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Contemporary approach to Manual Therapy

“Manual therapy within an evidence based framework is under threat and struggling for relevance”

(Elvey & O’Sullivan 2005)

• The reasons for this are twofold
– Manual therapy developed largely from a culture of treating signs & symptoms resulting in the inappropriate
application of intervention for many disorders
– There has traditionally been a lack of consideration given to diagnosis and in particular classification of
disorders both in clinical practice and evidence based research
– These have led to the lack of recognition that the complaint of pain is only one part of a disorder which is
complex and involves far more than the expressed complaint
• Manual therapy has sufficient scope of practice to enable its ethical use in disorders where the
characteristics of the disorder may be a combination of organic and non-organic features
• A classification system is essential in order to prescribe an intervention which addresses the
multidimensional nature of the disorders presenting for manual therapy
• The only avenue to demonstrate manual therapy efficacy is in the promotion of a disorder
classification system which would allow manual therapy intervention to be tested for its effect on a
specific disorder
• Diagnostics embraces
– a diagnosis
– a stage
– a classification
• This allows the limitations of the intervention to be recognised before the research trial
• Classification diagnostics is of utmost importance in chronic disorders where there may be a
domination by non-organic morbidity such as psychosocial issues
Defining disorder

“Disorder is a term used to embrace and acknowledge all of the cumulative features of an anomaly
resulting from some type of presumed initial tissue pathology. These features of a disorder are
either ‘morbid’ or they are ‘effects’.” (Elvey & O’Sullivan 2005)
In some disorders the morbid features may dominate whilst in others the effects may dominate
Morbidity = pertains to unwholesomeness, unhealthy, disease or illness and may be physical or
• Physical morbidity
– Physical state of tissue pathology
– Red flag issues may be incorporated here (eg cauda equina pathology {Waddell 1996})
• Psychological morbidity
– Underlying emotional state which might be regarded as psychiatric in nature
– Yellow flags may be incorporated here (Linton 2000)
Effects = an outcome of the consequences of an underlying disturbance
• Physical effects
– Physical outcome which is associated with an underlying physical state
– Impairments and organic effects
• Psychological effects
– Refers to an experience of unpleasantness or unpleasantness associated with an underlying emotional state.
– Constitutes various forms of suffering.
– Fear avoidance, abnormal illness behaviour or psychosocial features will accompany an ankle sprain to
some extent and chronic low back pain to a larger extent.
– When non-organic effects dominate they are referred to as morbid in nature and the term ‘yellow flags’ applies.
Such application allows for reasoning as to whether manual therapy intervention is indicated or contraindicated
and what form of intervention is appropriate. Manual therapy is not indicated where the non-organic features are largely out of context with the organic features or where they have become morbid in nature (Elvey & O’Sullivan 2005)

Scope of manual therapy

• Treatment is regarded as a specific intervention performed by the clinician
• Management is either general or specific, and deals with strategies for the prevention of further tissue strain, damage or injury, the maintenance of restoration of general function and the prevention of the recurrence of the disorder. Management uses a cognitive behavioural approach which takes into account the impact of non-organic aspects of a disorder
• This distinction increases the scope of manual therapy. For example, where non-organic effects dominate a disorder, management in this sense must be cognitive behavioural in nature which may incorporate a functional restoration program which would be an adjunct to a more central intervention based on dealing with the non-organic dominance of the disorder, thereby maintaining
the credibility of manual therapy.
• Single treatment techniques used in isolation do not have the capacity to resolve a disorder, given
the fact that the nature of the disorder is multifactorial.
• A range of interventions must be available incorporating treatment and management where
indicated. When incrementally incorporated it must have the capacity to reverse the pathology of a
disorder in part or in full, leading to partial or full recovery
• The view is held that manual therapy intervention simply stimulates, activates or promotes innate
mechanisms leading to recovery
• The premise for the benefits of manual therapy is that it replicates normal physical and
physiological function.
• Stimulation of physiological and biological functions lead to normalization of homeostasis in the
region of pathology – therefore this occurs at a cellular level of functioning at the various stages of
recovery (repair, remodelling, recovery)
• Management may be the prevention of excessive tissue strain due to aberrant movement, or the
for non-organic effects such as functional restoration or reduction of excessive muscle guarding
as a result of excessive fear


• Is the nature of the patients complaint suitable for manual therapy?
• In general, is the apparent nature of the disorder suitable for manual therapy?
• Is the diagnosis suitable for manual therapy? Does it involve physical or organic pathology which might be
favourably influenced by manual therapy?
• Is the disorder classification suitable for manual therapy? Does it involve the presence of organic features which
dominate over any non-organic features and which might be favourably influenced by manual therapy?
• Is the disorder stage suitable for manual therapy?
• Have all considerations been given and appropriate evaluations been carried out to ensure that the proposed
intervention does not have the potential to cause harm?
• Is the patient compliant with the proposed intervention?
• Does the proposed intervention satisfy the intent of the patient referral?
• Has informed consent for manual therapy intervention been obtained?


