MT20 course review
Acute & Early Subacute BURSITIS Treatment
● Cool or cold! ● Reduce pain and stress in structures that refer to it or around it but that are not on it ● Techniques closer to and distal: keep it super light!
Acute & Early Subacute CONTUSION Treatment
● Cool or cold! ● Reduce swelling ● Remain proximal to contusion site Early Subacute ● Light non-circulatory techniques distal to site
Acute & Early Subacute DISLOCATION Treatment
● Cool or cold! (doughnut) ● Reduce swelling ● Remain proximal ● Treat unaffected side ● No Onsite work Early Subacute ● Cool/Warm Contrast (3:1) ● Light onsite work ● TrP that refer to area ● Modify stretch
FRICTIONS Indications
● Decreased range of motion due to scar contracture ● Decreased extensibility of subcutaneous connective tissue Essentially: presence of restricting scar tissue
Moderate Contusion
● Moderate crushing of tissues with bleeding and swelling. ● Difficulty continuing the activity due to pain and muscle weakness.
PROPRIOCEPTIVE TECHNIQUES: Golgi Tendon Organ
● Muscle contracts which causes pull and tension on the tendon ● GTO is stimulated and sends an impulse to inhibit contraction and have muscle relax ● Protective reflex to prevent the tendon or musculoskeletal junction from tearing due to excessive muscle contraction ○ Can also occur if the muscle is being so excessively stretched that it starts to pull and compress the tendon - however this would be counterproductive to the actions of the muscle spindle
4 Stages of Healing
1. Acute Stage 2. Subacute (Proliferative) Stage 3. Postacute (Maturation) Stage 4. Chronic Inflammation
MYOFASCIAL Trp Procedure
1. Describe to the client why you want to do trigger point therapy. What is the purpose of performing a Myo-fascial Trigger point technique? "This is to help reduce and get rid of that painful knot in your muscle" 2. Prepare the client by briefly explaining what sensation to expect. "This can be a painful technique, when I apply pressure on the trigger point you may experience a radiating pain, but it should gradually reduce." 3. Establish a pain scale and inform the client that the pain level should not go over a 4 out of 10. 4. Warm the tissue with effleurage and specific petrissage. Also may warm with deep heat. 5. Trigger point release using Ischemic Compression: ** A. Confirm referral pain/pattern with CL - state pattern B. Reinforce finger or digits C. Hold and maintain pressure on tender nodule - the most tender spot D. Hold for 30 seconds - 2 minutes, holding until the muscle fibers release (melt) under your fingers and the pain felt by the patient has dissipated or for the duration of the client's tolerance E. 2 sets maximum 6. Following each pressure release flush the area with petrissage and effleurage. 7. Passively stretch affected muscle holding stretch for 30 seconds. 8. May follow compression by application of deep moist heat or instruct client to do so later as home care.
MLD Procedure
1. Perform deep diaphragmatic breathing 2. Remove pillows and loosen draping 3. Always start with neck & terminus pumping 4. Start at distal end of the most proximal segment of a limb and pump towards lymph nodes 5. Move to next segment (moving distally) and again start at distal end of that segment pumping and moving proximally 6. Start in upper quadrant of back and pump towards respective axillary nodes 7. Move to lower quadrant (below umbilicus) of back and pump towards respective inguinal/greater trochanter lymph nodes 8. Close with 2 or 3 Swedish Lymphatic Drainage Techniques
JOINT PLAY Indications Simplified
Grade 1 & 2: ● Maintain current ROM ● Reduce pain ● Reduce muscle guarding/spasm ● Increase joint nutrition Grade 3 & 4: ● Increase ROM ● Break up joint adhesions Grade 5: ● Out of scope for RMT's to perform ● This will never be an indicated joint mobilization on an RMT exam
Contraindications to continuing Frictions:
If at any time the client is getting a negative response to the friction therapy where the discomfort caused by frictions is increasing or if the scar is more painful on re-testing: ● Stop friction technique ● Superficial effleurage to drain towards nearest lymph node ● Apply ice until visible blanching to tissue occurs ● Client has been over-treated with frictions if they have broken capillaries/blood vessels, resulting in bruising (cold hydrotherapy is recommended).
