Manipulation

Members do not see these Ads. Sign Up.

Greetings

I am interested in manipulative techniques for the foot and ankle. The only one that I am aware of is H. Dannaberg's article on ankle manipulation. Does anyone here uses manipulation in their practice and where can you find information about it? I learned nothing about this in school.

 

Ted Jedynak's practice(foot and leg) in Adelaide exclusively uses mobilisation and manipulation and is running a course commencing April. His website www.footandleg.net may give you further information
Iona Millar

 

Here is my $0.02 ....

There are two aspects to the use of "manipulation" in podiatry practice (its all borrowed from other disciplines, but I am talking about what we can use it
for)

1. There are certain pathologies that we see that can be very responsive to 'manual therapy' (of which manipulation is a part of) that physiotherapists are good at. Those first MPJ "aches" (with no real diagnosis) respond well; cuboid syndrome can respond to manipulation; chronic pain following trauma; manipulation can help patients with significant forefoot supinatus adapt to foot orthoses; there is some good data using ankle manips early post ankle sprain; there is the work that Howard D published on increasing ankle joint ROM with proximal and distal fibula manipulation; etc; ---- ie all quite specific indications (some more evidence based than others).

2. Then there is manipulation of the foot as a philosophy - I prefer to call this 'Functional Manipulative Therapy' (FMT) --- this is more a chiropractic approach - in which the whole sales pitch is about 'subluxations', 'adjustments' etc etc; claims are made about realigning the foot through a series of adjustments and that the patient has things like a "Grade 2 subluxation" (...dosen't that sound serious?). Claims are made about not needing to wear orthotics again etc etc

There are many clinicians using it and I have discussed it with many of them - I have no doubt it will become a more important modality at our disposal. We will be running course on it here at LTU ---- but it will be like the Bill O'Rielly show on Fox --- "the no spin zone" "the spin stops here" - there is so much spin and sales pitch (ie BS) associated with FMT that it is ruining the more widespread uptake of it into clinical practice.

Here are some of the issues I have:
1) The inventing of terminology (eg grade 2 subluxation) to make something sound serious (read any of the anti-chiropractic books out there on this tactic - The Naked Chiropractor is a good one)
2) The approach by some is to make the whole thing into some sort of 'religious' experience - the theosophy of the approach is so ingrained that it is not possible to have a discussion about it --- all you get is a sale pitch and not a discussion (BTW - many Podiatrists are also like that with foot orthoses )....
3) They have to stop making the claims about permanently correcting foot alignment. I have looked at the x-ray changes that are claimed to be made by the adjustments - all they are doing is strecthing out a forefoot supinatus -- so of course the arch height returns and maybe they can do without the foot orthoses ---- but something caused the supinatus!!! - the adjustments do not take away the cause! (but they claim it does).

There is no doubt FMT will become more widely used in the future, but the "spin" and "sales pitches" have to stop.

We will have a "no spin zone" FMT continuing ed course here at some stage.

 

Thank you for your responses. It has given me a lot of think about!

 

Before applying manual therapy via mobilisation or manipulation, think of what you are trying to achieve as a practitioner. One suitable aim is joint ROM increase. A pre-cursor to this aim however, is the accurate assessment of below-physiological joint motion. Applying the mobilising force to the affected joint should yield motion that is similar or better.


If the joint motion is worse on reassessment, then either the direction of force or the magnitude was not right. Perhaps even consider the joint needs immobilisation; the opposite of manual therapy.

 

Check out podiatric manipulation at:
http://health.groups.yahoo.com/group/podiatric-manipulation/

 

Ron - I was hoping you would come to this thread

I think what you are talking about applies to (1) in my message.

We need to catch up and have a chat about (2).

 

I would be interested in your thoughts.



I am in the minority as a musculoskeletal practitioner, when I will invariably emphasise an initial 'cotton-wool' or protective phase post (acute) injury. Suggestions such as "bed rest" for LBP that is aggravated by any weightbearing, and that is better first thing in the morning, is under-prescribed in my opinion.