• Any other form of intervention is more appropriate
• The nature of the patient is unsuited for manual therapy
• The nature of the disorder in terms of the diagnosis, classification and stage is unsuited for manual therapy
• There are any unrelated features to the disorder, or co-morbidity, which mean that manual therapy or certain
interventions are contraindicated
• The intent of the patient referral is not satisfied by the proposed intervention.
• The patient is likely to have any type of adverse reaction to manual therapy.
• Any form or harm may result
• Informed consent has not been obtained
• The patient is affected by alcohol or illicit drugs

Evidence based practice

• Significant debate regarding the efficacy of manual therapy treatment for acute low back pain
(Maher et al 1999), and little evidence for efficacy in the treatment of chronic low back pain (Koes
et al 1996)
• Reasons for this are
– Groups of individuals with ‘non-specific …..pain’ are not homogeneous
– Lack of consideration that the complaint of back or neck pain is only one feature of the
disorder. In itself pain is not a disorder.
– General lack of appreciation that the reduction of pain does not necessarily result in
resolution of the disorder
– There appears to be a necessity to continually search for a physical ‘technique’ or ‘protocol’
which will favourably influence pain
– There appears to be continuous clamour for supremacy in the physical treatment of the spine
by different professional groups
– There is a lack of appreciation that manual therapy has a scope of practice which includes
many interventions and that these interventions must be used systematically and
incrementally towards the resolution of a disorder
– There appears to be a lack of appreciation that disorders are different even though there may
be a superficial pattern or sameness and complaint of pain. The vast majority of RCT use specific techniques in isolation in non-specific conditions ‘while there is evidence for the benefits of the McKenzie protocol for the treatment of low back pain there isn’t for manual therapy’ (McKenzie 2000) is a contradiction in terms as the McKenzie approach is in fact manual therapy

Movement based classification of pain disorders

• Mobility of spinal segments in isolation is not predictive or diagnostic in classifying pain disorders
• “It is the association between the mobility and control of the spinal segment, and its relationship to the pain disorder, which appears to be critical” (O’Sullivan 2005)
Peter O'Sullivan has put forward 3 sub-categories
• "Pain disorders associated with movement impairments are associated with a loss of normal physiological movement of lumbo-pelvic mobility, and abnormally high levels of muscle guarding and co-contraction of lumbopelvic muscles with generation of intra-abdominal pressure....[resulting in].....excessive force closure"
• "Pain disorders associated with control impairment are associated with no impairment to the mobility of the symptomatic spinal segment, but rather present with impairments or deficits in control of the symptomatic spinal segment pressure...[resulting in]....reduced force closure"
• "......mal-adaptive movement and motor patterns result in chronic abnormal tissue loading and ongoing pain and distress......These disorders are also invariably associated with non-organic factors but these factors do not dominate the disorder, leaving them more amenable to physiotherapy intervention based on a cognitive behavioural motor learning model"
(5th Interdisciplinary World Congress on Low Back and Pelvic Pain, Melbourne, 2004, Australia p132)