Signs & Symptoms of inflammation
PRISH: Pain (dolor) Redness (rubor) Immobility Swelling (tumor) Heat (calor) SHARP: Swelling (tumor) Heat (calor) A loss of function Redness (rubor) Pain (dolor)
Subclavicular (Infraclavicular) DISLOCATION
○ Less common ○ Humeral head comes to rest more medially under the clavicle. ○ May be caused by a fall on an outstretched hand.
Swedish Lymphatic Drainage Techniques
○ Light unidirectional effleurage ○ Light course running vibrations ○ Passive relaxed range of motion ○ Muscle setting ○ Shaving ○ Soothing stroking
Late Subacute CONTUSION Treatment
● Contrast hydrotherapy ● Can add/progress with earlier techniques ● Can use circulatory techniques distal to site ● Can start frictions
Anterior Subcorocoid DISLOCATION
○ Most common ○ Head of the humerus dislocates anterior and inferior coming to rest inferior and lateral to the coracoid process. ○ A weak portion of the joint a capsule known as the Foramen of Weitbrecht allows for easy displacement. ○ Most commonly caused by direct or indirect trauma such as a fall on an outstretched hand or a blow from behind while the arm is in 90 degrees abduction and 90 degrees external rotation (tackle from behind in football).
MYOFASCIAL Trp Referral Patterns Tips & Tricks
○ Piriformis = Double Devil ○ Gluteus Minimus = Pseudo-sciatica ○ Supraspinatus = Subdeltoid Bursitis mimicker ○ Soleus = Jogger's Heel
Inferior Subglenoid DISLOCATION
○ Rare ○ Head of humerus is driven through the inferior joint capsule. ○ Usually caused by a trauma where the arm is flexed to 180 degrees (dive into shallow water). ○ In this dislocation the person cannot lower their arm and must hold it above their head until it is reduced. least common
Posterior Subglenoid DISLOCATION
○ Uncommon ○ The head of the humerus is driven posteriorly and inferiorly into the subspinous fossa inferior to the spine of the scapula. ○ May occur from a fall on an outstretched hand where the arm is internally rotated, adducted and flexed to 90 degrees. ○ May also occur from a blow to the front of the shoulder and is also seen as a result of epileptic seizures and convulsions.
PNF cannot be used when communication with the client is diminished:
○ language barriers ○ when the client's understanding is suspect ○ when the client is unable to provide effective feedback
PNF cannot be used in:
○ muscles with severe weakness, spasticity or paralysis ○ Nerve damage ○ Recent fracture ○ Osteoporosis
What is a FRACTURE
● A broken bone, either complete or incomplete
What is a CONTUSION
● A crush injury to a muscle that often results in hemorrhage and/or hematoma
MYOFASCIAL TECHNIQUES Contraindications
● Acute injury ● Hypotonic (defective muscular tension or tone) or atonic (without normal tension or tone) muscles ● Fragile skin ● Skin lesions and recent incisions ● Painful conditions ● Anticoagulant medication use
What is FROZEN SHOULDER
● An umbrella term used to vaguely define a number of conditions that result in painful restriction and reduced range of motion of the shoulder. ● Adhesive Capsulitis ○ Inflammation of the glenohumeral capsule and synovium leading to adhesion formation particularly of the axillary fold of the capsule.
