11830 Westline Industrial Drive St. Louis, Missouri 63146 MANUAL PHYSICAL THERA PY OF THE SPINE ISBN: 978-1-4160-4749-0 Copyright © 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitt ed in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: healthpermissions@ elsevier.com. You may also complete your request on-line via the Elsevier website at htt p://www.elsevier. com/permissions. Notice Neither the Publisher nor the Author assumes any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. Th e Publisher Library of Congress Cataloging-in-Publication Data Olson, Kenneth A. Manual physical therapy of the spine / Kenneth A. Olson. – 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4160-4749-0 (pbk. : alk. paper) 1. Spine–Diseases–Treatment. 2. Manipulation (Th erapeutics) 3. Temporomandibular joint–Diseases. I. Title. [DNLM: 1. Spinal Diseases–therapy. 2. Manipulation, Orthopedic. 3. Physical Th erapy Modalities. 4. Spinal Diseases–diagnosis. 5. Temporomandibular Joint Disorders– diagnosis. 6. Temporomandibular Joint Disorders–therapy. WE 725 O52m 2009] RD768.O57 2009 617.4′7106–dc22 2008013022 Vice President and Publisher: Linda Duncan Executive Editor: Kathy Falk Senior Developmental Editor: Christie M. Hart Publishing Services Manager: Patricia Tannian Senior Project Manager: Anne Altepeter Design Direction: Renee Duenow Working together to grow libraries in developing countries www.elsevier.com | www.bookaid.org | www.sabre.org Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 http://avaxho.me/blogs/ChrisRedfield To my wife, Janet, and children, Will and Emma, for their love and support, and for bringing joy to my life To my parents, John and Anna Mae, for providing a solid foundation to grow and learn To my grandmother, Miriam, for instilling a passion for helping and teaching Foreword Dr. Ken Olson’s textbook, ManualPhysicalTh erapyofthe DVD further facilitate instruction and learning of the Spine, is a welcome addition to the manual therapy litera- manual examination and manipulation techniques. A great ture. Ken’s strong clinical and academic backgrounds asset to students and clinicians, the video clips highlight patient provide him with the requisite perspective to write a textbook and therapist position and force application throughout each that is both relevant and practical. Writing a textbook with a demonstration. broad target audience in mind – physical therapist practitio- Th e textbook provides a thorough theoretical grounding ners, residents and students, physicians, and other manual ther- from the perspective of a physical therapist, making it essential apy practitioners – can be very challenging, but I believe Ken background information for physical therapist students, resi- has easily met this challenge. dents, and fellows. Th e material is also of value to practitioners Chapters 1 through 3 are of primary interest to the physical outside the physical therapy profession, because it promotes therapy community. Understanding the history of and theories bett er understanding of where we as professions overlap behind manual therapy – thrust joint manipulation in particu- and where we diverge. Dr. Olson’s thorough literature review lar – is essential for the appropriate use of such techniques. promotes an evidence-based approach to utilization of manual Th e history of spinal manipulation clearly provides evidence therapy techniques. If this approach is adopted by all inter - supporting the claim that no single “modern” health care pro- ested parties, then similarities between the various profes- fession invented or owns this intervention. What makes the sions should increase and the diff erences over time should various invested professions unique are the underlying disappear. rationale and terminology associated with their use of these ManualPhysicalTh erapyoftheSpine provides readers with procedures. the perfect blend between theory and practice. Th e textbook is Chapters 4 through 7 provide a fantastic array of examina- a rich teaching resource for physical therapist academic faculty tion and treatment techniques that are of interest to all manual and residency/fellowship instructors. For students, residents, therapy practitioners. Th e illustrations are clear and easy to and fellows, the textbook is invaluable not only during their follow. Learning a technique through drawings and photo- educational experience but also beyond. Dr. Olson is to be graphs is not easy, but the superb fi gures in this textbook allow commended and applauded for his eff orts to provide us with a a novice practitioner to begin appreciating the nuances of ther- textbook that is relevant