Vadim Kalganov BOst
“Osteopathic techniques such as articulation, soft tissue manipulation and Muscle Energy Techniques claim to be of benefit to synovial joints and their supporting structures. Explore the rationale and the evidence behind such claims”.
Health by definition is the state that allows the individual to be a fully functional member of society. The mobility of individual is the part the definition to be healthy. Body’s mobility is provided by functional, pain free joint. The purpose of this essay is to explore the claim if osteopathic techniques such as soft tissue manipulation, Muscle Energy Techniques and articulation are beneficial to synovial joins.
The definition of synovial joint and its supporting structure determined by Mennell (1964, p 5) as “synovial joint is two bones with periosteal covering, the ends of which are covered with hyaline cartilage upon which the ends move. These articular surfaces are enclosed in a synovial capsule, which maintains sufficient synovial fluid for mechanical lubrication of articular surfaces. The capsule is reinforced by well defined ligaments that strengthen it to withstand stresses of use and misuse”.
Fritz (1995, p 307) says “ligaments are found around joints and are high in collagen. Ligaments hold joints together and maintain joint space in synovial joints by keeping the joint apart. Ligaments are to maintain stability in many joints (ankle) in other joints stabilization is achieved by muscles (shoulder) or combination of ligaments and muscles (knee)”.
The joint has a nerve, blood and lymph supply. According to Tortora (2009, p 269) “nerves that supply a joint are the same as those that supply the skeletal muscles that moves the joint. Some of the nerve endings convey information about pain from joint to spinal cord and brain for processing. Other nerve endings respond to the degree of movement and stretch at joint (mechanoreceptors)”.
Joint position and velocity receptors inform the Central Nervous System (CNS) regarding where and how the body is positioned against gravity and how fast it is moving. Blood supply is performed by arteries that penetrate the ligament and articular capsule to deliver oxygen and nutrients. Veins remove carbon dioxide and wastes from the joints. The condrocytes in articular cartilage receive oxygen and nutrients from synovial fluid derived from blood; all other joint tissues are supplied directly by capillaries”.
The structure, which moves the joint is a skeletal muscles, that made of contractive fibres embedded in connective tissue. Where muscle fibres end and connective tissue continues the tendon develops. This is called musculo tendonous junction. Tendons attach muscle to ligaments and bones have high concentration of elastine fibres. Under many tendons there is fluid-filled bursa cushion that assists the movement of the bone under the tendon. Muscles are to move and to maintain stability of the joint; in addition many blood vessels and nerves supplying the joint are passing through the surrounding soft tissue. The healthy muscle is very important to joint function, according to Fritz (1995, p 262) “muscle spasm and contraction may pull the joint out of alignment”. This statement is agreed by Mennell (1964, p 5) that added “impaired muscle function perpetuates and may cause deterioration in abnormal joints”. Fritz (1995, p 307) insists that “in order for joint to move, the muscular elements must be functioning properly”.
Soft Tissue Manipulation (STM) directly manually affects a muscle by some specific techniques such as longitudinal stretch, lateralisation, cross fibre knotting and many more. They are employed to relax contractions, releasing constricted vessels and nerves, useful to lengthen the muscle and very helpful in dealing with fibrotic issues that restrict full range of motion (ROM) of the joint. DiGiovanna (2005, p 80) confirms “relaxation of contracted muscles, which decrease the oxygen demand of the muscle, decrease pain, and allow normalised range of motion across a joint”. It is suggested that joint with impaired ROM may be the cause of inflammation Tasker (1925, p 557) claimed that “continued non-use of muscles causes mal-nutrition, sluggish circulation and degeneration of muscle, we may see how the joint may become a place for germs to multiply”. If it is the case, DiGiovanna (2005, p 81) states that “STM are useful in breaking the pain-muscle tension-pain cycle. Increasing the circulation to and drainage from the tissue may aid in diminishing the inflammatory response”. STM by restoring the function of surrounding tissue of joint provides the condition, that necessarily to restore full range of movement of the joint that in term plays the major part to speed up the natural process of recovery.