MYOFASCIAL TECHNIQUES Procedure
● Assess the fascia with glide ○ Which direction is it restricted in? ● Perform a variety of fascial techniques from superficial to deep, back to superficial in the direction of restriction ● Reassess ○ Is there more movement? ○ Is there hyperemia? ● Sooth
JOINT PLAY Protocol
● Assess the joint if not already done: passive ROM ● Position joint into open-packed position ● Distract the joint ○ Confirm there is no pain with this ● Identify where the tissue barrier is (Grade 2 sustained glide) ○ How do you know what grade of mobilization you are doing if you don't know where the tissue barrier is?) ○ Confirm there is no pain with this ● Start the mobilization indicated ○ Confirm there is no pain ● Reassess with Grade 2 sustained glide and PR-ROM for indicated range ○ Has the distance to tissue barrier & ROM increased, decreased, stayed the same? ○ Gr. 1 & 2: should stay the same ○ Gr. 3 & 4: should increase
PNF: Contract-Relax-Contract
● Autogenic & Reciprocal Inhibition ● Contract muscle being stretched, relax, contract INTO stretch, move to next barrier
PNF: Hold-Relax
● Autogenic Inhibition ● Isometrically contract the muscle being stretched
PNF: Contract-Relax
● Autogenic Inhibition ● Isotonically contract the muscle being stretched
MYOFASCIAL Trp Precautions
● Avoid vigorous techniques on active trigger points. May cause "kick-back" pain ● Full stretch of muscle with trigger points when hypermobility present. ● Prolonged chilling of muscle, Ex. Draft from window
HYPOTENSION Precautions
● Be prepared and offer to assist client off table to prevent injury ● Encourage gradual movement to a standing position and inform client of possible dizziness from getting up too quickly ● Have client sit at edge of table and move legs to assist in skeletal muscle contraction to normalize blood flow.
Hemorrhage
● Bleeding - this includes external and internal
PROPRIOCEPTIVE TECHNIQUES: GTO & O&I Techniques
● Both act on the GTO to stimulate it and thus get the inhibitory signal to relax the muscle ● Reduces tone and spasm. ● Particularly useful when onsite petrissage is too painful or ineffective. ● GTO ○ Best for treating tendons which are long and easily palpable. ○ ex: the Achilles, biceps brachii, hamstrings and forearm tendons ● O&I ○ Used on muscles with a large, broad bony attachment. ○ ex: infraspinatus, rhomboids, gluteus maximus and pectoralis major,
Late Subacute DISLOCATION Treatment
● Cold/Hot Contrast (1:3) ● Moderate onsite work (frictions) ● Gr 1 & 2 Joint play in opposite direction
What is a DISLOCATION
● Complete separation of the surfaces of a joint ● Subluxation is a partial separation of a joint
HYPERTENSION Contraindications & Precautions
● Contraindicated BP readings: ○ Stage 2 that is UNCONTROLLED (160-179 systolic AND/OR 100-109 diastolic) ■ If this is the client's regular reading and they are on medications then it is considered as a controlled Stage 2 ○ Stage 3 or higher, regardless if it is controlled or not (≥180 systolic AND/OR ≥120 diastolic) ● BP readings that will require modifications & precautions: ○ Stage 2 that is CONTROLLED (160-179 systolic AND/OR 100-109 diastolic)
Late Subacute BURSITIS Treatment
● Contrast hydrotherapy ● Can add/progress with earlier techniques ● Can start to introduce light techniques over the bursa ● More aggressive techniques can be done directly peripheral to it - such as frictions
PASSIVE STRETCHING Precautions
● Do not passively force a joint beyond its normal ROM ● Extra care should be taken with suspected or known osteoporosis ● Prolonged use of steroids causes thinning of soft tissues ● Prolonged immobilization leads to atrophy and tissue fragility ● Strengthening exercises should be coupled with stretching at some point, so that the client develops a balance between flexibility and strength ● Post-stretching, a client should feel muscle soreness lasting no more than 24 hours, if any, otherwise too much force was used during stretching ● Edematous tissue is fragile ● Overstretching weak postural muscles can increase muscular imbalances
PNF Precautions
● Do not passively force a joint beyond its normal ROM ● Prolonged use of steroids causes thinning of soft tissues ● Prolonged immobilization leads to atrophy and tissue fragility ● Strengthening exercises should be coupled with stretching at some point, so that the client develops a balance between flexibility and strength ● Post-stretching, a client should feel muscle soreness lasting no more than 24 hours, if any - otherwise too much force was used during stretching ● Edematous tissues are fragile ● Overstretching weak postural muscles can increase muscular imbalances
DISLOCATION Contraindications
● Do not test in Acute and sub-acute. ● Begin remex in sub-acute. ● Avoid heavy applications of hydrotherapy on joint (bags of ice) use cool 'donut' ● Do not remove all protective muscle guarding in acute and early sub-acute. ● Do not congest injury site with circulatory techniques distal to injury. Use reflex techniques only. ● Do not attempt to increase lateral rotation of arm if it has been surgically reduced. ● No joint play where the joint is unstable (eg. positive apprehension test). ● Avoid positioning client in ROM's that make the joint unstable. ● Passive ROM and AF-ROM must be done with caution.