to today’s practice and will remain so apist hand placement, applied direction of force, and patient far into the future. positioning, thus facilitating student and practitioner skill development and confi dence. Video clips on the accompanying William G. Boissonnault, PT, DHSc, FAAOMPT vii Preface This textbook has integrated an impairment-based manual Chapter 1 provides an introduction to the components of physical therapy approach with use of research evidence the textbook, presents the essential elements of an impairment- to support management of spinal and temporomandibu- based manual physical therapy approach, reviews the history of lar joint (TMJ) conditions. Th e textbook provides the neces- manipulation with the physical therapy profession, and intro- sary background information and detailed instructional duces the essential defi nitions and principles of evidence-based materials to allow full integration of manipulation and manual practice and manual physical therapy. physical therapy examination and treatment procedures of the Chapter 2 provides a framework for completing a compre- spine into physical therapist professional education and clini- hensive spinal examination, including medical screen, patient cal practice. Additionally, the textbook advocates for physical interview, disability assessment, and tests and measures. In therapists, physicians, and other health professionals to follow addition, evaluation of the examination fi ndings and principles the recommendations of high-quality clinical practice guide- involved in arriving at a diagnosis and plan of care are included. lines and systematic reviews for management of spinal and Th e tests and measures presented in this chapter are the TMJ disorders and provides the necessary background and basic examination procedures used to screen the spine or are instructional information to assist in skill development to techniques used across anatomical regions to complete a com- eff ectively implement the evidence-based treatment recom- prehensive spinal examination. Additional special tests and mendations related to manual therapy, manipulation, and ther- manual examination procedures, such as passive intervertebral apeutic exercise. motion tests, are presented in detail in subsequent chapters Th e primary audience for this textbook is physical therapy that focus on each anatomical region of the spine. students and faculty in professional physical therapist educa- Chapter 3 includes the principles related to the practice tion programs. Th e secondary audience for this textbook is of mobilization/manipulation. Th eories are described to practicing physical therapists, chiropractors, and physicians explain the eff ects of manipulation, and the available re - who wish to keep up with what is being taught in professional search to support each theory is presented. A brief overview physical therapist education programs. Additionally, persons of evidence to support the use of manipulation is presented; in manual physical therapy residency, fellowship, and post- further detail regarding the evidence is provided in the professional degree programs in orthopaedic and manual phys- chapters that cover anatomical regions. Potential adverse ical therapy will fi nd this textbook to be a useful adjunct to eff ects and contraindications to manipulation are discussed, other instructional materials. and concepts of learning and teaching manipulation are also Although physical therapists have been practicing man- presented. ipulation since the inception of the profession, all physical Chapters 4 through 7 provide a review of evidence to sup- therapist professional degree programs in the United States port the examination and treatment techniques presented in must now demonstrate full integration of both thrust and the chapter as well as the kinematics and functional anatomy nonthrust joint manipulation in the curriculum to maintain of the anatomical areas to be covered in the chapter. Anatomi- accreditation. Th e textbook and accompanying DVD pro - cal areas are organized as follows: lumbopelvic, thoracic vide physical therapist education faculty and students and rib cage, cervical spine, and temporomandibular joint. with detailed instructional materials to eff ectively instruct Classifi cation of common conditions treated by physical and learn manipulation. Th e textbook also provides the research therapists is presented in each chapter to assist with clinical evidence to successfully integrate the use of manual physical decision making, and patient management principles are therapy procedures into the management of spinal and TMJ addressed