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Mechanisms of Action
of ManipulativeTherapy
University of Queensland
Bill VicenzinoProfessor in Sports Physiotherapy
Head of Division of Physiotherapy
of
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www.us.elsevierhealth.com
http://www.optp.com/
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Manipulation
1.
Low Velocity Techniques
Passive Mob
Under control of client Passive active or functional components*
Includes soft tissue, joints, nerual
2. High Velocity Thrust Techniques Beyond control of client Small amplitude (ie, HVLA)
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What is the majordifference
between
mobilisation andHVT?
Indicates successfulmanipulation!
Significance tomechanism of action?
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Brodeur R 1995 The audible release associated with
joint manipulation JMPT 18: 155-64
Audible release caused through
cavitation mechanism that isresponsible for:
Initiating reflex effects
Producing forces in target tissueswithout damaging muscle
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Does it work?
OrWhat is its clinical efficacy?
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Gross et al (2010) Manipulation or Mobilization for Neck
Pain: Cochrane Database of Systematic Reviews. DOI:10.1002/14651858.CD004249.pub3
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Gross et al (2010) Manipulation or Mobilization for Neck
Pain: Cochrane Database of Systematic Reviews. DOI:10.1002/14651858.CD004249.pub3
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Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K.Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in
the management of cervicogenic headache. Journal ofOrthopaedic & Sports Physical Therapy. 2007 Mar;37(3):100-7.
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Spinal manual therapy appears efficaciousin short to mid term
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Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan
mobilization with movement technique on ROM ad pressurepain threshold in pain-limited shoulders. Manual Therapy(2008) 13: 37-42. MWM versus Sham versus Control 11 male & 13 female mean age 46.1 SD 9.86 yrs
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Results - ROM
ROM: ICC = 0.98 and SEM 1.33
Interaction Plot ROM
95
100
105
110
115
120
Pre Post
ROM(
indegrees)
MWM
Sham
Control
* 15.611.4 (2.3 to 20.5)
9.9 (4.3 to 15.6)
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PPT: ICC = 0.96 and SEM 10.7 kPa
Interaction Plot PPT
275
295
315
335
355
375
395
Pre Post
PPT
Treatment
Sham
Control
* 62.5 kPa
45.1 (1.7 to 88.4)
46.3 (9.1 to 83.6)
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Green, Refshauge, Crosbie, Adams (2001) A RCT of a passive
accessory joint mobilization on acute ankle inversion sprains PhysTher 81:984-94
Acute ankle sprain (
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Green, Refshauge, Crosbie, Adams (2001) A RCT of a passive
accessory joint mobilization on acute ankle inversion sprains PhysTher 81:984-94
13/19 (68%) subjects discharged at 4th treatmentin PA mob group compared to 3/19
DF improved earlier in treatment group (11compared to 6 from baseline to treatment 2)
Gait variable improvements tended to favourthe treatment group
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Collins N, Teys P, Vicenzino B, The Initial Effects of a MulligansMWM Technique on DF & Pain in Subacute Ankle Sprains,Manual Therapy (2004) 9: 77-82
N = 14, grade II ankle sprain (4024 days old) WB DF, PPT and TPT (heat and cold) Deficit only on:
WB DF = 42 mm PPT (ATFL) = 58 kPa
WB-MWM, Placebo, control
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Collins N, Teys P, Vicenzino B, The Initial Effects of a MulligansMWM Technique on DF & Pain in Subacute Ankle Sprains,Manual Therapy (2004) 9: 77-82
*(dorsiflexion: 12 mm; p
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Initial effect of Mulligan MWM on ankle DF innormals: Weight bearing versus non-weight
bearing techniques.Vicenzino B, Prangley I, Martin D
[N=27 (18-27yr)](SMA website)
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% Dorsiflexion Improvement
0 1 2 3 4 5 6 7 8 9 10
*
**
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Nansel et al (1990) Time course considerations for the effects
of unilateral lower cervical adjustments with respect to theamelioration of cervical lateral flexion passive end rangeasymmetry, JMPT 13: 297-304.
