manipulation in pain medicine -cyriax approach-
TRANSCRIPT
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KPS 2019 Annual Meeting
Manipualtive Approach to Back Pain
Is the pain caused by a spinal disorder?
R/O psychogenic and visceral referred Pain
Is the condition an ‘activity-related’ (mechanical)
spinal disorder?
R/O non mechanical disorder like rheumatic dis-
eases, tumours and infections
Red Flag
? Sphincter disturbance: bowel or bladder
? History of cancer
? Unexplained weight loss
? Immunosuppression
? Intravenous drug use
? Recent onset of structural deformity
? Recent or on-going infection
? Fever
? Night sweats
? Non-mechanical pattern of pain
? Constant pain
? Wide spread neurological signs or symptoms
? Disproportionate night pain
? Lack of treatment response
? Thoracic dominant pain
If the spinal disorder is activity-related
(mechanical), to which ‘concept’ does it belong?
▣ KPS 2019 Annual Meeting ▣
Manipulation in Pain Medicine -Cyriax Approach-
Atlas Clinic, Korea
IL Hwan Kim
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IL Hwan Kim: Manipulation in Pain Medicine -Cyriax Approach-
Manipulation Indication for Backpain
“Reduction by manipulation is possible in 2/3 of
all case of backache, and in 1/3 case of sciatica”
---Cyriax --—
Manipulation Indication for Backpain
? Acute annular lumbago
? Backache with favourable symptoms/signs
? Sciatica with favourable symptoms/signs
? Mixed protrusions
? Patient over 60 years
Symptoms and signs favouring manipulative
treatment of backache
Favourable symptoms
Patient over 60 years Sudden onset of pain:On
bending forward or On coming up
Favourable signs
Partial articular pattern Side flexion away from
the painful side hurts most Painful arc with or with-
out momentary deviation Absence of gross deviation
Absence of gross limitation on movement
Symptoms and signs favouring manipulative
treatment of sciatica
Favourable symptoms
Backache still continues after root pain has begun
Root pain is recent
Favourable signs
Lumbar extension and side flexion hurt in the
back but not in the limb
Absence of deviation or muscle spasm Straight leg
raising is only moderately limited, with absence of
spasm of the hamstring muscles
Absence of neurological deficit
Manipulation Contraindication for Back pain
Danger to S4 roots Anticoagulant therapy Aortic graft
Last month of pregnancy Weakened body structures
Muscle spasm Seriously neurotic patients
When manipulation Useless
Too painful Too large a protrusion Too soft Too
long a duration of root pain>6Mo After laminecto-
my, protrusion at the same
level
Unfavourable articular signs in: Backache Sciatica
Primary posterolateral protrusion
Side Effect of Manipulation
further prolapse of a herniated disc, resulting in a
cauda equina syndrome [1 per 3.7 million treat-
ments]
sprains of the costovertebral and costochondral
junctions
fractures of a transverse process
Easy and Effective Manipulation technique
in Back pain
Dr. Maigne Approach
PMID (Painful Minor Intervertebral Dysfunction)
1. Pain on axial pressure of spinous process
2. Pain on transverse pressure of spinous process
3. Pain on friction of facet joints
4. Pain on transeverse pressure of interspinous lig-
aments
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KPS 2019 Annual Meeting
Pain on axial pressure of spinous process
Pain on transverse pressure of spinous process
Pain on friction of facet joints
Pain on transeverse pressure of interspinous
ligaments
Dr. Maigne Approach
Rule of no pain and opposite movement
manipulation ; at least 3 pain-free movements
repeated mobilization: 2 pain-free movements
contraindication; all movements are painful
Manipulation at least 3 pain-free movements
Repeated mobilization 2 pain-free movements
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IL Hwan Kim: Manipulation in Pain Medicine -Cyriax Approach-
Mr. Mckenzie Technique
Acute lumbago without deviation(D1)
prone lying 5min→lying prone in extension
5min→active extension in lying 10Rep
Acute lumbago with flexion deviation(D2)
prone lying with abdominal pillow 5min→pillow-
remove→gradual table head elevation→progression
to D1
Acute lumbago with lateral deviation(D4)
Prone lying lateral deviation correction→repeate-
dextension in prone→progression to D1
Mr. Mckenzie Technique
Centralization is the guide to all treatmentresults
Frequent repetition is important to maitaintreat-
ment effectiveness
Patient education(keep your back hollow)is the-
most important
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KPS 2019 Annual Meeting
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Jaeik Choi : Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince
Object of manipulation
Reduce discodural or discoradicular interaction by
moving a displaced cartilaginous rim away from
sensitive structures(dura, root)
Two principles
• position of intervertebral joint opening
• traction and tautening posterior longitudinal
ligament and causes suction in the disc, so ex-
erting a centripetal force
a) Indications
1) disc protrusion in the absence of contraindica-
tions
2) acute lumbago
- good indication, except if hyperacute.
