The place of manipulative therapy and its future

Published on 18/03/2015 by admin

Filed under Rheumatology

Last modified 18/03/2015

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There are two aspects to manipulation. First, it is an extremely effective form of reflex therapy in many types of pain, a feature that it shares in common with many other methods of physical therapy such as massage, electrical stimulation, and local anesthesia. Second, it is a specific form of treatment for important locomotor system dysfunctions, namely for functionally reversible movement restrictions involving joints and motion segments of the spinal column. And these movement restrictions can be regarded as a model for locomotor system dysfunctions in general.

It soon became clear that treatment of restricted joint movement had its limits and that passive movement restriction in itself involves not only joints but also muscles. It was this recognition of the importance of trigger points (TrPs) and their role in restricted joint movement and in the pathogenesis of locomotor system pain that signaled the next decisive step forward. Indeed, the close inter-relationships between joints and muscles became the starting point for further advances, leading to an improved understanding of active movement and its dysfunctions, and enabling us to identify muscle imbalance and faulty motor patterns.
No less important than movement are posture and statics, as demonstrated by the ever-increasing practical significance of excessive static strain in contemporary technological society. In recent years we have benefited immensely from progress in the field of developmental kinesiology made by Vojta & Peters (1992) and Kolář, 1996 and Kolář, 2001 and this now forms the basis of our understanding of upright posture in humans. These insights relate to the co-activation pattern of flexors and extensors in the trunk and of adductors and abductors and of external and internal rotation in the extremities. In addition, we know that the deep stabilizer system operates to maintain the otherwise labile equilibrium of the human body in the sagittal plane. The harmonious associated movement of all soft tissue, including the viscera, is a further important element that should not be forgotten, as demonstrated by the role of active scars in pathogenesis.
Familiarity with all the above aspects is indispensable if we wish to negotiate the uncharted ‘no man’s land’ of dysfunctions devoid of gross pathological changes that occupies the indeterminate borderlands between the traditional specialist disciplines of neurology, orthopedics, rheumatology, and physical medicine. We have coined the phrase ‘functional pathology of the locomotor system’ to describe this no man’s land. The most frequent clinical manifestation of this pathology is pain, the symptoms of which include TrPs, hyperalgesic zones, restricted joint movement, and changes in tissue tension.
Manipulative or manual medicine played a major role in these developments not only as the initial step toward ‘functional pathology’, but also because as a form of ‘bloodless surgery’ it called for precise palpatory diagnostic skills. While it is relevant in restricted joint movement, this palpatory diagnostic aspect also serves to enhance understanding of muscle TrPs, of soft-tissue mobility and relative displacement, and ultimately of pathological resistance in the abdominal cavity where active scars are present. In all these changes, the barrier phenomenon is utilized to impart a degree of objectivity to palpatory findings. Only a diagnostic approach that includes all tissues will permit comprehensive therapy that is consistent with the pathogenesis of locomotor system dysfunctions.
For all the importance that has come to be attached to the manipulative treatment of joints, it is only one method among many. Anyone who uses it should never limit themselves to just one method, no matter how effective it may be. The object of treatment is not any single method but the locomotor system and, primarily, its function, and historically this has had no specialist discipline of its own. Today there is a growing tendency to designate this emerging specialty as ‘musculoskeletal medicine’.
We should remind ourselves that locomotor system function is the most complex of all functions in the human body, and this is reflected in the fact that the largest part of the brain is associated with locomotor system function and control. This control is reflected in motor system programs that are designed to implement function: these relate to the locomotor apparatus as a whole, and this explains why dysfunctions only rarely affect a limited part of the locomotor system but usually involve the system as a whole. The clinical expression of this fact is the chain reaction pattern: this phenomenon was initially understood solely in empirical terms although we are now beginning to unravel something of the theoretical background too.
One major difficulty is that although we are familiar from experimental research with the basic neurophysiology of reflex mechanisms
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