16 traumatic & 16 non-traumatic subjectswith > 10 of unilateral side flexionrestriction
Thrust manipulation applied to side ofrestriction
Measurement of ROM @ 0.5, 4, 24 & 48 hrs 12 improvement @ 0.5 & 4 hours Improvement not evident at 48 hours
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McCollam & Benson 1993 Effects of P-A mobilisationon lumbar extension and flexion, JM&MT 1: 134-141.
PA mobilisation to L3, 4 & 5 spinousprocess for 9 minutes in 65asymptomatic participants
Compared to prone lying for 9minutes7.1% improvement in Ext for PANot present @ 1 week post treatment
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Spinal manual therapy is efficacious
Need for more peripheral manual therapy
studies
Short term effects are shown for a number ofjoints
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Does it work?
yes!
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How does it do it?
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Manual Therapy Widespread clinical use
Treatment of pain ( dysfunction) Clinically efficacious Mechanisms of Action
Poorly understood Complex
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Complex multifaceted
Wright (1995) Manual Therapy journal
Nociceptor
effects
Segmental
inhibition
Supraspinal inhibition
Psychologicaleffects
Total MIA effect
Treatment applicationTime
Jointrepair
C l ltif t d
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Complex multifaceted
Bialosky (2008) Manual Therapy doi: 10.1016/j.math.2008.09.01
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A proposed model for themechanisms of action of manual
therapy
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Biomechanical
Boney luxations
Reversing luxations
Straighten spine (Pare 1958)Unlocking locked joint
(Twomey 1992)
Shift an IVD fragment (Cyriax1975)
Reduce annular distortion(Farfan 1973)
Stretching, tearing or rupturingadhesions that limit joint ornerve range (Zusman 1986,Chrisman et al 1964)
Remove blockage orinterference of blood flow (Still
1899), nerve compression(Palmer 1910), sympatheticchain (Kunert 1965), andcerebrospinal fluid circulation
(DeJanette 1967)
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Correct abnormalsomatovisceral reflexes andvisceral organ dysfunction(Dhami & DeBoer 1992)
Stretch contracted muscles,causing relaxation (Perl 1975)Remove irrtable spinal lesions(Korr 1976)
Intense reflex effects (mainlymusculature, Lewit 1985)
Modulate peripheralnociceptors (Zusman 1987)
Inhibition of reflex musclecontraction (Zusman 1987)
Activates gating mechanism,neurotransmitters, opioidepeptides (Dhami and DeBoer1992)
Neurophysiological
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Biomechanical
Neurophysiological
MT
Proposed mechanism:
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Biomechanical
Neurophysiological
MT
Proposed mechanism:
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Biomechanical
MT
Subluxations?
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Subluxation hypothesis
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Subluxation hypothesis
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6
8
10
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16
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22
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Hubbard T, Hertel J (2008) Anterior positional fault ofthe fibula after sub-acute lateral ankle sprains.Manual Therapy, 13: 63-67.
Sub-acute ankle sprain (n =11) Non-injured (n =11)
2.9mm (-0.04 to 5.84)
Aff ankle Matched
Unaf ankle
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6
8
10
12
14
16
18
20
22
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Hubbard T, Hertel J (2008) Anterior positional fault ofthe fibula after sub-acute lateral ankle sprains.Manual Therapy, 13: 63-67.
Sub-acute ankle sprain (n =8) Non-injured (n =11)
1.8mm (-0.81 to 4.39)
Aff ankle Matched
Unaf ankle
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OBrien & Vicenzino (1998) A study of effects
of a MWM for lateral ankle pain using a casestudy design. Manual Therapy 3: 78-84.