To use a building analogy; if the initial post acute management is the foundation, if the swelling/debris clearance is wall construction, if mobilisation and restoration of range of movement is the roof, if strength is the paint-work, and if specific functional rehabilitation is a landscaped garden....I think most houses out there have a nice garden, a beautifully painted house, a slight leak in the roof, walls that are slightly off-centre, on a sloppy foundation.

 

If they manage to do this then thats not bad as a start is it? If they can do it I wonder what it means for the orthotic long-term. Should we all be doing this?

 

The foot is not an iron bar though Lawrence. OK, lets assume that a supinatus can be corrected with hands-on manual therapy (manipulation, mobilisation etc), this, I think, is only relevant in NWB.

Get full body weight on that 1st ray in late-stance/early-propulsion, do we think that just because mobilisation has augmented more 1st ray plantarflexion, that this will magically resist dorsiflexion moments at this critical functional weightbearing position?

In other words, the chronic long-standing forefoot supinatus has incorporated a 1st ray that is dorsiflexed. Mobilising it the other way (plantar flexion), IMO, will not suddenly limit the available range of dorsiflexion that the 1st ray has been used to for such a long period.

So in terms of dynamic weightbearing foot function (ala windlass...1st mpj), I am not sold on the idea.





However, if the supinatus itself is directly causing tension or compressive pathology locally, then achieving more forefoot pronation may assist. In other words, usually joints are happier in a more neutral position.

 

Definitely!! - and to a limited extent, I do. However, its the claims by those who treat the supinatus as a "subluxation" that can be corrected without foot orthoses that I have the problem with. Their advertisments make these claims. In the short term it can work --- but you need regular "maintenace" therapy to maintain the correction ---- when orthotics will do the same thing better and at a fraction of the cost.

 

Hmmm

Atlas, personally I can only see the use of manipulation to improve foot shape/ROM and thereby function as a good thing. Reduce "supinatus" or whatever, facilitate fibular motion, stretch calves.

Scenario 1 Pain gone - fine. Scenario 2 Pain went but now has returned - more manipulation or orthoses - a decision for the practitioner or the patient????? No bits of plastic but I need "maintenance" tx or change my shoes and have bits of plastic - I can imagine many pts pondering that.

Certainly manipulation on its own for other areas eg spine/neck does give rapid relief of symptoms possibly through a neuro-feedback mechanism not a mechanical effect. Therefore it is possibly massively under-used in Podiatry.

 

Hi

I like manipulative intervention. But the assumptions behind all that has been written is that supinatus is a condition, when it could be a variation of normal (so are people correcting anything?) and, secondly, if supination is a variation of normal surely the problem is the ground we walk on.

Cheers
Ian

 

Not long after I graduated from podiatry i began seeing a chiropractor who happened to work with a podiatrist who practiced solely as a manipulating podiatrist.The long and the short of it is that i ended up seeing the pod for free twice a week when i saw the chiro (Think he wanted to show the new pod the enlightened way) Hmmmm, much better than paying 2K upfront like i hear some people do!

Now i have terrible feet. I was the student brought up in front of the class to show them what a "pronated" foot was. I can't go without my orthoses for longer than 10-15 minutes when standing etc etc.

So i went through this manipulation twice a week for 6 months, along the way being told that i probably didn't need my orthoses any more. Before and after X-Rays showed squat improvement. I have to admit that my foot became much more mobile and they did get rid of most of my supinatus. I also learnt to stabilise (plantarflex) my first ray better by using my peroneals. But my feet are still as flat as before!

Now what worries me is the people out there with feet like mine getting told to throw their orthoses out. (They should atleast just suggest to put them in a box )

Cheers


Tom

 

Ligaments?

Hi All,

Has there been any evidence of improvements to ligaments in the manipulations etc. or in massage and the like, anecdotal or factual? Particularly when referring to the ligament holding the arch up and it's slight give on loading and also over time?

Regards,

Colin.

 

Tom

would you say you are better as a result of the manipulation? Do you feel it has added to the effect of your orthoses?