3) backache
• sudden onset, minor partial articular pattern.
• davourable articular signs (see above).
• painful arc without deviation.
4) Root pain
• better if the patient is not too young.
• other favourable elements :
if some backache remains
if the root pain is recent
minor or no deviation
favourable articular signs
only slight limitation of SLR
no neurological deficit.
b. Contraindications
1) danger to S4 roots
2) anticoagulant therapy
3) aortic graft
4) last month of pregnancy
5) osteoporosis
6) severe muscle spasm(guarding)
7) neurotic patient
c. Not Useful
Manipulation is unlikely to succeed in the follow-
ing cases
1) pain is too severe
2) fragment is too large
3) protrusion is too soft (nuclear)
4) root pain has existed for too long (over six
months)
5) compression phenomena : mushroom phenom-
enon, nuclear self-reducing disc protrusion
6) after laminectomy.
7) unfavourable articular signs
8) PPLP(primary posterolateral protrusion
▣ KPS 2019 Annual Meeting ▣
Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince
Dr, Choi’s Rehab. Med. & Pain Clinic, Korea
Jaeik Choi
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KPS 2019 Annual Meeting
d. Choice of techniques
Cyriax gives us some advices, partially based on
his own experience, partially because they are just
common sense
1) techniques with lever are avoided in elderly or
osteoporotic patients
2) rotation techniques usually do very well for an
L4-protrusion
3) extension techniques can be better for L5, S1
protrusion
4) no extension techniques for an acute lumbago
(the patient is fixed in flexion).
5) “stretch” is always the first technique (longitu-
dinal effect).
6) in a manipulation session several manoeuvres
are performed.
young adult : 7-8-9 manoeuvres in the same
session.
elderly patient : 3-4 manoeuvres
e. basic rules
1) each manoeuvre is first done at half the normal
intensity.
2) there is a control after each manoeuvre
(SLR if positive, articular lumbar movements in
standing)
3) a manoeuvre which helps the patient is repeat-
ed.
a manoeuvre which does not help is abandoned.
4) increase the intensity of a manoeuvre if the
slighter version has proved beneficial.
5) a manoeuvre ceases to afford further benefit,
another manoeuvre is chosen, again at half the
intensity first.
d. interpretation as an improvement
1) less pain
2) more movement (although the pain can be un-
altered)
3) fewer movements painful
4) “shortening” of the pain, i.e. centralization
5) appearance of a painful arc
e. Techniques
1) Manipulation : stretch
The couch is as low as possible.
Starting position : unilateral pain, patient lies on
the painless side.
central pain, either side or less SLR (+) side
Grip : one hand behind the greater trochanter
with the fingers pointing downwards, the other
hand at the front of the shoulder with the fingers
pointing upwards.
Maneuver : first shoulder and pelvic rotation, both
rotations being equal.
then adds a longitudinal taking up of the slack ris-
ing on tiptoe and using his body weight exactly
above the patient’s trunk with his arms extended.
Manipulative thrust with body drop
2) Manipulation : leg over
Starting position : one should estimate the correct
supine position of the patient. The therapist stands
at the painfree side.
Execution : right side is the painful one.
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Jaeik Choi : Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince
therapist grasps the right knee with both hands,
flexes the hip to about 90° and, under traction,
brings the patient’s knee to well below the edge of
the couch a slight counterpressure of the therapist
against his shoulder suffices.
Taking up the slack
Manipulative thrust is a sudden push downwards
with the hand on the knee.
For an upper lumbar protrusion, more hip flexion
is needed.
3) Manipulation : Dallison
- this manoeuvre is a leg over with built-in side
flexion.
- used for patients with pain and deviation.
- immaterial whether the pain is left or right
what matters is which side the patient opens
spontaneously.
Starting position : the correct supine lying posi-
tion.
therapist stand at the side he wants to build in a
side flexion and crosses the patient’s right knee
over the left one ; his right hand grasps the back of
the patient’s left knee, his left hand is put at the
outer aspect of the right knee. Both hips are flexed,
a side flexion to the right is built in, and maintained
by the therapist’s left knee.
rest of the manoeuvre is the same as for the leg
over
4) Manipulation : reverse stretch
Starting position : the couch is as low as possible.
patient lies on the painfree side, upper arm is re-
laxed in front of him
upper limb is brought backwards and hooked on
the edge of the couch.
