Diseases of the knee manual therapy diagnostics. What is manual therapy: indications and contraindications. Who has the legal right to treat with hands

An important stage of MT is the diagnostic process. Examination of patients with vertebrogenic neurological syndromes necessarily includes the following components: a) collection of complaints and anamnesis, general examination; b) study of neurological status; c) study muscular system(strength and tonic muscle tension); palpation of segments and joints; d) study of statics; e) study of simple active movements and more complex forms of motor stereotype; f) study of passive movements.
Patients are examined most often in connection with complaints of back pain, limitation of movement and deformation of the spinal column. Clarification of complaints will primarily concern the localization of pain (vertebral, extravertebral) and clarify its nature: acute, shooting, dull, aching, burning, itchy, aching, constant, periodic. Moreover, it is necessary to accurately verify the localization of the pain syndrome. Localization from the words of the patient (for example, "shoulder" or "thigh") may not correspond to reality. The patient should be asked to indicate the place of maximum pain and outline the area of ​​​​its distribution. Extravertebral pain syndrome can be independent or radiating. It is important to determine in which position the pain appears or increases (at rest, during static load or movement) and whether there are postures that lead to its weakening or disappearance. Determine the severity of the pain syndrome.
The qualitative characteristics of pain in general are not very informative, with the exception of acute shooting pain with irradiation, characteristic of root infringement.
To understand the nature of pain, it is necessary to note the factors that increase or decrease it. Pain associated with joint movement indicates its mechanical nature, especially if it increases with functional load and quickly decreases after it ends. Pain at rest, or pain that is worse at the beginning of a movement than at the end, indicates a pronounced inflammatory component. Night pain is a severe debilitating symptom for the patient. It reflects intraosseous hypertension and accompanies such pathological conditions as avascular necrosis or collapse of bone tissue in the area of ​​severe arthropathy. Constant (day and night) "bone pain" is characteristic of tumor metastases.
When collecting complaints, the presence of paresthesias and numbness (permanent, periodic, with which movements they increase), motor disorders (paralysis, paresis), vegetative disorders (the presence of a feeling of heat or coldness in the affected limb, muscle cramps), dysfunction of the pelvic organs.
From the anamnesis, the onset and previous provoking factors (when and under what conditions arose for the first time) manifestations of the disease are established. Determine which factors alleviate or aggravate the condition. They find out the duration of the first and subsequent exacerbations, their frequency, the treatment methods used, the effectiveness of treatment and the duration of remissions, as well as the profession, the nature of work and working postures, the microclimate at work, past injuries of the musculoskeletal system and spondylitis, hereditary predisposition to the disease. Information is required on temporary and permanent disability, change of profession and type of work due to illness. Specify the height and weight of the body.
General examination of the patient is carried out in a standing position, sitting and lying down, at rest and during movement. The patient must be naked. Pathological changes on the skin (hyperemia, edema, skin rash, tumor, etc.) are detected. An expanded subcutaneous venous vasculature indicates venous stasis, which led to pain. At the same time, it is important to clarify with the patient the presence of such concomitant diseases as varicose veins of the legs, thrombophlebitis and hemorrhoids. Signs of dysraphia in a patient - asymmetry of the nipples of the mammary gland, additional rudimentary nipples, a split chin and tip of the tongue, a high palate, irregular rows of teeth, a dysplastic structure of the face, ears, an unusual shape of the skull, six-fingeredness, selective hypertrichosis in the lumbar region - may indicate possible anomalies in the development of the spinal column.
During an external examination, first of all, attention is paid to the violation of the shape of the body, the position of the limbs (active, passive and forced), the severity and symmetry of the skin folds, the contours of the joints and the severity of the muscle ridges (visual assessment of the state of muscle trophism and its changes - hypertrophy, hypotrophy and atrophy) .
A favorable symptom is the active position of the trunk and limbs, indicating the absence of gross functional disorders in the damaged organ. The passive position of the patient indicates the severity of the disease (damage). It occurs with paralysis, fractures, crush syndrome. A forced position of a limb or torso can occur when the congruence of the articular ends of the bones is violated (for example, in case of traumatic dislocation of the shoulder). This state persists until the dislocation is reduced.
The presence of an antalgic posture is noted: deviation of the patient's torso to the side, forward, backward (very rarely). With a bent posture, the leg on the side of pain is somewhat deployed and set back, sometimes the patient stands with a half-bent leg. This is due to the transfer of body weight to a healthy leg. The patient's gait is constrained, extremely cautious, he takes small steps, he can limp on his sore leg. The antalgic posture in lumbar vertebrogenic syndrome also manifests itself in the position of the patient sitting on the tip of a chair, leaning only on the buttock of the healthy side, while the diseased leg is set aside outward. With a pronounced pain syndrome, the patient sits, leaning with both hands on the seat of a chair or the armrest with a straightened body, which reduces the load on the spinal column (tripod symptom). In the case of thoracic vertebrogenic syndrome, the patient tends to sit, leaning on the back of a chair, and with cervical localization of the pathology, he unloads the cervical region, supporting his head with his hands and resting his elbows on the table.
Often in the acute period, the patient takes antalgic postures in a horizontal position: lying on the sore side, bending the legs or only the sore leg at the hip and knee joints. There is a symptom of a lining pillow: the patient puts a pillow under the stomach, and with a sharp pain takes the knee-elbow position. Less often, the patient lies on his back with the affected leg bent and brought to the body, which resembles the Brudzinsky position for meningitis.
The presence of an antalgic posture is most often associated with displacement of the vertebra, which causes stenosis of the spinal canal or intervertebral foramen. The resulting pathological situation is usually combined with a change in the disk, and when

Rice. 37. Departments of the spinal column

Rice. 38. Identification points of the spinal column

its hernial protrusion is compression of one of the roots.
Examining the patient from the front, note the position of the head and neck, the height of the shoulders, the shape of the chest and its deformation (conical, flat, cylindrical, funnel-shaped, keeled), the course of the ribs (the presence of a costal hump), the position of the sternum, collarbones, the shape of the abdomen, symmetry and height crests and anterior superior iliac spines, the shape and symmetry of the upper and lower extremities. Examining the patient from behind, pay attention to the position of the head, the level of the shoulder girdle, the position of the shoulder blades, the contours of the waist, the triangles formed between the lowered arms, hips and waist, the deviation from the midline of the gluteus maximus muscle, anal fold, individual parts of the spinal column and head, installation and shape of the foot and knee, the height of the gluteal line.
The thoracic region is best observed from behind in the position of the patient standing with arms crossed on his chest.
To determine the localization of the pathological focus, it is necessary to know the identification points of the spinal column (Fig. 37, 38). The following identifying points are distinguished: 1) the protruding spinous process Cvm (Cvm - vertebra prominens), especially clearly visible when the upper limbs are lowered; 2) a line connecting the upper angles of the scapulae, it passes through the spinous process of Thin; 3) a line connecting the lower corners of the shoulder blades; it passes through the spinous process of ThVii; 4) a line connecting highest points iliac crests (linea cristarum posterior), which passes through the spinous process of Tsu.
From the spinous process of Sup down to the sacrum, a furrow of the back is visible, formed by the long muscles of the back. These muscles, with their abdomens, are located on the arches of the vertebrae, protruding above the level of the spinous processes.
Carefully examining the back, note the degree of displacement to the side, retraction or protrusion of the spinous processes. Determine the relief and symmetry of the muscles. According to the symmetry or asymmetry of the shoulders, shoulder blades and lateral triangles, it is determined whether there is a lateral curvature of the spinal column. With a mild curvature, each spinous process can be marked with ink dots, then the line of the spinous processes will be clearly visible, or the patient can be tilted forward and examine the back, LOOKING from the side of the head along the line of the spinous processes. In this position, the lateral curvature of the spinal column (scoliosis) is clearly visible, as well as a one-sided roller and a costal hump beginning to form. The asymmetry of the muscle ridges in the lumbar region can also be due to the tilt (roll) of the pelvis with different leg lengths (Fig. 39). In the absence of scoliosis, a plumb line fixed to the region of the spinous process Sup passes along the line of the spinous processes through the intergluteal fold (Fig. 40). With scoliosis, its degree is determined as follows: a centimeter tape connects the spinous process of Soup and the coccyx area; the distance from this tape to the line of the spinal column will show the degree of scoliosis.
The place of scoliosis is determined by the top of the arc (lumbar, thoracolumbar or thoracic), and the direction - by the side of the convexity (Fig. 41). Postural scoliosis (without internal disorders of the spinal column, ribs) disappears when the patient leans forward, in contrast to structural scoliosis, which persists or worsens when leaning. In thoracic scoliosis, the rotation of the vertebrae can lead to bulging of the ribs on the side of the convexity.
Scoliosis in vertebrogenic musculotonic syndromes is a reflex reaction aimed at relieving pain and creating the most favorable conditions for the affected segment of the spinal column. Scoliosis is considered homolateral when it bulges to the diseased side and heterolateral if the bulge is facing the opposite side of the scoliosis.

Rice. 39. Asymmetry of the skeleton with a short left leg: a - in order to compensate for the asymmetry, the patient stands on a short leg, putting aside and forward a long leg. With this position, the position of the pelvis is aligned; b - in the “legs together” position, the pelvis is tilted towards the short leg, scoliosis appears and the shoulder girdle tilts towards the long leg; c - the difference in the length of the legs was corrected by raising the heel of the short leg to the required height, the position of the pelvis was aligned

left syndrome. If, in response to the curvature of the affected part of the spinal column, a compensatory curvature occurs in neighboring, usually upper parts, then an S-shaped scoliosis is formed. Therefore, the direction of scoliosis is determined by the lumbar, and not the thoracic.
With compression syndromes, the formation of scoliosis (right or left) depends on the location of the disc herniation, its size, root mobility and the nature of the reserve spaces of the spinal canal (G. S. Yumashev, M. E. Furman, 1984). Heterolateral scoliosis develops when the root is located inwards, and homolateral scoliosis develops when it is located outward from the disc herniation (Fig. 42). Alternating scoliosis is characteristic of small protrusions, often median ones.
Scoliosis is accompanied by tension mm. erector trunci on

Rice. 40. Determining the degree of scoliosis (deviation of the line of the spinal column from the plumb line)

Rice. 41. Scoliosis (right thoracic)

Rice. Fig. 42. The ratio of the spinal root (a) to disc herniation (b) in homolateral (1) and hetero-lateral (2) scoliosis

convex side and mm. multifidi - on a concave. More often it is angular, less often it is S-shaped, and in 1/4 patients it is combined with kyphosis.
Ya. Yu. Popelyansky (1974) distinguishes three degrees of scoliosis and recommends using the following clinical and functional indicators for its assessment: I degree - scoliosis is detected only with functional tests (flexion, extension and lateral inclinations); II degree - scoliosis is well defined when viewed in the patient's standing position, but it is unstable and disappears when sagging on chairs and in the prone position; III degree - persistent scoliosis, which does not disappear when sagging on chairs and in the prone position.
To determine the severity of disadaptation of the entire spinal column, scoliotic deformity is assessed by the deviation of the head from the axis of the body, while distinguishing between two degrees of scoliosis: I degree - when the projection point of the head does not go beyond the foot, II degree - when the point is projected lateral to the foot (I. Yu. Popelyansky, 1989). M. Doherty and J. Doherty (1993) distinguish between compensated scoliosis (Th| centered above the sacrum) and decompensated scoliosis (perpendicular lowered from Th| passes outside the sacrum).
With S-shaped scoliosis, the gravitational vertical is preserved, the adaptation is considered secured (a relatively adapted form of vertebral deformity). During the formation of angular scoliosis, when at rest or after a load, the sections of the spinal column lying above the affected segment deviate from the gravitational vertical, the adaptation becomes insufficient (maladjusted form of vertebral deformity). Good adaptation should be preserved not only at rest, but also after loads on the spinal column. Vertebro-neurological syndromes, especially with scoliosis, lead to an uneven distribution of the axial load on the legs, reaching 5 kg or more. To study this distribution, you can use the usual floor scales (2 pcs.). The inclination in the lumbar region to the convex side is impossible due to increased pain, and the free inclination to the concave side is maintained.
When examining the patient from the side, it is revealed whether there are pathological curvatures of the spinal column in the sagittal plane, taking into account the fact that there is normal physiological lordosis in the cervical and lumbar regions, and kyphosis in the thoracic region, and also taking into account the possibility of various postural disorders, pathological kyphosis and lordosis . The shape of the body axis is analyzed, for which a plumb line drawn in front of the ankles on the os naviculare is used. In a normal static position, the plumb line passes from the external auditory meatus through Sup and Ly slightly behind the hip joint.

