M.R Physiotherapy and Rehabilitation Center

24/07/2025

Spinal manipulative therapy (SMT) applies quick force to joints, not to realign, but to desensitise areas for improved movement and reduced pain. It’s most effective when combined with personalised physical rehabilitation.
Manipulation is a manual therapy technique where a therapist applies a quick, controlled and directed thrust to a joint at the end of physiological range of movement, often causing an audible sound by the joint.

A joint manipulation is a sudden thrust or movement of a small size performed at a high speed at the end of range of a joint in a way that the patient is not able to prevent the movement unlike with joint mobilisations.

Manipulation is frequently performed at the intervertebral joints but can be performed at other joints too.

Joint manipulations can be very effective treatment methods though there is considerable risk when carrying out manipulations if the technique is poor or it is carried out inappropriately. All our physiotherapists who carry out joint manipulations are fully trained in manipulative skills.





M.R Physiotherapy and Rehabilitation Center

24/07/2025

23/07/2025

: Pre-surgery and Early Stage of Rehab for Hip and Knee

■ Pre-Operative Exercises: Prior to surgery, initiate exercises as tolerated to prepare for surgery. Practicing exercises prior to surgery will prepare you mentally and physically for the exercises to be done post-surgery

■ Early Stage of Rehab: The goal is to reduce pain and swelling. Gentle contraction of muscles will increase circulation to remove waste products and bring in healthy nutrients to repair tissue. Decreased pain and swelling will improve muscle control and increase mobility.

23/07/2025

, also known as knee-raise pull-ups or knee-sit pull-ups, are a compound exercise that combines the traditional pull-up with a knee raise at the top of the movement.

Bent knee pull ups are a great exercise which train every parts of core strength (exepted legs). It really builds functional strength.
This variation engages the core muscles more effectively, improving both upper body and abdominal strength.

of Knee-Raise Pull-Ups:

》Enhanced Core Strength:
Raising the knees at the top of the pull-up significantly increases the demand on the core muscles for stabilization and control.

》Improved Abdominal Strength:
The knee raise directly targets and strengthens the abdominal muscles.

Improved Upper Body Strength
Increased Muscular Endurance
》Enhanced Grip Strength:
Maintaining the grip throughout the exercise helps build forearm and grip strength.

》Compound Exercise:
This variation works multiple muscle groups simultaneously, including the back, biceps, and core.

23/07/2025

form

23/07/2025

(SMT) is defined as the application of high-velocity, low-amplitude (HVLA) manual thrusts to the spinal joints slightly beyond the passive range of joint motion.

This manipulation may then be repeated on the other side as required.”

Manipulation usually begins with preparatory movements of the vertebral joints to their extreme and then rotation is carried out.”

“Manipulation of the spine can be effective treatment for lumbar disc protrusions.”

■ Treatment (Acceptable Outcome)

◇ Central Low Back Pain Only

》heat/massage/exercise (83%)

》spinal manipulation (83%)

◇ Pain Radiation to Buttock

》heat/massage/exercise (70%)

》spinal manipulation (78%)

◇ Pain Radiation Down Thigh to Knee

》heat/massage/exercise (65%)

》spinal manipulation (96%)

◇ Pain Radiation down Leg to Foot

》heat/massage/exercise (52%)

》spinal manipulation (79%)

Spinal manipulation therapy: long-lever technique with rotation of the pelvis (Figure 1)

22/07/2025

》 Pectoralis stretch: Stand in a doorway or corner with both arms on the wall slightly above your head.
Slowly lean forward until you feel a stretch in the front of your shoulders. Hold 15 to 30 seconds.
Repeat 3 times.

》Thoracic extension: While sitting in a chair, clasp both arms behind your head. Gently arch backward and look up toward the ceiling. Repeat 10 times. Do this several times per day.

》• Arm slides on wall: Sit or stand against a wall with your elbows and wrists against the wall. Slowly slide your arms upward as high as you can while keeping your elbows and wrists against the wall. Do 3 sets of 10.

