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Joint manipulation

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For extended detail of manipulation of spinal joints, see Spinal manipulation.

Joint manipulation is a type of passive movement of a skeletal joint. It is usually aimed at one or more 'target' synovial joints with the aim of achieving a therapeutic effect. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine.[1]

Biomechanics

Manipulation can be distinguished from other manual therapy interventions such as joint mobilization by its biomechanics, both kinetics and kinematics.

Kinetics

Until recently, force-time histories measured during spinal manipulation were described as consisting of three distinct phases: the preload (or prethrust) phase, the thrust phase, and the resolution phase.[2] Evans and Breen[3] added a fourth ‘orientation’ phase to describe the period during which the patient is oriented into the appropriate position in preparation for the prethrust phase.

When individual peripheral synovial joints are manipulated, the distinct force-time phases that occur during spinal manipulation are not as evident. In particular, the rapid rate of change of force that occurs during the thrust phase when spinal joints are manipulated is not always necessary. Most studies to have measured forces used to manipulate peripheral joints, such as the metacarpophalangeal (MCP) joints, show no more than gradually increasing load. This is probably because there are many more tissues restraining a spinal motion segment than an independent MCP joint.

Kinematics

The kinematics of a complete spinal motion segment when one of its constituent spinal joints are manipulated are much more complex than the kinematics that occur during manipulation of an independent peripheral synovial joint. Even so, the motion that occurs between the articular surfaces of any individual synovial joint during manipulation should be very similar and is described below.

Early models describing the kinematics of an individual target joint during the various phases of manipulation (notably Sandoz 1976) were based on studies that investigated joint cracking in MCP joints. The cracking was elicited by pulling the proximal phalanx away from the metacarpal bone (to separate, or 'gap' the articular surfaces of the MCP joint) with gradually increasing force until a sharp resistance, caused by the cohesive properties of synovial fluid, was met and then broken. These studies were therefore never designed to form models of therapeutic manipulation, and the models formed were erroneous in that they described the target joint as being configured at the end range of a rotation movement, during the orientation phase. The model then predicted that this end range position was maintained during the prethrust phase until the thrust phase where it was moved beyond the 'physiologic barrier' created by synovial fluid resistance; conveniently within the limits of anatomical integrity provided by restraining tissues such as the joint capsule and ligaments. This model still dominates the literature. However, after re-examining the original studies on which the kinematic models of joint manipulation were based, Evans and Breen[3] argued that the optimal prethrust position is actually the equivalent of the neutral zone of the individual joint, which is the motion region of the joint where the passive osteoligamentous stability mechanisms exert little or no influence. This new model predicted that the physiologic barrier is only confronted when the articular surfaces of the joint are separated (gapped, rather than the rolling or sliding that usually occurs during physiological motion), and that it is more mechanically efficient to do this when the joint is near to its neutral configuration.

Cavitation (Audible release)

Main article: Cracking joints

Joint manipulation is characteristically associated with the production of an audible 'clicking' or 'popping' sound. This sound is believed to be the result of a phenomenon known as cavitation occurring within the synovial fluid of the joint. When a manipulation is performed, the applied force separates the articular surfaces of a fully encapsulated synovial joint. This deforms the joint capsule and intra-articular tissues, which in turn creates a reduction in pressure within the joint cavity.[4] In this low pressure environment, some of the gases that are dissolved in the synovial fluid (which are naturally found in all bodily fluids) leave solution creating a bubble or cavity, which rapidly collapses upon itself, resulting in a 'clicking' sound. The contents of this gas bubble are thought to be mainly carbon dioxide.[5] The effects of this process will remain for a period of time termed the 'refractory period', which can range from a few minutes to more than an hour, while it is slowly reabsorbed back into the synovial fluid. There is some evidence that ligament laxity around the target joint is associated with an increased probability of cavitation.[6]

Clinical effects and mechanisms of action

The clinical effects of joint manipulation have been shown to include:

