Manual & Manipulative Therapies for Spine Patients

[Justin]

Introduction to Manual and Manipulative Therapy

Manipulative and Body-Based Methods

Therapeutic massage and chiropractic and osteopathic manipulation are the best known of the manual therapies. Massage is widely practiced and licensed in 25 states. Manipulation procedures are practiced largely within chiropractic and osteopathic systems that emerged in the American heartland in the late 19th century. Both fields originally proposed that vertebral misalignments contribute to many diseases, each of which could be treated by appropriate manipulations. There were strong efforts by allopathic organizations to discredit chiropractic and osteopathic medicine. In part as reactions to these challenges, chiropractic medicine evolved as a discrete discipline that primarily uses spinal manipulation, most often to address musculoskeletal problems. Four years of postgraduate education lead to a Doctor of Chiropractic (DC) degree, and chiropractic physicians are licensed to practice in all states.

Osteopathic medicine also may use manipulative techniques, but historical differences between osteopathic medicine and allopathic medicine otherwise have disappeared. Other than teaching manipulation, undergraduate medical training for an osteopathic degree (DO) is now virtually indistinguishable from that which leads to the MD degree. Osteopathic physicians complete conventional residencies in osteopathic or allopathic hospitals and training programs, are licensed in all states, and have rights and responsibilities, such as military service, that are identical to those of allopathic physicians and surgeons.

From Chapter 34: Complementary and Alternative Medicine. Goldman: Cecil Textbook of Medicine, 22nd ed. Saunders. 2004. via Wikipedia

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Physical Therapists

Physical therapists provide services that help restore function, improve mobility, relieve pain, and prevent or limit permanent physical disabilities of patients suffering from injuries or disease. They restore, maintain, and promote overall fitness and health. Their patients include accident victims and individuals with disabling conditions such as low-back pain, arthritis, heart disease, fractures, head injuries, and cerebral palsy.

Therapists examine patients’ medical histories and then test and measure the patients’ strength, range of motion, balance and coordination, posture, muscle performance, respiration, and motor function. Next, physical therapists develop plans describing a treatment strategy and its anticipated outcome.

Treatment often includes exercise, especially for patients who have been immobilized or who lack flexibility, strength, or endurance. Physical therapists encourage patients to use their muscles to increase their flexibility and range of motion. More advanced exercises focus on improving strength, balance, coordination, and endurance. The goal is to improve how an individual functions at work and at home.

Physical therapists also use electrical stimulation, hot packs or cold compresses, and ultrasound to relieve pain and reduce swelling. They may use traction or deep-tissue massage to relieve pain and improve circulation and flexibility. Therapists also teach patients to use assistive and adaptive devices, such as crutches, prostheses, and wheelchairs. They also may show patients how to do exercises at home to expedite their recovery.

As treatment continues, physical therapists document the patient’s progress, conduct periodic examinations, and modify treatments when necessary.

Physical therapists often consult and practice with a variety of other professionals, such as physicians, dentists, nurses, educators, social workers, occupational therapists, speech-language pathologists, and audiologists.

Some physical therapists treat a wide range of ailments; others specialize in areas such as pediatrics, geriatrics, orthopedics, sports medicine, neurology, and cardiopulmonary physical therapy.

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2008-09 Edition, Physical Therapists, on the Internet at Physical Therapists (visited June 27, 2009).

To find a Physical Therapist in your area--> Click here to go to the American Physical Therapy Association's website.

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Physical Medicine and Rehabilitation (PM&R) Physicians

Rehabilitation physicians are nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move. Rehabilitation physicians have completed training in the medical specialty physical medicine and rehabilitation (PM&R).

Rehabilitation physicians treat a wide range of problems from sore shoulders to spinal cord injuries. Their goal is to decrease pain and enhance performance without surgery. Rehabilitation physicians take the time needed to accurately pinpoint the source of an ailment. They then design a treatment plan that can be carried out by the patients themselves or with the help of the rehabilitation physician’s medical team. This medical team might include other physicians and health professionals, such as neurologists, orthopedic surgeons, and physical therapists. By providing an appropriate treatment plan, rehabilitation physicians help patients stay as active as possible at any age. Their broad medical expertise allows them to treat disabling conditions throughout a person’s lifetime.

