Indications for and principles underlying individual treatment methods

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Manipulation 168

5.1.1 Indications 168
5.1.2 Contraindications 169
5.1.3 Traction 170
5.2 Soft-tissue manipulation 171

5.2.1 Skin stretching 171
5.2.2 Stretching a soft-tissue fold (connective tissue) 171
5.2.3 Application of pressure 171
5.2.4 Restoration of deep tissue mobility 171
5.2.5 Treatment of (active) scars 172
5.2.6 Relaxation of muscles 172
5.3 Reflex therapy 172

5.3.1 Massage 172
5.3.2 Exteroceptive stimulation 173
5.3.3 Local anesthesia – needling 173
5.3.4 Electrical stimulation 174
5.3.5 Acupuncture 174
5.3.6 Soft-tissue manipulation versus reflex therapy 174
5.4 Remedial exercise 175
5.5 Treatment of faulty statics 176
5.6 Immobilization and supports 177
5.7 Pharmacotherapy 178
5.8 Surgery 178
5.9 Lifestyle 178
5.10 The course of manipulative treatment 179
5.11 Conclusions 180
The indications for a particular treatment method should be established not only on the basis of the clinical diagnosis but also following an analysis of the pathogenesis so as to identify which lesion is most important at a given moment and is therefore likely to be the most effective object of therapy. Every therapeutic action should therefore result from a fresh examination, to keep up to date with the ongoing development of the patient’s condition.
In this setting it is of the utmost importance to identify chain reaction patterns of dysfunctions and to pinpoint the most relevant link in the chain. In establishing the indications for a particular treatment, it follows that no therapeutic intervention should be applied before examination of the patient has been completed and the findings have been meticulously analyzed.
If therapy is determined according to the principles set out here, it is likely to be effective and the condition of the patient should be found to have changed at follow-up examination. If the patient’s condition is unchanged, treatment was not adequate and should (generally) not be repeated.
Critical assessment of the preceding treatment and ongoing audit and review are essential here. To reiterate: this is primarily a question of analyzing the factors contributing to the pathogenesis and not simply of conventional clinical diagnosis. This attitude rules out an indiscriminate routine approach (e.g. ‘a series of intradermal injections’ or ‘a series of infiltrations’), presupposes critical assessment of any preceding treatment, and thus also enables the treatment program to be corrected in light of the results obtained with preceding treatments (evidence-based strategy).

5.1. Manipulation

5.1.1. Indications

Manipulative treatment is indicated if there is functional movement restriction (a pathological barrier) of a joint or spinal motion segment, and if this is considered relevant to the patient’s symptoms. In this setting, too, it should be emphasized that the decisive factor is not the clinical condition as such or even the clinical diagnosis (headache, dizziness, low-back pain), but rather the importance of the movement restriction for the pathogenesis.
Once this concept has been fully grasped, definition of the action required in spondylosis, disk herniation, osteoporosis, or ankylosing spondylitis is a straightforward matter: these conditions in themselves do not form the object of manipulative treatment. Nevertheless, if it is felt that movement restriction is a factor in patients with these diagnoses, then the restriction should be treated with a manipulative technique that is appropriate in the given circumstances.
Given the questionable importance of spondylosis for the pathogenesis, it is highly probable that diagnosis of a movement restriction will be the key finding.
In disk herniation, concomitant movement restriction may often cause the patient’s condition to deteriorate considerably and in such cases manipulation can be very successful. While it is far from easy to predict a successful outcome, it is always worth making an attempt with an appropriate technique.
Scoliosis is certainly not an object for manipulation, as in itself the condition does not usually cause pain. If a patient with scoliosis feels pain, and movement restrictions are diagnosed, these are far more likely to be the cause of that pain and should be treated. Manipulation is indicated if movement restrictions interfere with remedial exercise.
In both osteoporosis and juvenile osteochondrosis, stiffness (leading to immobility) will cause the patient’s condition to deteriorate. Adequate gentle mobilization techniques are therefore indicated to restore mobility.
Spondylolisthesis and basilar impression cannot be influenced by manipulation, but in clinical terms they are more often than not symptom-free. Here, too, dysfunctions associated with movement restrictions can be, and frequently are, the true cause of discomfort.
In ankylosing spondylitis, movement therapy is indicated, and therefore (self-)mobilization techniques are also appropriate; these have to be applied, however, to those segments that still show some degree of mobility.
The reason why manipulation may be regarded as safely indicated in all these patient groups is that the methods advocated in this book are extremely gentle and very effective neuromuscular mobilization techniques. They utilize the inherent muscle forces of the patient rather than those of the practitioner; indeed the practitioner tends to function more in a ‘directorial’ capacity, instructing the patient what to do and frequently allowing the patient to perform self-treatment.