for each condition. Detailed descriptions of exami- disorders. nation and manual therapy treatment procedures are the pri- ix x PREFACE mary emphasis of each chapter and the DVD. Common Th ree cameras were used to fi lm each examination and treat- exercises to address each diagnostic classifi cation are also ment technique from frontal, lateral, and cranial views, to allow included in each chapter. a unique three-dimensional perspective in order to appreciate In addition to providing the necessary research evidence to each procedure. I provide oral step-by-step instruction of each support a manual physical therapy approach for management procedure with the demonstrations. In the textbook an icon of spinal and TMJ disorders, the book provides detailed is used to alert readers to procedures that are demonstrated descriptions and multiple photographs of each examination on the DVD. Course instructors can use the DVD to present and treatment procedure. Many of the manipulation tech- the techniques, and students can use the DVD to review most niques also include alternative methods to match various clini- of the manual therapy procedures included in the textbook. cal situations. Th e textbook and DVD will be very useful additions to the Professional photographer Jim Womack took the photo- permanent library of clinicians who practice manual therapy graphs. Multiple angles are presented of many techniques on techniques to manage spinal disorders. Although the body of live and anatomical models to clearly illustrate hand and body research evidence will continue to evolve over time, the tech- placement. Arrows are also used with many techniques to illus- nique descriptions and presentations will remain as valuable trate direction of force application. resources to reference when practitioners are presented with A professional media production team led by Gary Bargholz various spinal and TMJ disorders in the future. with Guy Simoneau, PT, PhD, fi lmed the DVD segments at Marquett e University, providing professional-quality clips. Kenneth A. Olson Acknowledgments Professionally, I am indebted to the infl uence and mentor- practice and my current and past students who have challenged ship of Stanley Paris and the faculty and staff of the Uni- me to fi nd bett er ways to teach and practice manual physical versity of St. Augustine for Health Sciences who guided therapy. my graduate education. Other professional mentors include Kathy Falk, Christie Hart, and Anne Altepeter have been Bill Boissonnault, Tim Dunlop, Laurie Hartman, Mary Jane helpful and effi cient at Elsevier in helping to move this book Harris, Trish King, David Lamb, Steve McDavitt , Catherine along in a timely manner. Jim Womack took the photographs Patla, and Mariano Rocabodo. I am grateful to Guy Simoneau, used in the textbook. Charlie Cardon provided the mobiliza- Elaine Lonnemann, Ron Schenk, and Josh Cleland for review- tion table (Cardon Rehabilitation Products, Niagra Falls, N.Y.) ing multiple chapters of the textbook and providing useful used for the DVD, and the excellent DVD was fi lmed at feedback to improve the quality of the project and to Jacob Marquett e University. Slusser, who worked with me when he was a student physical therapist to develop the format used to describe the manipula- Kenneth A. Olson tion techniques. I also acknowledge my colleagues in private xi CHAPTER 1 Introduction OVERVIEW This chapter introduces the purpose of the textbook, describes the history of manipulation, defines common terminology used in the textbook, introduces evidence-based principles, and provides an explanation for use of the textbook and the accompanying DVD. OBJECTIVES ■ Describe the purpose of the textbook and DVD ■ Explain the philosophy of treatment used in orthopaedic manual physical therapy ■ Describe the history of manipulation ■ Define common terminology used in orthopaedic manual physical therapy ■ Explain evidence-based principles for assessment of the reliability and validity of clinical examination procedures and clinical trials ■ Explain how to use this textbook and DVD PURPOSE Th e purpose of this textbook is to provide the necessary back- Th e intent of this textbook and DVD is to provide physical ther- ground information and detailed instructional materials to apist programs detailed instructional materials for more eff ec- allow full integration of manipulation and manual physical tive instruction of manipulation. therapy examination and treatment procedures of the spine Prerequisites in the curriculum should include clinical into physical therapist professional education and clinical tests and measures for musculoskeletal