Evidence Based Practice
Mulligan Maitland Mckenzie Mcconnel Taping Dry needling
Brian Mulligan's concept of mobilizations with movement (MWMS) in the extremities and sustained natural apophyseal glides (SNAGS) in the spine are the logical continuance of this evolution with the concurrent application of both therapist applied accessory and patient generated active physiological movements.
Principles of Treatment
In the application of manual therapy techniques, Physiotherapists acknowledge that contraindications to treatment exist and should be respected at all times. Although always guided by the basic rule of never causing pain, therapist choosing to make use of SNAGS in the spine and MWMs in the extremities must still know and abide by the basic rules of application of manual therapy techniques.
"The Maitland Concept of Manipulative Physiotherapy [as it became to be known], emphasizes a specific way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy ("know when, how and which techniques to perform, and adapt these to the individual Patient") and a total commitment to the patient."
The application of the Maitland concept can be on the peripheral or spinal joints, both require technical explanation and differ in technical terms and effects, however the main theoretical approach is similar to both The concept is named after its pioneer Geoffrey Maitland who was seen as a pioneer of musculoskletal physiotherapy, along with several of his colleagues. The Maitland concept is a fantastic tool for approaching an initial assessment as it can be used to form a logical and deduced hypothesis about the nature of the origins of the movement disorder or pain. It is worth considering using mobilisations in your assessment process and reading the Initial Assessment section in Maitlands book Peripheral Manipulation.
As with any treatment decision a competent and effective assessment is crucial to any patient interaction. The Subjective Assessment is necessary for determining whether or not mobilisations are suitable for this patient or if they are contraindicated by looking for red flags such as cancer, recent fracture, open wound or active bleeding, infective arthritis, joint fusion.
The Objective Assessment is an area which the versatile nature of mobilisations becomes clear. Additionally to being a treatment method they are available to the therapist to assess a patients joints and tissues by analysing their extensibility, pain reproduction, bony blocks or abnormal end feels.
Decisions Which Need to be Made
- The Direction - of the mobilisation needs to be clinically reasoned by the therapist and needs to be appropriate for the diagnosis made. Not all directions will be effective for any dysfunction.
- The Desired Effect - what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness?
- The Starting Position - of the patient and the therapist to make the treatment effective and comfortable. This also involves thinking about how the forces from the therapists hands will be placed to have a localised effect.
- The Method of Application - The position, range, amplitude, rhythm and duration of the technique.
- The Expected Response - Should the patient be pain-free, have an increased range or have reduced soreness?
- How Might the Technique be Progressed - Duration, frequency or rhythm?
Each joint has a different movement arc in a different directon to other joints and therefore care needs to be taken when choosing which direction to manipulate; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:
- A-P (Anteroposterior)
- P-A (Posteroanterior)
- Longitudinal Caudad
- Longitudinal Cephalad
- Joint Distraction
- Medial Glide
- Lateral Glide
The McKenzie method (also MDT = Mechanical Diagnosis and Therapy) is a comprehensive method of care primarily used in physical therapy.
New Zealand physical therapist Robin McKenzie (1931–2013) developed the method in the late 1950s. In 1981 he launched the concept which he called Mechanical Diagnosis and Therapy (MDT) - a system encompassing assessment (evaluation), diagnosis and treatment for the spine and extremities. MDT categorizes patients' complaints not on an anatomical basis but subgroups them by the clinical presentation of patients.
MDT uses primarily self treatment strategies, and minimises manual therapy procedures, with the McKenzie trained therapist supporting the patient with passive procedures only if an individual self treatment program is not fully effective. McKenzie states that self treatment is the best way to achieve a lasting improvement of back pain and neck pain.
In this context, centralization of pain during evaluation and treatment is a phenomenon of diagnostic relevance. When centralization is present, pain in an extremity moves sequentially back to the spine. There it may be felt more intensely. If pain centralizes, this is a positive prognostic sign and the detected directional preference guides further treatment. A 2012 systematic review found that lumbar centralization was associated with a better recovery prognosis in terms of pain, short- and long-term disability, and the likelihood of undergoing surgery in the following year. Clinical research demonstrates reliability of the McKenzie Evaluation.
According to a meta-analysis of clinical trials in 2006, treatment utilizing the McKenzie method is somewhat effective for acute low back pain, but the evidence suggests that it is not effective for chronic low-back pain. A 2012 systematic review agreed with this, finding that centralization occurred more frequently in acute patients (74%) compared to subacute (50%) and chronic (40%).
Also, centralisation was found to be more common in younger patients. Cervical centralization was observed in only 37% of patients. There have also been other reviews of the literature.