Rice. 43. Physiological (a) and pathological (b) posture

The concept of correct, or physiological, posture is based on the symmetry of individual parts of the human body, its harmonious structure and ease of posture. The curvature of the spinal column is held by the active strength of the muscles, ligaments and the shape of the vertebrae themselves, which is very important for maintaining a stable balance without undue expenditure of muscle strength. Violations of correct posture (stoop, round, round-concave and flat back) create unfavorable biomechanical conditions for the body in relation to the pelvis due to the shift of the center of gravity back in relation to the lumbar vertebrae. The most typical is a “relaxed” posture, in which the pelvis is pushed forward in relation to the plumb line (V. S. Goydenko et al., 1988).
Weakness of the muscles of the body, in which physiological bends of the spinal column are not created, leads either to an arcuate curvature of the spinal column posteriorly and the formation of a stoop (Fig. 43), or to the development of an infantile type of the spinal column - a flat back. Physiological curves are very closely interconnected, therefore, an increase in kyphosis in the thoracic region will always be accompanied by hyperlordosis in the lumbar region and neck.
Compensatory hyperlordosis appears as a result of a shift in the center of gravity of the body forward, which is observed with obesity, constantly bent hips in women wearing high-heeled shoes, with spondylolisthesis. Lumbar hyperlordosis, contributing to the balance of the body, over time leads to an overload of the posterior sections of the spinal column.
Straightening of the lumbar and cervical lordosis in patients with vertebroneurological syndromes is considered as a compensatory adaptive reaction. It is known that in the cervical and lumbar regions, due to lordosis, the posterior disc sections are lower than the anterior ones. Therefore, straightening of the lordosis, and sometimes kyphosis, leads to an equalization of the height of the anterior and posterior parts of the disc, with a decrease in the load on its posterior section as the most degenerated. Due to the stretching of the posterior sections of the fibrous ring, the output decreases

Rice. 44. Various types of curvature of the lower extremities: a - normal axis of the limb, b - outward deviation of the lower leg - valgus deformity of the knee joint, c - deviation of the lower leg inwards - varus deformity of the knee joint

protrusion (protrusion) of the disc and the sagittal diameter of the intervertebral foramen increases. In such situations, even a bent position of the spinal column can form, and an attempt to straighten up will lead to an increase in pain. However, when the annulus ruptures, bending forward leads to infringement of the disc herniation and increased pain. In the thoracic region, as a result of physiological kyphosis, the opposite picture is observed. Therefore, the anterior sections of the discs are subjected to the greatest load. With the defeat of several segments, an increase in kyphosis occurs more often - an increase in the physiological bend, while with lumbar and cervical vertebrogenic syndromes, the bends straighten.
Further, during examination, the position of the head in relation to the chest is noted. Assessment of the position of the head in a calm state is carried out in a sitting and standing position. At the same time, the cervical spine and muscles in this area are observed, and the angle that the chin makes with the neck line is also noted. With the correct position of the head, moderate lordosis and moderate tension of the posterior cervical muscles are detected. The angle formed by the chin and neck is about 90 degrees. In the thoracic region, moderate kyphosis, moderate tension of the interscapular and subscapular

Rice. 45. Other types of curvature of the lower extremities: a - hyperextension of the knee joint (genu recurvatum), b - posterior subluxation of the lower leg, c - flexion contracture

muscles and upper quadrants of the abdominal muscles. Shoulder joints should not be pushed forward, the upper part of the trapezius muscle should not be tense.
In some cases, the normal axis of the limb is disturbed. Normally, the axis of the lower limb passes from the anterior-superior iliac spine through the middle of the patella and the gap between the 1st and 2nd toes of the foot (Fig. 44, a). The axis of the arm is a line passing through the center of the head of the humerus, head of the radius and ulna.
Violations of the normal axis of the limb can be the result of deformities in the joint area and along the diaphysis of the limbs. For example, deviation of the lower leg in the knee joint outward from the normal axis is called genu valgum (typical for inflammatory processes with damage to all parts of the joint, for example, rheumatoid arthritis and psoriatic arthritis), deviation to the middle - genu varum (typical for osteoarthritis, when the process affects the medial parts as much as possible; Fig. 44, b, c). Among other types of curvature of the lower extremities, there are: hyperextension of the knee joint (usually for generalized hypermobility), posterior subluxation of the lower leg (typical for childhood, for example, with hemophilia, juvenile chronic arthritis), flexion contracture (occurs with various arthropathies; Fig. 45). A similar curvature is noted on other segments - humerus valgus, humerus varus, femur valgum, femur varum (Fig. 46, a, b, c).
Pathological forms of feet are revealed (Fig. 47). Thus, the hollow foot (pes excavatus) is characterized by an excessively high longitudinal arch with a large protrusion of the metatarsal and tarsal bones, in which the calcaneus and metatarsal heads become the reference points of the foot, the head of the I metatarsal bone is sharply lowered to the sole, the plantar aponeurosis is shortened and tense. The outer and inner edges of the foot are arched. The hindfoot (calcaneal) is in a slightly supinated position, and the forefoot is pronated.

Rice. 46. ​​Types of curvature of the upper limbs: a - normal axis, b - outward deviation of the forearm (cubitus valgus), c - inward deviation of the forearm (cubitus varus)

More often, its combination with the “horse” and “adducted” feet is observed with paralytic deformities on the ground (poliomyelitis, myelodysplasia, Friedreich's disease, Charcot-Marie, spastic paralysis, etc. The hollow foot is often accompanied by extensor-flexion contracture of the fingers - the so-called hammer-shaped fingers. The extensor tendons of the fingers are stretched under the skin.
Flat foot (pes planus) is a type of foot deformity characterized by flattening of the arch of the foot of varying degrees. Lowering the longitudinal arch leads to longitudinal flat feet, transverse to transverse. Expanding the forefoot. The outsole rests heavily on large area horizontal surface than normal. With a flat foot, the support is the entire surface of the sole. At the same time, the function of the limb is impaired, the gait is changed, it is lost.

Rice. Fig. 47. Imprints of the sole with a normal and pathologically changed foot: a, b - normal, c, d - hollow (in a mild and pronounced form), e - flattened, e - flat

elasticity. The imprint of the foot acquires a shape characteristic of flat feet - the inner notch is weakly expressed or absent. With a pronounced flat foot, the inner edge of the contour is convex, the foot is pronated. Often, flat feet are combined with outward deviation of the foot, and then they speak of a flat-valgus foot. By evening, patients may experience swelling on the back of the feet, simulating heart failure. Congenital flat feet are rare and are the result of primary intrauterine malformations of embryonic tissues. Acquired flat feet are divided into static, rachitic, traumatic and paralytic. With an increase in the degree of transverse flatfoot, hallux valgus and hammer toes appear. Paralytic flatfoot is caused by paralysis of the muscles that support the arch of the foot, most commonly after polio.
There are other types of foot deformities: "horse", "heel", "valgus" and "varus" foot (Fig. 48-51).
"Horse" foot (pes equinus) is expressed in excessive plantar flexion (Fig. 48). Anatomical changes consist in shortening and contracture of the muscles - the flexors of the foot, mainly the calf. At the same time, the capsule and ligamentous apparatus of the posterior ankle joint, plantar aponeurosis and foot muscles are tense. Calcaneus in varus position. The foot rests on the toes and heads of the metatarsal bones. In severe and long-term forms, deformation and a change in the relative position of the foot bones occur: the calcaneus is pulled up by a shortened calcaneal tendon, the talus is displaced anteriorly, the neck and head of the talus descend to the plantar side, which leads to subluxation in the transverse subtarsal joint (shopar joint), the navicular and cuboid bones are wedge-shaped, the metatarsal bones diverge fan-shaped, the longitudinal arch of the foot is pronounced.
The congenital "horse" foot is the result of a delay in the embryonic development of the foot in the first weeks of its formation and can be either one of the components of congenital clubfoot or an independent deformity.
Among the acquired forms of the "horse" foot, the first place is occupied by diseases associated with lesions of the central or peripheral nervous system: poliomyelitis, spastic hemiparesis, polyneuritis, myopathy, injuries of the sciatic and peroneal nerves, lumbosacral radiculitis with L5 lesions, etc. The foot is formed as a result of the predominance of traction of the gastrocnemius muscle against the background of paresis or paralysis of the extensors of the foot. Function

Rice. 48. "Horse" foot (pes equinus) - a type of foot deformity, which is expressed in excessive plantar flexion, one of the types of ankle joint contracture

Rice. 49. "Heel" foot (pes calcaneus) - a deformity of the foot, which is characterized by the position of a sharp fixed extension

Rice. 50. "Valgus" foot (pes valgus) - a type of deformity characterized by abduction of the forefoot, pronation of the heel, raising the outer edge of the foot

Rice. 51. "Varus" foot (pea varus) - clubfoot (pes equinovarus) - a complex combined deformity of the foot, in which the foot is turned inward

