1. 操作治療簡介 長庚大學醫學院物理治療學系 課程:操作治療學及實習 授課老師:林燕慧
參考資料：Greenman PE. Principles of Manual Medicine. 2nd., William & Wilkins, Baltimore, 1996.

2. Manual Therapy: Mobilization, manipulation of soft tissues, massage
A systematic method of evaluating and treating dysfunctions of the neuromusculoskeletal system in order to relieve pain, increase or decrease mobility, and in general normalize function

3. History of Manual Therapy
Hippocrates ( BC)
Galen ( AD)
Bone-setter (England):
.Stiffness and pain in joints were immobilized for a long period of time after fractures, dislocations, or sprains
.Stiffness and pain resulting from disuse after soft tissue injuries
.Internal deragements after rupture of the meniscus
.Subluxations of small bones of the hands and feet
.Ganglion development around the wrist
.Treatment of neck and back disorders
Graham ( )
Massage:
any procedure done by the hands (friction & manipulation)

4. William Merrell ( )
A scientific mode of treating certain forms of disease by scientific manipulation, including passive range of motion, mobilization, and manipulation

5. Osteopaths: Andrew Taylor Still (1828-1917)
The body as a unit had the ability to fight off all disease and that the cause of all disease was mechanical pressure on blood vessels and nerves produced by dislocated bone, abnormal ligaments, or contracted muscles in the back(osteopathic lesion)

6. Chiropractors: Daniel David Palmer (1845-1914):
To put bones back into place
.Straights:
.Mixers:

7. Medical Manipulators for Physical therapist
Mennell:
NAAMM merged with AAOM (American Association of Orthopaedics Medicine)
Cyriax

8. Practice of Manual Medicine
the functional capacity of the human organism
dynamic processes of disease
musculoskeletal system comprises over 60% of the human organism
Structural diagnosis
to evaluate the musculoskeletal system for its particular disease and dysfunctions
to evaluate the somatic manifestations of disease and derangement of the internal viscera.
to increase mobility in restricted areas of musculoskeletal system
to reduce pain

9. Goals of Manipulation
To restore maximal, pain-free movement of the musculoskeletal system in postural balance (1983)

10. Concepts

11. A.     Holism:
the musculoskeletal system deserves thoughtful and complete evaluation (treat patients, not to treat disease

12. B. Neurological control: (fig)
1.        somaticosomatic reflex pathways
2.        viscerovisceral reflex arc
3.        sympathetic reflex pathways
4.        ANS
a)       parasympathetic
b)       sympathetic
(1)     above diaphragm: T5
(2)     below diaphragm: T5
(3)     musculoskeletal system
5.        endocrine system: neuroendocrine control

13. B. Circulatory function
1.        Arterial system 2.        venous system 3.        lymphatic system 4.        muscular activity 5.        diaphragm
C.      Energy expenditure: musculoskeletal activity

14. D.      Self-regulation:
1.        homeostatic mechanism 2.        iatrogenic disease l       

15. Manipulable lesion “osteopathic lesion”, ”chiropractic subluxation“ ,
”joint blockage“,
”loss of joint play“,
”joint dysfunction“
current “somatic dysfunction”

16. Manipulable lesion
A.   defined as impaired or altered function of related components of the somatic (body framework) system; skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic, and neural elements B.   emphasized is on altered function of the musculoskeletal system C.  The art of structural diagnosis is to define the presence of somatic dysfunction(s) and determine any significance to the patient‘s complaint or disease process presenting at the time.

17. Diagnostic triad for somatic dysfunction
“ART“ through observation or palpation
1.        A: Asymmetry
2.        R: Range of motion of a joint, several joints or regions of musculoskeletal system
a)       Active or passive movement
b)       Hypermobility or Hypomobility
3.        T: Tissue texture abnormality of soft tissue of the musculoskeletal system for location, status (acute, or chronic), prognosis, treatment response

18. Relief of nerve-root pressure- reacting only to the spine
A.       Specific- chiropractors recommend the movement of one specific vertebra on another.
B.       Nonspecific- Cyriax recommends general manipulation with traction       

19. Relief of pain- relating to the spine or extremities
A.       Graded oscillations- Maitland believes in mobilizations subthreshold to pain
B.       Contrary movement- Mainge recommends therapeutic movement in a direction exactly opposite to that which cause pain

20. Normalization of joint mobility- relating to the spine or extremities
A.       Osteopathy- osteopaths advocate specific techniques for mobilizing the spine and extremities
B.       Treatment of stiffness- & Kaltenborn advocates the use of arthrokinematic principles to regain mobility without regard to pain
C.      Paris: a concept of facet disorder as the primary cause of spine dysfunction
D.      The cause of the dysfunction and treatment of pain

21. Joint mobilization Passive exercise Physiologic movement:
the creation of motion within a joint by an outside force taking the body part through all or part of its range of motion
Accessory movement:
movement that occurs between the articulating surfaces of a joint that is involved in a physiological motion, either active or passive.