  • Temporary relief of musculoskeletal pain.
  • Shortened time to recover from acute back sprains (Rand).
  • Temporary increase in passive range of motion (ROM).[7]
  • Physiological effects upon the central nervous system.[8]
  • No alteration of the position of the sacroiliac joint.[9]

Common side effects of spinal manipulative therapy (SMT) are characterized as mild to moderate and may include: local discomfort, headache, tiredness, or radiating discomfort.[10]

Shekelle (1994) summarised the published theories for mechanism(s) of action for how joint manipulation may exert its clinical effects as the following:

  • Release of entrapped synovial folds or plica
  • Relaxation of hypertonic muscle
  • Disruption of articular or periarticular adhesions
  • Unbuckling of motion segments that have undergone disproportionate displacement

Practice of manipulation

In the context of healthcare, joint manipulation is performed by several professional groups. In North America and Europe, joint manipulation is most commonly performed by chiropractors who perform over 90% of all manipulative treatments[11]. Other providers include physical therapists and osteopaths. When applied to joints in the spine, it is referred to as spinal manipulation.

Terminology

Manipulation is known by several other names. Historically, general practitioners and orthopaedic surgeons have used the term "manipulation"[12]. Chiropractors refer to manipulation of a spinal joint as an 'adjustment'. Following the labelling system developed by Geoffery Maitland,[13] manipulation is synonymous with Grade V mobilization; a term commonly used by physical therapists. Because of its distinct biomechanics (see section above), the term high velocity low amplitude (HVLA) is often used interchangeably with manipulation.

Safety issues

The safe application of spinal manipulation requires a thorough medical history, assessment, diagnosis and plan of management. Manipulative therapists, including chiropractors, must rule out contraindications to HVLA spinal manipulative techniques. Absolute contraindications refers to diagnoses and conditions that put the patient at risk to developing adverse events. For example, a diagnosis of rheumatoid arthritis and other conditions that structurally destabilizes joints, is an absolute contraindication of SMT to the upper cervical spine. Relative contraindications, such as osteoporosis are conditions where increased risk is acceptable in some situations and where mobilization and soft-tissue techniques would be treatments of choice. Most contraindication apply only to the manipulation of the affected region.[14]

Adverse events in SM studies are believed to be under-reported [15] and appear to be more common following HVLA manipulation than mobilization.[16] Mild, frequent and temporary adverse events occur in SMT which include temporary increase in pain, tenderness and stiffness.[17] These events typically dissipates within 24-48 hours [18] Serious injuries and fatal consequences , especially to SM in the upper cervical region, can occur.[19] but are regarded as rare when spinal manipulation is employed skillfully and appropriately.[14]

There is considerable debate regarding the relationship of spinal manipulation to the upper cervical spine and stroke. Stoke is statistically associated with both general practitioner and chiropractic services in persons under 45 years of age suggesting that these associations are likely explained by preexisting conditions.[20][21][22]Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke.[23] A 2012 systematic review determined that there is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.[24]

