Manual Medicine (8/30)

define somatic dysfunction

"impaired or altered function of related components of the somatic (body framework) system; skeletal, arthrodial, and myofascial structures; and related vascular, lymphatic, and neural elements"

define end feel

-sensation which is experienced by an examiner as a barrier to further motion at the end of a passive ROM -felt when performing overpressure at the end of the motion *abnormal end feel suggests need for intervention

a physical examination should consist of...

-vital signs -posture analysis and gait analysis -scanning examination (upper and lower quarter scan) -joint examination (AROM, PROM, MMT) -neurologic tests -functional assessment -special tests -joint play -palpation

Kaltenborn's approach emphasizes...

... translatoric joint play movements ◦Use of grades and sustained mobilizations ◦Concave-convex rule ◦arthrokinematics and osteokinematics in both assessment and treatment of articular motion dysfunctions

the quantity of joint play movement is measured on a scale from __-__

0-6

the 3 effects of joint mobilization are

1. MECHANICAL effects (•Stretching of joint restrictions •Breaking of adhesions •Alter positional relationships •Decrease barriers to normal motion) 2. NEUROPHYSIOLOGICAL effects (•Activation of type Aβ articular mechano- and proprioceptors •Activation of type Aβ cutaneous and muscular receptors •Altered nociception) 3. PSYCHOLOGICAL effects (•Confidence gained through improvement •Positive effects from manual contact •Response to audibles)

2 types of movement

1. classical (physiological) ex: flexion and extension 2. accessory (intra-articular) ex: roll and glide

before a joint mobilization you should... Examine... Identify... Prepare... Protect...

1. perform a thorough examination 2. identify direction of restriction and determine technique to be used 3. prepare the soft tissue (warm up, soft tissue mobilizations, etc..) 4. protect any neighboring hypermobility

3 types of joint play

1. traction 2. compression 3. gliding

what is the CPT code for manual therapy

97140 *includes mobilization, manipulation, manual lymphatic drainage, and manual traction*

joint play movement is normally <__mm in any one direction

<4mm

what does the acronym ART stand for and what does it indicate?

A: asymmetry R: range of motion T: tissue texture abnormality **indicates the need for manual therapy

name some contraindications for joint mobilizations

Any undiagnosed lesion Hypermobility Ankylosed joint Presence of pathological hard end-feel Joint effusion RA or infectious arthritis Malignancy (depending on the stage) Bone disease (osteoporosis, etc.) Any indication of vertebrobasilar artery insufficiency

assessing the quantity of movement allows us to determine...

Determine if there is any limitation of range (hypomobility) or excess of range (hypermobility/laxity) both are determined by assessing passive physiologic movement

T or F: tribonucleation / cavitation is a goal of a joint manipulation

FALSE

T or F: Maitland grade V is a true Maitland technique

FALSE it is a small-amplitude high-velocity thrust technique (manipulation)

T or F: the direct method of joint mobilization is less likely to cause an adverse reaction compared to the indirect method

FALSE (indirect is less likely to cause adverse reactions)

when you hear the "Nordic Approach" what pioneer should you think of

Freddy Kaltenborn

what pioneer is responsible for developing the use of gentle oscillatory movements?

Geoffrey Maitland *can be used prior to manipulations to more accurately attain the motion barrier (oscillations are often superior to thrust techniques)

describe the application of Kaltenborn's Grades

Grade I ◦Distraction is used with all gliding motions ◦Low intensity Grade II ◦Progressive intensity from the slack zone (SZ) to the transition zone (TZ) up to the point of tissue resistance Grade III ◦Stretch mobilization beyond the barrier of tissue resistance **Amount of time stretch is applied is more important than force used**

describe the rationale of Kaltenborn's Grades

Grade I ◦Pain relief ◦7-10 sec for several cycles Grade II ◦Initial treatment to determine sensitivity ◦Pain relief, relaxation, joint nutrition ◦Maintain joint play when ROM is not allowed Grade III ◦Used to stretch the joint structures ◦Increase joint play ◦6 sec stretch followed by partial release and repeat

describe the application of Maitland's Grades

Grade I ◦Small amplitude near beginning of range Grade II ◦Large amplitude that goes well into the range, occupying any part of the range that is free of stiffness or muscle spasm Grade III ◦Large amplitude that moves into stiffness or muscle spasm Grade IV ◦Small amplitude moving into stiffness *Grade V (not a Maitland technique) ◦HVLA thrust