Copyright ©2009 AAPM&R All Rights Reserved

The physiatrist is specially trained in management of musculoskeletal disorders and various other entities including pharmacologic control of spasticity, chronic pain, bowel and bladder management, and behavioral training in head-injured patients. Invasive techniques such as injections are options for arthritis, bursitis, tenosynovitis, overuse, and myofascial pain syndromes.

Physical medicine refers to the use of physical principles and dynamic intervention to decrease pain, improve range of motion, and maximize musculoskeletal function.

Examples of these agents are listed in Table 1 below:

Type

Specific Modality

superficial

cold ice massage, ice baths

superficial heat

hot packs, heat lamp, paraffin baths, fluidotherapy

deep heat

ultrasound, short wave, microwave

electricity

transcutaneous nerve stimulation (TENS), high voltage galvanic stimulation (HVGS),
interferential current, iontophoresis, functional electrical stimulation (FES)

hydrotherapy

whirlpool, contrast baths

manual

massage, manipulation

other

traction, biofeedback, positive pressure pumping, phonophoresis,
laser, ultraviolet light, microwave diathermy

The physiatrist is also trained in writing specific exercise programs tailored to the patient's needs. The emphasis is on maintaining and increasing range of motion, muscular strengthening, improving proprioception (awareness of joint position in space) muscle relaxation, and aerobic fitness, all in the context of improving function. Examples might include strengthening and enhancing proprioception in a runner's sprained ankle, improving range of motion and preventing contracture in a spastic spinal-cord-injured patient, or providing optimal cardiopulmonary fitness in someone who has recently suffered a myocardial infarction.

Also available to the physiatrist is a host of assistive and adaptive equipment including gait and mobility aids, environmental control devices, communication aids, and various other tools to allow greater independence, optimal safety, and decreased energy expenditure in activities of daily living (ADLs).

One area of expertise is the selection and fitting of wheelchairs and appropriate seating. The PM&R physician is also specially trained to prescribe proper orthoses (e.g., upper and lower limbs, and back bracing) and to recommend prostheses to amputee patients.

Much of the practice of PM&R is built on the "team approach," a unique interdisciplinary perspective on patient care. The patient's physical, functional, emotional, and psychosocial well-being are all considered in treatment. The typical members of a rehabilitation team, in addition to the physiatrist, might include representatives from:

• physical therapy
• recreational therapy
• social services
• internal medicine
• occupational therapy
• rehabilitation nursing
• speech therapy
• neuropsychology

If patient contact is high on your list of priorities, this field offers the opportunity to work closely with individuals who have long-term disabilities and could continue to have changing needs with advancing age. This provides the satisfaction of observing the response to therapeutic intervention over a longer period of time. In a sense, the physiatrist may serve the role of the "primary caregiver" for individuals with disabilities.

Copyright ©2009 AAPM&R All Rights Reserved

Here's a link to a thread in this Forum about PM&R physicians. <-- Clickable link.

To find a rehabilitation physician in your area, search the "Find a PM&R Physician database" on the AAPM&R website. <-- Clickable link.

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Doctor of Osteopathic Medicine (DO)
specializing in Osteopathic Manipulative Medicine (OMM)

Osteopathic Manipulative Treatment

With osteopathic manipulative treatment (OMT), D.O.s use their hands to diagnose injury and illness and to encourage the body’s natural tendency toward good health. OMT involves moving a patient’s muscles and joints using techniques including stretching, gentle pressure and resistance. D.O.s are specially trained in the nervous system and the musculoskeletal system. OMT can be used to help patients with a number of health problems, such as back pain.

Osteopathic Physician (D.O.)

