1. Jack Dolbin, DC CSCS

2.  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 Greeman DO, Professor of Biomechanics  Michigan State University School of Osteopathy Medicine

3.  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,

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

5.  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.

6.  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: Substabnce P, endorphines, enkephalines, and neurotransmitters can be altered by biomechanical alterations  Alterations in neurothropin transmission can be detrimental to the health of target cells.

7.  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.

8.  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

9.  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.

10.  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

11.  Asymmetry  Range of motion  Tissue texture

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

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

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

17.  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.  Shoulder Injuries  Hamstring strains  Knee, ankle, foot injuries

18.  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.

19.  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.

20.  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.

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

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

23.  Mobilize Scar tissue  Breakdown Adhesions  Allows muscle to broaden  Controlled Imflammation  Pain modulation  1. Right Location  2. Right amount of pressure

24.  During first 24-48 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

27.  Isometric Contraction of shortened muscle.  Improves resting length  Increase Joint movement  Improves overall range of motion.  3-5 repetitions 5-7 seconds.  Inhalation/Exhalation as activating force

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

32.  By Stimulating the Golgi Tendon organs the shortened muscle lengthens. Myotendinous Junction.  Reset Neurological bed. Bone and muscle belly  Activates mechanoreceptors:  Can be alternative treatment to myofascial release: Opinion

33. 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 ??

34. 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

35.  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 revel and change plan.  Transition to active care: Usually concurrent with your manual therapy

36.  Volume: Maximum of 30-35 patients per day.  A goal of developing a volume based practice is antithetical to the practice of manual medicine