describe Kaltenborn's grade I of translatoric movement

Grade I "Loosening" Movement is an extremely small traction force which produces no appreciable increase in joint separation; nullifies normal compressive forces acting on the joint (hand is making contact with the joint and just initiating movement nothing much is happening to the joint or the tissues)

describe Maitland's grade I of joint mobilization

Grade I: Small-amplitude rhythmic oscillations are performed at the beginning of the range; manual vibrations

describe Kaltenborn's grade II of translatoric movement

Grade II "Tightening" Movement first takes up the slack in the tissues and then tightens the tissues (tissues start to feel taut; 1st stop of resistance)

describe Kaltenborn's grade III of translatoric movement

Grade III "Stretching" Movement is applied after the slack has been taken up and all tissue become taut to stretch the capsule and surrounding tissues (tissue is actually being stretched)

describe the rationale of Maitland's Grades

Grades I-II ◦Used for joints limited by pain or muscle guarding ◦Inhibitory effect of oscillations ◦Improve joint nutrition Grade III-IV ◦Used for stretching maneuvers ◦Vary speed for different effects *Grade V (Not a Maitland technique) ◦High-velocity low-amplitude (HVLA) thrust manipulation ◦Snap adhesions

for someone in the active inflammation stage of healing the level of reactivity would be ______ (high/moderate/low). and grades ___- ___ mobilization should be used

HIGH (pain before end range) Grades I-II

what are the indications for joint mobilizations? (7)

Increase joint extensibility Correct positional faults Improve joint nutrition Control pain Facilitate muscle relaxation Address meniscoid impingement ◦Torn meniscus can fold under or up and block normal movement Prevent restrictions

what are some possible adverse reactions to joint mobilizations

Increased pain Increased swelling Increased muscle tone Decreased motion

capsular patterns were proposed by which PT pioneer

James Cyriax

do the following statements refer to Kaltenborn or Maitland: •Pain: Apply intermittent distraction for 10" with a few seconds of rest between cycles •Joint restriction: •Minimum of 6" stretch followed by partial release •Repeat at 3-4" intervals

Kaltenborn

does the following statement refer to the Kaltenborn or Maitland technique: •Only applied for translatoric (linear) movements of the joint (traction, compression, glide)

Kaltenborn

does the following statement refer to the Kaltenborn or Maitland technique: •Rate of application is slow and sustained for several seconds followed by partial relaxation and repeated

Kaltenborn

what is important to notice in patient history?

LISTEN TO THE PATIENT!!! -PMH -Social/family history/occupation -Current injury history -Systems review -RED or YELLOW flags -Establish a working diagnosis/hypothesis Refer if necessary

for someone in the maturation stage of healing the level of reactivity would be ______ (high/moderate/low). and grades ___- ___ mobilization should be used

LOW (pain after end range) Grades III-V

describe Maitland's grade III of joint mobilization

Large-amplitude rhythmic oscillations performed up to the limit and stressed into the tissue resistance; 2-3/sec for 1-2 minutes

describe Maitland's grade II of joint mobilization

Large-amplitude rhythmic oscillations within the range, not reaching the limit; 2-3/sec for 1-2 minutes

for someone in the granulation stage of healing the level of reactivity would be ______ (high/moderate/low). and grades ___- ___ mobilization should be used

MODERATE (pain at end range) Grades III-IV

do the following statements refer to Kaltenborn or Maitland: •Pain: Apply smooth, regular oscillations quickly 3/sec (low amplitude, high speed) for 1-2 minutes •Muscle relaxation and/or joint restriction: Apply smooth, regular oscillations slowly 1 in 2 sec for 1-2 minutes (Speed determines effect)

Maitland

does the following statement refer to the Kaltenborn or Maitland technique: •Oscillations may be performed using physiologic motions or joint play techniques

Maitland

does the following statement refer to the Kaltenborn or Maitland technique: •Rate of application is variable depending on intended treatment

Maitland

name some precautions for joint mobilizations

Malignancy (depending on the stage) Systemic connective tissue disorder ◦Ehlers Danlos Unhealed fracture Recent trauma Excessive pain of unknown origin Pregnancy/post-partum ◦Relaxin hormone à hypermobile Long term use of corticosteroids Skin rashes/open wounds in region Total joint replacements

if contractile tissue is the cause of the dysfunction... A/PROM both reproduce symptoms and are restricted in the ________________ direction and range

OPPOSITE

Maitland practiced non-thrust ________________ techniques

OSCILLATION

what are some considerations for joint mobilizations

Patient position Therapist position Joint position Hand position Stabilization One motion, one joint at a time Bilateral comparison Treatment plane Treatment direction Treatment grade/force Speed, rhythm, duration of mobilization Position of joint Monitor PAIN Reassess and modify throughout treatment

what types of things should you be observing during a MSK examination?