4.5 cm PVAS reduction following 1 treatment
7.4 units/day on Kaikkonen scale withtreatment over 5 weeks compared to 1.4units/day with natural resolution
OBrien & Vicenzino (1998) A study of effects
o a MWM or lateral ankle pa n us ng a casestudy design. Manual Therapy 3: 78-84.
4.5 cm PVAS reduction following 1 treatment
7.4 un ts/day on Ka kkonen scale w thtreatment over 5 wee s compare to 1.4units/day with natural resolution
because there is a beneficial therapeutic effect, it doesnot follow that the proposed (speculated) mechanism
underlying the treatment is supported!
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Biomechanical
MT
Subluxations: may well occur butdifficult to measure?
Unresolved: does the MT reverse bonyluxation?
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Biomechanical
MT
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Biomechanical
MT
Effects of manipulations onbony position?
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Gal et al (1997) Movements of vertebrae during
manipulative thrusts to unembalmed humancadavers, JMPT 20: 30-40.
Evaluated positional change afterunilateral PA T-sp HVT in cadavers using3D kinematic analysis and forcemat
Demonstrated that: < 10 mm linear displacement of vertebra Change in position was short lived - mostly
for the duration of the technique
Restoration of baseline position within 10minutes of the treatment application
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R 1st MCP pain with F after hyperabduction injury
Positional fault on MRI: 4 pronationof R 1st MCP
Hsieh C-Y et al 2002 Mulligans MWM for the thumb: a single
case using MRI to evaluate the positional fault hypothesis.Manual Therapy 7: 44-9.
Glide reversed positional fault on MRI
Post-3 weeks self treatment: pain andfunction improved but positional fault
stayed same
Note: therapist was blind to this finding
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MT
BIOMECHANICS
Human studies
Transient changein bone position
Factors such as:Direction, Force,
Velocity/Frequency,Technique,
Localization, Audible
Specificity ofapplication?
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Direction of force:
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Johnson A, Godges JJ, Zimmerman GJ, Ounanian LL, The effect ofanterior versus posterior glide joint mobilisation on external rotation
range of motion in patients with shoulder adhesive capsulitisJOrthop Sports Phys Ther 2007;37(3):88-99. doi:10.2519/jospt.2007.2307
31 73 11
Specificity of direction:Manual therapy improves ROM
n = 8
n = 10
Direction of force:
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Johnson A, Godges JJ, Zimmerman GJ, Ounanian LL, The effect ofanterior versus posterior glide joint mobilisation on external rotation
range of motion in patients with shoulder adhesive capsulitisJOrthop Sports Phys Ther 2007;37(3):88-99. doi:10.2519/jospt.2007.2307
Unresolved issue:What is the relevance of ROM
improvement in ROM in pain
(mm VAS) & function outcomes
31 73 11
17 34mm
25 24mm
n = 8
n = 10
Direction of force:
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Lateral glide with
0
or
5 posterior inclination
NOT 5 anterior to direct lateral
Direction of force:
Abbott et al, 2001, The initial effects of an elbow MWM techniqueon grip strength in subjects with LE. Manual Therapy 6: 163-9
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Concept of the joint plane: gross
A li d F (N)
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Applied Force (N)
In the Treatment Plane Out of the Treatment Plane
Glide Orientation / Direction
C f h j i l fi
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Concept of the joint plane: fine tune
Amount of force:
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Di ti & A t f f
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Direction & Amount of force:
Are importantAre related
to produce better effects
i i f i
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Localization of spinal level:
L li ti f i l l l
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Chiradejnant A, Maher CG, Latimer J and Stepkovitch N (2003):Efficacy of therapist-selectedversus randomly-selected
mobilisation techniques for the treatment of LBP: A randomisedcontrolled trial. Australian Journal of Physiotherapy 49: 233241
140 patients with non-specific LBP Randomized to therapist selected level or
random selected level Both groups showed improved pain Selected level did not seem to be
superior to random Low lumbar spine mobilisation was
superior to upper
Localization of spinal level:
L li ti f i l l l
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Schomacher J (2009) The effect of an analgesic mobilizationtechnique when applied at symptomatic or asymptomatic levelsof the cervical spine in subjects with neck pain: a RCT. JM&MT17(2): 101-8.