》• Scapular squeezes: While sitting or standing with your arms by your sides, squeeze your shoulder blades together and hold for 5 seconds. Do 3 sets of 10.

》• Mid-trap exercise: Lie on your stomach on a firm surface and place a folded pillow underneath your chest. Place your arms out straight to your sides with your elbows straight and thumbs toward the ceiling. Slowly raise your arms toward the ceiling as you squeeze your shoulder blades together. Lower slowly. Do 3 sets of 15. Progress to holding soup cans or small weights in your hands.

》• Thoracic stretch
A. Sit on the floor with your legs out straight in front of you. Hold your mid-thighs with your hands. Curl you head and neck toward your belly button. Hold for a count of 15. Repeat 3 times.

B. To stretch your right upper back, point your right elbow and shoulders forward while twisting your trunk to the left. Hold for a count of 15. Repeat 3 times.

C. To stretch your left upper back, point your left elbow and shoulder forward while twisting your trunk to the right. Hold for a count of 10. Repeat 3 times.

》• Rowing exercise: Tie a piece of elastic tubing around an immovable object and grasp the ends in each hand. Keep your forearms vertical and your elbows at shoulder level and bent to 90 degrees. Pull backward on the band and squeeze your shoulder blades together. Repeat 10 times. Do 3 sets.

22/07/2025

Back pain is one of the most common causes.

It’s important that you also consult your GP, physiotherapist or orthotist as required, as they will be able to advise what’s best in your individual case.

Exercises you can do at home: strengthening your muscles, avoiding poor posture.

The majority of those with back problems experience non-specific back pain. It may be triggered by bad posture while sitting or standing, bending awkwardly, or incorrectly lifting heavy loads. Over time, these movements can lead to muscle strain, irritation and wear and tear on the spinal cord.

Specific back pain is as a result of a disorder of the spinal cord, which could include osteoporosis, fractures and congenital deformities. Specific back pain typically worsens with age.

Exercise improves health and wellbeing and can help you avoid back problems. Cycling, hiking and swimming

22/07/2025

Manipulation has three phases:

1. Positioning.

2. Taking up the slack.

3 Manipulation per se.

■ Let us take the same example of a patient lying supine. The operator has taken the patient's head between his hands as described above; this is positioning. Then he rotates the patient's neck toward the right to its full extent. The patient himself also feels that his neck cannot turn any further. The operator maintains this position of maximal rotation. That is what we call tightening. It is at that moment that the operator adds a very slight supplementary rotation by a small sudden thrust of his left wrist. He has suddenly the impression that a resistance has been overcome and that the spinal column has moved by a few additional degrees. This is accompanied by a characteristic clicking sound. This forced, short, unique motion, executed at the point of tightening, is the manipulation. A manipulation must always start at the point of stretch. It is a very small motion. One should avoid a large, forceful motion which cannot be measured, which is violent, painful and dangerous.

22/07/2025

in which is not useful
》Too much pain
In hyperacute lumbago, manipulation is impossible because of unbearable pain on any attempted movement. These patients are best treated by the immediate induction of epidural anaesthesia and manipulation is postponed until dural irritation has mostly ceased.

》Too large a protrusion
There are two categories.

●Protrusions causing impaired root conduction

All such protrusions are impossible to reduce by either manipulation or traction.

●Sciatica with an excessive flexion or side flexion deformity

In such cases, an attempt to move in the contrary direction causes pain to shoot down the leg. Surgery is indicated.

》Too soft a protrusion
Nuclear protrusions causing backache and sciatica do not respond to manipulation (except in small and very recent cases, and provided that the manipulation technique is changed to sustained pressure). The consistency of the protrusion is too soft to be influenced by a quick thrust. Traction is the treatment of choice. The history is rather typical and usually identifies this type of disc lesion.

》Too long a duration of root pain
In patients under 60 years, 6 months of root pain have been shown to be the limit for manipulative reduction. However, if backache persists together with root pain, manipulation should be tried because these patients often do not recover spontaneously.

