Manual Therapy for the Upper and Lower Quadrant: What Do I Need to Know? Objectives 1. Describe the current best evidence for manual therapy in the management of a variety of disorders. 2. Recognize subgroups for which manual therapy interventions are most appropriate. 3. Select and demonstrate manual physical therapy interventions based on current best evidence. 4. Select appropriate exercises to augment manual physical therapy techniques. 1
Contraindications to Thrust Manipulation Absolute Fracture/dislocation Instability Bone malignancies Bone infections CNS Disorders Bleeding Disorders Osteoporosis Relative Interventions Spondylolesthesis Hypermobility Post-surgical joints Benign bone tumors Nerve root compression Pregnancy Thoracic Spine and Ribs 2
Flexion/Opening Manipulation (T3-T10) Cross the patient s arms across her chest (right above the left) Establish your left hand contact on the transverse processes of the inferior vertebra Localize motion through the patient s arms. Further localize by flexing, left sidebending, and left rotating from above down to the dysfunctional segment Once the barrier is engaged, apply a high velocity, low amplitude thrust with your body in a anterior to posterior direction. The thrust introduces a flexion moment to open the right zygapophyseal joint. Flexion/Opening Manipulation (with modification for an external rib torsion) This is essentially the same technique as the supine flexion opening technique for the thoracic spine With the patient rolled toward you, establish your right hand contact medial to the rib angle and twist upward. This ensures that the thenar eminence lifts the medial aspect of the rib angle Localize motion through the patient s arms to the motion segment. Further localize by flexing, right sidebending, and right rotating from above down to the dysfunctional segment Once the barrier is engaged, apply a high velocity, low amplitude thrust with your body in a anterior to posterior direction. The force is focused just lateral to the left facet joint and should introduce a flexion moment 3
HVT T1/2 Distraction Cross the patient s arms across his chest opposite arm on top and roll him toward you Use a pinch grip to contact spinous process and distract T1 on T2 Place the patient supine while maintaining distraction Localize contact via cehpalad motion of the thorax Apply a high velocity, low amplitude thrust with your body in a cephalad/posterior direction Tip: Patient may bridge to further localize technique if needed Cross the patient s arms across his chest opposite arm on top and roll him toward you Use a pinch grip to contact spinous process and distract T1 on T2 Place the patient supine while maintaining distraction Localize contact via cehpalad motion of the thorax Apply a high velocity, low amplitude thrust with your body in a cephalad/posterior direction Tip: Patient may bridge to further localize technique if needed HVT T1/2 Distraction 4
Prone CT Junction (C7-T3) Patient is prone with R arm flexed at the shoulder and elbow so that the right hand is above their head Place patient s head in R rotation, L lateral flexion and lower cervical extension so that they are resting directly on their L eye socket Apply your left thumb on the left side of the SP or C7 T3 as appropriate, and take up slack Using right hand, make contact with the patient s right zygomatic arch and introduce left lateral flexion, right rotation and extension to the point of pre-thrust tension With the left hand the thrust is towards the patient s right shoulder Mid-Thoracic Distraction Manipulation With the patient sitting or standing, ask him to loosely interlock his fingers at the base of his neck Place your upper right or left pectoral region on the area of the spine you wish to manipulate Reach around the patient and grasp his elbows; your knees should be slightly flexed Compress the patient s upper body through his arms. Simultaneously, extend your knees to lift his body slightly up and over the fulcrum you established with your chest Tip: You will need to use your chest, your arms, and your body to effectively localize the force to a specific region of the thoracic spine 5
Extension/Closing Manipulation (T1-T2) Close Right T1-2 Place your left hand on the patient s head and your forearm along the side of the patient s face Place your thumb or pisiform just medial to the right side of the spinous process of the superior vertebra Introduce extension, right sidebending, and right rotation to the restrictive barrier. Use your whole body to translate the patient from posterior to anterior and right to left Apply a high velocity, low amplitude thrust in a right to left direction toward the opposite S-C joint to close the right facet joint Tip: Do not compress on the head and neck Extension/Closing Manipulation (T3-T10) Place your right hand over the right transverse process of the superior vertebra; rotate your hand caudally to obtain a skin lock and introduce an anteriorly directed force with your right hand Place your left hand on the left transverse process of the same vertebra; rotate your hand caudally to obtain a skin lock and introduce a caudally directed force to engage the restrictive barrier Apply a high velocity, low amplitude posterior to anterior thrust into the restrictive barrier Tip: This is a very low force technique 6
