Jack Dolbin, DC CSCS

 Much of this module is the result of study references, books, tapes and personal conversations with Dr. Philip Greenman, DO. His work has guided me and given me a rationale for the diagnosis, treatment and now teaching of manual medicine for athletes.  I strongly recommend his work as the gold standard for any manual medicine intervention.

 When properly utilized, manipulative procedures have been noted to reduce pain, Increase the level of wellness, and in helping the patient with a myriad of disease processes.  Philip Greenman DO, Professor of Biomechanics  Michigan State University School of Osteopathy Medicine

 The goal of manual medicine is to restore maximal, pain free movement of the musculoskeletal system in postural balance.  Dvorak J, Dvorak V,Schneider W : Manual Medicine 1984,

 1. Holistic man  2. Neurologic man  3. Circulatory man  4. Energy-expending man  5. Self-regulating man

 The musculoskeletal system comprises most of the human skeleton and alterations within it influence the rest of the human organism.  Our role as physicians is to treat patients and not disease.  Deep Fascia

 Most highly developed nervous system in the animal kingdom.  All functions of the human body are under some form of neurologic control.  Control of all glandular and vascular activity is under the control of the ANS.  Neuroendocrine Control: Substance P, endorphines, enkephalines, and neurotransmitters can be altered by biomechanical alterations  Alterations in neurothropin transmission can be detrimental to the health of target cells.

Formed by lower motor neurons in the lateral horns of C2-C4 Ascends through the foramen magnum, receives fibers from the nucleus ambiguous and decends along the jugular foramen. Sends branches to the Vagus Nerve Has SVE and GSE. Thoracic branches matched to vagus innervation of the embryonic heart.

 Anything that interfered with with sympathetic autonomic nervous system outflow, segmentally mediated, can influence vasomotor tone to the target end organ.  Maximal function of the musculoskeletal is important to the efficiency of the circulatory system and maintainance of a normal cellular milieu.

 Restriction of one major joint in the lower extremity increase the energy expenditure in walking by 40%, two major joints in the same extremity 300%.  Multiple minor restriction of movement, especially in the lower extremity gait can have a detrimental effect on the total body function

 The goal of the physician should be to enhance all the body’s self regulating mechanisms to assist in the recovery from disease. ( injury).  One in seven hospital days are the result of adverse reactions to pharmaceuticals.  Anything placed with in the body alter the self regulating mechanism.

 Primary goal is to determine the specific spinal motion segment that is dysfunctional, determine the direction of altered motion, and determine the tissue involved in the restrictive motion.  Primary emphysis is placed on motion loss and its characteristics

 Directed toward restoring maximal motion to all joints, symmetry of length and strength to all muscles and ligaments, and symmetry of tension within fascial elements throughout the body.  Maximum function in postural balance  Top down or bottom up.

 Asymmetry  Range of motion  Tissue texture

 Pelvic unleveling: Effect on lower extremity function. Shoulder function.  Scapular Winging:  Anterior Shoulder posture: TOS, entrapment  Pronation

 1. Range of movement  2. Quality of movement  3. End feel  In the spine: Goal is to determine which specific vertebra is dysfunctional  Which joint within that segment is dysfunctional  The direction of altered motion  Tissue involved in the restricted movement.

 Passive: note end feel. Hard or mushy  Active: Neuromuscular Control

 Motion loss and its characteristics are more important diagnostic criterion that the presence of pain and the provocation of pain by movement.  Greenman: Michigan State University School of Osteopathic Medicine.

 The most important element in the postural model has been the restoration of maximum pelvic mechanics in the walking cycle.  The Pelvis from below to above must be considered to achieve the symmetrical movement.  Pelvis is the cornerstone  Shoulder Injuries  Hamstring strains  Knee, ankle, foot injuries

 Check Pelvic leveling in the standing position.  If unlevel: does it level in the sitting position.  If so check leg length. Look for structural or functional short leg.  If functional check SI joints and pronation.  If Structural: broken leg or past injuries.  Equestrian Illustration: Broken Femur leading to shoulder entrapment.

 Spasm  Contracture: Hypertonicity  Shortening: Chronic adaptation  Adhesions: Scar Tissue  Temperature: Inflammation

 Alteration in the characteristics of the soft tissues of the musculoskeletal system.  Skin  Fascia  Muscle  Ligament

 Most tissue texture abnormalities result from altered nervous system function with increased alpha motor neuron activity maintaining increased muscular hypertonicity and altered sympathetic nervous system function.

 Lateral chain ganglia in the thoracic region are bound by the deep fascia to the posterior chest wall and overlie the rib heads.

 It would seem reasonable to attempt to reduce aberrant afferent stimulation to hyperirritable sections of the sympathetic nervous system to reduce hyperactivity to the target end organs.

 The physiological process where cells sense and respond to mechanical loads.  Various forms of exercise and or movement prescription promote repair and remodeling of tendon, muscle, articular cartilage and bone.  Mechanotransduction: Maintains normal musculoskeletal structure in the absence of injury. Homeostasis  Mechanotherapy: Treatment of injuries using exercise prescription or manual therapy

 The process where the body converts mechanical loading into cellular response.  Three phases:  A. Mechanicalcoupling: Trigger  B. Cell-Cell communication:communication throughout a tissue to distribuite the loading message.  C. Effector response:Response at the cellular level to effect the response that will produce the necessary materials to correct alignment.