conditions, including practice. manual muscle testing, muscle length testing, and goniometry. Th e primary audience for this textbook is physical therapy Knowledge of therapeutic exercise, anatomy, physiology, and students and faculty in professional physical therapist educa- functional anatomy and biomechanics should also precede tion programs. Th e secondary audience is practicing physical instruction in manipulation. Each chapter provides a review therapists, chiropractors, and osteopathic physicians who want of the evidence to support the examination and treatment to keep current with professional physical therapist education techniques presented in the chapter and the kinematics and programs. In addition, this textbook is a useful adjunct to other functional anatomy of the anatomic areas covered in the chap- instructional materials for manual physical therapy residency, ter. Classifi cation of common conditions treated by physical fellowship, and postprofessional degree programs in orthopae- therapists is presented in each chapter to assist with clinical dic and manual physical therapy. decision making, and patient management principles are Although physical therapists have been practicing manipu- addressed for each condition. Detailed descriptions of exami- lation since the inception of the profession, as of January 2006, nation and manual therapy treatment procedures are the pri- all physical therapist professional degree programs must dem- mary emphasis of each chapter and the DVD. Common onstrate full integration of both thrust and nonthrust joint exercises to address each diagnostic classifi cation are also manipulation in the curriculum to maintain accreditation.1,2 included in each chapter. 1 2 CHAPTER 1 Introduction HISTORY OF MANIPULATION they are focused on other specialty areas such as internal medi- cine or emergency medicine. Osteopathy in many European Manipulation in recorded history can be traced to the days of countries remains primarily a manual therapy profession. Hippocrates, the father of medicine (460-355 bc). Evidence is Chiropractic was founded in 1895 by Daniel David Palmer. seen in ancient writings that Hippocrates used spinal traction One of the fi rst graduates of the Palmer School of Chiropractic methods. In the paper “On Sett ing Joints by Leverage,” Hip- in Davenport, Iowa, was Palmer’s son B.J. Palmer, who later pocrates describes the techniques used to manipulate a dislo- ran the school and promoted the profession. D.D. Palmer cated shoulder of a wrestler.3 Succussion was also practiced in was a storekeeper and a “magnetic healer.” According to leg- the days of Hippocrates. Th e patient was strapped in an inverted end, in 1895, he used a manual adjustment directed to the position to a rack that was att ached to ropes and pulleys along fourth thoracic vertebra that resulted in the restoration of a the side of a building. Th e ropes were pulled to elevate the man’s hearing.8 Th e original chiropractic philosophy is based patient and the rack as much as 75 feet, at which time the ropes on the “Th e Law of the Nerve” that states that adjustment of a were released and the patient crashed to the ground to receive a subluxed vertebra removes impingement on the nerve and distractive thrust as the rack impacted the ground.4 Six hun- restores innervation and promotes healing of disease pro- dred years later, Galen wrote extensively on manipulation pro- cesses.3 Th e “straight” chiropractors continue to adhere to cedures in medicine.3 Palmer’s original subluxation theories and use spinal adjust- Th e Middle Ages saw litt le advance in the practice of medi- ments as the primary means of treatment. Th e “Mixers” incor- cine and manipulation because of the reliance on the church for porate other rehabilitative interventions into the treatment most healing.3 In the Renaissance era, Ambrose Paré emerged. options, including physical modalities such as therapeutic Paré was a famous French physician and surgeon in the 1500s3 ultrasound and exercise. who used armor to stabilize the spine in patients with tuber- Physical therapy evolved from medicine to provide physical culosis.4 His manipulation and traction techniques were sim- treatments such as manual physical therapy within the medical ilar to those of Hippocrates, but he opposed the use of model. In 1899, the Chartered Society of Physiotherapy was succussion.4 founded in England.3 Physical therapists formed their fi rst Th e bone sett ers fl ourished in Europe from the 1600s professional association in the United States in 1921, originally through the late 1800s. Friar Moulton in 1656 published the named the