22. Accessory movement glide, spine, roll
Accessory movement cannot be produced actively
Component motion:
the motion occurring in a related joint that allows the primary joint to function normally

23. Joint play:
the motion that occurs within the joint but only as a response to an outside force and not as a result of voluntary movement

24. Joint Mobilization:
the attempt to improve joint mobility or decrease pain originating in joint structure by the use of selected grades of accessory movement

25. Classification of synovial joints
Simple:
one joint space with two surfaces ( one concave and one convex) and a single capsule (metacarpophalangeal joint)
Compound:
one joint has more than two joint articulating surfaces within a single capsule (elbow)
Complex:
an anatomically compound joint with meniscus or intracapsulaar disk (knee)

26. structural forms of joint- articulating surfaces
Unmodified ovoid-
ball-and-socket articulation, spheroid, (3 axes and 3 degree of freedom) (hip, shoulder)
Modified ovoid-
ellipsoid and sellar, (2 axes and 2 degree of freedom), (metacarpophalangeal joint) (2 axes and 2 degree of freedom)

27. structural forms of joint-articulating surfaces
Unmodified sellar- saddle,
the surfaces are convex and concave at right angles (2 axes and 2 degree of freedom)( 1st metacarpal joint)
Modified sellar-
a hinge, ginglymus, or trochoid joint( one axes, one degree of freedom) (interphalangeal joint, the ulnohumeral joint, and knee)

28. Joint Positions: Congruence
Loose-packed position:
any other position of the joint aside from the closed-packed position.
The maximal loose-packed position: resting position (the optimal position for mobilization)
elbow flexed to 70 degrees and supination
the knee in 30 degrees of flexion with a slight external rotation of the tibia
Close-packed position:
occurs when the joint surface are most congruent
a testing position but never used for mobilization because there are no degrees of freedom of movement

29. Osteokinematics: the study of movements of the bone
Spin: a pure rotation around a mechanical axis, clockwise or counterclockwise, (the head of femur, humerus, and radius), not simultaneous with a spin, transverses the shortest route between two points
Swing: any movement other than pure spine
pure or cardinal swing
impure or arcuate swing

30. Arthrokinematics: the study of the joint Gray‘s anatomy
Gliding (translation): an arc surface simply slides over another surfacewithout adding a component of angulation or rotation
Angular movement
Circumdution: conical outline
Rotation: movement around a longitudinal axis

31. MacConaill and Basmajian
Spin: rotation around a stationary mechanical axis
Gliding or sliding: one point on a moving surface comes into contact with new points on another surface
pure gliding (involuntary motion)(translation or translatory glide
Rolling: when new points on one surface come into contact with new points on a second surface
Rolling and gliding motion are usually found to occur simultaneously
Knee

33. Kaltenborn: more gliding---> nearly congruent
more rolling---> nearly incongruent
The rolling portion of the combined roll- glide movement always follows the direction of the bone movement
The gliding portion of the combined roll- glide movement

34. Kaltenborn: whether the moving surface is convex or concave
If the moving surface is concave---> both the gliding and the bone movement follow the same direction
If the moving surface is convex---> the gliding follows the opposite direction

36. Traction Stage I (grade I): piccolo traction
which involves neutralizing pressure in the joint without actually separating the joint surface
pain relief and prevent the trauma of grinding when performing mobilization techniques

37. Stage II (grade IV):
to separate the joint surfaces and take up the “slack” in the joint capsule
“slack”: the amount of looseness or play allowed by the capsule and ligaments in a normal joint
pain relief

38. Stage III (grade IV+)
involves an actual stretching of the soft tissues
used to increase the mobility in a hypomobile joint

39. Mobilization Pain relief Relaxation Stretch Grade I-II Traction
Vibration and oscillation
Relaxation
Stretch
Grade III
Stretch traction
Stretch-glide
Rotation

41. Three-dimensional traction:
spine, positioned relative to all three cardinal planes (with relative position such as flexion, lateral flexion, and rotation)

42. Translatoric gliding:
used to increase mobility in a hypomobile joint, preceded by piccolo traction to eliminate the compressive force

43. Maitland Grade I Grade II Grade III Grade IV Grade V
is a small-amplitude movement conducted from the beginning of the available range of motion
Grade II
is a large-amplitude movement conducted within the range. It does not reach either end of the range
Grade III
is a large-amplitude movement that does reach the end of the range of motion
Grade IV
is a small-amplitude movement conducted at the very end of the range of motion
Grade V
is a high-velocity thrust of small amplitude at the end of the available range of motion and within is anatomical range.
“Popping”, “ manipulation”

45. General Rules of Mobilization Techniques
The patient must be relaxed
The operator must be relaxed
Do not move into or through the point of pain
When performing any of the joint mobilization techniques, one hand will usually stabilize while the other hand performs the movement
The operator must consider

46. General Rules of Mobilization Techniques
Direction of movement
Velocity of movement
slow stretching for large capsular restriction
faster oscillation for minor degree of restriction
Amplitude of movement:
graded according to pain, guarding and degree of restriction

47. General Rules of Mobilization Techniques
Compare accessory joint movement to opposite side ( extremity), if necessary, to determine presence or degree of restriction
One movement is performed at a time, at one joint at a time
Each technique can be used as
Examination procedure: slack only to see accessory movement and pain
Therapeutic procedure: High-velocity, small-amplitude thrust or graded oscillation
Reassessment

48. Indications: Joint dysfunction Restriction of accessory joint motion
Capsuloligamentous tightening
Internal derangement
Reflex muscle guarding
bony blockage

49. Contraindication Absolute: Relative bacterial infection, neoplasm,
Joint effusion or inflammation
Arthrosis ( e.g. degenerative joint disease) if acute, or if causing a bony block to movement to be restored)
Rheumatoid arthritis
Osteoporosis
internal derangement
General delilitation ( e.g. influenza, pregnancy, chronic disease)
Absolute:
bacterial infection,
neoplasm,
recent fracture

50. To increase proprioceptive input
to the spinal cord to inhibit ongoing nociceptive input to anterior horn cells and central receiving area
Grade I-II
cycles/second