1st Rib Manipulation Position the patient as demonstrated Your right thumb should contact the shaft of the 1st rib just lateral to the T1 transverse process while allow the web space of your thumb to pull the trapezius posteriorly Engage the barrier with sidebending to the right and rotation to the left at T1 Apply a high velocity, low amplitude thrust to the shaft of the 1st rib in a diagonal direction towards your left thigh Tip: Use your whole body to translate the patient and engage the barrier. Your left leg should be stationary during the thrust. Lumbopelvic Region 7
Sacro-Iliac Region Manipulation: Supine Translate the pelvis towards you and maximally side-bend the patient s lower extremities and trunk to the right Without losing the right sidebending lift & rotate the trunk so the patient rests on their left shoulder Contact the patient s right ASIS with your left hand Grasp the top shoulder and scapula with your right hand and rotate the trunk to the left while maintaining the right side-bending Once the right ASIS starts to elevate, perform a smooth thrust in an anterior to posterior direction Reassess symptoms and impairments Sacro-Iliac Region Manipulation: Supine with Alternate Operator Arm Position Translate pelvis toward you and maximally side-bend the patient s lower extremities and trunk to the right Thread your right forearm through the patient s arms. Rest your fingertips on the patient s sternum or the table. Stand upright and rotate the trunk to the left (maintain the right side-bending) Contact the patient s right ASIS with your left hand. When the ASIS rises from the table, perform a smooth thrust in an anterior to posterior direction Reassess symptoms and impairments 8
Lumbar Spine: General Neutral Gapping Mobilization Place the patient on his side with the painful or stiff side up Grasp the left arm and shoulder and introduce right rotation Using your left arm, stabilize the patient s trunk With your right arm, apply a mobilizing force through the patient s right posterior hip into lumbar rotation Position yourself: more cephalad to affect the upper lumbar spine more caudad to affect the lower lumbar spine in midrange to affect the the middle lumbar spine Reassess symptoms and impairments Lumbar Spine: Segmental Neutral Gapping Manipulation Flex the top leg until you first begin to palpate motion at L4-L5 interspace; place the patient s foot in the popliteal fossa as shown Grasp the patient s right arm and shoulder and induce right sidebending & left rotation until you begin to palpate motion at the L4-L5 interspace Place your left thumb on the left side of the L4 SP & position the patient s arms around your left arm While maintaining your setup log roll the patient towards you While monitoring the right side of the L5 SP, use your right arm to induce a high velocity, low amplitude (HVLA) thrust in anterior direction Reassess symptoms and impairments 9
Lumbar Spine: Flexion (Opening) Manipulation Flex the top leg until you first begin to palpate motion at L3-L4 motion segment; place the foot in the popliteal fossa as shown Flex the upper body down until you begin to palpate motion at the L3-L4 motion segment Rotate the upper trunk to the right until you begin to palpate motion at the L3-L4 motion segment Place your right thumb on the right side of the L3 SP & position the patient s arms around your right arm Log roll the patient towards you While monitoring to the left of the L4 SP, use your left arm & body to induce a high velocity, low amplitude thrust in an anterior and cephalward direction Reassess symptoms and impairments Lumbar Spine: Extension (Closing) Manipulation Grasp the trunk and translate towards you until you localize the extension to the L4-L5 motion segment Rotate the patient s body to the right until you begin to palpate motion at the L4-L5 motion segment Place your right thumb or finger on the right side of the L4 SP & position the patient s arms around your right arm as demonstrated Log roll the patient towards you With your left arm induce a high velocity, low amplitude thrust in anterior and cephalward direction Reassess symptoms and impairments TIP: Place the patient s right foot in the popliteal fossa 10