Execution : taken up in rotation ; both rotations
should be equal.
second element is the distraction : the therapist
faces the patient’s head, rises on tiptoe and uses his
body weight above the patient in a longitudinal di-
rection. The manipulative thrust is a downward jerk
towards distraction using the body weight.
- unsuited for obese or very stiff patients who do
not have much pelvic rotation.
5) Manipulation : reverse stretch with thigh
Starting position : thigh is used as a lever in some
90° hip flexion. The therapist grasps the inner side
of the patient’s limb (at the knee) and brings it to-
wards himself.
take up slack is as follows : the therapist stands
with slightly bent knees and both feet together in a
45° direction to the couch.
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KPS 2019 Annual Meeting
pulled the patient’s limb towards himself, applies
his body weight on the shoulder.
manipulative thrust is a swift trunk rotation away
from the patient.
- in order to have an effect in the lumbar spine
instead of at the hip joint the correct angle of hip
flexion is important.
6) Manipulation : central pressure
Starting position : the couch is at knee-height, the
patient lies prone.
Grip : first, the middle of the fifth metacarpal
bone apply between two spinous processes, the
other hand reinforces
maneuver : therapist leans against the couch with
his feet apart and his arms extended.
takes up the slack and the manipulative thrust
with the body weight
if, during the taking up of the slack, the patient
feels a pain in the buttock or the limb, the manoeu-
vre is abandoned. It is important, just before the
manipulative thrust, not to lose the slack.
7) Manipulation : unilateral pressure
Starting position : as for the central pressure. The
patient does not lie in the middle of the couch, but
as near as possible to the therapist.
The therapist’s position : at the left for a right
unilateral pressure.
With the pisiform bone, reserve of skin is taken
towards the midline, hand is pulled backwards for a
bony contact as close to the midline as possible,
thus avoiding the risk of fracture of a transverse
process.
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Jaeik Choi : Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince
reinforces with other hand, therapist leans for-
wards beyond the midline
part of the body weight takes up the slack
manipulative thrust is performed with straight
arms in a medial and downward direction.
8) Mobilization : stretch in prone lying
Starting position : patient lies prone, open painful
side with trunk side flexion.
Execution : with a reserve of skin, the therapist
puts his hands (arms crossed) against the lower ribs
and the iliac crest.
manoeuvre (a mobilization rather than a manipu-
lation) is a rhythmic jerking downwards of the tho-
rax with elbows bent 90°, thus distracting the pain-
ful side.
9) Antideviation technique, rotation
Starting position : the patient lies on the convex
side, e.g. on the left side for a deviation to the right.
upper leg flexed with the foot behind the other
knee, and the knee hanging beyond the edge of the
couch.
Execution : the therapist stands before the pa-
tient, immobilizes his knee and leans with his body
weight on to the patient’s shoulder in a combined
rotation and distraction direction.
maintained for up to a minute, then released and
repeated again.
10) Antideviation technique, side flexion
In a left deviation side flexion towards the right is
limited. This direction will be mobilized.
patient lies supine,
therapist stands at his right side and crosses the
right knee over the other one.
Execution : the therapist’s right hand, under the
patient’s right knee and above his left knee, grasps
the back of the left knee.
hips are brought in flexion. The left hand is at the
outer aspect of the patient’s right knee. swinging
with both hands,
rhythmic side flexion movements towards the
right
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KPS 2019 Annual Meeting
11) Antideviation technique, extension
therapist stands at the side of the deviation and
with both hands grasps the patient’s other pelvis.
The therapist pushes with his trunk and pulls with
the arms in order first to neutralize, then to correct
the deviation.
movement towards extension follows
maintained for a few seconds and performed three
times in succession.
Strategy
start is always the stretch at low intensity with the
painful side up.
1) first possibility
- stretch, followed by checking the SLR (or a
lumbar movement in standing if SLR is nega-
tive).
- patient is better, the stretch is repeated, again
with a control afterwards. repeated with increas-
ing intensity.
- a point is reached in which the patient is al-
ready much better but the last manoeuvre has
ceased to afford further benefit. change method
same direction as the previous rotation but
more intence : leg over. performed at low in-
tensity first, and then repeated a few times
- a patient with pain and also deviation : the use
of the Dallison. now 5 or 6 sessions will be re-
quired instead of 3 or 4 to obtain reduction.
each session we might use 2-3 times the stretch,
2-3 times the leg over and 1-2 times the Dalli-
son technique.