》Compression phenomena
Central stenosis, lateral recess stenosis and the ‘self-reducing’ disc protrusion do not respond to manipulative treatment. In stenosis, the underlying condition is the reason that attempted manipulation or traction fails.The self-reducing disc protrusion, with symptoms at the end of the day only, may be reduced by manipulation but will prove to be transient anyway.

》After laminectomy
New protrusions, at the same level, are seldom successfully reduced by manipulation. Traction is often more effective.

》Unfavourable articular signs in a patient under 60 years
In backache, side bending towards the painful side is an unfavourable sign for manipulation but this does not apply in lumbago.

If any movement other than flexion hurts in the lower limb instead of the back, manipulation is almost certain to fail.

If an attempted extension manipulation gives rise to root pain, the manœuvre should be discontinued, as the protrusion is pressed harder against the nerve root.

》Primary posterolateral protrusions
These protrusions all consist of nuclear material and therefore cannot be reduced by manipulation.

22/07/2025

form

21/07/2025

!
Back Pain
■ Three categories
》Lumbar Spinal pain
》Sacral Spinal Pain
》Lumbosacral Pain

■ Lumbar Spinal pain

"Pain perceived as arising from anywhere within a region bounded superiorly by an imaginary transverse line through the tip of the last thoracic spinous process, inferiorly by an imaginary transverse line through the tip of the first sacral spinous process, and laterally by vertical lines tangential to the lateral borders of the lumbar erectores spinae.

■ Sacral Spinal Pain

"Pain perceived as arising from anywhere within a region bounded superiorly by an imaginary transverse line through the tip of the first sacral spinous process, inferiorly by an imaginary transverse line through the posterior sacrococcygeal joints, and laterally by imaginary lines passing through the posterior superior and posterior inferior iliac spines."

■ Lumbosacral Pain:

"Pain perceived as arising from a region encompassing or centred over the lower third of the lumbar region as described above and the upper third of the sacral region as described above."
Another overlapping definition is thoraco-lumbar pain, but this is not low back pain.

□ Not Low Back Pain
Pain in regions adjacent to the above topographical areas are not low back pain. There are a variety of other taxonomical definitions to describe pain in other areas.

Pain:

"Referred pain over the lower limb girdle posteriorly may be described as gluteal pain. For this purpose the gluteal region may be defined as a sector central on the greater trochanter and spanning from the posterior inferior iliac spine to the anterior superior iliac spine. "

Hip Pain

"Referred pain immediately below [the gluteal pain region[ posteriorly should be qualified as posterior hip pain"

Hip Pain

"Pain immediately below [the gluteal pain region anteriorly[ should be qualified as anterior hip pain."

Pain

"Pain focused over the inguinal ligament may be qualified as groin pain."

Pain:

"Pain located over the posterior region of the trunk but lateral to the erectores spinae is best described as loin pain to distinguish it from lumbar spinal pain."

Spinal Pain:

"Pain perceived as arising from anywhere within the region bounded superiorly by an imaginary transverse line through the tip of first thoracic spinous process, inferiorly by an imaginary transverse line through the tip of the last thoracic spinous process, and laterally by vertical lines tangential to the most lateral margins of the erectores spinae muscles. "

Chest Wall Pain:

"Pain located over the posterior chest wall but lateral to the above region [for thoracic spinal pain] is best described as posterior chest wall pain to distinguish it from thoracic spinal pain. If required, thoracic spinal pain can be further qualified by dividing the above region into thirds from the top down, to establish regions of upper thoracic, mid thoracic, and lower thoracic spinal pain"

-Lumbar Pain:

"Pain perceived as arising from a region encompassing or centred over the lower quarter of the thoracic region as described above and the upper third of the lumbar region as described above."

:

"This term is an anachronism and should be abandoned. It stems from an era when the mechanisms of referred pain and radicular pain were poorly understood. It was used to describe pain that appeared to travel along the course of the sciatic nerve. Furthermore, because nerve root compression has been believed to be the cause of sciatica, many forms of referred pain in the lower limb have been erroneously ascribed to this cause. Consequently, at the most, sciatica and radicular pain can be considered as synonymous. Pain in the lower limb should be described specifically as either referred pain or radicular pain.