Thoraco-Lumbar Junction: Rotational Manipulation With the patient seated and straddling the plinth, rest the patient s arms on a pillow over your left shoulder Reach underneath the patient s opposite axilla and grasp the lateral scapula Use your right pisiform to contact the right transverse process of T12 Induce left spinal rotation with your left arm and body Engage the restrictive barrier Apply a low velocity, high amplitude thrust into left rotation Reassess symptoms and impairments Lower Extremity Distraction Manipulation Abduct the hip of the involved side to maximum relaxation (typically about 15 degrees) Block the opposite foot with your thigh Apply a high velocity, low amplitude thrust in a caudad direction through the involved lower extremity Reassess symptoms and impairments Notes: This technique may be contraindicated with certain hip and knee pathologies Your cephalad hand supports the knee to prevent hyperextension In very mobile individuals, you may need to internally rotate the hip to increase the motion that is generated through the pelvis 11
Cervical Spine OA Joint Mobilization Mobilize the left OA With your left hand, support the occiput below the superior nuchal line Introduce OA flexion around an imaginary transverse axis running through the patient s external auditory meati Introduce the coupled motions of right sidebending and left rotation When the OA joint is positioned at the restrictive barrier, apply a posterior glide through the occiput with the right hand 12
OA Joint Flexion Manipulation Flex the Right OA joint Cup the patient s chin and cradle the side of the head with your right forearm With your left hand, support the occiput below the superior nuchal line Introduce OA flexion around an imaginary transverse axis running through the patient s external auditory meati Introduce the coupled motions of left sidebending and right rotation by translating the head from left to right When the OA joint is positioned at the restrictive barrier, apply a high velocity, low amplitude traction (cephalic) thrust AA Joint Contract-Relax Technique in Rotation Right Rotate the AA Grasp the head and fully flex the neck to reduce available rotation from C2 C7 Use your index fingers to palpate the posterior arch of C1 and rotate the neck to the right, engaging the restrictive barrier Instruct the patient to gently look or turn the head to the left and perform a 3-5 second isometric contraction Allow the patient to fully relax and engage the new right rotation restrictive barrier Do not allow the neck to extend during the rotation 13
Cervical Gapping Manipulation in Flexion Use your left hand to control the head/neck and place your right 2 nd MCP over the right facet joint of the motion segment Flex the patient s neck and translate from right to left to localize movement to the dysfunctional segment When the motion segment is at the restrictive barrier, apply a low amplitude, high velocity translatory thrust to open the left facet Tips: Ensure your right 2 nd MCP contact remains posterior to the facet joint, not over the transverse process. Keep your right forearm in line with the direction of thrust Hip 14
Lower Extremity Distraction Manipulation Abduct the hip of the involved side to maximum relaxation (typically about 15 degrees) Block the opposite foot with your thigh Apply a high velocity, low amplitude thrust in a caudad direction through the involved lower extremity Reassess symptoms and impairments Notes: This technique may be contraindicated with certain hip and knee pathologies Your cephalad hand supports the knee to prevent hyperextension In very mobile individuals, you may need to internally rotate the hip to increase the motion that is generated through the pelvis Hip Mobilization: Caudal Glide Progression Use a mobilization belt placed firmly in the patients hip crease Flex the patient s hip to the restrictive barrier Use your body to apply a caudally directed force to the proximal thigh Use an oscillatory passive accessory mobilization force Adjust the amount of hip flexion, rotation, & add/abduction to find the position of optimal mobilization Reassess symptoms and impairments after mobilization 15
Hip Mobilization: Anterior to Posterior Progression Position the lower extremity with the hip in a position of flexion, adduction, internal rotation Use your body to impart an oscillatory, passive mobilizing force to the postero-lateral hip capsule through the long axis of the femur Progress the technique by adding more flexion, adduction, & / or internal rotation Reassess symptoms and impairments after mobilization Hip Mobilization: Posterior to Anterior Mobilization in Flexion, Abduction, & External Rotation Bring the prone lying patient s hip into varying degrees of flexion, abduction and external rotation. Contact the proximal hip and use your body to impart an oscillatory, passive mobilizing force in a posterior to anterior direction. Vary the vector of your mobilizing force, dependent on stiffness and the patient s symptoms. If extremely stiff, start with a pillow under the patient s left trunk to decrease the amount of hip abduction required. Progress to lying flat on the table when able. Reassess symptoms and impairments after mobilization 16