Immobilized (Acute - Early Subacute) FRACTURE Treatment
● Elevated ● Cold distal to cast ● Heat for compensatory structures (but not immediately proximal to cast) ● Maintain circulation with careful & modified techniques directly distal & proximal to cast
FRICTIONS Protocol
● Establish a pain scale ● Warm up the area ● Remove lotion from the skin ● Put tissue into appropriate position ○ Tendon/muscle with synovial sheath: in a stretched position ○ Tendon/muscle without synovial sheath: in a neutral position ○ Ligament: in a neutral position ● Friction for 2 minute cycles up to 20 minutes total ○ This is dependent on client tolerance and comfort - may not reach this maximum ● Flush and sooth area between cycles ● Stretch the area after the full technique is complete ● Cold hydrotherapy should be applied last or recommended for home care
Less obvious causes of inflammation
● Extreme temperatures ● Obesity ● Diet ● Stress ● Anxiety
Where is BURSITIS
● Found between tendons and bone at most joints
GENERAL TREATMENTS
● From Acute → Early Subacute → Late Subacute → Chronic it is always a progression ○ Rarely, if ever, would there be a technique you cannot perform in a later stage that you can in an earlier stage ● Acute will nearly always indicate cold for hydrotherapy, MLD, no aggressive techniques over the area or too close to it, only very light and gentle techniques close to or distal to it ○ Early subacute is often similar if not the same as Acute ● Late Subacute will often introduce contrast hydrotherapy with a gradual introduction of techniques over the inflamed area ○ Always remember your principles: Peripheral-Central-Peripheral ○ More aggressive techniques such as frictions will be indicated directly around the area but not on it ● Chronic is the simplest to navigate as there will be very few, if any techniques that will be contraindicated and generally hot hydrotherapy can be introduced at this stage
Chronic CONTUSION Treatment
● Heat! ● Can pretty much do anything that is indicated
Chronic BURSITIS Treatment
● Heat! ● Can pretty much do anything that is indicated ● Just be conscious of any techniques performed on the bursa that they are not directly compressing it
Chronic DISLOCATION Treatment
● Heat! Proximal to dislocation ● Gr 1-4 joint play in opposite direction ● Can pretty much do anything that is indicated
Subacute (Frozen Stage) FROZEN SHOULDER Treatment
● Hot to affected area ● Can incorporate joint play Gr 3 & 4 ● Frictions
Acute (Freezing Stage) FROZEN SHOULDER Treatment
● Ice to affected area, heat to compensatory ● Relaxation ● Treatment to periscapular & rotator cuff muscles (TrP, petrissage, PNF, fascial) ● Joint play Gr 1 & 2 to GH ● PR-ROM to GH ● GTO & O&I to GH muscles
Immobilization Removed (Cusp of early - late subacute) FRACTURE Treatment
● In position of comfort ● Contrast hydrotherapy ● Can add/progress with earlier techniques ● Start reducing fascial restrictions and scar tissue as the healing progress - be mindful of CI's mentioned earlier ● Consider general rules for Acute, early subacute, late subacute, and chronic
What is BURSITIS
● Inflammation of the bursa, a small flat sac lined with synovium that provides cushioning
4. Chronic Inflammation
● Inflammatory process is not successful ● Pathogens/ irritants were not removed
1. Acute Stage
● Initial inflammatory phase ● Exudate and edema develops ● Cells arrive ● May last 1-3 days
Hematoma
● Internal bleeding that results in a bruise and/or swelling
JOINT PLAY Contraindications
● Joint effusion / swelling - too much fluid, a sign of infection or joint trauma ● Excessive hypermobility, joint is unstable ex. Pregnancy ● Inflammation e.g. infection- for grade 3, 4 mobilizations ● Unhealed fractures (Fx) ● Dislocations: Only a medical doctor can mobilize or reduce a dislocation ● Surgical Implants ex. full hip or knee replacement
PASSIVE STRETCHING Indications
● Limited ROM due to adhesions, contractures, and scar tissue ● Limited ROM that interferes with ADL's ● When muscle is shortened due to weakness in the opposing muscle
Mild Contusion
● Minor crush to tissues with minimal bleeding. ● Minimal or no loss of strength and minimal loss of range of motion. ● Activity is limited only by mild discomfort.
