PART THREE: Manual Therapy
So this is where it starts to get interesting. . .
One of the most important parts of manual therapy is the initial assessment. There no use in trying to mobilise an already hyper-mobile joint for example, in fact this is likely to be detrimental. So it is first essential to know what is normal and what is not. This can often been established by comparing one side to another, but also through patient mileage and experience. . . .does it feel normal by comparison to others. . .does it look normal by comparison to others. Once you have established this you can determine what is the right level of mobilisations.
Joint mobilisations can be graded into 5 parts. A grade 5 mobilisation is also known as a manipulation and is commonly used by chiropractors. Personally I find these extremely hard to perform and even harder to be effective, even on people. I also find the Gr V manips can be painful, cause increased muscle spams and, where they do have a positive effect, wear off very quickly. So personally I don't tend to go there. Instead I work mostly from GrII - IV mobs incorporating mobilisation with movement (MWM), natural apophyseal glides (NAGs) and Sustained natural apophyseal glides (SNAGs) depending the the joint I am working on and the feedback from the client (person, horse or dog).
So when do I use it?
I use manual therapy once I have released the soft tissue around the joints, particularly around the neck and thoracic spine, but still feel that there is an underlying stiffness. Commonly, if your horse for example, struggles to turn his head all the way to the left without moving hes feet this is likely to be for one of two reasons;
1. The musculature in the right side is too tight to allow for the movement to happen OR
2. the facet joints (see below) on the left side are too stiff to allow for the movement too happen.
So once I feel I have dealt with number one, I will try to deal with number two.
Above shows the equine cervical spine (ours and dogs are much the same just a slightly different shape) There are a number of ways in which I could mobilise the above, again depending upon what I have found in the assessment. but for example I may start with a dorsal-ventral (DV) mob, this just means applying pressure from the top (dorsal) in a downward motion to the bottom (ventral) - This may clear things up substantially for those that have had to try read though my notes!
So finding my boney marker (one of the transverse processes from C0-4 -after that there's a lot of muscle to get through to feel much!) again which one(s) I apply pressure too will depend upon my assessment, I then apply pressure in an oscillating pattern. Depending on what I am treating for will then depend on the grade I chose.
Grade One (GrI) - Small oscillations at the beginning of joint motion - good to improve severe pain and should be very relaxing
Grade Two (GrII) - Large oscillations from the beginning of motion to the start of resistance - should be pain free and are good to help ease moderate pain and help to improve range
Grade Three (GrIII) - Large Oscillations from mid range into resistance - Good to help reduce pain through the pain gate theory (remind me to cover this at some point) and improve range, but maybe uncomfortable for the patient.
Grade Four (IV) - Small oscillations at the end of range - good for very reduced range but can be painful.
So I will pick my direction of force, the force and amplitude to apply and the position to apply it in. If I am treating the facets, but they are very sore and stiff I may turn the client away from the painful side, thereby creating room between the facet joint and making treatment less painful. If there is very little pain but the range just not quite normal I may turn the patients head towards the affected side, thereby creating a smaller space between the facets and working in their very end of range.
This is where MWM's, NAGs and SNAGs are useful. If I have a client who struggles with looking over the right shoulder for example, I can help with this by assisting the movement from the facet,and following the physiological movement through the range, creating space between the facets and improving pain and range -have I lost you yet?!
So actually when I come to treat your horse/dog/you there is a surprising amount of decisions that are going on in my head, and these decisions are constantly changing and evolving depending upon the reaction I get from the client - maybe that's why I'm so terrible at making day to day decisions?!
Whilst I have used the cervical spine as an example here, these techniques can be used on any joint. You can use them as an accessory physiological movement i.e. one when you are mobilising the joint but not moving through range or through the movement as a MWM.
And What can it help with?
*Reduced range of movement
Specific examples include facet joint dysfunction or osteoarthritis (degenerative joint disease DJD) of any joint, SIJ dysfunction or stiffness as a consequence of postural change. This may resonate as difficulty bending on one rein, difficulty picking up correct canter lead and looking to the outside on the lunge.
Contraindications include spinal instability, hypersensitivity of the skin, malignancy haematoma or recent fractures- amongst others.
I hope some of that makes sense. If you have any questions please do not hesitate to leave a comment below or get in contact with me.