Maitland Mobilizations in the Treatment of Low Back Pain - Literature review Example

 Maitland Mobilizations in the Treatment of Low Back Pain Introduction During the assessment and diagnosis of low back pain, Physiotherapists use a range of techniques. The most common used techniques include those of Sahrmann (movement impairment), Robin McKenzie (derangement, dysfunction), and Geoffrey Maitland (mobilizations). The process of determining on the best approach to use can be confusing to some physiotherapists. However, this paper aims at discussing Geoffrey Maitland (mobilizations). This concept mainly involves the application of accessory oscillatory and passive movements to the vertebral and spinal joints to treat stiffness and pain of a mechanical nature. Notably, this technique aims at restoring glide and roll between joint surfaces and motion of the spin. With this in mind, the paragraphs that follow offer a clear and precise literature review of Maitland's Mobilizations technique towards the treatment of low back pains. Apart from the description of Maitland's Mobilizations technique, this literature review will discuss some of the effects related to Maitland's Mobilizations technique. Maitland's Mobilizations technique Maitland's Mobilizations technique refers to the gentle coaxing of a movement through passive rhythmical oscillations executed in the beginning, within or at the limit of the range (Maitland, 2006). As stated by Maitland, the mobilization technique can be used in two basic sets of circumstances that include the treatment of pain rather than stiffness and the treatment of the stiffness. However, the method of mobilization differs in reference to its objective. The major objectives include minimal symptoms, moderate symptoms, and severe symptoms (Maitland, 2006). The objective of minimal symptoms includes the use of staccato technique that is similar to staccato notes played when plucking violin strings. Moderate symptoms involve use of staccato technique that is similar to staccato notes played with the bow on the violin. Severe symptoms involve the use of oscillatory movements of even and smooth nature such that a change in direction of movement is inappreciable. In the understanding of Maitland's Mobilizations technique, one has to understand some of the keywords used in the technique. The major keywords include accessory movement, physiological movement, injuring movement, and overpressure (Wyss & Patel, 2013). Below is a description of these keywords; Accessory Movement – These are movements that cannot be performed by the individual. Some of these movements include slide, roll and spin. These movements accompany physiological movements of the spine. Understanding the idea and the dysfunction of accessory movements is very important for the appliance of Maitland techniques (Wyss & Patel, 2013). Physiological Movement – These are movements that can be performed actively and achieved by a person and can be analyzed for symptom and quality response. Injuring Movement – These are movements that are used to make the pain come on through the process of moving the joint in a particular direction during the process of clinical assessment. Overpressure – each joint in the spinal has a passive range of movement that surpasses its available active range. So as to achieve this range, a stretch is applied to the end of the normal passive movement. Notably, this stretch has a degree of discomfort. As per Maitland's Mobilizations technique, a mobilization is a controlled oscillatory repeated movement of the joint (REF). However, Maitland's Mobilizations are classified into five grades namely, Grade I, Grade II, Grade III, Grade IV, and Grade V (Maitland, 2006). These grades vary in the force against resistance and the amplitude of the movement. Below is a brief analysis of the five grades; Grade I - Large amplitude is applied at the beginning of the range of movement, which is against no resistance that is pain grating effect. Grade II - There is an appliance of large amplitude movements. However, the amplitude are applied to a range up to a feeling of resistance. Grade III – There is large amplitude movements superficially into resistance but not to the full feeling of the constrained movement. Grade IV – There is small amplitude movements that are deep in a resistance to begin. This increments the range of motion of the joints in the lower back. Grade V – There is low-amplitude thrust to the joints, high velocity. This begins at the end point of resistance of the joint with decreased range. This is commonly known as manipulation. Although the above-described grades used in Maitland's Mobilizations technique appear to be specific, Banks and Hengeveld (2010) assert that adaptations to the technique will constantly need to be made as each patient is different and may present different symptoms in relation to lower back pains. However, a study carried out by Chiradejnant et al (2003) reveals that although Maitland's Mobilizations technique has immediate pain relieving effect on patients, the specific mobilization performed was not of importance. Maitland's Mobilizations consists of rhythmic oscillatory movements that are responsible for stimulating the type-2 dynamic mechanoreceptors (Magee, Zachazewski, & Quillen, 2009). Through this stimulation, Maitland's Mobilizations technique can inhibit the type-4 nociceptive receptors. However, in order for mobilization to occur, mechanical force has to be used. Mechanical force used during mobilization include increasing the fibre glide when the specific movements stress the intended part of the capsule, realigning collagen or adhesions. Apart from stimulating the type-2 dynamic mechanoreceptors, Maitland's rhythmic oscillations have an effect on the circulatory perfusion. The ongoing circulatory stasis in the spinal area may lead to ischemia and the possibility of fibrosis, intra-neural oedema, and inflammation. Maitland's Mobilizations has an effect on the fluid flow as blood flow in the vessels in the spinal area supply the nerve fibres and synovial fluid flow