individual surviving muscles causes a combination of the "horse" foot with other deformities - heel supination, adduction of the forefoot, etc. The arthrogenic form of the "horse" foot occurs with various diseases of the ankle joint (rheumatoid, tuberculous arthritis, synovitis), purulent processes in the joints of the lower leg feet. Myogenic traumatic forms are caused by inflammatory processes in the gastrocnemius muscle, foot muscles, improperly fused fractures of the bones of the foot, ankles, errors in immobilization of the ankle joint after injury or surgery. With improper treatment of patients with severe burns and extensive soft tissue injuries in the shin area with a defect in the skin, muscles, tendons, cicatricial forms of the "horse" foot appear. In weakened, emaciated patients, prolonged sagging of the feet leads to the formation of the habitual, or vestimentary, form of the "horse" foot. The compensatory form of the "horse" foot is formed as a result of the patient's static adaptation to align the unequal length of the lower extremities.
"Heel" foot (pes calcaneus) is characterized by the position of a sharp fixed extension (Fig. 49). The shape is the complete opposite of the "horse" foot. The support occurs on the tubercle of the calcaneus, there is no active flexion. Deformation most often develops with paralysis of the posterior (tibial) muscle group.
"Valgus" foot (pes valgus) is characterized by abduction of the forefoot, pronation of the heel and elevation of the outer edge of the foot (Fig. 50). When walking, the patient leans on the inner edge of the foot. "Valgus" foot is often combined with longitudinal flat feet - the so-called flat-valgus foot (pes planovalgus). The area of ​​the ankle joint is deformed. The metatarsal bones protrude sharply anteriorly. The reason for the formation of this shape of the foot is the weakening of the ligamentous apparatus and the anterior group of muscles of the lower leg, especially the anterior tibial muscle. "Valgus" deformity of the feet can be congenital, paralytic (for example, due to spastic cerebral palsy, poliomyelitis, etc.), develop as a result of injury or be static.
"Varus" foot (pes varus) - clubfoot (pes equinovarus) - a complex combined deformity of the foot (Fig. 51), in which the following changes in its shape and position are observed: 1) the foot is turned inward - supinated, mainly the calcaneal region and tarsus, - internal clubfoot (pes varus, talipes); 2) the foot is in the position of plantar flexion - pes equinus, the sum of these changes is called pes equinovarus; 3) adduction - adduction of the forefoot - pes adductus. When walking, the patient's foot rests on the outer-lateral surface, the plane of the sole approaches the vertical; when walking, the back and front points of support fall out; the supporting surface of the sole is very insignificant, and the person maintains balance with the help of accessories of the body.
Congenital clubfoot (congenital internal horse-clubfoot foot) is one of the most common deformities. Clubfoot ranks first among congenital deformities.
Acquired clubfoot. Paralytic clubfoot is observed in neurological disorders accompanied by paralysis of the peroneal muscle group, and the function of the muscles that supine the foot is preserved (for example, in poliomyelitis, peroneal nerve injury, etc.). Clubfoot occurs after incorrectly treated fractures of the talus or several bones of the foot, with a fracture of the ankles with subluxation of the foot in the ankle or talocalcaneal joints (traumatic clubfoot). Clubfoot can be the result of various inflammatory processes of the ankle joint. Cicatricial forms of clubfoot occur after deep burns, inflammatory processes. Clubfoot can form after ischemic necrosis of the leg muscles.
For statics, the external rotation of the foot matters. In this position, when walking, the foot does not roll from the heel to the toes, but from the outer edge to its inner edge. In the case of external rotation of the thigh (turning the foot outward), tension occurs in the abductor and stretching of the adductor muscles, while in the case of internal rotation of the thigh (rotation of the foot inward), tension occurs in the adductor and stretching of the adductor muscles.
It is advisable to examine the patient in a standing position on one leg, bending the other. At the same time, all joints of the limb on which the patient is standing are observed, the axis and center of gravity of the body are noted. With proper standing on one leg, all its joints are on the same axis one above the other. The center of gravity shifts in relation to the standing position on both legs forward, from the os naviculare to the gap between the proximal heads of the II and III metatarsal bones. The iliac crest is located horizontally, the physiological curves of the spinal column do not change. Normally, standing on one leg is accompanied by tension of the paravertebral muscles on the opposite side (contralateral). On the side of the supporting leg (ipsilateral), the paravertebral muscles relax. If the patient manages to stand on the affected leg, the ipsilateral muscle group does not turn off (a symptom of paravertebral muscle tension). In addition, scoliosis may appear or increase, physiological curves may change, the leg joints may not be located on the same axis.
Then the patient is examined in a sitting position on a chair without support during a conversation with a doctor. Pay attention to the position of the feet, the height of the iliac crests, the position of the lumbar spine and the tone of the abdominal,

Rice. Fig. 52. The main phases of normal gait (nearest leg): a - heel touch phase, b - load-standing phase, c - toe repulsion, d - transfer phase

paravertebral, lumbar and gluteal muscles. With proper sitting, the feet always rest on the ground, the iliac crests are at the same height, the lumbar lordosis is straightened, the muscle tension is even, moderate. It is noted whether kyphosis has appeared in the lumbar region, whether the patient sits symmetrically, located on both halves of the buttock, or shifts from one half to the other.
Purposefully examine the gait, how the patient sits down and gets up, lies down on the couch, note the stiffness of movements. The patient is asked to walk naked and barefoot. At the same time, they observe how he loads the limbs, how he steps, pay attention to the movements of the pelvis and spinal column, the position of the head, the accompanying movements of the upper limbs, the position of the center of gravity (Fig. 52). With proper walking, the length of the steps of both legs is the same, and the load is evenly intermittent. Stepping on the floor, the patient touches it with the heel and then rolls the entire foot like a paperweight. The position of the pelvis is horizontal, it rises and falls evenly on both sides. The range of these fluctuations in women is greater than in men. While walking, the gluteal muscles evenly contract and relax. The spinal column freely and evenly moves slightly from side to side, with maximum excursions observed at the level of the middle of the lumbar region, and in the thoracic region there is a slight compensatory scoliosis in the opposite direction. The head hardly moves to the sides when walking. The upper limbs produce uniform accompanying movements that start from the shoulder joint, the shoulder blades are fixed by the dorsal muscles (“the patient does not push with the shoulders”). The movement of the center of gravity in the vertical and horizontal planes is hardly noticeable and uniform, that is, the patient does not sway or jump when walking (K. Levit, 1975).
According to M. Doherty and J. Doherty (1993), a normal gait is characterized by:
smooth movement of the arm associated with the movement of the opposite leg;
smooth, symmetrical movement of the pelvis pivoting forward with the front leg;
bending in hip joint when setting the heel, extension in this joint when pushing with the toe;
extension of the knee joint when setting the heel, flexion during transfer;
normal heel position, pronation of the foot in the middle position, lifting the heel before pushing off, dorsiflexion of the ankle joint during transfer.
In neuropathology, when the motor and coordinating systems are affected, the following pathological gaits are distinguished: paretic, spastic, ataxic, "puppet", "duck", "dancing", "hysterical".
Patients with vertebrogenic neurological syndromes while walking spare the sore leg (sparing, or antalgic, gait; Fig. 53), touching the floor only with their toes; almost all the load falls on a healthy leg. With vertebrogenic radiculo- or myelopathy, a paretic gait occurs, in which the patient walks, moving his legs with difficulty. Such a gait is characteristic of peripheral paresis. In order for the sagging feet not to cling to the ground, the patient is forced to make unnecessary movements in the knee and hip joints: raise the limb high and throw it forward. Due to the fact that during the throw the foot takes a horizontal position, and also due to the weakness of the extensors, it drops sharply to the floor. As a result, a characteristic slap is heard, by which one can determine the gait without even looking at the patient. This gait, reminiscent of the step of a rooster or a thoroughbred horse, was called "steppage", "stamping" or "rooster" gait (V.P. Guba, 1983). With damage to the peroneal nerve or root L5, a "horse" foot is formed, which is expressed in excessive plantar flexion ("dangling foot"). With more damage

Rice. 53. Antalgic gait. Pain and deformity cause the patient to quickly transfer body weight from the affected leg to the healthy leg, lingering on the latter (often with concomitant asymmetry of arm movement)

Rice. 54. Trendelenburg gait. As a result of ineffective abduction in the hip joint in the phase of standing on the affected leg on the opposite side, the pelvis descends. "Duck" gait - bilateral Trendelenburg gait

tibial nerve or root Si, a "calcaneal" foot is formed, characterized by excessive dorsiflexion. In form, it is the complete opposite of the "horse" foot (V. V. Kovanov, A. A. Travin, 1983). Difficulty moving the affected leg forward will indicate weakness of the iliopsoas muscle. The lowering of the opposite side of the pelvis and its lateral displacement to the affected side when standing on the same leg or walking (Fig. 54) indicates weakness of the hip abductors. Difficulty in holding the knee while transferring the weight of the body to the affected leg indicates weakness of the quadriceps muscle.
Some techniques performed by the patient contribute to a better detection of weakness in the corresponding muscles:
while walking, raising the leg with each step - in the iliopsoas muscle;
raising the body - in the gluteus maximus and quadriceps muscles;
squatting and then lifting - especially in the quadriceps;
walking on the heels - in the anterior tibial muscle and extensors of the toes;
walking on toes - in the triceps muscle of the lower leg.
When studying movements (motor tests), it is desirable to demonstrate the patient's labor activities and the position of his body at the same time; analyze production movements.
Thus, the patient's gait, combined with visible muscle hypo- or atrophy, would indicate weakness in certain muscles.
Patients with vertebroneurological pathology in most cases are examined by a therapist. Therefore, they usually do not need a detailed therapeutic examination, but it is necessary to measure blood pressure and count the pulse, listen to the lungs and heart in every patient. The presence of internal pathology allows us to judge the secondary vertebrogenic syndrome.
In the neurological status, the main functions are noted: consciousness, the state of the cerebral cortex, cranial nerves, movements, sensitive; examine the state of reflexes and the autonomic nervous system. It is not necessary for all patients to conduct a complete clinical examination of the nervous system. Usually, only the area that causes concern to the patient is comprehensively examined, and the rest of the nervous system is examined briefly.
The patient becomes against the light. Investigate photoreactions, the state of the pupils, the reaction to accommodation and convergence. To determine the volume of movements of the eyeballs and nystagmus, the patient needs to follow the movements of the malleus in front of his eyes with a fixed head. The innervation of the face and tongue is checked by closing the eyes, baring the teeth and protruding the tongue. The range of motion of the upper and lower extremities is checked. Examine pain sensitivity from top to bottom and from right to left. Of the reflexes, only the main ones are studied: on the upper limbs - from the tendons of the triceps, biceps muscles and the carporadial reflex; on the lower - knee, Achilles and plantar reflexes, as well as three pairs of abdominal reflexes. Of the coordinating samples, the finger-nose, knee-heel and Romberg's poses are checked. When examining the state of the autonomic nervous system, the pulse rate and the nature of dermographism, the presence of acrocyanosis and hyperhidrosis are checked. To identify focal pathology in organic lesions of the nervous system, it is important to establish the presence of pathological reflexes in the patient: Strumpell, Babinsky, Rossolimo, Oppenheim, Gordon, Schaefer, grasping, oral automatosis, clonuses and synkinesis.
Pain points are determined in the patient (Valle, Tara, cervical sympathetic nodes, Erb, naderb points, points of the spinal

Rice. 55. The location of some pain points and zones of the head and face (B. S. Agte, 1981): 1 - points of the trigeminal nerve 2 cm lateral to the midline; a - supraorbital - along the edge of the superciliary arch, 6 - infraorbital, 1 cm below the edge of the orbit, c - chin, 2 cm below the edge of the gums; 2 - temporal zone of Razdolsky - along the artery, 3 - ocular zone of Kerer - Kuimov - eyeball, 4 - orbital point of Grinstein - inner upper edge of the orbit, 5 - parietal point of Grinstein (apex of the parietal bone), 6 - projection of the sagittal sinus, 7 - point of the large occipital nerve (middle of the line: mastoid process - spinous process C)), 8 - atlantooccipital membrane, 9 - spinous processes of the cervical vertebrae and interspinous ligaments, 10 - cervical paravertebral points (2 cm lateral to the spinous processes), 11 - point of the vertebral arteries (1/3 of the distance from the top of the mastoid process to the spinous process Sc), 12 - point of the small occipital nerve (behind the mastoid process), 13 - Erb's supraclavicular point (behind the sternocleidomastoid muscle, 2 - 3 cm above the clavicle ), 14 - naderbo points (behind the same muscle, along the anterior-lateral surface of the vertebrae), 15 - Mussy diaphragmatic point (between the legs of the same muscle), 16 - carotid artery zone (along the carotid artery), 17 - point of the upper sympathetic node (anterior surface of the transverse processes of Sc-ts|), 18 - point of the stellate node - anterior surface of the transverse processes Cvi_vii> 79 - point of the anterior scalene muscle - behind the sternocleidomastoid muscle, above the 1st rib

nyh arteries, muscles, etc.), symptoms of tension (Lasega, Bekhterev, Bragar, Neri, Matskevich, Dezherin, Wasserman, Bonnet-Bobrovnikova, "landing") and other symptoms ("bell", Klein, Edson's test, Birchi's test) .
Pain points are palpation painful areas of various tissues. These are, first of all, foci of neuroosteofibrosis, which have the characteristics of myofascial trigger points, as well as periosteal zones and perineurium areas, perivasal sympathetic plexuses and vegetative nodes,