What I mean is, does a combination approach work better?

 

By the rivers of Babylon

Harking back to Craig's original reply, I think a significant issue arising out of this business is that of the zealotry of some practitioners. To promote any singular approach to the treatment of complex issues is fraught with danger. It reeks of snake oil and prestidigitation.

I have no problem with the use of manipulation. In fact, I believe that we spend an awful lot of time on epidermal tissue (or the removal thereof) and not enough on the issues and tissues that lie beneath. By using manipulation wisely, safely and effectively, in combination with a range of therapeutic modalities, we have a great deal to offer our patients.

My problem lies with those practitioners who make claims that a specific treatment is 100% effective (gosh, wouldn't that be splendid). Who tell patients to 'throw away orthotics' (heck, I don't mind what patients do with their orthotics, but does it have to sound like a religious revival meeting?). And whose eyes shine bright with the fervour of the fundamentalist.

I honestly believe we as a profession are not yet on such solid ground that we can afford the singular approach.

Whew! I've got that off my chest.

Felicity

(OK, I confess, I think I've had to deal with a few too many people who have had some less-than-satisfactory experiences with a small percentage of our colleagues in this respect. I admit a bias, please feel free to covert me, or at least have a jolly good try).

 

Hi

I usually consider whether to mobilise or manipulate joints / soft tissue as part of the fitting and follow up process in orthotic supply. However, following the conversations on this thread can someone explain a number of things:

1. If the joints of the foot have been partly modeled by long term over pronation via a supinated forefoot, how does manipulation etc remodel these, to the extent that congruency occurs in an individuals new way of walking?

2. Again the question of assumptions arises in this in that who is to say that the supinatus is not normal to that individual (albeit more marked in various cases) and that by the above mentioned techniques mobilising etc we are forcing the foot into an unnatural position.

3. If you take the view that the surface for ambulation is a major contributor to foot pathology then mobilising as above can only be very temporary.

4. Can mobilising in the above way address the ligament laxity that can accompany many foot conditions.

Not sceptical just need to be convinced.

Cheers
Ian

 

Felicity

Religious fundamentalism; orgasmic curly-toes - whatever next? I hope you appreciate that our IT gatekeeper has now decreed Arena as having 'adult content' and blocked all access forthwith. It could be said though, that you’re responsible for maturing the profession single-handedly….but that’s possibly not the best way of putting it.

Keep it up!

Mark

 

I dont think that many chiropractors would say that through manipulation they are re-aligning the spine any more.

I think they suggest manipulation improves pain and swelling through a neuro feedback mechanism. Also it stimulates healing through its effect on circulatory system.

Sure it wont correct the foot deformity but if a pt has a supinatus their talus will be habitually moving in an anterior/medial direction in late midstance rather than a posterior/lateral direction. One could hypothesise that many soft tissues will become atrophied as a result and these could potentially be improved by "hands-on" therapy.

I dont know this, just ruminating...

 

hi,
i trainied in lower limb foot and ankle manipuation 18 months ago.i can honestly say that it has only improved my practice. i do not see it as a single treatment option but often combine it into a treatment programme which in many cases includes orthoses.
catch ya soon,
claire, belfast

 

That the crux of the "problem" and this thread - its either that integrative approach to practice or a philiosophy that takes over the practice.

 

i have found that manipulation has helped alot of my patients in the acute phase of a pathology e.g lateral ankle sparin, plantar fasciitis etc as long as it continues to do so i see no harm in offering it as a treatment option. I do not suggest that biomechanics is ignored but addressed and treated appropriately. claire

 

How does manipulation help an acute lateral ankle sprain?

What joint are you manipulating? Which direction?

