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Manipulation for hallux valgus

Discussion in 'General Issues and Discussion Forum' started by Hylton Menz, Oct 12, 2005.

  1. Hylton Menz

    Hylton Menz Guest

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    From the latest Clinical Chiropractic :

    A pilot study of the efficacy of a conservative chiropractic protocol using graded mobilization, manipulation and ice in the treatment of symptomatic hallux abductovalgus bunion

    James W. Brantinghama, Sioban Guiryb, Heidi H. Kretzmannc, Victoria J. Kitea and Gary Globea


    The purpose of this study was to determine the efficacy of a conservative chiropractic management approach in the treatment of symptomatic hallux abductovalgus (bunions). The study was a prospective, randomized clinical trial involving 60 subjects, 30 in each group, selected from the general population. Group A received a progressive mobilization of the first metatarsophalangeal joint, used in conjunction with cryotherapy and adjustment of all other fixations found in the foot and ankle. Group B received placebo treatment de-tuned Action Potential Therapy. There were six treatments over a two-week period and a one-week follow-up consultation.

    Objective assessment was made by a digital algometer and subjective assessment by the Numerical Pain Rating Scale-101 (NRS-101) and Foot Function Index (FFI). The Hallux-Metatarsophalangeal-Interphalangeal Scale (HAL) incorporated both objective and subjective measurements. Assessments were made at the first, third, sixth and one-week follow-up consultations.

    Statistical analysis was completed at a 95% confidence interval. The parametric two-sampled paired t-test, the Friedman's test and the Dunn's post-test were used to analyse the data within each group (intra-group analysis), whilst the parametric two-sampled unpaired t-test and the non-parametric Mann–Whitney unpaired U-test were used to analyse the data between the two groups (inter-group analysis).

    In terms of objective findings, analysis of the treatment group revealed a statistically significant improvement in the pressure-pain threshold (algometer readings) at each treatment interval, whereas the placebo group had no statistically significant improvement for this measurement.

    In terms of the patients’ subjective response to treatment, both groups experienced a statistically significant decrease in pain perception (NRS-101) in the overall treatment interval; however, only the treatment group had a statistically significant improvement in pain perception at the early and intermediate intervals. A statistically significant improvement in the Foot Function Index (FFI), in terms of pain and disability experienced by the patient, was noted in the treatment group only.

    On assessment of the Hallux-Metatarsophalangeal-Interphalangeal Scale, both groups revealed a statistically significant improvement in the overall treatment interval; however, the improvement in the placebo group was only found to be in the subjective aspect of the scale.

    A statistically significant difference was noted between the treatment and placebo groups at the third, sixth and one-week follow-up consultations, for each measurement parameter assessed. This difference indicated greater improvement in the treatment group when compared to the placebo group, in terms of each measurement parameter.

    It was concluded that this conservative chiropractic management approach was effective, in terms of objective and subjective measurements, in the treatment of patients suffering from symptomatic hallux abductovalgus (bunions). It was found that the placebo treatment was effective in alleviating the pain perceived by the patients in the overall treatment interval (NRS-101); however, this improvement was not substantiated by any significant improvement in the Foot Function Index (FFI) and the objective assessment of the patients’ pressure-pain threshold levels.

  2. podrick

    podrick Active Member

    all this means is that mpj and bump pain was relieved via crossfrictional massage and passive rom exercise.however,the question is how soon after the regimen ended,did the pain and shoe discomfort return?
  3. pablo2081

    pablo2081 Member

    I have found 2 forms of manipulation of the 1st ray to be very effective in alleviating hallux pain that's not synovitis pain:
    1. Longitudinal Manipulation: releases the interphalynx pressure
    2. 1st MT-phalangeal manipulation: Angle of force is Lateral/ slightly superior
    This is a Gonstead adjustment.
    3. Taping the 1st ray with 1/4" in a straightened position following
    manipulation for 1 day afterwards.
    If the joint is painful to touch as in synovitis, ultrasound 15 minutes
    and have patient soak in Hi Conc. Epsom salt foot bath for 30 minutes will alleviate it.
  4. Matt Dilnot

    Matt Dilnot Member

    I still can't understand what pain these patients were suffering from. Doesn't appear too clear from the abstract.

    We all see hundreds of bunion patients a year. Very few experience pain in the joint other than from shoe pressure. Therefore it seems like an interesting sub-group to have organised for this study and therefore either they had a common cause of pain or a variety. I would like to know how they assessed the cause of pain e.g. sesamoid, synovitis, OA in MTPJ, etc.

    It seems like a pretty dodgey study to me but I will wait until I have the full paper before I really can it!

