Chapter 10: Manual Techniques

CHAPTER OBJECTIVES

At the completion of this chapter, the reader will be able to:

1. Give definitions for commonly used biomechanical terms used in manual therapy (MT).

2. List the criteria that are important for the correct application of a manual technique.

3. Summarize the various types of MT.

4. Describe the importance of knowing the shapes of the various articular surfaces and how that determines the direction of the application of a technique.

5. Apply the knowledge of the various MTs in the planning of a comprehensive rehabilitation program.

6. Recognize the manifestations of abnormal tissue and develop strategies using manual techniques to treat these abnormalities.

7. Categorize the various effects of MT on the soft tissues.

8. Make an accurate judgment when recommending an MT technique to improve joint or muscle function.

OVERVIEW

Touch has always been and continues to be a primary healing modality. The first written records of massage go back to Ancient China, and wall paintings in Egypt depict hands-on healing techniques that go back 15,000 years.¹ From this early “laying on of hands” evolved many of the techniques used today.

The techniques of manual therapy (MT) fall under the umbrella of therapeutic touch. MT interventions are the preferred treatment for both healthcare professionals from a variety of disciplines and patients with musculoskeletal pain conditions.² Indeed MT has become such an important component of the intervention for orthopaedic and neurologic disorders that it is considered by many as an area of specialization within physical therapy. This, despite that systematic reviews only find small to modest effect sizes or fail to recommend these interventions.² Much of the appeal for MT is likely its targeted approach for personalizing treatment.^3–5

Of the approaches commonly applied, the Cyriax,⁶ Mennell,⁷ and osteopathic techniques^8,9 (Table 10-1) originated from physicians, whereas the Maitland,^10,11 Kaltenborn,¹² and McKenzie and May¹³ approaches (Table 10-2) were derived by physical therapists.

Within these major philosophies, a number of subsets have also emerged, including myofascial release (MFR), positional release techniques, neurodynamic mobilization techniques (see Chapter 11), manually resisted exercise, proprioceptive neuromuscular facilitation (PNF), joint mobilization, and high-velocity thrust (manipulation) techniques.

While drug effects are often attributed to a specific and well-defined active ingredient, the mechanisms underlying complex interventions, such as those used for MT, are multifaceted and comprise specific and nonspecific factors related to the intervention, the patient, the provider, and the environment in which the intervention is provided.² MT techniques have traditionally been used to produce a number of therapeutic alterations in pain and soft-tissue extensibility through the application of specific external forces to decrease pain and improve motion quality in an area with restriction.¹⁴ Some of these therapeutic alterations may be neurophysiologic and are therefore difficult to clinically assess. Unfortunately, the therapeutic efficacy of many MT techniques remains undetermined. Thus, many of these techniques ...