Hip Mobilization: Posterior to Anterior Progression Grasp and support the patient s lower extremity with your left arm and trunk Place either the 1 st web space, thenar eminence, or hypothenar eminence of your right hand just inferior and medial to the greater trochanter Bring the patient s hip into varying degrees of flexion/extension, abduction/adduction, and internal/external rotation to find the vector of force that most effectively stretches the hip Use your body to impart an oscillatory, passive mobilizing force through the proximal femur in a posterior to anterior direction. The stretch should be felt by the patient in the anterior hip region Tip: To progress the technique increase the amount of extension, adduction, and internal rotation. Hip Mobilization: Internal Rotation in Extension Flex the knee to 90 degrees, ensure that the hip is in neutral or slight adduction Internally rotate the hip until the contralateral ilium raises approximately 1-2 inches from the table Stabilize the lower leg and impart an oscillatory, passive mobilizing force through the contralateral pelvis Note: If the patient experiences knee discomfort, grasp the distal thigh and place your forearm along the medial aspect of the patient s tibia Reassess symptoms and impairments after mobilization 17
Knee Flexion Flex the knee Note end-feel, range, pain and resistance Apply mobilizing force Retest impairments 18
Flexion External Rotation Flex and externally rotate the knee. Note end-feel, range, pain and resistance Apply graded mobilization Retest impairments Flexion Internal Rotation Flex and internally rotate the knee Note end-feel, range, pain and resistance Apply graded mobilization Retest impairments 19
Extension Stabilize the limb at the ankle Place the heel of your mobilizing hand over the tib tuberosity as shown Note end-feel, range, pain and resistance Apply graded extension mobilization Retest impairments Extension Abduction Stabilize the limb at the ankle so there is a lower leg abbduction moment Place the heel of your mobilizing lateral to the tib tuberosity as shown Apply an extension mobilization with your mobilizing hand into tibiofemoral adduction Note end-feel, range, pain and resistance Retest impairments Note: This technique is named for the distal seg ABBduction moment 20
Extension Adduction Stabilize the limb at the ankle so there is a lower leg adduction moment Place the heel of your mobilizing medial to the tib tuberosity as shown Apply an extension mobilization with your mobilizing hand into tibiofemoral abbduction Note end-feel, range, pain and resistance Retest impairments Note: This technique is named for the distal seg Adduction moment Proximal Tib/fib A-P Place your thenar eminence on the anterior fibular head Apply a force in an anterior-posterior direction Note end-feel, range, pain and resistance Retest impairments 21
Proximal Tibio-Fibular Joint Manipulation Place your 2nd MCP in the popliteal fossa, then pull the soft tissue laterally until your metacarpo-phalangeal joint (MCP) is firmly stabilized behind the fibular head. Use your right hand to grasp the foot and ankle as demonstrated and externally rotate the leg and flex the knee to the restrictive barrier your. Once at the restrictive barrier, apply a high velocity, low amplitude thrust through the tibia (direct the patient s heel towards his ipsilateral buttock). Foot and Ankle 22
Subtalar Joint Manipulation (Rearfoot Distraction) Grasp the dorsum of the patient s foot with interlaced fingers Provide firm pressure with both thumbs in the middle of the planar surface of the forefoot Engage the restrictive barrier by dorsiflexing the ankle & applying long axis distraction Pronate & dorsiflex the foot to fine-tune the barrier Apply a high velocity, low amplitude thrust in a caudal direction Dorsiflexion Cup the heel with one hand Place other hand across forefoot and heel Apply DF force by DF the ankle and/or keeping the foot parallel to the floor and gliding the heel cephalward Note end-range, pain and resistance 23
Patient position Prone, knee flexed 90 degrees Therapist position One hand cups proximal calcaneus Other hand grasps midfoot with forearm placed along plantar foot Mobilization technique Graded mobilizations into dorsiflexion with rocking motion Quick flicks at end range for added emphasis Physiological Motion: Ankle Dorsiflexion Physiological Motion: Ankle Plantarflexion Patient position Prone, knee flexed 90 degrees Therapist position One hands grasps plantar surface calcaneus Other hand grasps dorsal midfoot Mobilization technique Graded mobilizations into plantarflexion with rocking motion Quick flicks at end range for added emphasis 24