Rice. 56. Location of some pain points and zones of the trunk and limbs (B. S. Agte, 1981): 1 - Erb's subclavian point - in the recess below the clavicle and at the medial edge of the coracoid process, 2 - point of the coracoid process of the scapula (medially and 2 - 3 cm below the acromioclavicular joint), 3 - zone of attachment of tendons and serous bags of the shoulder joint, 4 - zone of the neurovascular bundle of the shoulder, 5 - point of the ulnar nerve, 6 - zone of the median nerve, 7 - zone of the carpal tunnel - palmar surface wrist joint, respectively, thenar (passage of the median nerve), 8 - zone of passage of the ulnar nerve and artery, 9 - zone of the radial nerve (between the deltoid muscle and the outer head of the triceps muscle of the shoulder), 10 - Lazarev's scapular point, 11 - points of the intercostal nerves, 12- costal-sternal joints, 13 - spinous processes of the thoracic and lumbar vertebrae and interspinous ligaments, 14 - paravertebral points - 2-3 cm lateral to the spinous processes - posterior points of Tara - disks L, v - Ly, 15 - anterior points of Tara - Shkolnikov ( anterior surface of the spinal column at the level of the umbilicus disc L,v and 3-4 cm below - disk C,), 16 - solar points - under the xiphoid process, on the border of the middle and upper, middle and lower thirds of the sterno-umbilical line, 17 - the abdominal aorta zone (to the left of the midline above and below the navel), 18 - hypogastric zone (4-5 cm below the navel), 19 - ovarian zones (in the iliac region, above and lateral to the pubic fusion), 20 - Valle points: a - gluteal, b - femoral, c - popliteal, d - fibula , d - gastrocnemius, 21 - zone

places of transition of muscles into tendons and their attachment to bones, fibrous rings of intervertebral discs and joint capsules, spinous and transverse processes (Fig. 55-56).
It is believed that two mechanisms act in the genesis of all symptoms of tension: irritation of pain receptors in the tissues of the corresponding parts of the limb and spinal column and a muscular tonic reflex reaction to irritation of the receptors.
The symptom of Lasegue is characterized by limited flexion in the hip joint and the appearance of pain along the back surface of the outstretched leg when it is raised (Fig. 57). If at this moment bend the leg at the knee, the pain disappears. The cross symptom of Lasegue (Bekhterev's symptom) consists in the occurrence of pain on the side of the lesion when lifting a healthy leg. It is believed that it is due to an additional displacement of the irritated root. During raising the leg from 0 to 40°, there is no tension on the nerve roots, but the sagging of the sciatic nerve is eliminated. Between 40 and 70 * marked stretching of the nerve roots (mainly l_5, Si and S2). At an angle above 70 * no further deformation of the roots occurs, and any pain that occurs after this level is articular in nature. After lifting the leg to 70”, the patient is asked to flex the neck and touch the chin to the sternum, or passive dorsiflexion of the foot of the raised leg is performed (Bragar sign). The appearance of pain in any way indicates the tension of the dura mater (central prolapse causes pain of greater intensity in the back than in the leg, lateral prolapse - on the contrary). Pain in a raised leg that does not appear with these two techniques indicates a process in the posterior thigh muscle group or pain of lumbar or sacral origin (felt more in the back than in the leg). The pronounced symptom of Lasegue is associated with a mechanical obstruction in the nerve root (disc herniation, narrowing of the intervertebral foramen). Swelling of an irritated or compressed nerve root can give a variety of options for the severity of the Lasegue symptom. The reproduction of pain on the affected side when lifting the opposite leg often indicates

piriformis muscle (the apex of an equilateral triangle, the base of which is a line connecting the sciatic tubercle and the greater trochanter), 22 - the zone of the sacroiliac joints, 23 - the zone of the greater trochanter, 24 - the coccyx zone, 25 - the point of the popliteal artery, 26 - the zone of the vascular nerve bundle of the thigh, 27 - Lapinsky's femoral point (anterointernal surface of the thigh, 3 - 4 cm above the patella), 28 - Achilles tendon zone, 29 - tarsal canal zone (below and behind the internal epicondyle of the lower leg - passage of the posterior tibial nerve), 30 - mid-plantar Bekhterev's point

Rice. 57. Symptom of Lasegue: raise the leg until pain occurs (a), lower the leg slightly and dorsiflex the foot (b; Bragar's symptom) or bend the leg (c)

on shell compression by a large formation located medially to the nerve root (disc herniation or tumor). If both legs are raised together (the "two-sided straight leg raise test"), there is a slight twisting of the nerve roots. Pain that occurs when lifting the leg up to 70° probably comes from the sacroiliac joint, more than 70 'from the lumbar spine.
Allocate muscular "pseudo-Laseg", which is not accompanied by signs of irritation, tension or compression of the nerve roots. As a result of the displacement of the vertebra, compensatory mechanisms are activated to keep the body in an upright position and stabilize the spinal column. With a relatively small degree of displacement of the vertebra, the rectifier of the back in the lumbar region is mainly strained. With further displacement, to keep the torso in a vertical position, the calf flexors are strongly strained, the points of attachment of which are located on the pelvic bones. With an unstable form of significantly pronounced spondylolisthesis, the task of keeping the trunk in a vertical position becomes even more complicated and leads to neurodystrophic changes with loss of muscle elasticity.
Thus, the formed persistent contracture of the muscles limits the flexion of the trunk and the outstretched leg during the study of the symptom of Lasegue.
Signs such as pain and paresthesia radiating to the zone of innervation of the corresponding root, paresis or paralysis, decrease or loss of reflexes, muscle hypo- and atrophy, autonomic angiodystonic disorders in combination with antalgic postures, smoothness of lordosis or kyphosis of the lumbar region, as well as the presence of Lasegue's symptom indicates radicular compression syndrome.
The contracture state of the flexor muscles of the legs in patients with significant spondylolisthesis is a consequence of forced compensation to keep the trunk in a vertical position and a sign of an objective reflection of the compression of the spinal roots in the spinal canal or in the intervertebral foramina (I. M. Mitbreit, 1978).
Neri's symptom manifests itself acute pain in the lumbar region and along the sciatic nerve, provided that the head of the patient, lying on his back with straightened lower limbs, is sharply bent to the chest.
Dejerine's symptom is characterized by a sudden increase in pain during physical exertion during laughter, coughing, sneezing, or when straining during the act of defecation. The mechanism of the onset of the symptom is explained by a sudden increase in the pressure of the cerebrospinal fluid or a muscular-tonic reflex reaction to irritation of the zones of neuroosteofibrosis.
Wasserman's symptom is detected in the position of the patient lying on his stomach. It is characterized by the occurrence of pain along the anterior surface of the thigh or in the lower back while raising the extended lower limb upward (extended at the knee joint).
Matskevich's symptom is that in a patient lying on his stomach, when the lower limb is flexed in the knee joint, pain intensifies or appears in the anterior surface of the thigh or in the lower back.
Tension symptoms (Lasega, Matskevich, Wassermann) with posterior median or paramedian cartilage nodes are usually detected on both sides, and with posterolateral ones - on the one hand. With unilateral lumbosacral radiculitis, a cross symptom of Lasegue and Matskevich is often observed.
The symptom of the "bell" ("button") is to reproduce or increase radicular pain with intense palpation of the paravertebral points. This symptom may have a certain topodiagnostic value.
The symptom of "landing" is caused as follows: the patient, lying on his back with outstretched lower limbs, is offered to sit down without changing their position. With a positive symptom, flexion of one or both limbs in the knee joint is observed. If you prevent their bending, the patient's torso deviates back.
Carrying out the Birchi test, the doctor stands behind the sitting patient, placing the bases of the palms on the lateral surface of the head in the region of the mastoid processes. Leaning with his forearms on the shoulders of the patient, the doctor, as it were, pushes his head up, performing rhythmically 5-8 movements. During the test, due to the unloading of the segments and an increase in the diameter of the intervertebral foramen, pain and paresthesia decrease.
The Edson test is characterized by coldness of the upper limb, cyanosis, numbness, swelling, decrease, and sometimes the disappearance of the pulse on the radial artery with a deep breath, raising the chin and turning the head to the side being examined (I.P. Kipervas, 1985). The pulse on the radial artery is palpable both at rest and with deep inspiration, turning the genitals, and abducting the arms. During the test, compression of the subclavian artery occurs as a result of a decrease in the interstitial space with contraction of the anterior scalene muscle and elevation of the first rib. G. S. Yumashev and M. E. Furman (1984) believe that the leading role in this is played not by direct compression of the artery, but by a violation of sympathetic innervation.
Klein's symptom is manifested by dizziness and horizontal spontaneous nystagmus during the turning of the eyes to the sides when the head is thrown back, turned to the sides or lateral tilts.

Manual therapy is a unifying medical term mechanical action, where the hands are the main instrument of treatment. Manual massage is considered the most advanced form of contact interaction. The basis of the treatment and diagnostic methods of an alternative (non-traditional) method of treatment is osteopathy, which the manual therapist considers as the root cause of the painful relationship between the structural and anatomical systems of life. In this article, we will define what manual therapy is in terms of contact interaction with the musculoskeletal system, what are the advantages, what are the indications and main contraindications for manual therapy, we will consider the main methods and techniques of manual therapy.

The current fundamentals of manual technique combine:

• The idea of ​​the treatment of the spinal column, as the main bone-articular formation of the supporting system, its ligamentous-muscular and vertebral elements: intervertebral discs, articular segments, vascular and nerve plexuses.
• The concept of postisometric relaxation of the muscles of various parts of the vertebral motor segments in osteochondrosis, hernial protrusion of the pulpous contents in the body of the spine, deforming spondylarthrosis, displacement and / or compression pinching of the meniscoids, and the like.
• The concept of the work of the anatomical organs of vital activity.
• Development of diagnostic methods and special techniques for conducting manual therapy with natural passes for the displacement of the mobile regional department.

Thus, it becomes obvious that manual therapy methods contribute to the pathobiomechanical exclusion of musculoskeletal disorders and their pain symptoms. In other words, manual massage does not significantly affect the degenerative activity and dystrophy of the vertebral-motor parts of the supporting apparatus. However, craniosacral and osteopathic gymnastics, carried out by a manual specialist or masseur, has an extremely positive effect on the healthy functionality of the main organ of the nervous system and musculoskeletal vertebral regions, and also significantly helps in relaxing all its muscular-ligamentous plexuses.

What is a function block (FB)

Under the functional block of the vertebral-motor section is meant a reversible restriction of intra-articular mobility of the connective tissue elements relative to each other, which means their violation of periarticular reflex myopically. The reversibility of the functional block ensures the action of passive mobilization movements, traction impulse, as well as different kind relaxation actions (manual massage, post-isometric muscle relaxation, autorelaxation). The most common causal factors for the appearance of a functional block are:

• Trophic muscle failure due to prolonged immobilization.
• Overload of dynamic impact (sharp jerks, etc.).
• Static overload.
• Nociceptive reflex effect in diseases of the spinal system.
• Inertial overvoltage of the musculoskeletal segment.

When evaluating the characteristic of a limited block, the manualist determines its direction. The opposite of FB is articular hypermobility of the vertebral segments. The difference lies in the increased anterolateral, ventrodorsal and dorsoventral displacement of the spinal motion segments. Such differences in excess mobility increase the reversibility of a certain range of motion with manual methods of mobilization of the articular segments of the spine. Manual exercises are selected by the manualist based on the pathogenesis and type of biomechanical functional disorder. TO general requirements therapies used include:

• Indicator of clinical and radiographic examination, excluding the main contraindications to manual therapy.
• Determination of the type of pathobiomechanical functional disorder.

A correct assessment of the situation and an accurate definition of a differential approach to an alternative method of influence helps the doctor to establish positive compatibility with the patient, which makes the manualist psychologically contactable.