surrounding the avascular articular cartilage (Petty, Moore & Petty, 2011). This, by a pressure gradient, is produced which helps in encouraging exchange of liquid, that is, dispersing the chemical irritants and increased venous drainage. This causes a reversal of the edema, inflammation cycle, and ischemia and lessens joint effusion and alleviates pain by diminishing the pressure the nerve endings. Effects of Maitland's Mobilizations technique Active and passive movements help in the preservation of the full range of motion (ROM) and the flexibility and strength of particular tissues on the spinal (Maitland, 2006). However, physiological movements are described as passive and active functional movements. Accessory movements on the spinal are movements that can only be performed passively by a third party such as a therapist. Nevertheless, both accessory and physiological movements performed to the spinal can be utilized so as to mobilize a joint. Hengeveld and Banks (2013) claim that Maitland's Mobilizations techniques are more effective at improving the range of movement as compared to Mobilization With Movement (Mulligan approach - MWM). However, Mobilization With Movements are more effective if the pain at the lower back is the most protuberant factor for the patient involved. The most readily though of effect of Maitland's Mobilizations technique are mechanical. Maitland's Mobilizations technique can restore voluntary movement, aid in intervertebral disc nutrition, aid in cartilage nutrition, improve the quality and rate of tendon repair, and aid in metabolism of soft tissue structures (Chevan & Clapis, 2013). So as to achieve the mechanical effect, oscillations (repetitive passive joint movements) have to be carried out at the limit of the joint’s availability range. Additionally, the tissues need to be stretched. However, according to Shacklock (2007), mobilization should be engrossed predominantly on the specific spinal segment that are painful so as to achieve the mechanical effect fully. Shacklock (2007) continues to argue that in Maitland's Mobilizations technique, regular re-assessment must be carried out so as to determine if the treatment has positive effect on the patient. The neurological effects of Maitland's Mobilizations techniques are reportedly an inhibition of reflex muscle contractions and reduction in acute pain (Von, 2007). The achievement of neurological effects by Maitland's Mobilizations techniques require sustained manual stimulation or repetitive (oscillatory) which results in a hysteresis effect. However, the hysteresis effect involves the process of inhibiting high threshold nociceptors, inhibiting low threshold mechanoreceptors, both of which result in a reduction of peripheral afferent discharge and the intra-articular pressure. Conclusion Maitland's Mobilizations technique refers to the gentle coaxing of a movement through passive rhythmical oscillations executed in the beginning, within or at the limit of the range. However, in the understanding of Maitland's Mobilizations technique, one has to understand some of the keywords used in the technique that include accessory movement, physiological movement, injuring movement and overpressure. The mobilization technique can be used in two basic sets of circumstances that include the treatment of pain rather than stiffness and the treatment of the stiffness. Maitland's Mobilizations are classified into five grades namely, Grade I, Grade II, Grade III, Grade IV, and Grade V. notably, these grades vary in the force against resistance and the amplitude of the movement. Apart from the five grades, Maitland's Mobilizations consists of rhythmic oscillatory movements that are responsible for stimulating the type-2 dynamic mechanoreceptors. Apart from stimulating the type-2 dynamic mechanoreceptors, Maitland's rhythmic oscillations have an effect on the circulatory perfusion. The ongoing circulatory stasis in the spinal area may lead to ischemia and the possibility of fibrosis, intra-neural oedema, and inflammation. Conversely, Maitland’s mobilization technique does have its effect where the most though effect is a mechanical effect. Maitland's Mobilizations technique can restore voluntary movement, aid in intervertebral disc nutrition, aid in cartilage nutrition, improve the quality and rate of tendon repair, and aid in the metabolism of soft tissue structures. Additionally, Maitland's Mobilizations technique has neurological effects. The achievement of neurological effects requires sustained manual stimulation or repetitive which results in a hysteresis effect. References Banks, K., & Hengeveld, E. (2010). Maitland's clinical companion: An essential guide for students. Edinburgh: Elsevier. Chevan, J., & Clapis, P. A. (2013). Physical therapy management of low back pain: A case based approach. Burlington, MA: Jones & Bartlett Learning. Chiradejnant, A., Maher, C., Latimer, J. and Stepkovitch, N. (2003). Efficacy of “therapist selected” versus “randomly selected” mobilisation techniques for the treatment of low back pain: A randomised controlled trial. Australian Journal of Physiotherapy, 49(4), pp.233-241. Hengeveld, E., & Banks, K. (2013). Maitland's Peripheral Manipulation: Management of Neuromusculoskeletal Disorders - Volume 2. London: Elsevier Health Sciences UK. Magee, D. J., Zachazewski, J. E., & Quillen, W. S. (2009). Pathology and intervention in musculoskeletal rehabilitation. St. Louis, Mo: Saunders/Elsevier. Maitland, G. (2006). Manipulation der Wirbelsäule. Heidelberg: Springer. Petty, N. J., Moore, A. P., & Petty, N. J. (2011). Neuromusculoskeletal examination and assessment: A handbook for therapists. Edinburgh ; New York: Churchill Livingstone/Elsevier. Shacklock, M. O. (2007). Clinical neurodynamics: A new system of musculoskeletal treatment. Edinburgh [u.a.: Elsevier Butterworth-Heinemann. Von, P. H. (2007). Craniofacial pain: Guidelines for a neuro-orthopaedic approach. Edinburgh: Butterworth-Heinemann. Wyss, J., & Patel, A. (2013). Therapeutic programs for musculoskeletal disorders. New York: Demos Medical Pub. Read More