WHAT IS ORTHOPEDIC MANIPULATION
Manipulations or “adjustments” have been a medical intervention since 400 BC in the days of Hippocrates. This phrase can mean many things in the health care field. In physical therapy, it refers to applying mobilizations to joints at varying degrees of needed intensity. If gentle mobilizations are required to heal the patient, that is what is performed for the patient. If the joint needs a stronger movement (aggressive mobilization or manipulation), it can be performed in effective ways with varying speeds and amplitudes, including a small amplitude/high-velocity therapeutic movement within or at the end range of motion.
Maitland has provided a framework for the description of 5 various grades of mobilization/manipulation based on depth within the range of motion that the force is applied and the rate of oscillation application. Grade 1-2 are within the range that is free of resistance, grade 3-4 are a passive movement that moves up to the point of resistance. Grade 5, known as manipulation, is when a joint is positioned near its end range of motion during the manual therapy technique with high velocity and low amplitude force application.
The audible joint “pop” or “crack” phenomenon associated with a joint manipulation has been investigated in a principal study, namely Roston and Haines. They discuss findings from the application of increasing tension at the metacarpal-phalangeal joint of the third finger and monitoring the amount of joint separation with intermittent radiographs. This study showed that when a critical amount of tension is reached to produce a joint “pop,” a sudden increase in joint separation is noted. Roston and Haines interpreted the space noted after the cracking as a “partial vacuum occupied by water vapor and blood under reduced pressure”. A joint that has been “cracked” is not typically capable of being re-manipulated for 20 minutes which is due to the gases needing to be reabsorbed before the joint can be audibly cavitated again.
Popping joints is often associated with chiropractic treatments. Although traditional chiropractic philosophy is based on detection and correction of spinal subluxations and realignment, no valid research has shown that subluxations/positional faults correlate with pain or are a cause of lack of mobility in the spine. As seen above in the research of the metacarpal-phalangeal joint, the audible pop is associated with negative pressure in the joint in conjunction with blood gases and not mal-alignment.
The beneficial effects of the manipulation are not dependent on the audible “crack” of the joint. Flynn et al compared immediate effects of a lumbopelvic manipulation for patients who did and did not have a joint sound with manipulation. Comparing the response to the two groups, Flynn et all reported no difference in outcomes. Therefore, the creation of a joint sound should not be the primary goal and focus of a manipulation technique.
WHO SHOULD PERFORM ORTHOPEDIC MANIPULATIONS
Spinal manipulation is not designated as being under the exclusive domain of any one specific profession or group of practitioners. Physical therapists, chiropractors, medical doctors, and osteopathic physicians are all educated and trained to employ manipulation within the scope of their respective licenses and in a manner that protects the public’s health, safety, and welfare. One profession does not “own” a
specific technique or dictate clinical practice through such legislation.
The FAQ most commonly noted is “what differences are noted between PT administered manipulations and chiropractic adjustments”. The above link is designed to provide information and facts about physical therapists and spinal manipulation. In addition, the information will explain the difference between spinal manipulations and chiropractic adjustments.
The state of Idaho licensure rules for a physical therapist (Section 10) describes the scope of practice for manual therapy.
Skilled movements to mobilize or manipulate soft tissues and joints for the purpose of:
- Modulating pain, increasing range of motion, reducing or eliminating soft tissue swelling, inflammation or restriction.
- Inducing relaxation
- Improving contractile and non-contractile tissue extensibility
- Improving pulmonary function
- Efficiency and ease of delivery
- Provide reduction of neurophysiological tone and rigidity in the treatment area
As with any physical therapy treatment, it is critical that a comprehensive subjective history with a thorough objective examination is performed by a skilled therapist prior to manipulation/mobilization. Disregarding a thorough assessment and doing a shotgun or general approach with manipulation can lead to unnecessary injury. The largest risk of injury from manipulation is cervical artery dysfunction. Cervical artery dysfunction is considered a rare, random, and unpredictable event with almost all instances being avoided through appropriate medical history and screening. Trauma-related injury of the cervical spine also limits the application of receiving manipulation. The Canadian Cervical Spine Rules is an evidence-based screening tool used for trauma-related injury determining criteria for X-Ray.
Manipulation can lead to rapid reduction in pain. Often, as evidence-based medicine shows, skilled therapeutic interventions and education in combination are required to gain long-term benefits of the manipulation. When performed appropriately in a gentle and prompt manner, manipulation provided by a physical therapist can make a significant difference in the treatment of pain and range of motion. We collectively look forward to answering questions and collaborating at high levels in helping your patients return to what they love.