American Women’s Physical Th erapeutic Associa- text Th e Complete Bone-Sett er. Th e book was later revised by tion.1 As the Association grew in the 1930s and men became Robert Turner.4 No formal training was required for bone set- physical therapists, the organization eventually changed its ters; the techniques were oft en learned from family members name to the American Physical Th erapy Association (APTA).1 and passed down from one generation to the next. Th e clicking Between 1921 and 1936, at least 21 articles and book reviews sounds that occurred with manipulation were thought to be the on manipulation were found in the physical therapy literature,9 result of bones moving back into place.4 including the second edition of the book Massage and Th erapeu- In 1871, Wharton Hood published the book On Bone- tic Exercise by the founder and fi rst President of the APTA, Sett ing, which was the fi rst such book by an orthodox medical Mary McMillan. In a subsequent editorial,10 she wrote of the practitioner.5 Hood’s father had treated a bone sett er, Richard four branches of physiotherapy, which she identifi ed as “manip- Hutt on. Hutt on was grateful for the medical care and off ered to ulation of muscle and joints, therapeutic exercise, electrother- teach Hood’s father about bone sett ing. Instead, Wharton apy, and hydrotherapy.”11 Titles of articles during this period Hood accepted the off er. Hood thought that the snapping were quite explicit regarding manipulation, such as “Th e Art of sound with manipulation was the result of breaking joint adhe- Mobilizing Joints”12 and “Manipulative Treatment of Lumbo- sions.5 Paget6 believed that orthodox medicine should consider sacral Derangement.”13 Th e articles used phrases such as “adhe- the adoption of what was good and useful about bone sett ing sion . . . stretched or torn by this simple manipulation”14 and but should avoid what was potentially dangerous and useless. “manipulation of the spine and sacroiliac joint.”15 Th is usage Osteopathy was founded by Andrew Still in 1874. In 1896, helps to illustrate that manipulation has been part of physical the fi rst school of osteopathy was formed in Kirksville, Mo.4 therapy practice since the founding of the profession and Still developed osteopathy based on the “Rule of the Artery,” through the 1930s.9 with the premise that the body has an innate ability to heal and From 1940 to the mid 1970s, the word manipulation was not that with spinal manipulation to correct the structural align- widely used in the American physical therapy literature.3 Th is ment of the spine, the blood can fl ow to various regions of the omission may have been due in part to the American Medical body to restore the body’s homeostasis and natural healing Association’s Committ ee on Quackery that was formed in the abilities. Still’s philosophy placed an emphasis on the relation- 1960s and was active for the next 30 years in an att empt to dis- ship of structure to function and used manipulation to improve credit the chiropractic profession. Th e committ ee was forced to the spinal structure to promote optimal health.7 Th e osteo- dissolve in 1990 because of the Wilk’s “restraint of trade” case pathic profession continues to include manipulation in the that was upheld in the US Supreme Court.8 Because physical course curriculum but does not adhere to Still’s original treat- therapy remained within the mainstream medical model, ment philosophy. Many osteopathic physicians in the United the terms mobilization and articulation were used during this States do not practice manipulation on a regular basis because timeframe to separate physical therapy from chiropractic. CHAPTER 1 Introduction 3 However, physical therapists continued to practice various developed the I-IV grading system to further describe oscilla- forms of manipulation. tory manipulation techniques.21 Th rough the mid 1900s, several prominent European physi- Physical therapist Stanley Paris was originally from New cians infl uenced the practice of manipulation and the evolution Zealand. Early in his career, in 1961 and 1962, he was awarded of the physical therapist’s role as a manipulative therapist. In a scholarship to study manipulation in Europe and the United 1949, James Mennell published the fi rst edition of his textbook States.9 He had the opportunity to study with Cyriax, Stod- titled the Science and Art of Joint Manipulation. Mennell adapted dard, and Kaltenborn during this time and in 1965 published knowledge of joint mechanics in the practice of manipulation the textbook Spinal Lesion.19 In the late 1960s, Paris immigrated and coined the phrase “accessory