- patient with pain and deviation has lost his pain
after 5 or 6 sessions, but the deviation has re-
mained unaltered.→ antideviation techniques
are called for.
2) second possibility
low intensity stretch was the first manoeuvre ; no
effect
→ low-intensity reverse stretch : effective
avoid more forceful stretch or to try a leg over.
→ reverse stretch with thigh.
3) third possibility
- we start with the stretch. Either it helps or it
does not.
If it helps, we repeat it several times ;
if not, we do it only once. choose a second
technique :
→ central pressure. Why ?
* patient is elderly or osteoporotic, or he has an
osteoarthrotic hip, we cannot use the thigh as a
lever.
* L5-disc protrusion, which might better respond
to an extension than to a rotation technique.
* patient, in standing, has a good extension and a
very painful flexion.
→ unilateral pressure on the painfree side first, on
the painful side afterwards
→ stretch in prone lying to end the session.
- taking up the slack for the central pressure
causes a pain in the limb abandon this tech-
nique, try unilateral pressure
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Jaeik Choi : Manipulation Treatment of Lumabr Spine with Cyriax Method Korea Academy of Cyriax Orthopaedic Medicince
Conclusion
Cyriax manipulation is easy to learn and apply.
Manual treatment of lumbar spine helps to im-
prove symptoms and to prevent recurrence.
It is important to recognize that manual treatment
has its own limitations and is a secondary treatment
of injections treatment for lumbar spine problems.
Thank you!
Search for the “시리악스” keyword on YouTube to
revisit today's unabridged lecture video.
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KPS 2019 Annual Meeting
History of osteopathy
- Andrew Tailor Still
- M.D.
- 1828-1917
- American Osteopathic Association
Dr Still's philosophy
- unity of the body
- healing power of nature
- somatic component of disease
- form and function
- use of manipulative therapy
osteopathy current situation in USA
- 70 % of D.O. is primary physician like M.D.
- about 100000 D.O.s
- Different point of D.O. from M.D. is using ma-
nipulative therapy
34 osteopathic colleges in USA
OHWI(osteopathic health & wellness institute)
- international osteopathic manipulation educa-
tion program(www.ohwi.org)
- osteopathic college of Ontario, Canada program
▣ KPS 2019 Annual Meeting ▣
All about osteopathic manipulation
Yonsei Rehabilitation Clinic, Korea
Jae Hwan Lee
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Jae Hwan Lee: All about osteopathic manipulation
Unity of the body
- integration of the total human organism rather
than a summation of parts.
- connection between viscera and viscera, muscu-
loskeletal and musculoskeletal, between viscera and
musculoskeletal.
- connection between mind and body.
Healing power of nature
- He recognized body's ability to heal itself and
stressed preventive medicine, eating properly and
keeping it.
Somatic component of disease
- every disease contains abnormality of musculo-
skeletal system.
- based on anatomy.
- osteopathy is called 整骨醫學
Form and function
- every human organ correlates with its function
- form and functions are interrelated.
Use of manipulative therapy
- manipulation corrects the body structure.
- Correcting the body structure release the ten-
sion of fascia, improve blood supply and lymphatic
drainage, and wash out the cellular wastes.
- so helps the body to heal itself.
Many manipulation method
- counterstrain
- MET(muscle energy technique)
- visceral osteopathy
- cranial osteopathy
- myofascial release
- HVLA(high velocity low amplitude)
- ligamentous articular strain
Osteopathic diagnosis
- Involves using hands to "listen" to the patient's
body.
- When the particular tissue is ill, it loses its elas-
ticity, disrupts the patient's membranous equilibri-
um, and becomes a new axis or pivot point for mo-
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KPS 2019 Annual Meeting
bility and motility.
The listening method
- Global listening
- Local listening
- Thermal listening
- Cranial rhythm listening
- Visceral rhythm listening
Physical diagnosis
T: Tissue texture abnormality
A: Asymmetry
R: Restriction of motion
T: Tenderness
Radiologic diagnosis
F: Flexion E: Extension R: Rotation R: Right L:
Left
S: Side bending
예) FRRSL - Flexion Rotation Right Side bending
Left
Counterstrain
- invented by D.O. Lawrence Jones
- He recognized the decrease of muscle spasm
when the position of spasm muscle's origin and in-
sertion is put in most relaxed position for 90 sec-
onds.
- tender muscle or ligaments' origin and insertion
is put in the shortest position for 90 seconds
- 90 seconds?: the time for reaching a new appro-
priate set point for gamma motor fiber.(longest limit
time to decrease the muscle spasm in Lawrence ex-
periment.)