Manual action: classification of techniques

To eliminate pain and other manifestations of clinical symptoms, the manualist selects the appropriate mechanical effect:

1. Segmental relaxing manual massage. For a duration of 3–5 minutes, the manualist gently strokes and kneads the spasmodic muscles to provide them with a warming effect. As a result of this action, muscle tension is significantly reduced, the osteoarticular segment becomes more sensitive and pliable to stretching. The patient's response is a decrease or complete disappearance of pain, dizziness disappears, the body becomes more obedient, while the head becomes heavier and sleepy. Such a reaction of the body indicates the high professionalism of the therapist.
2. Segmental mobilization, that is, ensuring painless recovery of the FB or spasmodic shortening of the muscle segment by passively repeated unhurried movements within the articular physiological volume.

At the same time, mobilization requires certain conditions:

• Stable fixation of the higher or lower parts of the body, these conditions are especially strictly met when manual therapy of the neck is performed.
• Providing complete muscle relaxation.
• Any performance of a manual technique should be performed in the exhalation phase.
• The manualist ensures the direction of smooth and soft movements along the longitudinal axis of mutual sliding and mutual removal of the articular surfaces.
• Mobilization is carried out until there is a slight sensation of pain and a slight resistance in the joint, after which the articular segment returns to its original position.
• Patient and consistent conduct of mobilization sometimes completely replaces the manipulation action.

So, after establishing the pathogenetic and clinical condition, as well as a detailed neurological examination of the patient, a therapeutic tactic of mechanical action is developed and the question of the appropriateness of treatment is decided.

Advantages and disadvantages

It is now becoming fashionable to impose various methods of alternative medicine. Street poles are full of advertisements for reliable healing by osteopathy, craniopathy and/or visceral manual medicine methods. It is very difficult to understand this terminology, how they differ from each other, whether these treatments are good or bad for human health, and whether it is worth paying attention to at all. Often, homegrown medical specialists insist that manual therapy during pregnancy is the only way to eliminate pain in the musculoskeletal system of the spine, and also recommend such alternative ways treatment for young children.

What are the features and differences between osteopathy and manual therapy

Osteopathy finds out the causes of diseases, and provides a mild therapeutic effect on muscle structures, which is acceptable even for infants. Classical manual therapy is the definition of pain symptoms that reveal the consequences of their appearance and methods of mechanical action. Craniosacral manual therapy is a dosed manipulation of the hands of a chiropractor on the cranial bones.

Indications for therapy

The therapeutic effect of mechanical intervention in the spinal motion segment must be due to certain conditions, or indications of manual therapy. There are two types of such therapeutic and regenerative prophylaxis - absolute and relative indications and contraindications.
Absolute:

• Diseases of the osteoarticular organization of the spine associated with a degenerative disorder leading to the development of functional blocks of PDS - osteochondrosis, deforming spondylarthrosis, and so on.
• Discogenic reflex disorders at the level of the cervical (cervicalgia), thoracic (thoracalgia) and lumbar (lumbodynia) vertebrae, expressed by a certain degree of local pain.
• Diseases of spondylogenic pathology with irritative-reflex muscular-dystonic disorder.
• Irritative-vegetative-trophic bone-articular disorders - coxarthrosis, arthrosis of the iliac-sacral segment, humeroscapular periarthrosis, and so on.
• Acroparesthesia, pseudoarteritis, thermal paresthesia, restless legs syndrome, that is, all those clinical manifestations, which belong to the irritative-reflex-vascular syndromes of spondylogenic pathology.
• Diseases of the osteoarticular segments that provide myofascial pain in trigger zones.

Relative:

• The severity of pain syndrome exceeding the third degree.
• Spondylogenic symptoms of radicular syndrome with paresis, hyporeflexia, etc.
• Spondylogenic syndromes with a pronounced neurodystrophic disorder.
• Sympathetic syndromes with pronounced posterior cervical spondylogenic characteristics.
• Symptomatic disorders of the functional block of the spinal motion segment with visceral reflex muscular and/or pain syndrome.

Methodological contraindications

Mechanical impact may be limited by absolute and relative signs, which provide a certain amount of harm from manual therapy.
Absolute signs:

• Presence malignant neoplasms in the segmental part of the proposed procedure.
• The presence of acute infectious lesions.
• Severe spinal instability.
• Inflammatory disorders in the spinal organization.
• Violation of the main blood supply.
• Spinal injury or arterial thrombus.

Relative features include:

• Unstable psycho-emotional state of the patient.
• Stage of decompensation of clinical pathologies of internal organs.

Summary

Attention! All manipulations should be carried out only by a highly qualified specialist who has a state diploma and confirms medical state certificates of special training as a neurologist, orthopedist or traumatologist.

Rough or unprofessional movement of the hands can provoke a complication: fracture of the vertebrae of the cervical or other parts, rupture of the ligamentous apparatus, violation of the main blood circulation.

Chiropractor is a medical specialist who uses manual techniques for the treatment of diseases - techniques produced by the hand. Chiropractor literally means "healing hand" ( "manus" is Latin for "hand"). The branch of medicine that this specialist studies and practices is called "manual medicine".

Manual medicine is the science of manual methods of influencing the musculoskeletal system, joints or ligaments, including the ligamentous apparatus of human internal organs. The chiropractor has a higher medical education, a diploma of a medical specialist and a certificate in manual therapy. A doctor has been studying manual therapy for 2 years, however, in order to be able to undergo professional retraining, a doctor, after graduating from a medical university, must receive one of the narrow specialties related to manual therapy.

The following specialists can become a manual therapist:

• sports doctor- specialist in physical therapy and sports medicine;
• neurologist- specialist in diseases of the nervous system ( brain and spinal cord);
• therapist- general practitioner;
• pediatrician- pediatric general practitioner ( he becomes a pediatric chiropractor);
• traumatologist- a doctor who treats bone fractures;
• orthopedist- a doctor who treats various pathologies of the musculoskeletal system;
• maxillofacial surgeon- a doctor who treats diseases of soft tissues and bones in the face and jaw;
• rheumatologist- specialist in autoimmune connective tissue diseases ( rheumatic diseases), which affect bones, joints, muscles and internal organs;
• reflexologist- a doctor who treats by acting on biologically active points on the human body.

The presence of these narrow specialties distinguishes a chiropractor from an osteopath ( oriental manual therapist) and a reflexologist, since doctors of almost all specialties can learn osteopathy and reflexology. The fact is that manual therapy, unlike other similar specialties ( hand work), requires a deeper knowledge of the nervous, musculoskeletal system and diseases of the internal organs.

Until 1997, in the CIS countries, there was no medical specialty "manipulation therapist", but still patients turned to specialists in manual therapy, who then did not have a medical education. They "treated" only the symptoms, without delving into the cause, so their help could bring not only benefit, but also harm. In 1997, in Russia, manual therapy was included in the list of medical specialties, due to the need for this specialist. The need was to increase the number of patients with pathology of the musculoskeletal system, for whom manual therapy effectively helped to get rid of painful symptoms.

A chiropractor can work in the following medical institutions:

• hospitals ( in the department of neurology, traumatology, therapy or in a specialized manual therapy department);
• polyclinics ( in the department or office of manual therapy);
• health resorts.

What does a manual therapist do?

A manual therapist has theoretical and practical skills in the field of manual therapy, is engaged in the study, diagnosis and treatment of special conditions of muscles, joints, bones and ligaments that can be eliminated using manual methods. As a reason pain and dysfunction of movement, the chiropractor sees a block and a non-optimal movement stereotype. A block is a violation of the natural movement in the joints or a limitation of mobility. As a result of the block, the body begins to adapt to the painful state, reorganizes itself in such a way as to reduce the load on the overloaded ( blocked) plot. Such a habitual and almost imperceptible condition for the patient is called pathological ( suboptimal) motor stereotype. Based on this, the chiropractor works on the principle of "no block - no pain."

The manual therapist deals with the pathology of the following structures:

• spinal column;
• bones;
• joints;
• ligaments;
• fascia ( membranes of muscles and organs);
• muscles.

All of the above structures make up the musculoskeletal system, while the passive part of the apparatus consists of bones and joints ( joints), and the active part is from the muscles. While other specialists restore these structures through something else ( physiotherapy, medicines), then the chiropractor acts on them directly. The musculoskeletal system is the subject of study by an orthopedist and traumatologist, and the nervous system is a subject of study by a neurologist. So it turns out that a chiropractor must know neurology and orthopedics, as well as be able to distinguish "their" pathologies from those that cannot be eliminated with the help of manual therapy.

musculoskeletal and peripheral nervous systems ( nerve fibers) are of interest to the chiropractor in terms of movement function. The functional unit of movement in the spine is the spinal motion segment.

Spinal motion segment(PDS)consists of the following components:

• two adjacent vertebrae, which form the intervertebral joint at three points - two joints with the help of the processes of the vertebrae and one through the intervertebral disc;
• one intervertebral disc cartilage) , which connects the vertebrae, acting as a shock absorber ( thanks to the disc, the vertebral bodies are not injured during movement);
• ligaments and muscles- provide connection of two intervertebral discs and create one spinal column.

There are 24 such segments in total ( 7 cervical, 12 thoracic and 5 lumbar). Each motor segment forms openings that are designed to exit ( or entry) spinal roots ( nerves), vessels and veins. Each front spine nerve exiting the spine) has its own muscle group, which it can regulate - myotome ( "myo" - muscle and "tome" segment). At the same time, the same segment of the spine has sensitive posterior roots ( nerves that enter the spine), which receive information from a specific area of ​​the skin - the dermatome ( dermis - skin). Ligaments, fascia, tendons and periosteum receive their "portion" of nerves from the roots ( sclerotome).

Thus, in the pathology of the spinal motion segment, muscle tone, skin sensitivity, degree of ligament tension and organ functions are disturbed.

A chiropractor sets himself 2 goals that are achieved by the same methods - the elimination of pain and the restoration of impaired movement function. They have the same cause - a block in the spinal motion segment.

traffic violation(block)in the motor segment can be:

• functional- reversible violation, not associated with pronounced changes in the structure of the organ;
• organic- irreversible restriction of mobility and changes in the structure of the body.

A function block can have the following causes:

• abnormal voltage- passive restriction of joint mobility within its natural function;
• local hypermobility- reversible increased joint mobility due to excessive stretching of the ligaments.

The outcome of a functional block is an organic block, and hypermobility can turn into organic instability.

Organic movement disorders can be:

• fixed ( bound, stable) - when the patient's posture changes, the relative position between the two segments does not change;
• unfixed ( overly relaxed, unstable) - offset segments ( vertebrae) varies with posture.

The work of a chiropractor is to restore the function of movement before the pathological process becomes irreversible, while such a moment as a reserve of movements is important. The reserve of movements is the ability to loosen the joint with the help of joint play. This reserve is associated not so much with the bones as with a spasm of the musculo-ligamentous apparatus, which disrupts movement in the joints. In order to perform manual therapy, the reserve must be maintained ( this is the function block). Thus, manual therapy does not affect the processes occurring in the bone tissue. No osteoporosis or osteochondrosis ( bone tissue pathologies) a chiropractor does not treat, he only corrects impaired functions. This is important to consider, since manual therapy is not a panacea and does not replace other methods of treatment, but complements them.

The work of a manual therapist, depending on the stage of therapy, can be:

• diagnostic- manual diagnostics;
• medical- manual correction or therapy;
• preventive- manual therapy after correction.

How is a chiropractor appointment?

The office of a chiropractor is equipped in the same way as a doctor's office of any other specialty, there are no decorative elements typical for massage parlors. Posters with pictures of the anatomy of the musculoskeletal system can be hung on the walls. The main thing that is present in the office of a chiropractor is a couch for manual therapy, on which the patient lies or sits down during manipulations.

In order for a chiropractor to "have a hand", it is necessary to undergo a detailed examination and find out the causes of the ailment, that is, consultation and diagnostics are required from therapists, neurologists, traumatologists, orthopedists, rheumatologists. The chiropractor accepts the patient already with materials about his illness. This is very important, because there are a number of contraindications for manual therapy, and they must be excluded before contacting a manual therapist.