Ankle Inversion (TC and STJ) Patient position Prone, knee flexed 90 degrees Therapist position One hand cups plantar surface of calcaneus Other hand grasps plantar midfoot Tips of fingers along proximal talus (move to proximal calcaneus for STJ) Mobilization technique Graded mobilizations into inversion with rocking motion Ankle Eversion: (TC & STJ) Patient position Prone, knee flexed 90 degrees Therapist position One hand cups plantar surface of calcaneus Other hand grasps plantar midfoot Tips of fingers along proximal talus (move to proximal calcaneus for STJ) Mobilization technique Graded mobilizations into eversion with rocking motion 25
Talocrual PA in prone Block the distal tibia and fibula with your caudal hand Cup the calcaneous with the other hand (or use your web space at the talus) Apply a posterior to anterior force Note pain and resistance Talo-Crural Joint PA Mobilization in Prone Use your left hand to firmly stabilize the lower leg at the malleoli and grasp the posterior, medial, and lateral talus with your right hand Apply a posterior to anterior oscillatory mobilization force to the talus Tip: Use your thigh to help stabilize the calcaneus and to progressively increase the amount of ankle plantar flexion used with this technique 26
Block the posterior distal tibia and fibula Contact the anterior talus with web space of opposite hand Apply an anterior to posterior force Note pain and resistance *** Use your shoulder to keep the ankle in more of a neutral position than is shown here. Talocrual AP Cuboid Manipulation Place the tips of your thumbs over the plantar & medial aspect of the cuboid Translate the foot in a caudad and lateral direction while simultaneously ulnarly deviating your left hand Ensure that you create the fulcrum of motion and approach the restrictive barrier at the cuboid Once at the restrictive barrier, apply a high velocity, low amplitude manipulative thrust in a sweeping J like motion (plantar flexion & varus) 27
Talo-Crural Joint AP Mobilization Use your left hand to firmly stabilize the lower leg at the malleoli Grasp the anterior, medial, and lateral talus with your right hand Apply an anterior to posterior oscillatory mobilization force to the talus Tip: Use your thigh to help stabilize the foot and to progressively increase the amount of ankle dorsiflexion used with this technique You may need to adjust the amount of supination / pronation to optimize the technique Distal Tibio-Fibular Joint Mobilization AP to the fibula: Use your left hand to stabilize the distal tibia Grasp the distal fibula between the pads of your fingers and the thenar eminence / heel of your right hand Apply an anterior to posterior oscillatory mobilization force to the distal fibula or tibia Optimize the technique by adjusting and maintaining various angles of ankle dorsiflexion PA to the fibula: Apply the same technique with the patient in a prone position 28
Talo-Crural Joint (TCJ) & Subtalar Joint (STJ) Lateral Glides TCJ Lateral Glide: Grasp the malleoli just proximal to TCJ with your left index/thumb and use your forearm to stabilize the patient s left leg against table Place your right thenar eminence on the talus just distal to malleoli and grasp the rearfoot Use your body to Impart a mobilizing force through your right arm and thenar eminence to the medial talus STJ Lateral Glide: Shift your left hand/forearm distally and grasp the talus with left index/thumb Place your right thenar eminence on the patient s medial calcaneus and grasp the rearfoot Use your body to impart a mobilizing force through your right arm and thenar eminence to the medial calcaneus Shoulder 29
Inferior Glide of Humerus With the patient s shoulder stabilized on the table, the examiner guides the patient s arm into approximately 90º of abduction with one hand. When this position is obtained, the examiner applies an inferior force at the proximal humerus and assesses the amount of mobility and symptomatic response. Posterior Glide of Humerus With the patient s shoulder stabilized on the table, the examiner guides the patient s arm into approximately 90º of abduction with one hand. When this position is obtained, the examiner applies an posterior force at the proximal humerus and assesses the amount of mobility and symptomatic response. 30
Anterior/Posterior glide of Acromioclavicular Joint The examiner grips the distal clavicle with the index finger on the superior/posterior surface and the thumb on the anterior surface with their thumb. The examiner then glides the clavicle in an anterior and posterior direction while assessing mobility and symptoms response. Anterior/Posterior glide of Sternoclavicular Joint The examiner places the hypothenar eminence on the medial aspect of the clavicle. The examiner applies a posteriorly directed force while assessing mobility and symptoms response. 31