See also

References

  1. ^ Keating JC Jr (2003). "Several pathways in the evolution of chiropractic manipulation". J Manipulative Physiol Ther. 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626.
  2. ^ Herzog W, Symons B. (2001). "The biomechanics of spinal manipulation". Crit Rev Phys Rehabil Med. 13 (2): 191–216.
  3. ^ a b Evans DW, Breen AC. (2006). "A biomechanical model for mechanically efficient cavitation production during spinal manipulation: prethrust position and the neutral zone". J Manipulative Physiol Ther. 29 (1): 72–82. doi:10.1016/j.jmpt.2005.11.011. PMID 16396734.
  4. ^ Brodeur R. (1995). "The audible release associated with joint manipulation". J Manipulative Physiol Ther. 18 (3): 155–64. PMID 7790795.
  5. ^ Unsworth A, Dowson D, Wright V. (1971). "'Cracking joints'. A bioengineering study of cavitation in the metacarpophalangeal joint". Ann Rheum Dis. 30 (4): 348–58. doi:10.1136/ard.30.4.348. PMC 1005793. PMID 5557778.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ Fryer GA, Mudge JM, McLaughlin PA (2002). "The effect of talocrural joint manipulation on range of motion at the ankle". Journal of Manipulative and Physiological Therapeutics. 25 (6): 384–90. doi:10.1067/mmt.2002.126129. PMID 12183696.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ Nilsson N, Christensen H, Hartvigsen J (1996). "Lasting changes in passive range motion after spinal manipulation: a randomized, blind, controlled trial". J Manipulative Physiol Ther. 19 (3): 165–8. PMID 8728459.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ Murphy BA, Dawson NJ, Slack JR (1995). "Sacroiliac joint manipulation decreases the H-reflex". Electromyography and clinical neurophysiology. 35 (2): 87–94. PMID 7781578. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  9. ^ Tullberg T, Blomberg S, Branth B, Johnsson R (1998). "Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis". Spine. 23 (10): 1124–8, discussion 1129. doi:10.1097/00007632-199805150-00010. PMID 9615363. Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  10. ^ Senstad O, Leboeuf-Yde C, Borchgrevink C (1997). "Frequency and characteristics of side effects of spinal manipulative therapy". Spine. 22 (4): 435–40, discussion 440–1. doi:10.1097/00007632-199702150-00017. PMID 9055373. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  11. ^ Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992). "Spinal manipulation for low-back pain". Ann Intern Med. 117 (7): 590–598. PMID 1388006.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  12. ^ Burke, G.L., "Backache from Occiput to Coccyx" Chapter 7
  13. ^ Maitland, G.D. Peripheral Manipulation 2nd ed. Butterworths, London, 1977.
    Maitland, G.D. Vertebral Manipulation 5th ed. Butterworths, London, 1986.
  14. ^ a b Anderson-Peacock E, Blouin JS, Bryans R; et al. (2005). "Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash" (PDF). J Can Chiropr Assoc. 49 (3): 158–209. PMC 1839918. PMID 17549134. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
    • Anderson-Peacock E, Bryans B, Descarreaux M; et al. (2008). "A Clinical Practice Guideline Update from The CCA•CFCREAB-CPG" (PDF). J Can Chiropr Assoc. 52 (1): 7–8. PMC 2258235. PMID 18327295. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  15. ^ Ernst E, Posadzki P (2012). "Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review". N Z Med J. 125 (1353): 87–140. PMID 22522273.
  16. ^ Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM (2005). "Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study". Spine. 30 (13): 1477–84. doi:10.1097/01.brs.0000167821.39373.c1. PMID 15990659. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  17. ^ Ernst, E (2007). "Adverse effects of spinal manipulation: a systematic review". Journal of the Royal Society of Medicine. 100 (7): 330–8. doi:10.1258/jrsm.100.7.330. ISSN 0141-0768. PMC 1905885. PMID 17606755. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help); Unknown parameter |month= ignored (help)
  18. ^ Gouveia LO, Castanho P, Ferreira JJ (2009). "Safety of chiropractic interventions: a systematic review". Spine. 34 (11): E405–13. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Thiel HW, Bolton JE, Docherty S, Portlock JC (2007). "Safety of chiropractic manipulation of the cervical spine: a prospective national survey". Spine. 32 (21): 2375–8. doi:10.1097/BRS.0b013e3181557bb1. PMID 17906581.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Hurwitz EL, Carragee EJ, van der Velde G; et al. (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  21. ^ Paciaroni M, Bogousslavsky J (2009). "Cerebrovascular complications of neck manipulation". Eur Neurol. 61 (2): 112–8. doi:10.1159/000180314. PMID 19065058.
  22. ^ Cassidy, JD (15). "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study". Spine. 33 (4 Suppl): S176-83. PMID 18204390. {{cite journal}}: |access-date= requires |url= (help); Check date values in: |date= and |year= / |date= mismatch (help); Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)
  23. ^ Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist. 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ. (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice. 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMID 22994328.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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