  5. Craig Payne

    Craig Payne Moderator

    According to the paper, the inclusion criteria was, among others, "pain around the first MPJ" ... so I assume that this did also include those with pain from shoe pressure and pain in the joint.
    Its shocking paper to read, with way too many secondary analyses.
  6. pablo2081

    pablo2081 Member

    Hallux Valgus Pain

    I've seen many bunions that hurt. The pain arises from a structure within the joint complex that appreciates a good adjustment. The recalcitrant sesamoiditis pain that did not respond to any conservative measures was pain located on the plantar surface. Also, patients with mild rheumatoid arthritis experiencing 1st metatarsal phalangeal joint pain responded poorly..
  7. John Spina

    John Spina Active Member

    I think that the pain is caused by adhesions in the 1st MPJ,so manipulation will help.Try to give the patient some physical therapy as well.
  8. Regarding, Halux valgus pain i pracice chiropractic for 10 years did reserch for palmer college davenport, iowa publish few articles, the term ADJUSTMENTS are aply to the CHIROPRACTIC "SUB-luxation" of the vertebral column not to the rest of the joints, so manipulation is more a medical-osteopatic than chiropractic term, So this Menz article should be rewriten and aply the proper tems to begin with. Poping mpj bones gets a sympatetic reflex through the propiosensors of the golgi apartus and send information to the brain to relax, producing a pain relif via massage alone with or with out movilization of the join range of motion with out any othermean of Physical terapy. The correction of a HV painfull is surgery. Fernando vazquez,d.d.s.,d.c.,d.p.m.,M.D.
  9. Craig Payne

    Craig Payne Moderator

    "Menz" did not write the article - he just posted the abstract from the article. The first author of the article is from the Cleveland Chiropractic College and it was published in a chiropratic journal, so I assue they are using terminology that is apprropiate in Chiropractic.
  10. Dear Craig, i am adjuned profesor of texas chiropractic college, and past-faculty member at palmer college of chiropracic graduate 1980 did research for them publish it and depeloper of several chiropractic technics so i know what i am talking about Chiropracic is art, Philosophy that deal with an "ineit" of the body ¿¿¿ Chiropractic is not a Medical Science i been in both sides of the wall They articles are directed to chiropractos that have the same eduction. an ingland md call ciriax developed manipulation within medicine for the medical profesions call orthopeadic medicine long time ago and he manipulate the spine and the rest of the joints with the stresh reflex teory thats what happens in MPJ`s But a painfull HV with a bump and deviation most be fix Surgically with a proper technic and proper podiatrist. We are having a seminar in mexico at The Instituto de Investicacion y Educacion Podiatrica between the 16-20 of November www.commecipac@yahoo.com.mx i can send you more info. at this or fernandovazquezmd@yahoo.com Best Regards
  11. pablo2081

    pablo2081 Member

    "Chiropractic Manipulation"

    The "Adjustment" is the word originating from the chiropractic profession 110 years ago. Today it does not carry any philosophical significance anymore than does the term "extremity manipulation". Extremity manipulation/adjustments have been a part of chiropractic education at most chiropractic colleges as much as spinal manipulation. That includes Palmer College of Chiropractic, Davenport, Iowa from where I graduated. As a chiropractor for 25 years and an author of 3 peer review papers on foot manipulation, painful HV is highly responsive to "Chiropractic Manipulation". And what is that??? It's time to look at manipulation from a historical basis:
    1. Chiropractic is a modernization of "ancient long lever manipulation" which can be described as "general" or "regional manipulation". That is, hold the head and wrench the neck, moving any or all bones capable of being mobilized. The Osteopathic profession were the first group to be licensed as "long lever manipulators" That differs from chiropractic which developed "specific (short lever) manipulation". Isolate the involved segment and move it while stabilizing the rest of the region or spine from being unecessarily moved. Because of that Quantum change in approach and the development of skills necessary to accomplish this task, "Chiropractic Manipulation Instruments" evolved. Examples are: A. Thompson Drop Piece Table, B. Activator Adjustment Instrument, C.Tepperwedge, D.SOT Blocks, E. Cox Lumbar Distraction table, Etc. What these tools have in common is: "Short Lever Manipulation" AKA "chiropractic manipulation/adjustment". As one commentor mentioned that in the future manipulation will be more widely used or here to stay: Yes, that is right and it had nothing to do with the feet, rather it was the NIH 1995 Report on Acute Low Back Pain that ranked manipulation as "very effective". That decision had "0" to do with the practice of Physiotherapy since 90% of the research papers/studies reviewed originated from the Chiropractic Profession and "0" from the Medical Profession, perhaps 10% from the US Osteopathic Profession. James Cyriax MD was an english maverick that used ridiculously Forceful Long Lever Manipulation and acted as if the chiropractic profession's development of modern manipulation didn't even exist; he called them "lay manipulators" as if Allopathy already had invented modern manipulation but in fact Did Not. If podiatrists think that an allopathic philosphy of "we can do everthing" based on degree rather than skills, I suggest you take my weekend seminar in black belt karate. There, I'll charge you a handsome fee and you will walk away with an understanding of the biomechanics of each Kada but you will have learned 0 skills since that will take you years to accomplish those "feets". Paul Kell DC, San Diego
  12. Matt Dilnot

    Matt Dilnot Member

    I love these high brow discussions!!
  13. Bob Woodward

    Bob Woodward Member

    Included in the vagaries of this paper is the lack of specific descriptions of the type of joint mobilization and manipulation used. I support the use of manual therapy on joints so more precise descriptions would be useful. For example, were the mobilizations simply joint distractions or were there more aggressive techniques used? Were these joints losing range of motion in a capsular pattern?

