Manual Therapy: Joint mobilisations and Massage

What are the 4 pillars of modern physiotherapist

• Exercise, movement and rehabilitation

• Manual therapy and therapeutic handling

• Therapeutic and diagnostic technologies

• Allied approaches

What is manual therapy?

• Massage

• Mobilisation

• Manipulation

• Neurodynamic Mobilisations

• Touch

What are the potential risks of manual therapy?

• During and post treatment discomfort

• Cervical artery dissection and stroke

• Self efficacy reduction

What does manual therapy not do?

• Increase blood flow

• Break down scar tissue

• Release muscles

• Lengthen fascia

What are the suspected mechanisms which allow Manual therapy to be affected?

• Hypoalgesic response

• Increased sympathetic nervous system changes

• Mechanism mediated by the brain

• Changes in the spinal dorsal horn

• Endocrine - opioid release

• Placebo

What is the gait control theory of pain?

The transmission of pain signals can be modulated at the spinal cord by non-painful inputs which inhibit the initial pain signals

When are joint mobilisations indicated?

• Pain relief

• Increased ROM

• Decrease muscle guarding or spasm

• Treat reversible joint hypo mobility of capsular origin

What are the 2 types of joint mobilisations

• Accessory

• Physiological

Describe Accessory joint mobilisations

When the physio completes a small movement at a joint which the patient couldn’t do non their own

Describe a physiological mobilisation

A movement which the patient couldn’t do non complete on their own

Describe the grades of the maitland joint mobilisation grading

• Grade 1-small amplitude rhythmic oscillating mobilisations in early range movement

• Grade 2-large amplitude rhythmic oscillating mobilisations in midrange of movement

• Grade 3-large amplitude rhythmic oscillating mobilisations to point of limitation in range of movement

• Grade4-Small amplitude rhythmic oscillating mobilisations at end of the available range of movement

• Grade 5-Small amplitude, quick thrusts at end of available Range of movement (outside of a physios scope, further training required)

When are grade 1 and 2 mobilisations used?

When reducing pain and irritability

When are grade 3 and 4 mobilisations used?

When aiming to increase ROM and stretch passive tissues around the joint

How do you measure the effect of Joint mobilisations?

• Measure Joint ROM

• Proprioception test

• Visual analogue pain scale

• Functional movement test

What are the contraindications to articulatory techniques?|

• Patients with vertebral malignancy

• Infection or inflammation

• Myelopathy

• Multiple adjacent radiculopathies

• Cauda equine syndrome

• Vertebral bone disease

• Bone joint instability

• Cervical rheumatoid disease

What are the contraindications for direct manipulation?

• Spinal deformity

• Systemic anticoagulation Treatment

• Severe diabetes or atherosclerotic disease

• Degenerative joint disease

• Vertebral basilar disease or insufficiency

• Spondyloarthropathies

• Ligamentous joint instability or congenital joint laxity

• Aseptic necrosis

• Local aneurysm

• Osteoporosis

• Acute disk herniating

• Osteomalacia

What are the potential uses of massage in practice?

• Relaxation

• Management of post traumatic swelling

• Influence muscle tone

• Improving tissue flexibility/mobility

• Pain management

• Recovery

How can massage help manage swelling?

Following trauma ‘sticky’ inflammatory exudate pools in anatomical spaces. If left undisturbed it can become organised leading to adhesions. Massage helps to prevent the exudate becoming organised and helps to maintain joint function

How does massage influence tone?

• Afferent input to CNS

• Reduces hyperactivity

What are the 3 diffent massage techniques?

• Effleurage (stroking and gliding)

• Petrissage (Kneading)

• Tapotement (tapping or percussion)

What are the different techniques of effleurage massage?

• Single/flat hand

• V or double hand

• Cam and spindle

• Forearm

What are the methods of petrissage massage?

• Kneading

• Rolling

• Wringing

• Skin rolling

• Squeezing

• Picking up

What do physios need to be cautious of when performing pettrisage

• Downward pressure may provoke pain in underlying tissues

• Attempting to lift tissues that will not lift due to oedema, adipose tissue, scar tissue or dense connective tissue will result in pain

• Be careful not to pull body hair

What are the 4 methods of tapotement?

• Cupping

• Beating

• Hacking

• Flicking

What are the absolute contraindications to massage?

• Over open wounds

• In the presence of inadequate circulation

• When haemorrhage is occurring

• During early stages of healing

• On febrile conditions

• Over acute areas of inflammation

• Over acute bone growth

• Over skin conditions (psoriasis)

• When extra blood flow is not desirable (Malignancy, DVT)

What are precautions for physios before completing a massage?

• Fragile skin

• Collagenous weakness

• Patients with heart problems

What are the benefits of using ointments when massaging

• Reduce skin friction

• Fragile skin prevented from excessive stretch

• Hairy skin prevented from pulling

• The gliding effect of procedure enhanced

• Greater patient relaxation/comfort

Benefits of not using ointment when massaging?

• Deeper massage

• Less messy

• Avoid staining clothes

• Tissues more easily palpated

• Tissues can be more easily manipulated

What do physios need to consider about there own positioning when massaging a patient?

• Base of support

• Stance

• Bed height

• Patient position

• Techniques

• Tools/assistance