126 patients with non-specific neck pain Randomized to therapist selected level or
levels below (4pain relieving traction)
Both groups showed improved pain Selected level did not seem superior was there mechanical/treatment
overflow from 3 levels below?
Localization of spinal level:
Direction & Amount of force:
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Direction & Amount of force:
, but not the exact location in the
spine
Are important
Are relatedto produce better effects
S i l i h l?
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Spinal versus peripheral?:
MWM CLG
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-10
0
10
20
30
40
50
60
70
PFGS PPT
MWM CLG
Audible (joint pop/crack sound):
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Audible (joint pop/crack sound):
Audible (joint pop/crack sound):
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Herzog 1996 On sounds & reflexes JMPT 19(3):216-8
PA T-sp (n 26):
high velocity versus low velocity -> both audible poponly high velocity produced muscle effects (EMG)
Audible (joint pop/crack sound):
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MT
BIOMECHANICS
Human studies
Transient changein bone position
&Increase ROM
Factors such as:Direction, Force,
Velocity/Frequency,Technique,
Localization, Audible
Potential mechanisms:
Descending Pain Inhibitor
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MT
BIOMECHANICS
Human studies
Pain effects human
animal
Associated systems & modeling
NEUROPHYSIOLOGIC
Transient changein bone position
&Increase ROM
Descending Pain InhibitorySystems (DPIS)
Endogenous opioidmechanisms
Neurotransmitters (5HT, NA, SP)
Spinal mechanisms
Gating Theory (Melazack andWall)
Peripheral receptors
Zusman M (1987) A theoretical basis for the short term relief of some
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types of spinal pain with manipulative therapy, Manual Medicine 3:
54-6.
Sustained or repetitive end range mobilisations-> reduction in firing rate (neural hysteresis)
Afferents fail following sustained intense loads, endrange positions, repetitive movements in normal animaljoints
Clinically manual therapy is not applied tonormal joints.
Notably, inflamed joint afferents exhibit: Spontaneous activity in neutral or rest and heightened
responses and reduced excitation thresholds to
midrange motion Indicating manual therapy may well provoke
pain through this mechanism not alleviate it!
Zusman M (1987) A theoretical basis for the short term relief of some
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types of spinal pain with manipulative therapy, Manual Medicine 3:
54-6.
Gate control theory (Melzack and Wall 1965)
Large diameter input modulating small diameterpain fibres (eg, TENS)
Problem with this model for manipulative therapyis that in an inflamed joint otherwise non-painful
movements become pain provocative. However, some large diameter fibres are spared(ie, not sensitised)
Manual therapists may through their examinationtarget these spared afferents?
Treatment effect > placebo & control
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Vicenzino B, Collins D & Wright A, (1996) The initial effects of acervical spine manipulative physiotherapy treatment on the pain
and dysfunction of lateral epicondylalgia Pain, 69-74.
Vicenzino B, Collins D, Benson H & Wright A, (1998) An investigationof the interrelationship between manipulative therapy induced
hypoalgesia and sympathoexcitation,Journal of Manipulative and
Physiological Therapeutics, 21, 448-53.