- Tender point, trigger point, acupuncture point,
neurolymphatic point, neurovascular pint: all simi-
lar.
- chronic, repetitive trauma causes histamine,
prostaglandine release: inflammatory proliferation
and vessel contraction.
- destruction of sarcoplasmic reticulum, interferes
with actin, myosin reaction through invasion of cal-
cium ion overflow
- countestrain technique reduces the continuous
abnormal hypersensitivity of gamma motor neuron
in muscle spindle.
MET
- developed by D.O. Fred.L. Mitchell, Sr. (1909-
1974)
- decrease the muscle spasm by letting patient
contract the muscle isometriccally in unpainful di-
rection , blocking the patient's motion.
- postisometric relaxation: decrease the muscle
tone causing reflex inhibition of Golgi tendon organ
after isometric contraction.
- reciprocal inhibition: release the muscle tone by
contraction of the muscle's antagonist.
Visceral manipulation
- developed by D.O. Barral
-mobility: The gross movement of the visceral in
relation to diaphragmatic movement
-motility: The inherent motion at the visceral as it
relates to embryonic
development
- all motion has axis
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Jae Hwan Lee: All about osteopathic manipulation
- mobility and motility has same axis of rotation in
healthy condition
- every healthy organ has appropriate motion
without restriction
- if there is any restriction, it causes functional
abnormality even if it is small
- if that restricted motion repeats and accumu-
lates hundreds of, thousands of time every day, it
causes serious change in that organ's function
- the visceral motions controlled by
1. somatic nervous system
2. autonomic nervous system
3. craniosacral rhythm
4. visceral motility
- mobility
Intracavitary Pressure
Exhalation
Inhalation
Articulations
- intracavitary pressure
thoracic cavity pressure: negative abdominal cav-
ity pressure: positive
so, thoracic cavity negative pressure reduces liver
weight adjacent to diaphragm
( relates to right shoulder pain)
- motion restriction
Articular restrictions
adhesion / fixation
Ligamentous laxity
ptoses
Muscular restrictions
- visceral manipulation in musculoskeletal pain
Reflex: somatovisceral, viscerosomatic
Fascia release is effective for all kinds of pain,
anywhere because pain is from fascia restriction,
low blood supply and poor lymphatic drainage.
- contraindication
1. right after surgery
2. surgical abdomen
Cranial manipulation
- developed by D.O. W. Sutherland
- introduced by D.O. Upledger to general popula-
tion as CST(craiosacral technique)
- D.O. calls it osteopathy in cranial field
- craniosacral rhythm
generated by CNS autonomic motility( primary
motion of occiput and sphenoid: flexion, extension)
other cranial bones move secondary to above
mentioned primary motion.
abnormal cranial rhythm causes disease.
Vault hold and various technique
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KPS 2019 Annual Meeting
HVLA
- Dr. Still used this technique in his early age, but
avoided later due to side effect such as ligament
laxity.
- D.D. Palmer created chiropractic in the same
period
- HVLA used a little different mechanism and di-
agnosis from chiropractic
ex) different terms in X ray listing
HVLA : R(rotation) S(side bending) chiro: PI AS
different bed
HVLA: general plain table chiro: Cox, Thom-
son, Leander etc
different mechanism
HVLA: short lever, long lever technique chiro:
mainly short lever technique
different diagnosis
HVLA: leg length difference is not so important
chiro: leg length difference is quite important
- HVLA is used in spine and extremity joint by
high velocity low amplitude thrust, resulting in re-
duction of subluxated joint
Ligamentous articular strain
- developed by D.O. H.A.Lippincott(1949) and
DOSG( Dallas Osteopathic Study Group)
- Membranous strain = Fascia strain
No Thrusts, No jerks, No lever
Dr. Still‘s principle: exaggeration of the lesion to
the degree of release and then allowing the liga-
ments or tendons to draw the articulations back into
normal relationship
If the injured ligaments or tendons are released
to the direction of injury vector, resistant tension
occurs not to be further injured in ligaments them-
selves. so they are released and stopped to a certain
point. That point is called balanced tension point!
- after injured ligaments reach the balanced ten-
sion point, several seconds later, they try to go back
to the original physiologic joint position(recenter-
ing) and go through healing process. ( they say no
need for immobilization)
- terminology
1. indirect: like pushing on the tail of the vector of
injury ( to the direction of no resistance) usually
used in ligaments or tendons injury
2. direct: like pulling on the tail of the vector of
injury or pushing on the point of the arrow( to the
direction of resistance) usually used in muscle inju-
ry. developed into myofascial release
Soft tissue technique, technique of Still, Lymphatic
technique etc