 

I'd be keen to hear a specific explanation of what specific tissue is being manipulated and what the reasoning is behind thinking it makes any difference at all and why it is thought this could have any lasting effect whatsoever......isn't standing and walking itself a manipulation of the foot? and how is occaisional manip by hand possibly going to counteract the magnitude and frequency of standing/walking?
Regards Phill Carter

 

I attended a manipulation course earlier this year, & during the course of it had my own feet manipulated. I was told that the ROM at my 1st MTPJs could be increased by manipulation. As I'd only just been shown weightbearing X-rays of my feet, which clearly showed a long 1st met & reduced joint space; & had been discussing the possibility of decompression osteotomy to relieve my symptoms (pain on walking), I was most intrigued. So I had my MTPJs manipulated - which I found VERY painful- my feet felt pretty good for about a few hours, but the pain returned on walking. I really doubt that the manipulation made a difference for me. That said, my colleague had manipulation to improve ankle joint dorsiflexion (which was limited following TA injury), & the improvement was astounding! In fact, 9 months on, the increase in ROM is still apparent. My conclusion: Manipulation is a treatment modality appropriate to some conditions, & it is not the cure for everything. (Mind you, I didn't have the surgery either!)

 

What a fabulous discussion to follow - I'm glad I stumbled upon it!

I am a passionate podiatrist who has specialised in the field of Foot Mobilisation Techniques (FMT) which includes manipulation. The religious fervour described so far would probably be attributed to myself by practitioners and clients alike.

I would like to contribute a few perspectives from someone who has decided to provide FMT as the primary service in his practice.

The perception that FMT is a 'cure all' cannot be justified. While FMT is the only service that we provide at the Foot & Leg Centre www.footandleg.net we certainly do not accept every case. The only cases we accept are those that present clinically with subluxation and have this confirmed radiologically. The FMT is then applied to correct the subluxation and this is confirmed with a post treatment x-ray. If FMT is not indicated, we refer the client on.

The comments raised about connective tissue adaptation to subluxation need to be addressed. Ligamentous tissue doesn't have the ability to contract and where the tissue has distorted beyond its ability to stabilise the joint, external assistance is required (read orthoses). Muscular tissue and other connective tissues however, will respond to the forces placed on them i.e. they become elongated or contracted. FMT is very effective in bringing about a change to these tissues which is the basis of alot of physiotherapy and chiropractic treatments.

Can clients be freed from their orthoses? I guess it depends on the etiological factor that the orthoses were provided for. In our practice, 92% of our clients function satisfactorily (according to their FHSQ results) and no longer need orthotic assistance. This is a biased group - those with high degrees of subluxation or high degrees of joint degeneration are advised to maintain their orthotic usage.

Imagine being able to offer a woman a treatment option that didn't require a limitation of her footwear. If she fits our criteria, then we will provide the service (with a guarantee). Having specialised in this field for 11 years now, I know what works when, how and why. I wonder how many other practitioners offer a money back guarantee on their services?

Cheers,

Ted Jedynak

PS isn't standing and walking itself a manipulation of the foot?

No, certainly not. Manipulation takes place at the paraphysiological limits of a joint and if you are walking on your joints at this limit you'll need more than FMT can offer. Mobilisation may occur with walking though.

PPS How does manipulation help an acute lateral ankle sprain?

An inversion sprain typically stretches/strains the lateral fibulo-talar and fibulo-calcaneal ligaments. The inversion force also subluxates the talus in an anterior direction (with lat or med involvement also possible. Manipulation/mobilisation of the talus in a posterior direction reduces the anterior tension from the subluxation permitting the tissues to re-organise and repair without the common post injury ankle laxity effect taking place. The lack of muscular attachments to the talus prevents the body's own homeostatic function from being able to restore the integrity of the joint's osseous relationship.

PPPS I dont think that many chiropractors would say that through manipulation they are re-aligning the spine any more.

May I suggest you look at Chiropractic Biophysics (CBP) and the growth in their data based on correcting spinal alignment. It is the fastest growing field within chiropractic today.

 

Did everyone see Sunrise this morning Channel 7 (Sydney Australia) Kosh had a manipulation from Podiatrists.