Reception of a manual therapist includes the following steps:

• questioning the patient- clarification of complaints, circumstances that led to the disease, living and working conditions, other illnesses that have been transferred or are present at the moment;
• inspection- the doctor examines the condition of the skin, changes in the area of ​​​​the joints, their mobility, soreness, tension and soreness of the muscles, curvature of the spine;
• anthropometry- the doctor measures the height and weight of the patient using a centimeter tape and floor scales;
• general therapeutic examination- measurement of blood pressure, pulse, auscultation of the lungs, examination of x-ray films of the place of interest;
• neurological examination- assessment of reflexes using a neurological hammer;
• orthopedic examination- assessment of the patient's posture ( free, forced, protective), his constitution, posture, bone elements and natural curves;
• spine examination- comparative assessment of symmetrical zones, diagnostic methods of manual therapy;
• manual muscle testing- assessment of strength and functionality individual muscles, which is carried out with the help of test movements performed by the doctor and the patient together;
• determining the change in the center of gravity- carried out using a plumb line ( thin thread with a small load), which is lowered from the middle of the distance between the occipital tubercles or from the angle of the shoulder blade to the heel.

At the appointment, the chiropractor may ask the following questions:

• Where does it hurt and where does the pain radiate?
• When did the complaints first arise?
• Are there sharp, shooting, stabbing pains?
• Does pain worsen with exertion? movement, weight lifting)?
• Is the onset of pain characteristic at the moment of starting the movement?
• What movement causes pain?
• Does the pain increase during exercise?
• Does the pain decrease with movement?
• Do you have pain at rest?
• Does pain improve at rest?
• Does the pain increase at rest or during sleep?
• Is there a feeling of numbness, tingling ( "goosebump")?
• Is there muscle weakness?
• Has the person been involved in sports? athletes feel pain is weaker than it really is)?

Before performing diagnostic techniques, a chiropractor evaluates the movements that a person in most cases performs “on the machine”. These habitual movements may be incorrect, which in manual therapy is called a pathological motor stereotype ( is a consequence of the block). To identify a motor stereotype, the doctor asks the patient to sit on a chair, get up from a chair, lift weights from the floor.

After the hands-free examination, the chiropractor asks the patient to take off their clothes ( during manual therapy sessions, men prefer to wear shorts, and women prefer bikini swimsuits). This is necessary so that the hands of the chiropractor do not slip on the clothes during the execution of the techniques ( reception requires fixing hands at certain points). The patient sits or lies down on the couch, and the chiropractor begins to search for the blocked area. In the absence of contraindications to manual therapy, this block is removed. "Search block" chiropractor performs with the help of hands.

Diagnostic techniques of manual therapy

Diagnostic reception	Description
Palpation	Palpation is the feeling of joints, muscle tissue, skin. With the help of this technique, the chiropractor evaluates soreness, increased muscle tone, their compaction, barrier and functional reserve.
stretching	The degree of extensibility of the “diseased” muscle is determined in comparison with the symmetrical muscle on the other side.
Joint study	The study of the joints includes an assessment of active ( produced by the sick) and passive ( produced by a doctor) movements in the joint. In addition, the chiropractor identifies specific joint phenomena, such as joint play ( "springing"), which determines the degree of change in the biomechanics of the joint ( degree of blockade).
Jog palpation of the joints	This method examines the spinal motion segments of the spine ( joints). The doctor conducts rhythmic shocks away from the spine in order to assess the functional reserve and mobility of these spinal motion segments.

After the reception, the chiropractor makes a functional diagnosis - a conclusion about the degree of dysfunction. This diagnosis is designed to develop a treatment plan. The plan depends on where it hurts and where the pain comes from ( where block), as well as on the severity of the reserve of movements. Thus, the doctor of manual therapy looks at the patient's condition from a slightly different angle. His diagnosis is a syndrome, which in turn is the result of a disease.

With what pathologies do people turn to a chiropractor?

Symptoms that lead a person to this specialist are pain and impaired movement ( dysfunction of an organ or part of the body). A chiropractor treats or alleviates the condition of a patient with a lot of diseases, but not all pathologies are “subject to” the hands of a chiropractor. There are clear indications and contraindications for manual therapy, which are known to doctors of other specialties. If the pathology is at the stage of dysfunction without deep ( irreversible) violations of the structure of the body, then specialist doctors advise you to contact a chiropractor.

According to one of the teachings of manual therapy, all diseases come from the spine. It is believed that if the nerves go to each organ through the spine, then by acting on the spine, it is possible to restore the normal innervation of the organ ( nerve supply and regulation). That is why all the pathologies that a chiropractor deals with are considered from the point of view of their connection with the spine.

Pathologies that a chiropractor deals with are:

• vertebrogenic ( vertebralis - vertebrate, genesis - origin) - pathologies associated with spinal disease;
• nonvertebrogenic- not associated with a disease of the spine or musculoskeletal system or, translating into the language of manual therapy, not due to changes in the spinal motion segment.

Vertebrogenic pathologies can be manifested by the following syndromes:

• vertebral syndromes- local pain, the location of the source of pain and the area of ​​pain coincide;
• extravertebral ( neural, muscular, vascular) - the zone of pain and movement disorders do not coincide with the location of the source of their cause.

Simply put, the pathology of the spine can have many masks that are not directly related to the spine. Such "masks" can occur when nerves and blood vessels are compressed ( compression syndromes) or during their reflex contraction ( reflex syndromes).

The most common pathology of the spine, which has many "masks", is osteochondrosis - dystrophic changes in the spinal motion segment.

Osteochondrosis includes:

• disc degeneration- damage causing compaction and protrusion of the disc;
• intervertebral arthrosis- violation of movement in the joints of the motor segment of the spine;
• spondylosis- proliferation of bone tissue on the surface of the vertebrae.

At the same time, if pain and movement disorders are associated with the spine, this does not mean that a chiropractor can eliminate them. It is important to know that manual therapy is not effective, and sometimes even dangerous, in acute inflammatory, infectious and malignant diseases, as well as fresh injuries and diseases that require surgical treatment.

Contraindications for manual therapy include:

• tumors of the spinal cord and spine;
• osteochondrosis of the spine above stage 3;
• complications of intervertebral hernia ( gap);
• any malignant tumors with metastases;
• ankylosing spondylitis ( inflammation of the intervertebral joints);
• acute disorders of cerebral circulation;
• acute cardiovascular failure;
• scoliosis ( in adolescence and above 2 degrees);
• congenital anomalies of the vertebrae;
• severe illness internal organs ( bleeding, injury, rupture of internal organs, inflammation);
• acute infectious diseases;
• tuberculous lesion of the spine;
• osteomyelitis ( purulent inflammation) spine;
• imperfect osteogenesis;
• vertebral dysplasia ( structural change);
• osteoporosis ( decrease in bone density) spine;
• spinal surgery;
• fixative ligamentosis ( dystrophic changes in ligaments);
• blockage of the lumen of the vertebral arteries by a thrombus;
• paresis ( partial paralysis) lower limbs;
• atrophy ( reduction in tissue volume) limb muscles;
• common areas on the body with weakened or lost sensitivity.

The list of indications for manual therapy is longer and includes many syndromes that get their name depending on where it hurts or where the block is located. It is also important to know that different stages of the same disease can be both an indication and a contraindication for manual therapy.

The most common pathologies dealt with by a chiropractor

Pathology	Origin mechanism	manifestations of pathology symptoms)	The effect of manual therapy in this pathology
Syndromes with local pain ( vertebral)
cervicalgia	cervicalgia ( cervix - neck, algia - pain) occurs due to damage to the connective tissue ( ligaments) of the cervical spine and reflex tension of the muscles of the neck, which is often the result of osteochondrosis of the cervical spine.	pain in the neck that extends to the occipital, parietal, or temporal region ( if the first two motor segments are affected) or in the shoulder girdle or shoulder area ( with damage from 3 to 7 segments); the pain comes on or gets worse when you cough, sneeze, laugh, or move your neck.	The therapeutic effect is due to the elimination of the reflex spasm of the cervical muscles and the block in the spinal motion segment of the spine, as a result of which the tension of the tissues and the formation of pain impulses cease.
Dorsalgia	Dorsalgia ( dorsum - back) occurs in the presence of a block of the costovertebral joints or in the pathology of the intervertebral disc ( osteochondrosis) in the thoracic spine. This causes tension in the paravertebral ( paravertebral) muscles.	restriction of movement of the spine in all directions; "stony" density of the back muscles; constant or paroxysmal pain in the upper and middle part of the back, especially with a sharp turn of the body, a deep breath.	The pain disappears if the chiropractor achieves muscle relaxation, corrects the location of the components of the motor segments ( reduces subluxation). Thus, on the one hand, the root cause of nerve compression is eliminated ( block), and on the other hand, relaxing the muscle relieves pain.
Lumbalgia		joint pain; limitation of movement in the joints; "clicks" in the joints during movement.		The therapeutic effect is achieved by eliminating chronic pain in the tense muscle of the joint. The absence of pain inhibits further changes in the structure of the periarticular tissues and makes it possible to work out the joint, restoring its function.
Tunnel syndrome in the arm	Tunnel syndromes occur when the nerve plexuses are compressed inside their bed - this is the name of the place between the muscles and fascia of the limb, which is intended for the passage of nerves ( that's why they are called tunnels). The cause of compression may be an overload of the muscles that form this tunnel, a tendency to edema, or the congenital narrowness of the tunnel. For the lower extremities, the footwear factor is also important.	pain, tingling ( goosebumps) or a decrease in sensitivity in the forearm, hand, elbow, fingers, which occur or increase when performing certain actions.	The therapeutic effect of manual therapy is due to a change in the motor stereotype, which caused pinching of the nerves inside the muscular-fascial canals. This is achieved through exercise and muscle relaxation.
Tunnel syndrome in the leg area		pain and numbness in the groin, inner, front or side of the thigh, lower leg and foot ( in soles and toes), which arise or intensify when performing a certain movement; intermittent claudication.
vertebral artery syndrome(vertebrobasilar disease)	The mechanism of the syndrome is associated with irritation of the nerve plexus of the vertebral artery ( passes through the foramen of the vertebrae), which most often occurs due to instability ( bias) discs of the middle cervical segments. As a result of this instability, the artery is compressed, its lumen decreases, and into the main vessel of the skull ( basilar artery) receives less blood.	headaches in the neck and occiput, spreading to the temple and forehead; dizziness ( occurs when the position of the head changes); promotion blood pressure; visual impairment.	The therapeutic effect in this pathology is due to the reduction of the displaced cervical vertebra, as a result of which the compression of the artery stops.
Heel spurs (plantar fasciitis)	Heel spurs are called bony growths of the calcaneus. The reason for their formation is excessive tension of the plantar ( plantar) fascia and its microtraumas ( fascia is active during walking). As a result, a blockade occurs in the ankle joint, causing painful tension of the fascia.	sharp pain in the heel while walking.	The analgesic effect of manual therapy is due to the relaxation of the muscles and fascia of the foot and ankle joint.
functional dysphonia	In the presence of a block in the cervical spinal motion segments, the coordinated activity of the muscles of the larynx is disrupted, they shorten ( spasm) or lose tone ( become lethargic).	sensation of a "tangle" in the neck or larynx; the need to cough during a conversation; hoarseness or a decrease in the "range" of vocal abilities ( especially noticeable in vocalists).	The therapeutic effect of manual therapy is due to the reduction of displaced segments ( block removal). This normalizes the nerve transmission to the muscles of the larynx.
Sliding costal cartilage syndrome	The cause of "slip" is increased mobility ( hypermobility) ends of the costal cartilages where they attach to the sternum. This can occur when the muscles that attach to the sternum and ribs are overstretched. This is where the block is located.	sudden pain in the ribs that spread to the sternum, shoulder ( looks like a heart attack); pain occurs when inhaling, coughing, tilting the torso, with pressure on the painful points of the ribs ( this produces a click).	With the help of manual therapy, instability in the area of ​​​​attachment of the ribs to the sternum is eliminated by reducing the displacement and relaxing the muscles associated with these bones.
Temporomandibular joint dysfunction	Movement disorder in the temporomandibular joint occurs due to increased tension ( spasm) chewing muscles. High tone can be observed with trigeminal neuralgia or any pathology in this area that causes a reflex spasm of the muscle.	pain when opening the mouth; decrease in the size of the oral fissure; difficulties with the act of chewing; "crunch" in the joint.	Restoration of movement in the joint is achieved by improving blood supply and relieving tension in the masticatory muscle, interrupting pain signals that cause it to spasm.
Respiratory disorders	In some cases, respiratory distress can be caused by a violation of the synchronism of the movements of the respiratory muscles if the blocked motor segment of the ribs ( joint) connects to the act of breathing later than the others, and ends its movement before anyone else. Another cause may be soreness in the muscles of the chest and abdomen.	shortness of breath and a feeling of incomplete inspiration; tightness of the chest in the form of a hoop.	Restoration of breathing with the help of manual therapy occurs due to the removal of the block that interfered with the synchronous movement of the chest and the elimination of pain points in the muscles that cause pain during breathing.
Functional disorders of the internal organs	The presence of a block in the spinal motion segment changes the normal transmission of the impulse to the organ along the nerve fibers ( although the anatomical neural pathways are preserved). This leads to violation motor activity organ muscles ( spasm or loss of tone) and contraction of its ligaments. It can also be considered an incorrect motor stereotype, which is manifested by the disease.	vegetative-vascular dystonia ( arrhythmias, high pressure, shortness of breath); bronchial asthma ( susceptibility to bronchospasm); chronic diseases of the gastrointestinal tract ( gastritis, enteritis, colitis, flatulence); biliary dyskinesia ( violation of the movement of bile); visceroptosis ( prolapse of internal organs); adhesive disease; reproductive diseases ( genital) organs; chronic prostatitis;	Manual therapy improves blood circulation in these organs, increases sensitivity to nerve impulses, which stimulates recovery processes. In addition, therapy restores the normal position of the internal organs, that is, it corrects the motor stereotype.
Pathologies in children
Birth trauma of the cervical spine (craniocervical injury)	The cervical spine in the fetus experiences the greatest load during childbirth ( although other parts of the spine may also be affected). With any pathology of labor or abnormal position of the fetus in the uterus ( breech presentation) this load increases. As a result, there is a displacement of the vertebrae and their instability in newborns ( "Children's" osteochondrosis).	the child cries and does not sleep well; twitches his hands and squeezes his palm into a fist; violated physical development child and brain maturation learning difficulties); posture changes and the spine curves.	Instability of the vertebrae in children is eliminated in the same way as in adults. The therapeutic effect is achieved by reducing the vertebrae and relieving muscle spasm.
Torticollis	The cause of "congenital" torticollis is an uncomfortable position of the child in the uterus during pregnancy or osteochondrosis in childhood. As a result, a block occurs in the cervical spinal motion segments, which causes compression of the nerves and reflex spasm of the neck muscles.	head leans towards one shoulder.	The therapeutic effect is due to the removal of muscle spasm, reduction of subluxation of the vertebrae and correction of the motor stereotype ( "learning" muscles).
Scoliosis	Scoliosis develops if the child's spine is in the wrong position for a long time ( violin playing, awkward sitting posture) or carries weights on the back ( backpack). As a result, part of the muscles of the spine is in constant overstrain and "pulls" the spine. There is also scoliosis, which occurs due to uneven tissue growth.	curvature of the spine to the side.	A chiropractor directs his skill to change the muscle stereotype - the removal of the usual muscle tension. On the other hand, manual therapy stimulates the growth of retarded muscles.
Myopia	The cause of this pathology in many children is a functional blockade of the craniovertebral junction - the base of the skull, which is formed by the occipital bone and the first two vertebrae ( atlas and axis).		The therapeutic effect of manual therapy is based on the removal of blocks in the base of the skull, which eliminates myopia in children in 97% of cases. In adults, this percentage is much less, since over the years of life, other causes of myopia may also join the functional block.

