1. DON’T JUST RECOVER. CONQUER. How Manual Therapy Works and Why it Matters The Integration of Manual Therapy into Sports Medicine Thomas R. Denninger, DPT, OCS, FAAOMPT 2015 Steadman Hawkins Clinic of the Carolinas Sports Medicine Symposium June 5 th -6 th, 2015

2. DON’T JUST RECOVER. CONQUER. ➔ Participants will acquire knowledge of the: o Theoretical basis of manual therapy techniques based off available scientific literature o Centering on the proposed model by Bialosky. ➔ Participants will demonstrate application of manual therapy for common sports medicine injuries at the: o Shoulder o Foot/ankle Based upon recent systematic reviews and randomized controlled trials comparing treatment including manual therapy vs. standard of care. Course Objectives

3. DON’T JUST RECOVER. CONQUER. What is Manual Therapy?

4. DON’T JUST RECOVER. CONQUER. ➔ Accupressure ➔ Anma ➔ Bodywork ➔ Bone setting ➔ Dom method ➔ Joint manipulation ➔ Joint mobilization ➔ Spinal manipulation ➔ Spinal mobilization ➔ Massage therapy ➔ Manual lymphatic drainage ➔ Medical acupuncture ➔ Muscle energy technique ➔ Myofascial release ➔ Narapathy ➔ Osteopathic manipulative medicine ➔ Rolfing ➔ Seitai ➔ Sotai ➔ Shiatsu ➔ Traction ➔ Tui Pa What is Manual Therapy?

5. DON’T JUST RECOVER. CONQUER. Years 1958-2015 Number of Indexed Articles

6. DON’T JUST RECOVER. CONQUER. “Manual therapy techniques consist of a broad group of passive interventions in which clinicians use their hands to administer skilled movements designed to modulate pain; increase range of motion, reduce or eliminate soft tissue swelling; inflammation; or restriction; induce relaxation; improve contractile and non-contractile tissue extensibility; and improve pulmonary function. These interventions involve a variety of techniques, such as the application of graded forces.” APTA/AAOMPT Definition

7. DON’T JUST RECOVER. CONQUER. ➔ A physiologic force applied therapeutically o Joint Based o Muscle Based o Nerve Based Our Definition

8. DON’T JUST RECOVER. CONQUER. How Manual Therapy Is Often Assumed to Work Manual Therapy Mechanical EffectClinical Benefit

9. DON’T JUST RECOVER. CONQUER. ➔ Biomechanical Evidence Summary o Joint biomechanics are variable especially in pathologic joints o Clinical benefits often not consistent with biomechanical theory o Studies demonstrate biomechanical changes are Short lasting Non-specific Do not change alignment or position However

10. DON’T JUST RECOVER. CONQUER. * *

11. NOT How Manual Therapy Works Manual Therapy Mechanical EffectClinical Benefit

12. DON’T JUST RECOVER. CONQUER. “When the scientific literature is considered, attributing successful (manual therapy) outcomes solely to the identification and correction of biomechanical faults makes as much sense as crediting a beard for winning a hockey playoff”

13. DON’T JUST RECOVER. CONQUER. Something is Missing Manual Therapy Clinical Benefit Mechanical Effect

14. DON’T JUST RECOVER. CONQUER. The Black Box

15. DON’T JUST RECOVER. CONQUER. It’s Much Messier

16. DON’T JUST RECOVER. CONQUER. Let’s Simplify a Bit Non-Specific Effects

17. DON’T JUST RECOVER. CONQUER. ➔ Peripheral Nervous System ➔ Central Nervous System ➔ Supra-Spinal ➔ Psychosocial Define Non-Specific Effects

18. DON’T JUST RECOVER. CONQUER. ➔ Manual Therapy has been demonstrated to: o Significantly reduce pain biomarkers o Increase in PEA Peripheral Nervous System

19. DON’T JUST RECOVER. CONQUER. ➔ Neuromuscular Responses o Motorneuron Pooling o Afferent Discharge o Muscle Activity ➔ Hypoalgesia o Temporal Summation o Selective blocking of neurotransmitters Central Nervous System

20. DON’T JUST RECOVER. CONQUER.

23. ➔ Injection causes activation primarily in dorsal horn of spinal cord ➔ Less activation in rats given knee mobilizations