Osteopathic physicians (D.O.s) are fully licensed to prescribe medication and practice in all specialty areas, including surgery. The osteopathic medical philosophy emphasizes preventive health care and focuses on the unity of all body parts. Instead of just treating specific symptoms or illnesses, D.O.s regard the body as an integrated whole and they help patients develop attitudes and lifestyles that help prevent illness. D.O.s also receive extra training in the musculoskeletal system – the body’s interconnected system of nerves, muscles and bones that make up two-thirds of its body mass. This training provides osteopathic physicians with a better understanding of the ways that an injury or illness in one part of the body can affect another. Furthermore, D.O.s incorporate osteopathic manipulative treatment (OMT) into their medical care. With OMT, osteopathic physicians use their hands to diagnose injury and illness and to encourage the body’s natural tendency toward good health.

© Medpedia, Inc. 2007 - 2009

Osteopathic manipulative medicine (abbreviated as OMM) is an approach to manual therapy, a form of therapy that uses physical contact, used to improve the impaired or altered function of the musculo-skeletal system (somatic dysfunction). With roots in ancient Greek "frictions", manual manipulation has long been a part of health care. In the United States, its country of origin, OMM is used by Doctors of Osteopathic Medicine (D.O.s) along with surgery and medication in treatment of patients. Outside the United States, practitioners of osteopathy (who may have the qualification of D.O. as a Diploma of Osteopathy, but do not necessarily have the same medical training as an American-trained D.O.) generally limit their scope to manual manipulation.

Also, OMM is a treatment that is intended to be used in conjunction with mainstream treatments where it is deemed appropriate. It is rarely used as a primary treatment regimen unless the D.O. is absolutely certain that the patient's problems are a result of a musculoskeletal somatic dysfunction. Furthermore, as with other medical treatment methodologies, there are certain situations where use of OMM is strictly contraindicated (for example, cervical spine HVLA techniques may never be used on patients with Down Syndrome).

While this OMM practice is traditionally ascribed to D.O.'s, it should also be noted that there are M.D. practitioners of OMM since many Osteopathic medical schools have created training programs for their M.D. counterparts. Recently OMM training programs have likewise been extended to other medical professionals including, but not limited to: Physician Assistants, Nurse Practitioners, Nurses, etc.

There are different techniques applied to the musculoskeletal system as OMM. These techniques can be applied to the joints, their surrounding soft tissues, muscles and fasciae.

From Wikipedia.

The techniques below are all clickable links:

Balanced Ligamentous Tension (BLT)

Counterstrain

Cranialsacral Therapy

High Velocity Low Amplitude Thrust

Joint Mobilization - Articulatory Techniques

Lymphatic Pump

Muscle Energy Technique (MET)

Myofascial Release

Neuromuscular Therapy (Trigger Points)

Soft Tissue Technique

Visceral Manipulation

I usually don't link to Wikipedia, but the techniques above are described well. Link --> Click here
(Wikipedia is great for a quick answer, but it's not peer reviewed; however, Medpedia is peer reviewed but the article on OMM is short, unfortunately.)

To find a DO that specializes in OMM, click here for the American Osteopathic Association's "Find a DO database." <-- Clickable link.

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Chiropractic

Chiropractors, also known as doctors of chiropractic or chiropractic physicians, diagnose and treat patients with health problems of the musculoskeletal system and treat the effects of those problems on the nervous system and on general health. Many chiropractic treatments deal specifically with the spine and the manipulation of the spine. Chiropractic medicine is based on the principle that spinal joint misalignments interfere with the nervous system and can result in lower resistance to disease and many different conditions of diminished health.

The chiropractic approach to health care stresses the patient’s overall health. Chiropractors provide natural, drugless, nonsurgical health treatments, relying on the body’s inherent recuperative abilities. They also recognize that many factors affect health, including exercise, diet, rest, environment, and heredity. Chiropractors recommend changes in lifestyle that affect those factors. In some situations, chiropractors refer patients to or consult with other health practitioners.

Like other health practitioners, chiropractors follow a standard routine to get information needed to diagnose and treat patients. They take the patient’s medical history; conduct physical, neurological, and orthopedic examinations; and may order laboratory tests. X rays and other diagnostic images are important tools because of the chiropractor’s emphasis on the spine and its proper function. Chiropractors also analyze the patient’s posture and spine using a specialized technique. For patients whose health problems can be traced to the musculoskeletal system, chiropractors manually adjust the spinal column.