PROPRIOCEPTIVE TECHNIQUES: Muscle Spindle
● Muscle is lengthening and being stretched which puts pull and tension on the muscle (and therefore the muscle spindle) ● Muscle spindle is stimulated and sends a signal to contract (shorten) the muscle ● Protective reflex to prevent the muscle from tearing due to overstretch ○ This is why stretching must be done in a slow controlled manner, otherwise the therapist could activate the client's muscle spindles, resulting in increased tone of the muscle
JOINT PLAY Indications
● Muscle spasms: low grade 1: does not stretch any structures ● Muscle guarding: low grade 1 ● Painful joints: low grade 1 to increase joint nutrition ● Some degenerative joint disorders, such as OA: apply low grade 1 to decrease pain, change fluid viscosity ● Decreased ROM due to joint capsule restrictions: grade 3 or 4 to break joint adhesions, capsular restrictions ● Joint subluxation: grade 2 ● Muscle spasms: low grade 1: does not stretch any structures ● Muscle guarding: low grade 1 ● Painful joints: low grade 1 to increase joint nutrition ● Some degenerative joint disorders, such as OA: apply low grade 1 to decrease pain, change fluid viscosity ● Decreased ROM due to joint capsule restrictions: grade 3 or 4 to break joint adhesions, capsular restrictions ● Joint subluxation: grade 2
3. Postacute (Maturation) Stage
● New scar tissue is remodelled and reshaped ● Becomes denser and aligns according to force - Important not to limit mobility during this stage to allow for ideal scar formation
HYPERTENSION Precautions & Modifications
● Once controlled by medication a modified massage may be performed ○ this is determined by the patient's doctor and the blood pressure reading taken by the therapist prior to treatment. ● Shorter duration treatment is recommended ● Mild hypertension that is controlled and stable with medication usually requires no treatment modifications, but the client's BP should be monitored before and after treatment. ● Moderate hypertension requires positioning, hydrotherapy, and technique modifications. ● Avoid stimulating techniques such as prolonged painful techniques and vigorous tapotement, since elevating sympathetic nervous system firing elevates BP ● Avoid long strokes towards the heart as well as large limb movements, (P-ROM) that may increase venous return, (use segmental strokes) ● Avoid large or extreme applications of heat such as hydrocollators or thermaphores to the core of the body or full body treatments such as steam rooms, saunas and whirlpools ● Seated, semi-reclined (3 pillows behind the torso), or right side lying position are used because they elevate the heart ● In the case of a client with mild controlled hypertension that is stable, limited time in prone position may be used (10 mins) ● Avoid elevating limbs above the heart for prolonged periods ● Avoid abdominal pillowing as this compresses the abdominal aorta ● Avoid prolonged neck stretches or deep anterolateral neck techniques
FRACTURE Contraindications: Cast Off
● Overpressure before consolidation ● Extreme hydrotherapy temperatures ● Deep longitudinal techniques before full tissue and muscle health regained ● Caution with passive stretching before full tissue and muscle health regained ● Local hot hydrotherapy with metal implants, pins or plates
Muscle Approximation Contraindications:
● Painful conditions local to the muscle belly ● Acute conditions local to the muscle ● Hypotonic or atonic muscles ● Tissue fragility ● Connective tissue pathologies ● Skin lesions
GTO & O&I Techniques Contraindications:
● Painful conditions local to the tendon ● Acute tendon conditions, such as tendinitis ● Hypotonic or atonic muscles ● Tissue fragility ● Pathologies of connective tissue ● Skin lesions
Obvious causes of inflammation
● Pathogens (infection) ● Trauma ● Chemical injury ● Immunological reactions (distortions or improper activation of the immune cells)
FRICTIONS Contraindications