Don Scott

 

Thanks for your info Ted....what does "paraphysiological limits" mean when it's not wearing the dinner suit?
Regards Phill

 

Hi Phil,
Thomas Michaud has a clear description in his 'Foot Orthoses and other forms of conservative foot care' Williams & Wilkins 1993, p124 Fig.3.119 outlining Range of Motion to a Diarthrodial joint. The figure is adapted from a chiropractic text and defines a joint's neutral position:active movement rangeassive movement range:elastic barrieraraphysiological space:limit of anatomical integrity. Within these parameters are the sites of mobilisation:manipulation:sprain.The paraphysiological limit is the border between paraphysiological space:limit of anatomical integrity, the site of manipulation. Mobilisation takes place at the elastic barrier.

These definitions are important because there is often confusion between the terms and their use. E.g. Dananberg's articles on ankle manipulation are actually mobilisations according to Michaud's and Maitland's (founder of manipulative physiotherapy) definitions.

Another important parameter is the 'speed' of the force; mobilisation occurs at a speed that the patient can overcome (as in Dananberg's studies) while manipulation occurs at a speed that the patient is unable to overcome.(Usually around 200-300ms when performed by a competent practitioner.

I hope this dressed up response gives you the naked answer you were looking for?

Cheers,
Ted

 

Hi Claire,
Where did you train? With whom? What was actually taught? Over what period of time?
Manipulation doesn't seem to be part of undergraduate podiatry programs... hmm, how come?

Cheers,
Ted

 

It would appear that the intended meaning of these terms is important to establish...thanks.
So to paraphrase your and Michauds words....the paraphysiological limit sits out at or near the "end of range" of motion of a given joint...and that the force applied must overcome the speed of neural response over which the patient has no conscious control...the reflex muscle action which may act to inhibit the result that you are trying to achieve?...on the right track?

But the level of force applied must be below the elastic limit for the joint tissues (for mobilization) involved or damage may be done in the process?...you don't want to actually cause any hysteresis in joint tissues? ....Except where manipulation is wanted you do want to create lasting change...so you do want change in tissue nature...hysteresis but not rupture?

Is this basically what these ideas are?

Regards Phill Carter

 

Ted

I believe what claire studied was exemplied by the napa podiatry workshops that another poster gave a web address for, podiatryworkshops.com ??

 

We include aspects of manipulation in the undergraduate course at La Trobe, as well as looking at mobilisation, stretching, strengthening and a number of other physical interventions.

This material is provided on a theoretical basis, with one of our staff (who has undergone additional training in the area) demonstrating a number of manipulative techniques.

I think the important thing to remember is that 4 years is nowhere near long enough for students to get into their heads all the material, skills, information, research, conflicting theories and everything else they need to become competent beginning practitioners. So, by giving them a taste of things at an undergraduate level we can inform them of options, but not give them the idea that they are ready to attack the unsuspecting public with their thoroughly undeveloped manipulative techniques.

I am pleased to hear you describe yourself at passionate, Ted, as I admire passion and enthusiasm enormously. My concern is for our brethren who really do tout lines like "throw away your orthotics", or "don't get ripped off by orthotics" and other inflammatory statements. My other concern is - why do Manip Pods in this state (Vic) demand the large payment up front? Surely incremental payment as fee-for-service would be the appropriate approach? I get concerned by the encyclopaedia salesman approach. Dammit, I think I ight be getting old fashioned in my old age.

cheers,

Felicity

PS. And I am delighted you have joined this forum, you are able to add much to this discussion!

 

These are impressive numbers. Here in the US there is no one practicing FMT. I have taken about 300 hours of applied kinesiology (an advanced chiropractic discipline) and even though I get relief of symptoms, I find a lot of recurrence with just foot manipulations. What joints do you manipulate to get these great results? What other manual therapy procedures do you do in addition to manipulation?