Prevalence of use
The McKenzie method is commonly used worldwide in diagnosis and treatment of low back pain, of neck pain and peripheral joint complaints.
McConnel Taping is a very useful technique for pain relief by correcting the biomechanical faults and maintaining them in the corrected position.
Osteopathy is a form of drug-free non-invasive manual medicine that focuses on total body health by treating and strengthening the musculoskeletal framework, which includes the joints, muscles and spine. Its aim is to positively affect the body's nervous, circulatory and lymphatic systems. This therapy is a unique holistic (whole body) approach to health care. Osteopaths do not simply concentrate on treating the problem area, but use manual techniques to balance all the systems of the body, to provide overall good health and wellbeing.
Dr. Andrew Taylor Still established the practice of Osteopathy in the late 1800s in the United States of America, with the aim of using manual 'hands on' techniques to improve circulation and correct altered biomechanics, without the use of drugs.
The benefits of osteopathy are the general improvement in mobility and structural stability of the body. In turn, other systems of the body such as the circulatory, nervous and lymphatic systems function more effectively and for a number of general conditions, minimal treatment is required.
What does Osteopathic treatment involve?
The initial consultation will take around 45 minutes to complete, after which the osteopath will be able to offer a diagnosis and discuss a treatment program. Treatment could include such techniques as soft tissue stretching, to increase blood flow and improve flexibility of joints and muscles; articulation to mobilise joints by being passively taken through their range of motion; and muscle energy, to release tightness on the muscles by alternatively being stretched and made to work against resistance. All treatment programs are highly individualised and depend on the patient's current condition, past history, and ability to adapt to change. Most simple problems often require only 3-4 treatments.
Dry needling is the use of either solid filiform needles or hollow-core hypodermic needles for therapy of muscle pain, sometimes also known as intramuscular stimulation (IMS). Dry needling for the treatment of myofascial (muscular) trigger points is based on theories similar, but not exclusive, to traditional acupuncture; however, dry needling targets the trigger points, which is the direct and palpable source of patient pain.
Technique: In the treatment of trigger points for persons with myofascial pain syndrome, dry needling is an invasive procedure in which a filiform needle is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle. Proper dry needling of a myofascial trigger point will elicit a local twitch response (LTR), which is an involuntary spinal cord reflex in which the muscle fibers in the taut band of muscle contract. The LTR indicates the proper placement of the needle in a trigger point. Dry needling that elicits LTRs improves treatment outcomes, and may work by activating endogenous opioids. Inserting the needle can itself cause considerable pain, although when done by well-trained practitioners that is not a common occurrence.
A Systematic review concluded that dry needling for the treatment of myofascial pain syndrome in the lower back appeared to be a useful addition to standard therapies. A recent systemic review and meta analysis released by JOSPT on "effectiveness of dry needling for upper-quarter myofascial pain" recommends the usage of dry needling, compared to sham or placebo, for decreasing pain immediately after treatment and at 4 weeks in patients with upper quarter myofascial pain syndrome.
- Mulligan's Manual Therapy Treatment Dosing for Subacute Mechanical Neck Pain - A Comparison between Loading and Movement Disorders of Cervical Spine.
- Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: A case report
- Effectiveness of Back School Versus McKenzie Exercises in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial
- Comparative Analysis of Muscle Energy Technique and Conventional Physiotherapy in Treatment of Sacroiliac Joint Dysfunction :Mullai Dhinkaran, Aarti Sareen Tanu Arora INDIAN JOURNAL OF PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
- The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system Maria Moutzouri, Evdokia Billis, Nikolaos Strimpakos, Polixeni Kottika and Jacqueline A Oldham
- Disc Prolapse : Evidence of reversal with repeated extension :Scannel JP, McGill SM (2009)
- Comparison Of Lumbar Range Of Movement And Lumbar Lordosis In Back Pain Patients And Matched Controls: J Rehabil Med 2002; 34: 109–113 Joseph K.-F. Ng,1 ,2 Carolyn A. Richardson,1 Vaughan Kippers 2 and Mohamad Parnianpour3
- The effect of a unilateral upper extremity load (backpack) on the resulting spinal posture. Knott et al. Scoliosis 2013, 8(Suppl 2):O26 http://www.scoliosisjournal.com/content/8/S2/O26
- Posture, the lumbar spine and back pain . International Encyclopedia of Rehabilitation.
- The Importance of Trunk Muscle Strength for Balance, Functional Performance, and Fall Prevention in Seniors: A Systematic Review. Sports Medicine : July 2013, Volume 43, Issue 7, pp 627-641