What are the types of manual therapy?

Manual therapy is a complex of manual techniques that have been used since ancient times, but scientific confirmation was found relatively recently. Many experts still do not recognize the "manual" as a science, considering it a pseudo-teaching. Manual therapy gained such a reputation due to the fact that in the United States, due to high profits, they began to “produce” too many chiropractors, who were called chiropractors ( hiro - hand). The activity of chiropractors was effective, but was not recognized by doctors, since chiropractors did not have a medical education. Due to the lack of contact between physicians and chiropractors, manual therapy in this form developed independently of traditional medicine.

Along with chiropractors there were osteopaths. Osteopathy is the same manual therapy that belongs to alternative ( unconventional) oriental methods of treatment.

We can say that manual therapy is a Western version of Eastern alternative medicine, which has an evidence base, that is, it can prove exactly how this therapy works in medical terms. This is one of the main differences from osteopathy, which uses "language" ( terminology) oriental alternative medicine.

Manual therapy techniques

Reception is the action of a manual therapist in order to restore the initial physiological state of the motor segment or its controlled structures ( muscles). Performing an appointment requires a doctor to have a deep knowledge of anatomy and physiology, neurology and orthopedics. Each department of the musculoskeletal system or part of the body has its own techniques, but they are all grouped, depending on the method of exposure.

To the methods of influence(techniques)manual therapy include:

• mobilization- smooth, rhythmic, as if playing or loosening movements in the joint ( multiple movements), which eventually stretch the shifted component, releasing it from the load, and help to return to "its place";
• manipulation- fast movement against the background of relaxation, which has a small force and a small "span", leading to the reduction of the displaced part in one moment ( reposition);
• relaxation- Techniques that relax the muscles.

All three techniques are often used together as steps in the same technique. Mobilization and relaxation are "soft" techniques, while manipulation is "hard". With proper execution, "hard" manipulation is performed gently ( in contrast to the reduction of dislocations produced by traumatologists).

Some chiropractors add a fourth to these three techniques - pressure. Pressure is an effect on painful points, which occupies an intermediate place between massage and manual techniques.

Manipulative techniques include:

• push;
• traction push ( force traction);
• hit.

Mobilization methods include:

• rotation ( rotation);
• bending;
• extension;
• deflection;
• traction ( traction);
• distraction ( stretching);
• tension ( pressure, tension);
• nutation ( rocking);
• twisting ( twisting);
• reduction ( retraining of a relaxed muscle).

Relaxation techniques include:

• - the doctor causes muscle tension, which is not accompanied by movement ( shortening or shortening), after which for some time the muscle relaxes as much as possible;
• post-reciprocal relaxation- stretching and relaxation of the “sick” muscle occurs in an active way, for which the patient himself “moves” the muscle, which causes movement in the other direction ( for example, if the flexor is diseased, the extensor is activated).

The term "mobilization" is used more often by chiropractors, and it may seem that they only do these techniques, but this is not at all the case. Everything depends on the goal. By mobilization, therapists understand the loosening that sets the tissue in motion. Loosening can relax a muscle or set a vertebra, so mobilization techniques can be used on both joints and muscles, ligaments and fascia. The main difference between mobilization and manipulation is the number of movements. If the movement is made once - this is manipulation, multiple movements in the same place - mobilization.

A chiropractor may use the massage technique in their practice as an additional method, but massage is not a purely manual type of therapy. Classical massage, although carried out with the help of hands, refers to reflexology. The “massage” that a chiropractor conducts is more like kneading tissues.

Depending on the point of application(block location)There are the following types of manual therapy:

• skin-subcutaneous-myofascial manual therapy;
• arthro-vertebral manual therapy;
• craniosacral manual therapy;
• visceral manual therapy.

Skin-subcutaneous-myofascial manual therapy

Muscle movement and skin sensitivity, according to the principle of manual medicine, are disturbed in the presence of a block in the spinal motion segment. This means that the chiropractor does not directly treat muscle pain and skin-subcutaneous thickening and tightness. But pain and dysfunction of muscles and skin are eliminated if the block in the spine is removed. On the other hand, muscle pain maintains a vicious circle of pain syndrome due to the formation of an incorrect musculoskeletal stereotype ( pain - muscle spasm - dysfunction - pain). With the help of skin-subcutaneous-myofascial therapy, a chiropractor removes one of the links from this chain - pain, which breaks the vicious circle. Nevertheless, despite this analgesic effect, skin-subcutaneous-myofascial therapy is not so much a therapeutic method as a diagnostic and preparatory method.

The diagnostic component of this therapy is that by determining increased or decreased muscle tone, painful points ( trigger points), compacted foci and a zone of numbness of the skin, the chiropractor finds out exactly where the block originated.

As a preparatory stage, skin-subcutaneous-myofascial therapy is an essential component of treatment. In order to manipulate or mobilize a blocked motor segment, the muscles that receive nerves from that segment must be relaxed. At the preparatory stage, the therapy techniques also help to relieve pain, but the cause of the pain, that is, a block in the spinal motion segment, remains. This means that if the next stage of treatment is not carried out, then the pain will return after some time.

Arthro-vertebral manual therapy

Arthro-vertebral manual therapy, as the name implies ( artus - joint, vertebralis - vertebral), is aimed specifically at the motor segments of the spine in order to remove the block. This type of manual therapy involves the use of mobilization and manipulation. Manipulation is done by pushing or punching, which is believed to produce a "crunch" when performed correctly. In fact, the appearance of a crunch during manipulation is not at all necessary. The cause of the "crunch" is the impact of two articular surfaces in the blocked segment, which occurs reflexively at the moment when the doctor stretches the muscles around the joint.

This type of therapy involves the use of both soft and hard techniques ( the last doctor conducts only with the consent of the patient).

Articular blockades are eliminated using the following techniques:

• manipulation- push, push with extension, blow;
• mobilization- rhythmic rocking in the joints;
• traction- rhythmic or non-rhythmic stretching to the limit;
• post-isometric relaxation- relaxation of the muscle after its tension.

Craniosacral Therapy

Craniosacral therapy is a gentle manipulation of the bones of the skull in the area of ​​the sutures ( junctions of cranial bones). The term "craniosacral" itself consists of two words. 'Cranium' means 'skull' and 'sacrum' means sacrum or 'holy bone'. This combination of words indicates the effect of craniosacral therapy - the normalization of the flow of cerebrospinal fluid along the "skull-sacrum" axis. There are not many specialists working on this method. The fact is that craniosacral therapy is slightly different from other classical methods of manual therapy, it is more related to osteopathic methods of treatment. However, since a chiropractor and an osteopath are like two people who look at the same mountain from its different slopes and therefore see different landscapes, craniosacral therapy, in a slightly modified interpretation, also applies to manual therapy methods.

A chiropractor using craniosacral therapy proceeds from the fact that the bones of the skull, despite the absence of joints between them, still tend to move due to the elasticity of the bone sutures. If this "movement" is disturbed, then various symptoms and diseases of the organs develop. The main difference between craniosacral therapists is that all manipulations are carried out exclusively within the skull.

Craniosacral therapy has advantages and disadvantages. Among the shortcomings, it should be noted the duration of the procedure ( at least 1 hour), and from the advantages - the absence discomfort and the need to be naked in front of a doctor.

Visceral manual therapy

Visceral ( viscera - insides) manual therapy literally translates as "treatment of the insides with the hand", while referring to non-surgical intervention. Internal organs are known to be covered with membranes and have muscles, therefore, they can move and block in the same way as muscles and joint capsules. This blockage is especially pronounced when the spine changes ( curvature). To breathe normally, pump blood through the vessels, move food through the gastrointestinal tract, empty the intestines and bladder, to have sexual intercourse and give birth, it is necessary that the movement of these organs is not blocked.