● Proud flesh or keloid scars, open, or healing scars ● Do not do frictions over nerves - gives client an electric shock sensation ● Acute stages of healing ● Rheumatoid arthritis when in flare up - because this is inflammatory in nature ● Too deep of a structure ex. abdomen - viscera ● Analgesic medication use ex. Anti-inflammatory, muscle relaxants, Tylenol, Aspirin, blood thinners ● Tissue fragility ● If the client's pain tolerance is low ex. Fibromyalgia
PNF: Agonist-Contract
● Reciprocal Inhibition ● Contract the opposite muscle from the one being stretched ○ Contract INTO the stretch
Osteokinematic Movements
● Refers to parts of the body ● Swing & Pivot
Arthrokinematic Movements
● Refers to the movements present between two joint surfaces ● Roll, Slide, & Spin
Chronic (Thawing Stage) FROZEN SHOULDER Treatment
● Same as subacute ● Focus on breaking up adhesions and returning ROM ● Be cautious of over-treating which can reverse the progress
Severe Contusion
● Severe crushing of tissue with rapid bleeding and swelling. ● Inability to continue activity due to significant pain and muscle weakness
PROPRIOCEPTIVE TECHNIQUES: Muscle Approximation
● Shortens the muscle thereby reducing the firing of the muscle spindle which then does not send signals for the muscle to contract ● Used for muscles with many origins, insertions or tendons that are not easily palpable ○ Ex. Quadriceps, erectors ● Used also in situations where the muscle is in a lengthened position and is tight. ○ ex. Erector Spinae through thoracic spine with hyper kyphosis
GTO & O&I Techniques Indications:
● Spasm in muscles ● Hypertonic muscles ● When onsite massage is too painful
2. Subacute (Proliferative) Stage
● Specific cells accumulate and fill in damaged tissue ● New capillaries grow ● Scar tissue forms ● WBC's clean up debris ● Can last 2-3 weeks depending on severity
JOINT PLAY Precautions
● Surgical pins/plates ● Malignancy: diagnosed cancer ● Bone disease: osteoporosis, Paget's Disease: low grade only ● Excessive pain ● Hypermobility ● Joint replacements: use repetitive passive range of motion instead ○ Passively move the joint 5-7 times in the affected movement within their pain-free range ● New or weakened connective tissue and Corticosteroid medication use, must wait 21 days, client cannot have more than 3 injections per joint/lifetime: very low grade ● Rheumatoid Arthritis: in flare up do not use joint play; otherwise, low grade ● Elderly people with weak connective tissue and decreased bone integrity ● Repeated dislocation
Concave-Convex Rule
● Swing and Roll will ALWAYS occur together (same direction) ● Slide and Glide will ALWAYS occur together (same direction) ● However, swing & roll my go in the same or opposite direction as slide & glide ○ This depends on the surfaces that are moving against each other ● Joint play mobilizations recreate the slide/glide motion of the joint, therefore when choosing which direction to do the mobilization you need to know which direction slide/glide is supposed to be for the given joint and range ○ Ex: Humeroulnar is concave moving on convex, therefore swing/roll and slide/glide are in the same direction ■ So if you want to improve or work on elbow extension (swing is posterior so slide/glide is posterior) you will do a posterior mobilization ○ Ex: Glenohumeral is convex moving on concave, therefore swing/roll and slide/glide are in the opposite direction ■ So if you want to improve or work on shoulder extension (swing is posterior so slide/glide is anterior) you will do an anterior mobilization
HYPERTENSION Treatment
● Take blood pressure before and after each treatment ● Decrease sympathetic nervous system firing via relaxation approach ● Deep diaphragmatic breathing may be taught to encourage slow relaxed breathing ● Decrease peripheral vascular resistance by starting with a hand and/or foot massage ● Avoid dramatic increases of venous return by working DISTAL TO PROXIMAL and using segmental massage techniques (i.e. no long effleurage; use retrograde effleurage) ● When working on the back, the therapist works segmentally avoiding long strokes, (i.e. divide back into boxes) ● Any potentially painful techniques are limited and interspersed with soothing techniques ● Therapist remains vigilant for any signs of cardiac distress throughout the treatment.