STM is related to Muscle Energy Techniques (MET) by the fact, that they both target the supporting structure of joint in form of muscles, normalising their functions, structure and length with difference that STM mostly targets the fluids circulation, while MET is concentrating on muscles nerves supply. The dysfunction of the joint may arise from impaired neural regulation of the muscle that moves the joint. Fritz (1995, p 265) describes “nerves stimulate muscle to contract, moving joints. Nerves respond to sensory stimulation, if signal is not quite strong enough the muscle may tense, but not contract. If threshold sensory signal does not occur, the nerve stays activated waiting to contract the muscle and discharge the tension. Tensed muscle constricts the flow of blood and lymph supply to joint”. The focus of MET is to stimulate nervous system (NS) to allow more normal resting length, stop contracting and to relax. The principals of MET has being employed by manual practitioners for hundreds of years under different names. Fritz (1995, p 269) gives the definition of the techniques “MET is voluntary contraction of patient muscle in specify and controlled direction, at varying level of intensity, against specific counterforce, applied by osteopath. MET is used to re-educate the nervous system.” The principle of MET: following contraction (which will have loaded the Golgi tendon organs and the musculotendinouse junction and reflexively inhibited the extrafusal fibres of muscle spindles) the muscle is in refractory state and can be lengthened easily to a new resting length. There are two major applications of the technique: reciprocal inhibition, that neurologically interrupts the signal and “turns muscle off” by contracting the antagonist. And Post isometric relaxation takes an advantage of autonomic relaxation of muscle after contraction. It is assumed by Fritz (1995, p 265) that “MET is effective to restore the joint function, because it provides a means of controlled stimulation of the joint sensory receptors. Movement initiates muscle tone readjustment through the reflex centre of spinal cord and lower brain centres. As position change, the supported movement gives the nervous system an entirely different set of signals to process. It is possible for the joint sensory receptors to learn not to be so hypersensitive. As a result the protective spasm and movement restriction may lessen”.
The pain in the joint is the symptom of dysfunction, Glasgow (1985, p 75) summarises the effect of STM and MET in relieving pain “one of the sign of dysfunction of joint is pain – excessive stimulation of mechanoreceptors. Since STM and MET are all procedures that stimulate the mechanoreceptors – it is suggested that it is primary through controlled stimulation of peripheral tissue mechanoreceptors by application of static or phasic forces relief of pain, especially that arising from mechanical or chemical abnormalities in joint tissues”. Glasgow further estimates (1985, p 320) “all joints tissue and structures are helped by STM and MET because of increased circulation, unrestricted soft tissue and normalised neuromuscular patterns. Both mentioned techniques can greatly affect the physiologic barrier. Joint may be traumatised and surrounding tissue becomes “scared”. When this happens all the proprioceptive mechanisms reset to limit the range of motion. STM and MET can affect ligaments, joint function and bone health”.
From motion point of view, STM is no movement of the joint is involved and MET involves the active joint movement, but “articulation is passive joint movement when osteopath moves the joint with no assistance from the patient” according to Fritz (1995, p 264), DiGiovanna (2005, p 93) adds to this definition, that “articulatory techniques are generally performed within the physiologic range of motion of any given joint and tend to be repetitive to free all planes of motion within the joint”. Greenman (1989, p113) states that “purpose of articulatory techniques are to restore range of motion and to stretch out the connective tissue surrounding the restricted articulation. One also articulates modulation of neural activity both to relieve pain and to restore more normal reflex activity to the nerves and spinal cord segments related to the area. The tendouse ligament and joint capsule are warmed from the ART. This mechanical effect helps keep this tissue pliable”. According to Tasker (1925, p 557) “joint movements, achieved through articulation, also encourages lubrication of the joint, an important addition to the lymphatic and venous circulation enhancement systems. Much of the pumping action that moves the fluids in the vessels resulting from compression against the lymph and blood vessels during joint movement and muscle contraction, leading to reduction of swelling and oedema”. He also states that articulation technique increases range of motion (ROM) of the synovial joint and decrease pain, associated with common joint problems. His statement was further confirmed in a study by Knebl (accessed 22.11.14) that says that Articulation significantly increases ROM and decrease perceived pain arising from dysfunctional joint.
In conclusion STM, MET and Articulation may be beneficial to synovial joints to restore function of the joints, relieving pain and speeding up the natural process of recovery. The principals of osteopathy state that, all systems in the body is interconnected and this fact should be used in treatment of the patient. STM, MET and Articulation affect the different systems with the same aim, which is to restore the function of the joint. By following the principles of osteopathy further it is worth to assume that applying all three techniques would be logical and appropriate part of the treatment of dysfunctional synovial joint.
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- Eileen l Digiovanna, Stanley Schiowitz, Dennis J Dowling (2005), Osteopathic Approach to Diagnosis and Treatment. Lippincott Williams& Wilkins, Third Edition.
- EF Glasgow, LT Twomey, ER Scull, A.M.Kleynhans (1985), Aspects of Manipulative Therapy. Churchill Livingstone, Second Edition.
- Philip E Greenman (1989). Principles of Manual Medicine. Williams & Wilkins.
- John McM.Mennell (1964). Joint Pain. Little, Brown and company.
- Gerard J.Tortora, Bryan Derrickson(2009). Principles of anatomy and physiology. John Wiley & Sons Inc., Twelfth Edition.
- Knebl JA , Shores JL. J Am Osteopath Assoc. 202 Jul; 102(7):387-96. Improving functional ability in the elderly via the Spencer techniques, an osteopathic manipulative treatment. www.ncbi.nlm.nih.gov
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