 Refers to a physical load causing physical perturbations to cells that make up tissue.  Key is the direct or indirect perturbations of the of the cell which is transformed into chemical signals both within and among the cells.

 Tendon:Up regulation of IGF-I and cytokines .  Associated with cellular proliferation and remodeling within the tendon.  Tendons can respond favorably to controlled loading after an injury.

 Highly responsive to changes in functional demands through the modulation of load induced pathways.  Overload: Upregulation of MGF (mechanogrowth factors)  MGF leads to Muscle hypertrophy  Scar stabilizes-controlled load  Leads to faster more complete regeneration and minimization of atrophy.

 Populated by mechanoreceptive cells: Chrondrocytes.  Studies: Alfredson and Lorentzon showed that cartilage under continuous passive motion healed much better and faster than those without CPM.  76% vs. 53%

 Doing the same thing over and over and expecting a different result.

 The best available evidence from valid peer reviewed studies combined with clinical experience to develop a treatment plan with an expected outcome.  A. Pubmed  B. 34 years of clinical experience

 Weak stimuli increases physiological activity while strong stimuli inhibits or abolishes physiological activity.

 Gentle and precise manipulation elicits an internal sensory feed back response designed to stimulate the body’s self correcting mechanism.

 Muscle Energy  Impulse Adjusting  High Velosity/ Low amplitude  Indirect Function technique: Sherringtons Law  Myofascial Release: Cyriax Crossfiber  Balance and Hold

 Mobilize Scar tissue  Breakdown Adhesions  Allows muscle to broaden  Controlled Inflammation: Prolotherapy research  Pain modulation  1. Right Location  2. Right amount of pressure

 During first hours. Light mobilizing maximum of 5 minutes.( usually less)  After 48 hours 5-15 minutes  Muscle Injury: Across the relaxed muscle to facilitate broadening. Followed by eccentric exercise or Faradic.  Tendon/Ligament Injuries: Across the ligament in an elongated position.  Every other day maximum.

 Limb is moved into the restrictive barrier.  Patient actively attempts to move the limb with the Physician resisting the movement  Hold 5-7 seconds, 3-5 times. Followed by inspiration/expiration.  As tissue releases move to next barrier  Followed by articular correction if necessary

 Isometric Contraction of shortened muscle.  Improves resting length  Increase Joint movement  Improves overall range of motion.  Inhalation/Exhalation as activating force

 Percussion cadencee: Seguin 1838  Manual Vibrations: Kellgren mid 1900  Janse, Wells, Howser 1947  Repetitive Thrusts: Maitland 1964  Fuhr: Activator  Colluca-Keller: Impulse Adjusting

 By Stimulating the Golgi Tendon organs the shortened muscle lengthens. Myotendinous Junction.  Pacinian Corpusles: Stimulated when skin is stimulated rapidly. Respond to high velocity changes in joint position.  Reset Neurological bed. Bone and muscle belly  Activates mechanoreceptors:  Can be alternative treatment to myofascial release.

 Balanced ligamentous tension/ Ligamentous articular strain Techniques 1. All joints are balanced ligamentous articular mechanisms. 2. The ligaments provide propriceptive information that guides the muscular response for positioning the joint and the ligaments themselves guide the motion of the articular compoments

 Position the joint so all forces within the articular mechanism converge on one specific point. This point becomes the fulcrum around which shift will occur  Use the respiratory mechanism to articulate the joint.

 Patients somatic dysfunction is treated by placing the restrictive barrier in a passive position.  Contact the motor point where the nerve pierces the fascia and enters the muscle belly.  Hold using respiratory mechanism until release is felt.

Mobilizes fixated Joints Improves Range of Motion in Dysfunctional segmments. Activates mechanoreceptor in Joints: Pacinian and Ruffini corpucles. Allows for normalization of afferent proprioception Effect on Visceral Function ??

 Gaining increased attention within the health care community.  Recent studies at Harvard and U of Vermont School of Medicine on Cell-Cell communication within the deep fascial elements.  Warren Hammer: Soft Tissue the key to the outcomes we have seen over the years.

 A bodywide communication system  Involved in myofascial force transmission  Fascia is a sensory organ and is relevant in proprioceptive and nociceptive function and relevant in shoulder and low back pain and dysfunction.

History: 7 Point History Minimum Observation of injured part Inspection of Injured part Examination: Palpation, Range of Motion Provocative tests. Evaluation of motion deficits in the kinetic chain. Treatment: Manual Medicine Prescription

 Evaluate the effect of your treatment  A. Did the muscles get strong  B. Is their gait better  C. Can they lift their arms more easily  D. Can they bend forward or backward with less pain.  A successful input/adjustment changes function and breaks the vicious cycle.

 Getting the restricted joint released  Releasing tight muscles  Deep fascial work to wake up the neuromuscular system  Functional rehab to retrain muscles  Always look for immediate functional change

 Have a purpose in your treatment. Not cookbook therapy  Have a reevaluation process to assess the effectiveness of your treatment  A. If not responding do a reeval and change plan.  Transition to active care: Usually concurrent with your manual therapy

 Volume: Maximum of patients per day.  A goal of developing a volume based practice is antithetical to the practice of manual medicine