Visceral manual therapy involves the use of the following techniques:

• direct mobilization- the doctor directly touches the organ with his hands from the side or from the edge, producing rapid rhythmic loosening;
• indirect mobilization- the doctor acts on organs that cannot be touched directly ( internal organs such as the heart) through the muscles and ligaments that have functional connections with the organ or bone structures through which the nerves pass to this organ.
• parallel mobilization displacements- are carried out to eliminate the contraction of organs in the presence of adhesions.

Visceral therapy is carried out on the following organs:

• lungs;
• pleura;
• heart;
• diaphragm;
• gallbladder;
• liver;
• duodenum;
• small intestine ;
• colon;
• kidneys;
• bladder;
• uterus and ovaries;
• prostate.

What methods does a manual therapist treat?

In each specific case, the manual therapist selects the necessary and most appropriate methods and techniques ( adequate means "directed to the cause"). There are a lot of techniques, some of them are copyrighted. They differ from each other in a different combination of techniques. Nevertheless, there is a conditional division of all methods, depending on the point of impact and purpose. It is conditional, because the chiropractor will not say “you have been assigned such and such a technique”, he will describe the techniques that he will carry out. Outwardly, these methods for an ordinary observer do not differ from each other ( the doctor presses on something, pulls on something, bends, unbends). In addition, often the patient has a block not in one place, but in several at once. That is why the same patient may require the use of different techniques at different stages of manual therapy, even if the original cause is the same.

It is important to note that the chiropractor is supposed to use only their hands. In this he differs from a vertebrologist, who can use not only manual therapy, but also other ways to eliminate blocks in the spinal motion segment ( physiotherapy, medical pain relief). This is a fundamentally important difference, since chiropractors believe that non-manual methods remove not a block in the spinal motion segment, but only its symptoms ( and that is temporary).

Techniques used by the manual therapist

Manual therapy technique	Mechanism of therapeutic action	For what pathologies is it used?	What is the duration of treatment?
Skin-subcutaneous-myofascial manual therapy	The point of influence with this technique is soft tissues. This method allows you to improve blood circulation and lymph flow by affecting the sensitive nerve endings of muscles, tendons and skin, which causes their reflex relaxation. pressure on pain ( trigger) points cause a reaction from the body - it activates the anti-pain system.	cervicalgia; dorsalgia; lumbalgia; sacralgia; coccygodynia; radiculopathy; radiculo-ischemia; anterior chest wall syndrome; inferior oblique muscle syndrome; anterior scalene syndrome; scapular-rib syndrome; interscapular syndrome; piriformis syndrome; crumpy; iliopsoas muscle syndrome; arthrosis and periarthritis of the joints of the extremities; vertebral artery syndrome vertebrobasilar disease); heel spurs ( plantar fasciitis); functional dysphonia; sliding costal cartilage syndrome; respiratory disorders; tunnel syndromes; myopia; birth injury of the spine; torticollis; scoliosis.	The average number of manual therapy sessions is about 10 sessions, the maximum number of sessions is 15. Several manual therapy sessions may be required throughout the year.
Arthro-vertebral manual therapy	Application point - joints ( spine and limbs). This therapy is carried out in order to restore the biomechanics of the motor segment ( relative positions of elements) and remove the block. After removing the block, abnormal tension in the muscles, ligaments and capsules of the joints is eliminated, blood flow and lymph flow improves, posture is corrected and the function of internal organs is normalized.
Visceral manual therapy	This therapy restores the relative position of the internal organs ( pathology of the musculoskeletal apparatus of internal organs), which changed when a functional block appeared in the spine. The visceral technique allows you to eliminate secondary blocks, that is, return the internal organs to their original position, which was before the formation of blocks in the spine.	vegetative-vascular dystonia; bronchial asthma; chronic gastritis, enteritis, colitis, flatulence; biliary dyskinesia; kidney pathology; prolapse of internal organs; adhesive disease ( after operations); gynecological diseases; chronic prostatitis; miscarriage.	Most often, 7 to 10 sessions are prescribed.
Craniosacral manual therapy	With this technique, soft techniques of rhythmic mobilization of bone elements and ligaments in the area of ​​bone sutures are used, which leads to an improvement in blood flow in the vessels of the brain, normalizes the movement of cerebrospinal fluid and contributes to the "return" of the vertebrae to their places.	cervicalgia; dorsalgia; lumbalgia; scoliosis ( with underdevelopment of tissues); functional disorders of the internal organs; subclavian artery syndrome vertebrobasilar insufficiency); dysfunction of the temporomandibular joint; prevention of adhesive disease ( done after surgery).	1 session lasts within one hour ( at least 30 minutes). The total number of sessions is set individually, depending on the pathology.

Manual therapy is the impact with the help of hands on a problematic area. Hand treatment is aimed at correcting or destroying painful foci formed due to pathology in the muscles, joints, ligaments and segments of the spinal column and not only.

The goal of manual therapy is to eliminate pain, restore the functioning of organs, joints and vertebrae. Each vertebra must take its place, only in this case our "backbone" works correctly. Our entire body is innervated through the spine, so many somatic diseases arise due to the fact that the important “wiring” for them is pinched. Chiropractors are sure that half of the complaints of dizziness, headaches, pain in the heart and in other organs are due to problems of the spinal column. A violation of the blood supply to the vessels of the brain often occurs due to damage to the cervical vertebrae.

The cost of manual therapy

Manual therapy methods

Methods of manual therapy can be therapeutic and diagnostic. The methods used in these cases are varied. When choosing an appointment, doctors take into account the process of pathology, the cause of its occurrence, the age of the patient.

1. Therapeutic methods

There are "soft" and "hard" healing movements. The "soft" technique is the safest, the application force is the smallest in the range of muscle tissue capabilities. "Hard" reception falls on the joint, segment of the spine. The work of a manual therapist should be filigree. The intensity of blood flow after the right sessions increases by 3-4 times.

1. Diagnostic methods

Diagnostic techniques are used before determining the treatment regimen. The patient is in a relaxed position, and the doctor carefully palpates the spine, joints, determines their mobility, evaluates changes, reveals pain zones and areas of muscle tension. A qualified specialist carefully approaches the choice of methods and determines their optimal ratio for each situation.

Indications for manual therapy

1. Dizziness, headaches.
2. Pain in the muscles.
3. Rachiocampsis.
4. Intervertebral hernia (for unloading a problematic place).
5. The rehabilitation period after some injuries.

Contraindications for manual therapy

Manual therapy is not indicated for all patients. Manual technique is not recommended for patients with the following diseases.

1. Spinal tumors.
2. Cracks.
3. inflammatory processes.
4. Acute infectious diseases.
5. Severe osteoporosis.
6. Fresh injury or condition after surgical intervention on the spine.
7. Recent stroke or heart attack.
8. Pregnancy and lactation.

A competent doctor will correctly assess the patient's body and determine contraindications in each case.

The Benefits of Manual Therapy

1. It is possible to avoid surgical interventions on the spinal column.
2. Quickly improves the work of muscles, joints, restores mobility of the vertebrae
3. Pain disappears or decreases without the use of drugs.
4. Relieves muscle tension and fatigue.
5. It is more effective in comparison with hardware methods for the treatment of diseases of the spine.

Be careful when choosing a specialist! If the doctor is illiterate, then the treatment can end in a disastrous result. The appearance of an intervertebral hernia, a fracture of a vertebra, a stroke, a muscle rupture is a far from complete list of complications if the patient falls into the hands of an unqualified doctor. A certified experienced doctor cannot have complications!

How is the course of manual therapy?

The first consultation can take up to half an hour. The doctor will take an interest in the anamnesis of life and illness, identify concomitant ailments, and conduct a detailed examination of the patient. Additional studies may be ordered as needed. For minimal results of treatment, a course of 10-15 sessions is required. One session can last from two to three minutes to one hour. After a course of treatment, the doctor may prescribe a second cycle in one to two months. Then the doctor will give recommendations for doing gymnastic exercises at home. This is very important - to choose exactly those therapeutic exercises that will not cause harm, will not contribute to the formation of intervertebral hernias, twisting of the vertebrae and disruption of the blood flow of the spinal cord. In order for the effect of the treatment to be better, the doctor will show some self-massage techniques for the worked areas that can be applied at home. Many patients believe that there will definitely be pain during the sessions, but this is not true. If the procedure is performed correctly, then the patient should not experience sharp pain, but a feeling of discomfort is possible. If discomfort occurs, the doctor can connect physiotherapy sessions.

Manual therapy at the European Center for Orthopedics and Pain Therapy

It is very important to find a professional chiropractor who will approach the problem with all responsibility and will not aggravate the process. at the European Medical Academy. Paul Ehrlich employs skilled orthopedic doctors, so they do not promise to relieve pain instantly. The healing process, as a rule, consists of several sessions, and maybe several courses. Our patients can be sure that no harm will be done to them, as the specialists of the Center strictly follow the medical principle “do no harm”.

There are practically no people with a healthy spine! Patients do not even suspect that many complaints are due to pathology of the musculoskeletal system. They continue to play sports, being sure that they benefit their body, but constant jumping, squats, overloads, turns and turns of the spinal column only injure the spine even more! Doctors of manual therapy say that with a sedentary lifestyle, it is necessary to undergo 2-3 courses of sessions during the year. Don't miss the time!

Slonimsky Alexey Alexandrovich

Manual therapist, traumatologist-orthopedist

A chiropractor is someone who literally does the treatment with their own hands. With the help of special techniques of manual therapy, massage, procedures, etc., the chiropractor successfully helps to eliminate unpleasant symptoms, and sometimes completely get rid of diseases of the musculoskeletal system.

Manual therapy is a specially developed system of techniques that are carried out with the help of hands. Manual impact on sore spots allows you to effectively solve problems associated with any pathologies of the spine, it is also possible to relieve pain in the joints, the muscular apparatus, with diseases of internal organs, cerebrovascular accidents, etc. The advantage of this treatment is that it application helps to get rid of diseases that are often beyond the power drug treatment. A chiropractor conducts in his work, to begin with, an examination, and then treatment of the spine, joints, muscles, as well as nervous diseases.

Manual therapy combines the latest techniques and techniques with massage, reflexology, which allows you to achieve the most effective result in the treatment of intervertebral hernias, vegetovascular dystonia, arthrosis of large joints, scoliosis, chronic headaches, musculotonic syndromes and many others.

Manual methods show good results in the complex treatment of many diseases of the internal organs. The health of our body directly depends on the condition of the spine. With problems with the cervical vertebrae, a person may suffer from dizziness, headaches, etc. This happens due to the fact that the diseased organ sends a nerve impulse to a certain section of the spinal cord, this causes impaired blood circulation and muscle changes. As a result, the chronic form of the disease develops. During the impact on the muscles, ligaments, the chiropractor removes the pain syndrome, and often eliminates the direct cause of osteochondrosis. Treatment with manual techniques is able to get rid of the cause of osteochondrosis only in one case, when the development of the disease is caused by a violation of the normal functioning of the organs adjacent to the damaged disc, without the formation of a hernia.

After a session of manual therapy, blood circulation in the muscles noticeably improves, as a result, the muscles become toned, tissue nutrition and metabolism become much better. On average, a full course of manual therapy takes 15-20 sessions. Before starting a course of manual therapy, it is necessary to consult a doctor, because sometimes, with some concomitant diseases, such treatment is not recommended.

A chiropractor in his work uses special procedures, massage techniques, physiotherapy. In each case, depending on the problem and the patient's condition, the specialist selects an individual set of therapeutic actions: thermal procedures, vibration massage, physical education, etc.