Paungmali, A, O'Leary, S, Souvlis, T and Vicenzino, B, Hypoalgesia
and sympathoexcitatory effects of mobilisation with movement forlateral epicondylalgia, Physical Therapy, 83 (2003) 374-383
Sterling, M, Jull, G and Wright, A, Cervical mobilisation: concurrenteffects on pain, sympathetic nervous system activity and motor
activity, Manual Therapy, 6 (2001) 72-81
Treatment effect > placebo & control
Initial manipulation induced hypoalgesia
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Initial manipulation induced hypoalgesia
demonstrated in other studies:
45% increase in PPT post HVT of Csp(Vernon et al 1990)
140% increase in cutaneous paintolerance following T-sp HVT (Terrett andVernon 1984)
17 & 11% increase in VAS following HVTand mobilisation, respectively (Cassidy etal 1992)
50% increase in VAS following PT manualtherapy (Zusman et al 1989)
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Transient changein bone position
&
Increase ROM
Pain effects human
NEUROPHYSIOLOGIC
What are the features?endogenous opioidneurotransmitters
Manual therapy produces an initial hypoalgesia
Treatment effect > placebo/control procedures
(e.g., Cassidy et al 1992, Paungmali et al 2003, Sterling et al
2001, Terrett and Vernon 1984, Vernon et al 1990, Vicenzino
et al 1996, Vicenzino et al 1998, Zusman et al 1989)
Opioid mechanisms:
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Naloxone blockade
Tolerance to repeated stimulation
Plasma levels?
Opioid mechanisms: naloxone/tolerance?
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Vicenzino et al, The Influence of Naloxone on the InitialHypoalgesic Effect of Spinal Manual Therapy. In: M. Devor, M.Rowbotham and Z. Wiesenfeld-Hallin (Eds.), Proceedings of the 9th
World Congress on Pain, Vol. 16, IASP Press, Seattle, 2000, pp.
1039-1044.
Zusman et al, Investigation of a proposed mechanism for the reliefof spinal pain with passive joint movement, J Manual Medicine
4(1989): 58-61
Souvlis et al, Does the initial analgesic effect of spinal manualtherapy exhibit tolerance?, 9th World Congress on Pain. Book ofAbstracts, Vienna, 1999.
Opioid mechanisms: plasma levels?
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Christian et al (1988) Immunoreactive ACTH, -endorphinand cortisol levels in plasma following SMT, Spine, 13: 1411-7.
Richardson et al (1984) The effect of osteopathic
manipulative treatment on endogenous opiateconcentration, JAOA 84: 127
Sanders et al (1990) Chiropractic adjustive manipulation onsubjects with acute low back pain: VAS and plasma -
endorphin levels, JMPT 13: 391-5
Evidence of opioid mechanism:
Vernon et al (1986) Spinal manipulation and -endorphin: a
controlled study of the effect of a spinal manipulation onplasma -endorphin levels in normal males, JMPT 9: 115-23
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Transient changein bone position
&
Increase ROM
Pain effects human
NEUROPHYSIOLOGIC
What are the features?Xendogenous opioidneurotransmitters
Manual therapy produces an initial hypoalgesia
Treatment effect > placebo/control procedures
(e.g., Cassidy et al 1992, Paungmali et al 2003, Sterling et al
2001, Terrett and Vernon 1984, Vernon et al 1990, Vicenzino
et al 1996, Vicenzino et al 1998, Zusman et al 1989)
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Transient changein bone position
&
Increase ROM
Pain effects human
NEUROPHYSIOLOGIC
What are the features?Xendogenous opioidNeurotransmitters?
Manual therapy produces an initial hypoalgesia
Treatment effect > placebo/control procedures
(e.g., Cassidy et al 1992, Paungmali et al 2003, Sterling et al
2001, Terrett and Vernon 1984, Vernon et al 1990, Vicenzino
et al 1996, Vicenzino et al 1998, Zusman et al 1989)
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MT
BIOMECHANICS
Human studies
Pain effects human
Animal?
NEUROPHYSIOLOGIC
Transient changein bone position
&Increase ROM
Skyba et al (2003) Joint manipulation reduces hyperalgesia byactivation of monoamine receptors but not opioid or GABA receptors in
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5-HT & Norad = DPIS
No local spinal circuitry
& no opioid involvement
spinal cord. Pain 106: 159-68.
