
Fibrous Cartilaginous Synovial
Fibrous Joints
1. Sutures
2. Gomphoses (peg and socket- teeth)
3. Syndesmoses– has interosseus ligament
• eg. inferior tibiofibular ligament
Cartilaginous Joints
Synchondroses (primary cartilaginous joints)hyaline growth cartilage (function = growth mechanism)
- sternales, xiphosternalisSymphyses (secondary cartilaginous joints)
hyaline growth cartilage, bonded by fibrocarilaginous disc
- pubis, intervertrebrales, manubriosternalis **
Synovial Joints
• Typical features:– freely moveable– articular surface predominantly hyaline
cartilage, sometimes fibrocartilage– fibrous joint capsule– synovial membrane– synovial fluid– disc or meniscus– joint space
Synovial Joints
Complexity1. Simple
• one pair of articulating surfaces:• convex• concave
2. Compound• more than one articulating pair in a single capsule• neither will articulate with the surface that belongs to the
other
3. Complex• has an articular disc
Shapes of Articular Surfaces
1. Ovoid
2. Sellar
Ovoid
• concave or convex in all planes• degree of curvature will vary in all planes• egg shaped rather than spherical1. Unmodified ovoid
– shape is spherical enough to allow 3 degrees of motion (Hip)
2. Modified ovoid– degree of curvature is more marked in one plane than
the other– allows only 2 degrees of motion (MCP)
Sellar
• saddle shape• predominantly concave in one plane and and convex at right
angles to this• stable and efficient, requires fewer ligaments as surface is
more congruent1. Unmodified Sellar
– joint surfaces are purely concave in one plane and purely convex in the other (perpendicular to each other)
– allows for 2 degrees of motion (1st CMC)
2. Modified Sellar– joint surfaces have both a concave and a convex portion in the same
plane (not perpendicular to each other)– allows for only 1 degree of motion (TCJ, HUJ)
Planes and Axes
PLANE AXIS
median/sagittal transverse
(divides R/L) (runs M/L)
frontal/coronal sagittal
(divides A/P) (runs A/P)
transverse/horizontal vertical
(divides S/I) (runs C/C)
Degrees of Motion
• The number of planes through which a bone can be voluntarily (actively) moved around (3max)
Mechanical Axis– a line passing through the bone perpendicular to the
joint surface
– line of reference for osteokinematic motion
Axis of Movement– bone moves around this point
– perpendicular to the plane of motion
One Degree of Motion
• uniaxial– hinge joints (ulnohumeral)
• movement of the bone is limited to movement about a single axis
• motion of a bone is produced by a sliding action within a joint
Two Degrees of Motion
• biaxial– ellipsoidal (MCP, wrist)– pivot
• either a swing or spin
• has spin and swing or two distinct swings
• axes must be perpendicular to each other
Three Degrees of Motion
• multiaxial– spheroidal - ball & socket (hip)– planar joints (AC jt)
• movement about 3 distinct axes which are perpendicular to each other
• has a spin and two distinct swings (near pure)
Degrees of Freedom
• the number of independent axes that a bone can move around (6 max)
• axes are perpendicular to each other
• 3 rotations
• 3 translations
Degrees of Freedom
• 3 rotations
• 3 translations
Degrees of Freedom
Arthrokinematics
• study of the movement of one articular surface on another without regard to the movement of the bone or the forces producing that movement
• in the periphery, movement is named after the direction of motion of the distal bone
• in the spine, movement is named by motion of the superior bone
• describes:1. spin2. rock (concave moving)
roll (convex moving)3. glide (slide)4. traction/compression
Arthrokinematics
Convex/Concave Rule
• the relationship between the shape of articulating joint surfaces and the direction of gliding is defined by the convex/concave rule
• if the concave surface is moving on a stationary convex surface, gliding will occur in the same direction as the rocking motion
• if the convex surface is moving on a stationary concave surface, gliding will occur in an opposite direction to the rolling motion
Arthrokinematics
Arthrokinematics
Osteokinematics
• study and measurement of motion of a bone in space
• study of movement of a bone around its mechanical axis without regard to the motion occurring at the joint