Some chiropractors use other alternative medicines in their practices, including therapies using water, light, massage, ultrasound, electric, acupuncture, and heat. They also may apply supports such as straps, tapes, and braces to manually adjust the spine. Chiropractors counsel patients about health concepts such as nutrition, exercise, changes in lifestyle, and stress management, but chiropractors do not prescribe drugs or perform surgery.

In addition to general chiropractic practice, some chiropractors specialize in sports injuries, neurology, orthopedics, pediatrics, nutrition, internal disorders, or diagnostic imaging.

Many chiropractors are solo or group practitioners who also have the administrative responsibilities of running a practice. In larger offices, chiropractors delegate these tasks to office managers and chiropractic assistants. Chiropractors in private practice are responsible for developing a patient base, hiring employees, and keeping records.

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2008-09 Edition, Physical Therapists, on the Internet at Chiropractors (visited June 27, 2009).

To find a Chiropractor in your area through the American Chiropractic Association's database, Click here.

I hope this helps.

[cavalier]

Under this catesgory - you can add Prolotherapy as well many are DC's and some are MD's or DO's who can offer Prolotherapy - this wont work on the disc's themselves BUT it will help ligaments repair - it is felt weak ligaments are contributary to the degeneration fo discs by many doc's so the idea is to strengthen the ligaments before the discs are too far gone. It does have proven worth.

One quik note on the DO's - my bro is now a retired DO - even though trained initially as you noted on muscle skeletal more in depth generally than MD's are - many of the DO's depending on what field they get into can be very removed from manipulations as dont use it you loose it over time. The ONE big thing on a DO is they see & try to treat the whole body & are more into preventative as a whole - they see & get more cause & affect to not just one segment but the bigger picture as they believe it is all connnected largely. For example I tried to find a DO here to do manipulations as theirs tend to be more lasting not as often as a Chiro & not as hard but the DO's here are either into Family practice and other fields. My bro was a ER doc & then a Director over one of the Univ. of Iowa satellite hospitals and before that was in private practice as a family doc for many yrs. I hope this helps - so you have to find out what that DO does many dont use alot of that as my Bro said he had lost much of that as it was not used. They tend to be less drug oriented in general terms. This is what I ahve gathered from a few DO's over the yr's & from talks with my bro. He never liked the idea of fusion if one could avoid it as he felt it upset the dynamics of what the spine was intended to do is to move & put as we know more stress on the other segments. Jill
in rI

[cavalier]

Oddly here in our town one Physical Med doctor does do Manipulation under anesthesia for the spine. I believe this is for the lumbar only lpoint being it pays to ask around as sometimes specialists overlap a bit. One MD in our area moved here from another state & needs to do the state licensing for continuing ed for Prolotherapy once that is completed he hopes to be able to practice that again here - Jill

[Justin]

Under this catesgory - you can add Prolotherapy as well many are DC's and some are MD's or DO's who can offer Prolotherapy - this wont work on the disc's themselves BUT it will help ligaments repair - it is felt weak ligaments are contributary to the degeneration fo discs by many doc's so the idea is to strengthen the ligaments before the discs are too far gone. It does have proven worth.

One quik note on the DO's - my bro is now a retired DO - even though trained initially as you noted on muscle skeletal more in depth generally than MD's are - many of the DO's depending on what field they get into can be very removed from manipulations as dont use it you loose it over time.

Thanks for the information on prolotherapy. Regarding the Doctors of Osteopathic Medicine: the ones that specifically go into the field of Osteopathic Manipulative Medicine (OMM) are some of the only DOs that do manipulations. You will see some Primary Care DOs offer it to their patients, but you will rarely see the Cardiologist / Neurosurgeon / Orthopedic Surgeon offer manipulations to patients--they are far removed from their training in medical school and don't have time to use it.

Thus patients should seek out DOs that specialized in OMM for manipulations.

Thanks Jill!