24. DON’T JUST RECOVER. CONQUER.

27. Supraspinal and Psychosocial Domains

28. DON’T JUST RECOVER. CONQUER. Peripheral Nervous System -Changes in local pain biomarkers Central Nervous System -Muscle relaxation and excitation -Ascending Pain Inhibition Supra-Spinal Pathways -Endogenous Opioids -Changes in neural processing of nociceptive information -Autonomic Changes Psychosocial Components -Placebo -Changes in fear

29. DON’T JUST RECOVER. CONQUER. Less This

30. DON’T JUST RECOVER. CONQUER. More This

31. DON’T JUST RECOVER. CONQUER. In Fact

32. DON’T JUST RECOVER. CONQUER. Why Should We Use Manual Therapy?

33. DON’T JUST RECOVER. CONQUER. Manual Therapy for the Shoulder Impingement

34. DON’T JUST RECOVER. CONQUER. Manual Therapy and Exercise

35. DON’T JUST RECOVER. CONQUER. ➔ Randomized Controlled Trial (Pilot) ➔ N=14 ➔ Outcomes= Pain, Function, Change AROM ➔ Interventions= 3x week for 3 weeks o Supervised Exercise Stretching, Rotator Cuff Strengthening, Scapular Strengthening o Supervised Exercise and Joint Mobilization As above with addition of Glenohumeral mobilization Conroy, 1998

36. DON’T JUST RECOVER. CONQUER. ➔ Results Conroy, 1998 *

37. DON’T JUST RECOVER. CONQUER. ➔ Randomized Controlled Trial ➔ N= 52 ➔ Outcomes= Strength, function, pain ➔ Intervention: 6 sessions over 3-4 weeks o Exercise Group Stretching, Rotator Cuff Strengthening, Scapular Strengthening o Manual Therapy and Exercise Group Manual therapy to the upper quarter, stretching, strengthening Bang, 2000

38. DON’T JUST RECOVER. CONQUER. ➔ Results Bang, 2000 * *

39. DON’T JUST RECOVER. CONQUER. ➔ Results Bang, 2000 *

40. DON’T JUST RECOVER. CONQUER. Ankle Sprain *Consistent short term improvements in swelling, range of motion, function, and pain as compared to standard treatment (RICE, AROM, controlled weight bearing)

41. DON’T JUST RECOVER. CONQUER. Cleland, 2013

42. DON’T JUST RECOVER. CONQUER. Cleland, 2013

43. DON’T JUST RECOVER. CONQUER. Cleland, 2013

44. DON’T JUST RECOVER. CONQUER. Truloys, 2013

45. DON’T JUST RECOVER. CONQUER. ➔ Results o Pain (0-10): 1.5 point greater reduction with STM o Function (100): 16.6 point greater reduction with STM o Range of Motion Significant differences for plantar flexion and dorsiflexion o Pressure Pain Thresholds Significant change favoring STM group Truloys, 2013

46. DON’T JUST RECOVER. CONQUER. Truloys, 2013

47. DON’T JUST RECOVER. CONQUER. Plantar Heel Pain

48. DON’T JUST RECOVER. CONQUER. Cleland, 2009

49. DON’T JUST RECOVER. CONQUER. ➔ Randomized Controlled Trial ➔ n=60 ➔ Outcomes= Function, Pain, Global Rating of Change ➔ Intervention=6 visits over 4 weeks o Standard Care Calf and PF stretch, intrinsic muscle strengthening, US, Ionto, Ice o Manual Therapy and Exercise Soft tissue mobilization, eversion mobilization, manual therapy LE complex Cleland, 2009

50. DON’T JUST RECOVER. CONQUER. Cleland, 2009 LEFS NPRS FAAM

51. DON’T JUST RECOVER. CONQUER. ➔ Randomized Controlled Trial ➔ n=60 ➔ Outcomes= SF-36, PPT ➔ Interventions o Self Stretching Group o Self Stretching and STM Renin-Ordine, 2011

52. DON’T JUST RECOVER. CONQUER. Renin-Ordine, 2011

53. DON’T JUST RECOVER. CONQUER. ➔ Results o Significant between group differences for SF-36 Overall Physical Function Bodily Pain General Health Emotional Role Pressure Pain Threshold Gastrocnemius, Soleus, Calcaneus Renin-Ordine, 2011

54. DON’T JUST RECOVER. CONQUER. Thank You