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Nociceptive flexion reflex (NFR) threshold(Lim E, Sterling M, Stone A, Vicenzino B. 2011)
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Pain
Initial non-opioidhypo-algesia:
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MT
BIOMECHANICS
Human studies
Pain effects Human
Animal
NEUROPHYSIOLOGIC
Transient changein bone position
&Increase ROM
DPIS - PAGmediated?
Are there any other features
of manipulation induced
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Transient changein bone position
&
Increase ROM
animal
Pain effects human
NEUROPHYSIOLOGIC
Associated systems & modeling
hypoalgesia that may addto our understanding of the
underlying mechanisms of
action?
Area Under Curve SNS Data
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-25
-15
-5
5
15
25
35
45
TREAT PLACEBO CONTROL
%C
HAN
GE
*
*
*
*
CONDUCTANCE
HAND TEMP
HAND FLUX
ELBOW FLUX
*p < 0 05N = 24
Vicenzino B, Collins D, Benson H & Wright A, An investigation of theinterrelationship between manipulative therapy induced hypoalgesia
and sympathoexcitation,JMPT, 21 (7), (1998) 448-53.
McGuiness, J., Vicenzino, B. and Wright, A., The influence of a cervicalmobilisation technique on respiratory and cardiovascular function,
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Manual Therapy, 2, (1997) 216-220.
Simon, R., Vicenzino, B. and Wright, A., The influence of an
anteroposterior accessory glide of the glenohumeral joint on measures
of peripheral sympathetic nervous system function in the upper limb,
Manual Therapy; 2(1) (1997) 18-23.
Slater, H., Vicenzino, B. and Wright, A., Sympathetic Slump: The effectsof a novel manual therapy technique on peripheral sympathetic
nervous system function,JMMT, 2, (1994) 156-162.
Vicenzino B, Collins D. & Wright A, (1994) Sudomotor Changes Inducedby Neural Mobilisation Techniques in Asymptomatic Subjects.,Journal of
Manual and Manipulative Therapy, 2, 66-74.
Vicenzino B, Cartwright T, Collins D & Wright A, (1998) Cardiovascularand respiratory changes produced by lateral glide mobilisation of thecervical spine,Manual Therapy, 3, 67-71.
Sympathoexcitation is:
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Treatment technique specific
PA vs CLG vs Symp. Slump (magnitude) HVLA vs mobilisation
Frequency specific
Not present at less than 1 Hz oscillationRegion specific
Osteopathic HVT show differences
Are there any other features
of manipulation induced
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Transient changein bone position
&
Increase ROM
Initial sympatho-excitation
(e.g., McGuiness et al 1997, Simon et al 1997, Slater et al 1994,
Vicenzino et al 1994, Vicenzino et al 1998)
animal
Pain effects human
NEUROPHYSIOLOGIC
Associated systems & modeling
hypoalgesia that may addto our understanding of the
underlying mechanisms of
action?
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Vicenzino B, Collins D, Benson H and Wright A, An investigation of theinterrelationship between manipulative therapy induced hypoalgesia
and sympathoexcitation,JMPT, 21 (7), (1998) 448-53.
ULTT2b PFG PPT BLOOD FLUX CONDUCTANCE TEMPERATURE
SympathoExcitationHypoalgesia ?