Trending @ Back in B Physio

  • Thu 22 Dec 2016

    Ehlers Danlos Syndrome

    Is your child suffering Ehlers Danlos Syndrome? Hypermobile joints, frequent bruising, recurrent sprains and pains? Although a difficult manifestation to treat, physiotherapy can help. Joint Hypermobility Syndrome (JHS) When joint hypermobility coexists with arthralgias in >4 joints or other signs of connective tissue disorder (CTD), it is termed Joint Hypermobility Syndrome (JHS). This includes conditions such as Marfan's Syndrome and Ehlers-Danlos Syndrome and Osteogenesis imperfecta. These people are thought to have a higher proportion of type III to type I collagen, where type I collagen exhibits highly organised fibres resulting in high tensile strength, whereas type III collagen fibres are much more extensible, disorganised and occurring primarily in organs such as the gut, skin and blood vessels. The predominant presenting complaint is widespread pain lasting from a day to decades. Additional symptoms associated with joints, such as stiffness, 'feeling like a 90 year old', clicking, clunking, popping, subluxations, dislocations, instability, feeling that the joints are vulnerable, as well as symptoms affecting other tissue such as paraesthesia, tiredness, faintness, feeling unwell and suffering flu-like symptoms. Autonomic nervous system dysfunction in the form of 'dysautonomia' frequently occur. Broad paper like scars appear in the skin where wounds have healed. Other extra-articular manifestations include ocular ptosis, varicose veins, Raynauds phenomenon, neuropathies, tarsal and carpal tunnel syndrome, alterations in neuromuscular reflex action, development motor co-ordination delay (DCD), fibromyalgia, low bone density, anxiety and panic states and depression. Age, sex and gender play a role in presentaton as it appears more common in African and Asian females with a prevalence rate of between 5% and 25% . Despite this relatively high prevalence, JHS continues to be under-recognised, poorly understood and inadequately managed (Simmonds & Kerr, Manual Therapy, 2007, 12, 298-309). In my clinical experience, these people tend to move fast, rely on inertia for stability, have long muscles creating large degrees of freedom and potential kinetic energy, resembling ballistic 'floppies', and are either highly co-ordinated or clumsy. Stabilisation strategies consist of fast movements using large muscle groups. They tend to activities such as swimming, yoga, gymnastics, sprinting, strikers at soccer. Treatment has consisted of soft tissue techniques similar to those used in fibromyalgia, including but not limited to, dry needling, myofascial release and trigger point massage, kinesiotape, strapping for stability in sporting endeavours, pressure garment use such as SKINS, BSc, 2XU, venous stockings. Effectiveness of massage has been shown to be usefull in people suffering from chronic fatigue syndrome (Njjs et al 2006, Man Ther, 11, 187-91), a condition displaying several clinical similarities to people suffering from EDS-HT. Specific exercise regimes more attuned to co-ordination and stability (proprioception) than to excessive non-stabilising stretching. A multi-modal approach including muscle energy techniques, dry needling, mobilisations with movement (Mulligans), thoracic ring relocations (especially good with autonomic symptoms), hydrotherapy, herbal supplementaion such as Devils Claw, Cats Claw, Curcumin and Green Tee can all be useful in the management of this condition. Additionally, Arnica cream can also be used for bruising. Encouragment of non-weight bearing endurance activities such as swimming, and cycling to stimulate the endurance red muscle fibres over the ballistic white muscles fibres, since the latter are preferably used in this movement population. End of range movements are either avoided or done with care where stability is emphasized over mobility. People frequently complain of subluxation and dislocating knee caps and shoulders whilst undertaking a spectrum of activities from sleeping to sporting endeavours. A good friend of mine, Brazilian Physiotherapist and Researcher, Dr Abrahao Baptista, has used muscle electrical stimulation on knees and shoulders to retrain the brain to enhance muscular cortical representation which reduce the incidence of subluxations and dislocations. Abrahao wrote : "my daughter has a mild EDS III and used to dislocate her shoulder many times during sleeping.  I tried many alternatives with her, including strenghtening exercises and education to prevent bad postures before sleeping (e.g. positioning her arm over her head).  What we found to really help her was electrostimulation of the supraspinatus and posterior deltoid.  I followed the ideas of some works from Michael Ridding and others (Clinical Neurophysiology, 112, 1461-1469, 2001; Exp Brain Research, 143, 342-349 ,2002), which show that 30Hz electrostim, provoking mild muscle contractions for 45' leads to increased excitability of the muscle representation in the brain (at the primary motor cortex).  Stimulation of the supraspinatus and deltoid is an old technique to hemiplegic painful shoulder, but used with a little different parameters.  Previous studies showed that this type of stimulation increases brain excitability for 3 days, and so we used two times a week, for two weeks.  After that, her discolcations improved a lot.  It is important to note that, during stimulation, you have to clearly see the humerus head going up to the glenoid fossa" Surgery : The effect of surgical intervention has been shown to be favourable in only a limited percentage of patients (33.9% Rombaut et al 2011, Arch Phys Med Rehab, 92, 1106-1112). Three basic problems arise. First, tissues are less robust; Second, blood vessel fragility can cause technical problems in wound closure; Third, healing is often delayed and may remain incomplete.  Voluntary Posterior Shoulder Subluxation : Clinical Presentation A 27 year old male presented with a history of posterior shoulder weakness, characterised by severe fatigue and heaviness when 'working out' at the gym. His usual routine was one which involved sets of 15 repetitions, hence endurance oriented rather than power oriented. He described major problems when trying to execute bench presses and Japanese style push ups. In a comprehensive review of 300 articles on shoulder instability, Heller et al. (Heller, K. D., J. Forst, R. Forst, and B. Cohen. Posterior dislocation of the shoulder: recommendations for a classification. Arch. Orthop. Trauma Surg. 113:228-231, 1994) concluded that posterior dislocation constitutes only 2.1% of all shoulder dislocations. The differential diagnosis in patients with posterior instability of the shoulder includes traumatic posterior instability, atraumatic posterior instability, voluntary posterior instability, and posterior instability associated with multidirectional instability. Laxity testing was performed with a posterior draw sign. The laxity was graded with a modified Hawkins scale : grade I, humeral head displacement that locks out beyond the glenoid rim; grade II, humeral displacement that is over the glenoid rim but is easily reducable; and grade III, humeral head displacement that locks out beyond the glenoid rim. This client had grade III laxity in both shoulders. A sulcus sign test was performed on both shoulders and graded to commonly accepted grading scales: grade I, a depression <1cm: grade 2, between 1.5 and 2cm; and grade 3, a depression > 2cm. The client had a grade 3 sulcus sign bilaterally regardless if the arm was in neutral or external rotation. The client met the criteria of Carter and Wilkinson for generalized liagmentous laxity by exhibiting hyperextension of both elbows > 10o, genu recurvatum of both knees > 19o, and the ability to touch his thumbto his forearm Headaches Jacome (1999, Cephalagia, 19, 791-796) reported that migraine headaches occured in 11/18 patients with EDS. Hakim et al (2004, Rheumatology, 43, 1194-1195) found 40% of 170 patients with EDS-HT/JHS had previously been diagnosed with migraine compared with 20% of the control population. in addition, the frequency of migraine attacks was 1.7 times increased and the headache related disability was 3.0 times greater in migraineurs with EDS-HT/JHS as compared to controls with migraine (Bendick et al 2011, Cephalgia, 31, 603-613). People suffering from soft tissue hypermobility, connective tissue disorder, Marfans Syndrome, and Ehler Danlos syndrome may be predisposed to upper cervical spine instability. Dural laxity, vascular irregularities and ligamentous laxity with or without Arnold Chiari Malformations may be accompanied by symptoms of intracranial hypotension, POTS (postural orthostatic tachycardia syndrome), dysautonomia, suboccipital "Coat Hanger" headaches (Martin & Neilson 2014 Headaches, September, 1403-1411). Scoliosis and spondylolisthesis occurs in 63% and 6-15% of patients with Marfans syndrome repsectively (Sponseller et al 1995, JBJS Am, 77, 867-876). These manifestations need to be borne in mind as not all upper cervical spine instabilities are the result of trauma. Clinically, serious neurological complications can arise in the presence of upper cervical spine instability, including a stroke or even death. Additionally, vertebral artery and even carotid artery dissections have been reported during and after chiropractic manipulation. Added caution may be needed after Whiplash type injuries. The clinician needs to be aware of this possibility in the presence of these symptoms, assess upper cervical joint hypermobility with manual therapy techniques and treat appropriately, including exercises to improve the control of musculature around the cervical and thoracic spine. Atlantoaxial instability can be diagnosed by flexion/extension X-rays or MRI's, but is best evaluated by using rotational 3D CT scanning. Surgical intervention is sometimes necessary. Temperomandibular Joint (TMJ) Disorders The prevelence of TMJ disorders have been reported to be as high as 80% in people with JHD (Kavucu et al 2006, Rheum Int., 26, 257-260). Joint clicking of the TMJ was 1.7 times more likely in JHD than in controls (Hirsch et al 2008, Eur J Oral Sci, 116, 525-539). Headaches associated with TMJ disorders tend to be in the temporal/masseter (side of head) region. TMJ issues increase in prevelence in the presence of both migraine and chronic daily headache (Goncalves et al 2011, Clin J Pain, 27, 611-615). I've treated a colleague who spontaneously dislocated her jaw whilst yawning at work one morning. stressful for me and her! Generally, people with JHD have increased jaw opening (>40mm from upper to lower incisors). Updated 18 May 2017  Read More
  • Fri 09 Dec 2016