 

For anyone who's been on this thread, I know it's late (as I've been neglecting my Arena), but there hasn't been any resolution in the discussion, nor would I expect it, so I'll add my thoughts.
There may even be enuf interest in this area to some day have a gathering with presentations and workshops somewhere.
For me, I mostly mobilise the foot and ocassionally manipulate, if needed. This is based on an examination of joints for restrictions in movement of the individual bones. If they are restricted or blocked completely, then I work on them. For example, restoring the superior/inferior glide into the middle cuneiform will often relieve so called "plantar fasciitis". Every so often the foot also assumes an improved posture after treatment and that's interesting but not the goal. I have treated some folk only once and expect them back if symptoms return. Others have needed a few treatments which may be due to my skills not being up to perfection just yet, as I have seen more amazing results from others. Likewise for my failures. The mobes are a part of my quiver which often includes release of trigger points and orthotic therapy and a couple of more obscure manual techniques. The point is I think there has been some neglect of manual therapies in Podiatry. You do develop a greater 'feel' for what is not working when you get this close into the foot and you do get some 'miracles' - chronic problems that have resisted all treatment for years being resolved in one treatment.
Unfortunately, not every time, but very gratifying when it does. If not pods then who?
Cheers Shane

 

What you have summarised here Phil is accurate and is, in my experience of teaching FMT, probably the 2nd most difficult thing for a practitioner to grasp is the sense of 'feel' to determine the difference between elastic limit of a joint (for manipulation, not mobilisation) and the point where damage will occur. The purpose of manipulation is actually to cause a microtrauma to enable the tissues to repair and reorganise into a more functional state.

Think of the person who breaks an arm, is plastered for 6 weeks, has reduced ROM when the plaster is removed, so then needs to rehab the elbow to restore full functional capacity. The tissues have adapted to their shortest functional length (while immobilised). The rehab then literally tears apart those adaptations so that the full range of motion can be restored.

The skill necessary to generate and apply 35-40 kgs of direct pressure (the typical force required on an adult STJ) really takes some development. If I think back to 11 years ago and what I was doing, I'm sure some of the microtrauma intended was macrotrauma in effect! I don't recall any rupture, well, maybe one case... but she was my mother-in-law!

When a joint is subluxated, this same physiological process occurs; i.e. adaptation to the shortest functional length. FMT is designed to identify which joints have a reduced functional capacity and which tissues need to be worked (and in what direction) to restore the full functionality.

By hysteresis, do you mean '...the lagging of an effect behind its cause'? The effect of manipulation is immediate AND ongoing typically for 48-72 hrs rather than a 'lagging' effect.

The lasting change is dependent upon the forces that the joint is exposed to i.e. one can manipulate the STJ and increase ROM/reduce the degree of subluxation but if the forces that caused the subluxation persist, (work, play, injury, trauma, footwear, activity) the long term effect will be limited.

People receiving mob/manipulation treatment benefit from appropriate addition of stretching/exercises to accompany their progress. Again, these need to be tailored for the individual.

Cheers,
tedjed

 

I don't think anyone is denying the effectiveness of the method .... its just ... ummm ....arrrrhhrh....uuummmmm.....how much time do you think I have spent on the phone just today dealing with members of the public who have been given the spin, marketing hype and just plain BS. ..........

 

Wow! Are these actual quotes? I'm afraid that I haven't had any active involvement with the pods in Vic re FMT for some 2 years now and was not aware of this type of promotion. If I made these sort of claims in SA I'm sure there would be blood in the streets. I agree these are highly inflammatory comments and would be rather devisive.

I cannot speak for the boys' business practices but I can say that in my practice, we have modelled our fees on the orthodontic profession and some surgeons' practices. i.e. We establish a 'case fee' for our service (irrespective of the number of visits required). The duration of our service typically varies between 3 - 12 months. We offer a number of payment options which include paying in instalments or paying a one-off fee. It's then up to our client to decide which option will work best for them. I think demanding anything from people, let alone in business can pose enormous dangers and would not condone it at all.

I agree with your comment Felicity about the limited capacity to absorb (and appreciate) undergraduate training and be expected to deliver a high standard professional service upon graduation. I suppose this is why the Masters in Manipulative Physiotherapy came about after the realisation that the undergraduate could only perform at a certain level.

A post graduate Masters Degree in Manipulative Podiatry, now THAT is music to my ears!

tedjed