High-velocity, low-amplitude thrust techniques

After gentle mobilization has been performed, the experienced practitioner will sometimes sense that the effect is still not entirely satisfactory; for example, a segment may still not be completely freed from several neighboring segments or, despite a measure of improvement, an area remains that still requires treatment. Preceding mobilization ensures that such a segment is well-prepared for a high-velocity, low-amplitude (HVLA) thrust. Following the work of Mierau et al (1988) we know that use of HVLA thrust techniques is followed by temporary hypermobility, and that a very intensive reflex response characterized by hypotonus or reduced muscle tone is achieved, which can be beneficial in radicular compression or entrapment syndromes (e.g. carpal tunnel syndrome). HVLA thrust techniques should be delivered with a minimum of force, and the cracking or popping sound within the joints should never be ‘enforced’ by the practitioner. If the segment has been well prepared for a thrusting maneuver, then the technique should succeed with consummate ease. This also applies to the situation in children who are too young to cooperate; here it is important to exploit the precise moment when they are relaxed. However, this presupposes excellent technical skill.
In this connection it is worth quoting Stoddard’s (1961) system of recording degrees of joint mobility (Figure 5.1, Table 5.1).
Table 5.1 Stoddard’s classification of joint mobility
Classification Description
0 No mobility, ankylosis, not suitable for manipulative treatment
1 Severe movement restriction, only mobilization techniques to be applied
2 Slight movement restriction, both mobilization and thrust techniques can be used
3 Normal mobility, best left alone; however, if there is movement restriction in one direction, a thrust technique in the free direction can be useful (Maigne)
4 Hypermobility, all types of manipulative treatment should be avoided

5.1.2. Contraindications

The major technical advances achieved in the field of manual medicine in recent years have brought about a sea change specifically in the area of indications and contraindications. The situation can now be summarized concisely as follows: there is no real contraindication to manipulation and no possibility that patients will be harmed by it. What is contraindicated, however, is poor technique. Nowadays the basic approach comprises mobilization with neuromuscular techniques that primarily make use of the patient’s inherent muscle forces. This would be like forbidding the patient any spontaneous movements. HVLA thrust manipulation is employed to a very limited extent only and the ground is generally thoroughly prepared beforehand using mobilization techniques.
The following cardinal errors must be avoided:

• Over-frequent use of HVLA thrust techniques.
• Delivering an HVLA thrust before the patient is properly relaxed and before the slack has been taken up.
• Trying to enforce manipulation of any type against protective muscle spasm or in a direction that causes pain.
• Performing cervical manipulation in retroflexion, side-bending, and rotation with traction, especially in cases where the patient does not tolerate this position.
• Repeating HVLA thrusts at short intervals (i.e. of less than two weeks); in this context, even over-zealous examination of mobility in a painful direction may be contraindicated.

In the debate surrounding contraindications, repeated reference is made to serious incidents and even fatalities, such as those reported by Dvorák & Orelli (1985), Grossiord (1966), Krueger & Okazaki (1980), Lorenz & Vogelsang (1972) and cited in the memorandum issued by the German Association of Manual Medicine (1979). Basing their calculations on the results of a questionnaire sent to members of the Swiss Association of Manual Medicine, Dvorák & Orelli (1985) computed the number of serious complications after manipulation (thrust techniques) to be 1:400000. By far the most important cause of serious complications is undoubtedly injury to the vertebral artery, the wall of which may split longitudinally. Given the low incidence of vertebral artery damage and the rarity of such incidents, more recent publications (up to 2004) have suggested that these findings may be coincidental.

Unfortunately, an almost constant feature of the literature cited is a failure to specify the particular technique that was held responsible for the complications in question: this is rather like discussing postoperative complications without giving details of the surgical technique used. One exception, however, is the publication by Dvorák & Orelli (1985), which includes the following highly characteristic account:

Case study
A 35-year-old woman collapsed while attending a funeral and suffered from wry neck for three weeks afterward. Within the space of a few days she underwent HVLA thrust manipulation three times, administered by a qualified, experienced chiropractor. The patient was supine and manipulation consisted of passive rotation, reclination, and side-bending of the head. This was followed immediately by a short period of unconsciousness and later by tetraplegia. The patient was extubated after mechanical ventilation for 36 hours and administration of dexamethasone. After four months the patient was symptom-free apart from slight unsteadiness of gait. HVLA thrust techniques in acute wry neck are questionable in themselves, but to use the dangerous combination of ‘rotation, reclination, and side-bending’ is to court disaster. Another grave error was to repeat the thrusts in quick succession within the space of a few days because the patient’s condition did not show any improvement. In the few instances where detailed case reports are available, serious complications have indeed occurred most frequently when HVLA thrust techniques are repeated within a short space of time.