Confirmatory Factor Model*
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ULTT2b PFG PPT ELBFLXSKNCONHNDFLX HNDTMP
Sympatho -
excitation
Manipulation
InducedHypoalgesia
0.30* 0.52* 0.68* 0.03 0.57* 0.58* 0.48*
0.95*
* AUC effect; ML Method; Chi-square = 11.94; df = 8; p-value = 0.154; CFI = 0.922
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MIDBRAIN - PAG
MEDULLA
SPINAL CORD
DORSOMEDIAL
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DORSOLATERAL
VENTROLATERAL
LATERAL
Dorsal/Lateral
PAG
Analgesia (non-opioid)Sympathoexcitation
Movement
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Adapted from Lovick (1991) & Fanselow (1991)
Stimulus
PAG Movement
VentrolateralPAG
Analgesia (opioid)SympathoinhibitionImmobility
PAG - SNS links:
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(Carrive 1993)
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Confirmatory Factor Model*
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ULTT2b PFG PPT ELBFLXSKNCONHNDFLX HNDTMP
Sympatho -
excitation
ManipulationInduced
Hypoalgesia
0.30* 0.52* 0.68* 0.03 0.57* 0.58* 0.48*
0.95*
* AUC effect; ML Method; Chi-square = 11.94; df = 8; p-value = 0.154; CFI = 0.922
Dorsal/Lateral
PAG
Analgesia (non-opioid)Sympathoexcitation
Movement
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Adapted from Lovick (1991) & Fanselow (1991)
Stimulus
PAG Movement
VentrolateralPAG
Analgesia (opioid)SympathoinhibitionImmobility
Descending Pain Inhibitory System:
Vicenzino B, Cartwright T, Collins D and Wright A, An investigation ofstress and pain perception during manual therapy in asymptomatic
Stress response or pain induced DNIC?
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Vicenzino B, Cartwright T, Collins D and Wright A, An investigation ofstress and pain perception during manual therapy in asymptomatic
subjects, European Journal of Pain, 3 (1) (1999) 13-18.
Methods
Stress & pain levels before, during and after treatment Double blind, placebo-controlled, repeated measures (n =
24)
Results
No stress or pain was perceived during treatment Stress was greatest at the first session regardless of
treatment condition applied on that day, reducing on day2 & 3.
Conclusion
Stress and pain are not features of the lateral glide
Vicenzino B, Cartwright T, Collins D and Wright A, An investigation ofstress and pain perception during manual therapy in asymptomatic
Stress response or pain induced DNIC?
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Vicenzino B, Cartwright T, Collins D and Wright A, An investigation ofstress and pain perception during manual therapy in asymptomatic
subjects, European Journal of Pain, 3 (1) (1999) 13-18.
Important to understand:
All the techniques we have studied havebeen non-painful during their application
Are there any other features
of manipulation induced
hypoalgesia that may addt d t di f th
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Transient changein bone position
&
Increase ROM
Facilatory and inhibitory effects reported
unsure if this adds or detracts!
depend on deficit?
(e.g., Vicenzino et al 2010, Abbot et al 2001)
animal
Pain effects human
NEUROPHYSIOLOGIC
hypoalgesia that may addto our understanding of the
underlying mechanisms of
action?
Associated systems & modeling:motor?
Initial non-opioidhypo-algesia:
DPIS -PAGdi t d?
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MTSpecificity ofapplication
Pain effects human
animalAssociated systems & modeling
NEUROPHYSIOLOGICmediated?
BIOMECHANICS
Human studies
Transient changein bone position
&
Increase ROM
DirectionForce level
Temporal (f, v)Technique
Localization?
Not the pop!
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Initial non-opioidhypo-algesia:
DPIS -PAGmediated?
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MTSpecificity ofapplication
Pain effects human
animalAssociated systems & modeling
NEUROPHYSIOLOGICmediated?
BIOMECHANICS
Human studies
Transient changein bone position
&
Increase ROM
DirectionForce level
Temporal (f, v)Technique
Localization?
Not the pop!
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Complex multifaceted
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Complex multifaceted
Wright (1995)
Psychologicaleffects
Treatment applicationTime
Pre-existingbeliefs:
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Injury & damage
Catastrophisation
Fear-avoidanceExpectations:
Placebo
Practitioner
Treatments
Chronic pain =conditioned (learned) phenomenon (Zusman 2004)
MWM = a re-conditioning of a pain-movement association-
[possibly through non-associative learningtheory mechanism (Zusman 2004))]
Repetition seems to be critical in successful treatment!
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Chronic pain =conditioned (learned) phenomenon (Zusman 2004)
MWM = a re-conditioning of a pain-movement association-
[possibly through non-associative learning theory mechanism (Zusman 2004))]