    Physiotherapy with Sharna Hinchliff

    Physiotherapy with Sharna Hinchliff    Martin is pleased to welcome the very experienced physiotherapist Sharna Hinchliff to Back in Business Physiotherapy for one on one physiotherapy sessions with clients in 2017.  Sharna is a passionate triathelete and mother and has had several years experience working locally and internationally (New York and London) in the field of physiotherapy. Originally from Western Australia, Sharna graduated from the world renowned Masters of Manipulative Physiotherapy at Curtin University. read more Read More
  • Mon 07 Nov 2016

    Pilates – with Brunna Cardoso

    Pilates – with Brunna Cardoso Martin is pleased to welcome the bubbly Brunna Cardoso to Back in Business Physiotherapy for Pilates Classes in February 2017.  Brunno is an experienced pilates instructor and has had several years experience training with pilates instructors in Brazil. Read more Read More

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Updated : 10 May 2014

No responsibility is assumed by Back in Business Physiotherapy for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material in this and it's related websites. Because of rapid advances in the medical sciences, the author recommends that there should be independent verification of diagnoses and exercise prescription. The information provided on Back in Business Physiotherapy is designed to support, not replace, the relationship that exists between a patient/site visitor and their treating health professional.

Copyright Martin Krause 1999 - material is presented as a free educational resource however all intellectual property rights should be acknowledged and respected