Clinicians have been confronted by the challenge of selecting management for patient with spinal dysfunction. Patient treatment approach on the premises of pathology are not all the times useful in treatment choice as it is projected that a particular diagnosis can be made for only fifteen percent of patients with for instance low back pain (Grieve, 1991 and Waddell 1998). Making more complex this improbability is the absence of scientific proves to support a certain management models for patients with such conditions (Foster 1998 and Huijbregts, 2002). As a result, the choice of management model becomes even more complicated as it obliges physiotherapists to forecast the probable payback of a specific management model for each specific individual patient (Farrell and Jensennn 1992).
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This paper attempts to unravel critically the efficacy level of manual therapy to address vertebral dysfunction as supported by Maitland and Mulligan. The paper starts by giving a brief definition of manual therapy and vertebral dysfunction. It then looks at the physiological effects of manual therapy in reference to Maitland and Mulligan techniques. The paper is summarized by expounding on existing research gaps within this area and make recommendations towards bridging the research gaps,
Definition of manual therapy & vertebral dysfunction
The definition of manual therapy varies in regard to the profession that id describing it for lawful reasons to state what is allowed within a practitioner range of practice (Cyriax, 1941, Kochar and Dogra 2002). In physiology, manual therapies are described as clinical methods that uses skilled specific hand-on approaches that include but not restricted to manipulating or mobilizing employed by the physiotherapists for diagnosis and management of soft tissues and joint configuration with an objective of modulation of pain, raising range of motion, plummeting or eradicating soft tissue inflammation, inducing relaxation, enhancing contractile and non-contractile tissue restoration, and enabling movement among others (Di Fabio, 1992., McKenzie, 1981 and Maitland, 1991).
On the other hand, vertebral dysfunction is described as the anomalous function of the vertebral structure as a result of infection, traumatizing conditions, degeneration, metabolic, tumour, inflammation, and biochemical among other causes (Maitland, 1993 and Mennell, 1960).
Physiological Effects of Manual Therapy in Reference to Maitland & Mulligan Paradigms
The Mulligan model has become an essential constituent of several physical physiotherapists’ clinical practice. The Mulligan’s ideologies are of reinstating the partner constituent of physiological joint mobility. According to Mulligan, injuries or sprains could lead into minor positional error to joint consequently resulting to restrictions in physiological mobility. Peculiar to this idea is the mobilization of the spine and at the same time the spine is in a load posture situation guiding the mobilization analogous to the spinal facet planes. Inert oscillatory mobilization (NAG) and sustained mobilization with vigorous movement (SNAG) are the foundation of this ideology’s spinal management (Mulligan 1999). The author suggested that when a raise in pain free variety of mobility happens with a sustained natural apophyseal glides it is principally the adjustment of positional errors at the zygapophyseal joints, even though sustained natural apophyseal glides as well manipulate the whole spinal purposeful component.
Maitland on the other hand promoted administering of management method and instantly re-evaluating the patients’ symptoms and signs to investigate the treatment potential efficacy. With this investigation, modification of the treatment would be carried out until a technique is established that optimistically enhances symptoms like pain or signs for instance degree of motion or capability to carry out an activity (Jones, 992).
Maitland’s approaches entail the application of flaccid and accessory oscillatory movement to spine joints to care for pain and stiffness of a mechanical form and the approach is mainly geared towards restoration of movement of spin, glide and roll within between the joints.
Oscillatory mobilization can decrease pain by invigorating naturally pain killing endorphins (Hendricks, 1995). Nonetheless, except the cause of pain is eradicated, pain subsidence will be short lived and oscillatory mobilization would be expected to end the pain cycle in a situation of muscle spasm. Quicker signals are invigorated by manual oscillatory mobilization received by the brain before the pain sensation thereby blocking off the pain impulses and eventually breaking the cycle and as a result, there is immediate stoppage of muscle spasm and the hold of the “soft tissues” which could have led to nerve harm or deformation (Low & Reed, 2002).
In contrast, Mulligan employ motions in sympathy with physiological mobility whereby he is guided in the direction of restoring proper physiological tracking by the non-appearance of pain. His approaches are structured to address the conditions of hurting movement but are not very irritable. These approaches are hence employed for conditions that are less severe when the biomechanics of joints may be distorted without stirring up pain and therefore Mulligan recommends taking the joint through its whole cycle of movement and it involves taking it towards resistive path.
The physiotherapist places over an accessory movement on top of the patients’ active physiological movement of the joints (Evans, 1980), where the prior-injury joints trailing are re-founded re-asserting the joints memories or previous conditioning of the healthy joints (Mulligan, 1999). The justification behind Mulligan’s approaches is that joints have developed in a way that allows free but restricted movement and at the same time minimizing compressive forces created by movement.
This equilibrium is ensured by a standard pro-prioceptive response (Grimmer et al 1999). Adjustment of the equilibrium and positioning of structure in and around the joints that might transpire from injury could adjust joints tracking leading to pain or restriction of movement (Exelby, 2001). It is hypothesized that these approaches calm an agitated, aided nervous system, especially the dorsal horn by bombarding it with the pain free routine it has for all time been structured to obtain (Glasgow and Twomey, 1985).
Maitland merits recognition for trying to bring answerability to the practice of manual therapy by the organized and purpose recording of evaluation and management of a condition (Butler, 1991, Farrell and Jensennn 1992). However, the forces applied in the use of manual therapy are inadequately acknowledged and there is evidence of broad disparity for provided grades of amplitude and in actual sense, there is no available published researches that have given a full force versus time record for common mobilization or thrust approaches (Threlkeld, 1992 and Wilson, 2001). Threlkeld (1992) suggest for a homogeneous catalogue of forces to be applied to direct physiotherapists and assist training and research and the Maitland’s prescription can be compared to patients’ but not just the discrete measure of force (Twomey, 1992).
Prescription force dose formula could require an integration of variables of severity and irritability which can only be gotten empirically (Smith, 1995, Hall, 2001 and Exelby, 1995). Literature on the effectiveness of Mulligan’s methods is lacking and controlled by explanatory or case report periodicals (Makofsky, 2003). Nevertheless, study assessing the neurophysiological or mechanical impacts has been carried out. A large number of this study is restricted to the marginal of mobilization with movements.
In summary, Maitland and Mulligan offer apparently efficient mobilization methods but the study is unsure regarding why they work. The methods are complementary and might be employed concurrently with one another or independently. The two authors are not rigid regarding application permitting therapists to select techniques and amend them according to the circumstance and their capability. It seems implausible the finding with reference to theoretical justification favors Mulligan even if his approaches are, in practice, efficient though their achievement is more probable to reflect the effect of movement than the effect of realignment and the manual therapy as a subject requires formulating identical researches to establish an area of reliable evidence on its renown efficacy (Wilson, 2001).
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Currently, there is little if any published study exhibiting the effectiveness of the management of the spine with these concepts. A starting point should be establishment of categories of spinal condition that responds to specific methods. Multicenter gathering of case study information would help in identifying tendencies and create the structure on which to establish bigger studies. For example, the case progression on acute locked back (Mulligan, 1999) would establish the ground for extra data collection and study.
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