motion”.16 to the United States, where he eventually completed his doc- James Cyriax published his classic Textbook of Orthopaedic toral work in neuroanatomy of the lumbar spine and developed Medicine in 1957. He made great contributions to orthopaedic extensive educational programs for postprofessional physical medicine with the development of detailed systematic exami- therapy education in manual physical therapy and manipula- nation procedures for extremity disorders, including refi ne- tion that eventually resulted in the formation the University of ment of isometric tissue tension signs, end feel assessment, and St Augustine for Health Sciences in St Augustine, Florida. Paris capsular patt erns.17 Cyriax att ributed most back pain to disor- also played key roles in formation of professional organizations ders of the intervertebral disc and used aggressive general in the United States, including the APTA Orthopaedic Section manipulation techniques that included strong manual traction and the American Academy of Orthopaedic Manual Physical forces to “reduce the disc.”17 Cyriax trained many physiothera- Th erapists (AAOMPT), two professional organizations that pists, including Stanley Paris and Freddy Kaltenborn, to carry have played roles in advocating for inclusion of manipulation on the skills and techniques required to eff ectively use within the scope of physical therapy practice and that have pro- manipulation. moted education, practice, and research in manual physical Alan Stoddard7 was a medical and osteopathic physician in therapy. Paris worked with physical therapists Maitland, England from the 1950s to the 1970s who used skillful specifi c Kaltenborn, and Gregory Grieve of the United Kingdom to manipulation technique and also mentored many physical form the International Federation of Manipulative Th erapists therapists, including Paris and Kaltenborn. Th ese therapists (IFOMT; Figure 1-1). both believed that the Cyriax approach to extremity conditions Th e IFOMT was founded in 1974 and represents organized was excellent but preferred Stoddard’s specifi c manipulation groups of manual/manipulative physical therapists around the techniques for the spine.18,19 world that have established stringent postgraduation special- John Mennell, the son of James Mennell, fi rst practiced ization educational programs in manual/manipulative physical medicine in England. In the 1960s, he immigrated to the therapy. Th e Federation sets educational and clinical standards United States, where he held many educational programs for and is a subgroup of the World Confederation of Physical Th er- physical therapists through the 1970s and 1980s to promote apy (WCPT). One organization of each WCPT country can be manipulation within the physical therapy profession. He pub- lished several textbooks including Joint Pain, Foot Pain, and Back Pain and coined the phrase “joint play.”20 Mennell brought att ention to sources of back pain other than the intervertebral disc. In the 1960s, several physical therapists emerged as interna- tional leaders in the practice and instruction of manipulation. Physical therapist Freddy Kaltenborn, originally from Norway, developed what is now known as the Nordic approach. He pub- lished his fi rst textbook on spinal manipulation in 1964 and was the fi rst to relate manipulation to arthrokinematics.18 His techniques were specifi c and perpetuated the importance of biomechanical principles such as the concave/convex and arthrokinematic rules. Kaltenborn also developed extensive long-term training programs for physical therapists to special- ize in manual therapy fi rst in Norway and later throughout FIGURE 1-1 Photograph was taken in 1974 in Montreal, Canada, Europe. at the successful formation of the International Federation of Australian physical therapist Geoff rey Maitland published Orthopaedic Manipulative Therapists (IFOMT). Dr. Paris was the fi rst edition of his book Vertebral Manipulation in 1964.21 Chair of the conference. The other three individuals were Maitland was also infl uenced by the work of Cyriax and Stod- consultants to the process and had served in that capacity for dard but further refi ned the importance of a detailed history 6 years before this event. IFOMT later became a subsection of the World Confederation for Physical Therapy. From left: and comprehensive physical examination. He also developed Geoffrey Maitland, Stanley Paris, Freddy Kaltenborn, and the concept of treatment of “reproducible signs” and inhibition Gregory Grieve. (From Paris SV: Phys Ther 86(11):1541-1553, of joint pain with use of gentle oscillatory techniques. Maitland 2006.)