• describes:– rotations
• spins• swings
– translations
Rotation
Spin
• the non-linear motion that occurs either at the joint surface (arthrokinematic spin) or around the mechanical axis of the bone (osteokinematic spin)
• motion of the bone is produced by a twisting action
Swing
• the linear motion that either occurs at the joint surface (arthrokinematic swing) or in the plane of the mechanical axis of the bone (osteokinematic swing)
• motion of the bone is produced by a sliding action within a joint
Pure Swing
• (cardinal or chordal)• shortest distance between two points• swing with no accompanying spin• bone moves in one plane• swing can occur without the bone taking a curved
path• only occurs in joints that have at least 2 degrees of
motion• is functionally abnormal and the exception rather than
the rule
Pure Swing
Impure Swing
• (arcuate)
• Is accompanied by spin (conjunct rotation)
• The bone does not stay in one plane
• Movement of a point on the mechanical axis follows a line (arc) other than the shortest one (chord)
Impure Swing
Translation
• all particles in the body at at given time have the same direction of motion relative to a fixed point
• there is no centre of rotation as the bone moves along a plane instead of through it
Translation
PPM/PAM
• Passive Physiological Movement– links with osteokinematics
• Passive Accessory Movement– links with arthrokinematics
Traction Technique ?
Articular NeurologyArticular Neurology
Wyke (1981) The neurology of jointsWyke (1981) The neurology of joints All joints are provided with similar arrays of All joints are provided with similar arrays of
corpuscular and non-corpuscular receptor corpuscular and non-corpuscular receptor nerve endingsnerve endings
Types I-IVTypes I-IV
Receptor CharacteristicsReceptor Characteristics
FunctionsFunctions
Functionally, the receptor systems Functionally, the receptor systems operate in three spheres:operate in three spheres:
1.1. ReflexogenicReflexogenic
2.2. PerceptualPerceptual
3.3. NociceptiveNociceptive
ReflexogenicReflexogenicMyelinated afferent axons that innervate Myelinated afferent axons that innervate mechanoreceptors in joint capsule and ligaments mechanoreceptors in joint capsule and ligaments enter spinal cord through related dorsal NRs are enter spinal cord through related dorsal NRs are dispersed to spinal and brain stem motoneurone dispersed to spinal and brain stem motoneurone pools, cerebellum, brainstem reticular system and pools, cerebellum, brainstem reticular system and thalamusthalamusIntegrated effects are expressed in coordinated Integrated effects are expressed in coordinated reflexogenic effects on the striated musculature in reflexogenic effects on the striated musculature in many parts of the bodymany parts of the body Arthrostatic – operate in absence of joint movementArthrostatic – operate in absence of joint movement Arthrokinetic – operate during joint movementArthrokinetic – operate during joint movement
PerceptualPerceptual
Articular mechanoreceptor projections Articular mechanoreceptor projections to the paracentral and parietal regions to the paracentral and parietal regions of the cerebral cortex (associated with of the cerebral cortex (associated with postural and kinesthetic sensationpostural and kinesthetic sensation
1.1. Postural sensation - staticPostural sensation - static2.2. Kinesthetic sensation – perception of Kinesthetic sensation – perception of
direction, amplitude, and velocity of direction, amplitude, and velocity of joint movementjoint movement
NociceptiveNociceptive
Free nerve endingsFree nerve endings
Active when there is:Active when there is: Mechanical deformation or tensionMechanical deformation or tension Mechanical or chemical irritationMechanical or chemical irritation
Classification ofClassification ofNerve FibersNerve Fibers
Two classification systems:Two classification systems:
1.1. Conduction velocityConduction velocity1.1. AA
1.1. α, β, γ, δα, β, γ, δ
2.2. BB
3.3. CC
2.2. Axonal diameter (used only for sensory fibers)Axonal diameter (used only for sensory fibers)1.1. Group I-IVGroup I-IV
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