vicenzino moa-mt slides

8/12/2019 Vicenzino Moa-mt Slides

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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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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

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 =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

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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

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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


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?




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, 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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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)



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MT

BIOMECHANICS

Human studies


&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


&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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&

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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&

Increase ROM

Pain effects human

NEUROPHYSIOLOGIC

What are the features?Xendogenous opioidneurotransmitters







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&

Increase ROM

Pain effects human

NEUROPHYSIOLOGIC

What are the features?Xendogenous opioidNeurotransmitters?







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MT

BIOMECHANICS

Human studies

Pain effects human

Animal?

NEUROPHYSIOLOGIC


&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


&Increase ROM

DPIS - PAGmediated?

Are there any other features

of manipulation induced


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&

Increase ROM

animal

Pain effects human

NEUROPHYSIOLOGIC


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




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&

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




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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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


Stress response or pain induced DNIC?


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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



hypoalgesia that may addt d t di f th


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&

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



action?

Associated systems & modeling:motor?


DPIS -PAGdi t d?


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MTSpecificity ofapplication

Pain effects human

animalAssociated systems & modeling

NEUROPHYSIOLOGICmediated?

BIOMECHANICS

Human studies


&

Increase ROM

DirectionForce level

Temporal (f, v)Technique

Localization?

Not the pop!


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DPIS -PAGmediated?


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MTSpecificity ofapplication

Pain effects human

animalAssociated systems & modeling

NEUROPHYSIOLOGICmediated?

BIOMECHANICS

Human studies


&

Increase ROM

DirectionForce level

Temporal (f, v)Technique

Localization?

Not the pop!


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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))]

vicenzino moa-mt slides

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