Identifying a Trigger Point
● Taut band ● Spot tenderness ● Visual or tactile identification of local twitch response/jump sign (objective) A. Jump sign i. occurs if a body part moves as a result of the palpation of the trigger point. ii. Ex. hip hikes, shoulder moves B. Local Twitch Response (LTR) i. Is a fasciculation contraction (1-2 seconds) of those muscle fibres in the taut band that are associated with the TrP. ● Recognition of current pain (subjective) a. Referred Pain
CONTUSION Contraindications
● Testing of moderate or severe contusion ● Only pain-free Active ROM ● On site work or distal ● Do not go beyond regular stretch ● Avoid heat post trigger point treatment ● Myositis ossificans - no deep work ● Do not congest the healing site: ○ Moderate/Severe: remain proximal (3 inches) in acute & subacute stage (replace with repetitive petrissage)
HYPERTENSION
● To classify a person into one of the hypertension stages it is an 'either/or' situation ● The higher of the 2 numbers determines which stage they are in ○ Ex. a person with 165/90 would be Stage 2 not Stage 1 because their systolic is in the stage 2 category ○ Ex. a person with 165/115 would be Stage 3 not Stage 2 because their diastolic is in the stage 3 category ● This is how a therapist must determine the modifications they will make ○ It should not be based off of systolic alone but BOTH systolic and diastolic must be considered ○ If one is in a higher stage than the other then the client must be treated as though they are in the higher stage category
FRACTURE Contraindications: Cast On
● Traction before union ● Hot hydro distal or immediately proximal ● AF & AR-ROM with muscular involvement ● With open reduction - onsite work if skin is not fully healed ● With stress fractures - onsite work if still point tender
MLD Precautions
● Tuberculosis ● Pregnancy (if Hx of miscarriage or 3rd trimester) ● Diabetes ● Hypotension ● Asthma
MLD Contraindications
● Untreated/undiagnosed cancer ● Acute infection ● Thrombosis ● Heart related edema
MYOFASCIAL Trp Contraindications
● Vigorous ischemic compressions done too quickly ● Heat directly proximal to an acute injury i.e. to forearm with wrist sprain ● Locally if there is a strain or sprain ● Vigorous Ischemic compressions within the same treatment as friction technique. Possible over-treatment of tissue.
FROZEN SHOULDER Precautions & Contraindications
● Watch use of extremes of temperature in clients with post-surgical implants such as pins, plates, pacemakers etc. or clients with high blood pressure. ● Modify heavy hydro application (hydrocollator) or heavy techniques in clients with osteoporosis. ● Do not be overaggressive in treatment as this may cause client to relapse to inflammatory stage especially if condition is related to tendonitis, bursitis, O.A., R.A. (to reduce pain and guarding) Lengthen before strengthening ● While client is on anti-inflammatories or analgesics ● Watch use of extremes of temperature in clients with post-surgical implants such as pins, plates, pacemakers etc. or clients with high blood pressure. ● Modify heavy hydro application (hydrocollator) or heavy techniques in clients with osteoporosis. ● Do not be overaggressive in treatment as this may cause client to relapse to inflammatory stage especially if condition is related to tendonitis, bursitis, O.A., R.A. (to reduce pain and guarding) Lengthen before strengthening ● While client is on anti-inflammatories or analgesics.
PASSIVE STRETCHING Contraindications
● When a bony formation limits ROM ex. Osteophytes ● Recent fracture ● Muscles in spasm ● Acute inflammation or infection ● Acute sharp pain with movement ● Severe contusion (bruising) or tissue trauma ● Hypermobility ● Paralysis or severe numbness
PNF Contraindications
● When a bony formation limits ROM ex. osteophytes ● Recent fracture ● Muscles in spasm ● Acute inflammation or infection ● Acute sharp pain with movement ● Severe contusion (bruising) or tissue trauma ● Hypermobility ● Paralysis or severe numbness