It should be emphasized here that HVLA thrust techniques are inappropriate for painful and severe movement restrictions, even if several adjacent segments are involved simultaneously. In such cases, HVLA thrusts are not only traumatizing but also ineffective, whereas neuromuscular techniques have proved outstandingly beneficial. For this reason, HVLA thrust techniques hardly ever form the initial component of therapy. The following contraindication may be inferred: if it is a mistake to perform thrust manipulation in the painful direction where there is major movement restriction, then use of this technique is also contraindicated where pain and gross movement restriction are present in all directions. In reversible functional movement restrictions, a distinction is made in any case between the direction of restriction and the direction of ease; movement restriction in all directions does not suggest dysfunction and therefore does not constitute an indication for manipulation.

For obvious reasons, manipulation of any kind is out of place in hypermobility. While this does not mean that no movement restriction should be treated in a hypermobile patient, it would be better to avoid thrust techniques because temporary hypermobility always follows any thrust maneuver.
Other contraindications include destructive conditions of an inflammatory or neoplastic nature. It is clear that no one would try to treat this type of pathology by manipulation; unfortunately, particularly in the initial stages of such conditions, diagnostic error is often unavoidable. The specialist usually sees such patients in hospital, at a later stage, when the putative diagnosis has already become clearer. Nevertheless, with modern-day techniques, these patients should come to no more harm than from the administration of analgesics. If, in a case of diagnosed tumor pathology, coexisting movement restriction is considered harmful to the patient’s condition, there is no reason why such a restriction should not be treated with an appropriate technique (see Case study 2 in Section 4.21.2).
While working at the neurology clinic in Prague-Vinohrady, I deliberately gave manipulation at the craniocervical junction to a patient with a decompensating acoustic neuroma; he was then able to be referred to the neurosurgery clinic in a well-compensated state. It is regrettable that a vertebral artery syndrome is considered to be a contraindication in this setting. Admittedly, treatment must only ever be given in a direction that is well tolerated, but there are few disorders where restrictions involving the craniocervical junction are more disastrous.

5.1.3. Traction

Traction is essentially a form of mechanotherapy or manipulation, but unlike other methods of manipulation it is generally accepted in traditional medicine. Within the framework of manipulative techniques, traction of the cervical and lumbar spinal column has a specific role in radicular compression syndromes in those spinal regions and in disk herniation. In fact, traction can also be useful for diagnosis: if it relieves discomfort in the lumbar region, then the diagnosis of a herniated disk is corroborated. Traction is also indicated in acute wry neck and low-back pain.

5.2. Soft-tissue manipulation

Soft tissue, in particular the deeper layers including the fascia and connective tissue, is intimately connected with the locomotor system, muscles, and joints. It is the function of soft tissue to be stretchable while yet able to resist stretch, and to be capable of being shifted while yet able to resist shifting. All this should take place in harmony with the locomotor system and may involve considerable ranges of movement.
The same also applies for the viscera: there are no standard measures whatsoever for the degree to which the internal organs may also move. Changes in soft tissue have usually been considered to be reflex changes, that is secondary changes. This is not always the case, however, particularly in the chronic stage of painful conditions, and in endocrine and metabolic disorders. The tissue changes then form what is termed a ‘terrain’ (or constitutional factor).
Clinically, a physiological and a pathological barrier can be detected in all soft tissue: both types of barrier constitute a possible indication for therapy, enabling disordered function to be corrected in precisely the same way as in restricted joints. If the soft-tissue changes are significant, they produce reflex inhibition of the locomotor system; it is then advisable to treat such soft-tissue lesions before performing joint mobilization, as the treatment itself may have a considerable mobilizing effect.

5.2.1. Skin stretching

This technique is specific for hyperalgesic zones (HAZs). It has an effect similar to that of Kibler’s skin-fold rolling test (1958) and of connective tissue massage as advocated by Leube & Dicke (1951)
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