    Also, the paper does not seem to discuss the invlovement of plantar intrinsic musculature esp. abductor hallucis. adductor hallucis and flexor hallucis brevis as they may be in either contracture or weakness which directly affect the ability of the joint to function.

    I'd really like to hear the treatment protocol used.


  14. pablo2081

    pablo2081 Member

    Good points to make!
  15. Okie Dokie:

    I think the manipulation theory is pretty cool; yet, if someone is looking to alleviate symptoms while weighbearing, the manipulation will do no good if that person continues to present with a biomechanical foot fault. Remember, HV is not caused by footwear ( as we can see when we see male patients present with the problem...and I am sure many do not wear high-heeled or pointy shoes; African bushmen who do not wear footwear have also been diagnosed with HV; footwear does indeed make worse the condition). I have found that many of my patients who presented with HV had a moderate to severe pes planus foot or a flexible pes cavus foot with a marked forefoot varus/valgus.

    All in all, by conservatively correcting the biomechanics the O/A H V pain was alleviated. I made a forefoot modification to the orthotic that included a Reverse Morton's Extension and a V-Wedge cut-out and the patient was on their merry way asymptomatic. But I think that the manipulation would also be a cool idea in the acute HV stages to attempt to bring that joint more neutral and align it versus those ugly and uncomfortable day or night HV splints.

    Where can i get a link to a paper that explains more of that manipulation theory I could read over>??


  16. DaFlip

    DaFlip Active Member

    Can you hear the drums fernando?
    I remember long ago another starry night like this
    In the firelight fernando
    You were humming to yourself and softly strumming your guitar
    I could hear the distant drums
    And sounds of bugle calls were coming from afar

    Fernando you've made me brake into song! If only i could write these in spanish, however no habla espanol!

    Your qualifications are awesome dude.The list went on and on and i was thinking you must be even more qualified than me! I didn't think this was possible. Chiro college in Texas, DDS, DPM, MD. This is phenomenal. Are you sure you don't have a background in track and field? I remember a competitor i raced against in '02 with a name like yours. ran the 100m in 21.26secs...blistering speed out of the blocks but really struggled over the last 10 meters. I smashed this person, ran a really quick first 30 then when i straightened up smoked down the final 70 for a 100m 21.21. RReally rocked that day but let past glory stay in the past i say.

    They were closer now fernando
    Every hour every minute seemed to last eternally
    I was so afraid fernando
    We were young and full of life and none of us prepared to die
    And I’m not ashamed to say
    The roar of guns and cannons almost made me cry

    DaFlip :mad:
  17. Hola any other comments, the structural complex of a Halux Valgus can only be corrected by a well disined surgical procedure. Pain at the mpj can be help by massage, traction-manipulation and some pt. best regards adios amigo
    fernando vazquez,d.c.,d.d.s,d.p.m.,m.d.
  18. NewsBot

    NewsBot The Admin that posts the news.

    Manual and manipulative therapy compared to night splint for symptomatic hallux abducto valgus: An exploratory randomised clinical trial.
    du Plessis M, Zipfel B, Brantingham JW, Parkin-Smith GF, Birdsey P, Globe G, Cassa TK.
    Foot (Edinb). 2011 Jan 13. [Epub ahead of print]
  19. TedJed

    TedJed Active Member

    If connective tissue contractures around the 1st MtPJ and related joints are contributing to the symptoms 'around the 1st MtPJ', releasing them through mobilisation and/or manipulation techniques would be a beneficial intervention.

    The non-specificity of what pathologies are actually being treated makes it difficult to truly determine what was responsible for the effects recorded.

    Bob's reference to the plantar musculature is also a very important factor to consider when analysing the results.

    I have found that defining the term 'adjustment' as the 'application of a force to reduce subluxation' clarifies the objective of the technique(s), but not the method. Chiropractic doesn't seem to use such a specific definition.

  20. NewsBot

    NewsBot The Admin that posts the news.

    Effect of the Manual Stretching Maneuver for Hallux Valgus
    Kyeong AhMoonaYe JinKimaJi-hyunKimaJoo-heeParkbHye-seonJeonb
    The Foot; 23 December 2021, 101900

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