Posture at all times. Deformities (Structural vs. functional vs. dynamic). Contours of bony tissue and soft tissue. Limb positions. integumentary issues (redness, blisters, ulcers, color, texture, temp, etc.). Crepitus, snapping, clicking, etc. Attitude of the patient. Willingness to move, patterns of movement. Presence of fear-avoidance. *is it neutral or is it symmetrical?

goals of joint mobilization (8)

Restore normal, pain free joint movement Restore joint play thus normalize roll-gliding Correct positional faults Unlock a joint in which motion is blocked Improve joint position Distribute mechanical stress to a joint more evenly Relieve pain Facilitate joint nutrition

if non-contractile tissue is the cause of dysfunction... •A/PROM both reproduce symptoms and are restricted in the _________ direction and range

SAME direction

Kaltenborn practiced non-thrust _____________ joint play techniques

SUSTAINED

describe Maitland's grade IV of joint mobilization

Small-amplitude rhythmic oscillations performed at the limit of the available motion and stressed into the tissue resistance; rapid oscillations

what PT pioneer emphasized treating the DYSFUNCTION and not the pain?

Stanley Paris *solo sail guy

inert tissue

Tissue that is not contractile or neurological (i.e. connective tissue, fascia, cartilage, bone, etc.)

What are Mennell's Rules for Joint Play?

a. Patient should be relaxed and supported b. Examiner should be relaxed and should use a firm, but comfortable grasp c. One joint should be examined at a time d. The unaffected side should be tested first e. One articular surface is stabilized while the other surface is moved f. Movement should be normal and not forced g. Movements should not cause undue discomfort

if a pt's quality of movement is pain free but has limited ROM... what is most likely affected

abnormal bone to bone (asymptomatic osteoarthritis) *abnormal

end feel is the (anatomical or physiological) barrier

anatomical

passive physiologic movement identifies a _____________ barrier

anatomical

examples of abnormal or pathological end feels are...

boggy: soft resistance indicative of intra-articular swelling springy: rebound effect→ found in joint with menisci empty: cannot reach end feel due to pain muscle spasm: protective to pull limb in the opposite direction of the motions being performed hard capsular: frozen shoulder *painful, reproduce symptoms

what is the main difference between contact and non-contact joint mobilization techniques

contact: •Hand/finger placement on the involved area/spinal segment non-contact: •Hand/finger placement away from area/spinal segment

what is the main difference between direct and indirect joint mobilization techniques

direct: •Force applied into direction of motion restriction/barrier indirect: •Force directed in the opposite direction of the motion restriction

quality of movement is assessed by what 3 things?

end feel capsular pattern inert tissue pattern *assessed through entire range to the first significant stop with free, smooth, movement independent of speed

T or F: capsular patterns tend to be unpredictable

false they tend to show predictable motion loss

for joint mobilization techniques there are... general vs. ______________ direct vs. ______________ contact vs. ______________

general vs. specific direct vs. indirect contact vs. non-contact

what is the main difference between general and specific joint mobilization techniques

general: •Load applied to multiple joints/segments at the same time specific: •Influence only one joint/segment

define thrust manipulation

high-velocity, low amplitude (HVLA) thrust technique applied at the end of the pathological limit

if a joint is measured a 4-6 for quantity of movement the joint is considered to be

hypermobile 4 = slight increased movement 5 = considerable increased movement 6 = complete instability

if a joint is measured a 0-2 for quantity of movement the joint is considered to be

hypomobile 0 = no movement 1 = considerable decreased movement 2 = slight decreased movement *usually involves a restriction in normal glide

hypomobility and hypermobility are only pathological if...

if they associated with symptoms and a pathological end feel

if a pt's quality of movement is painful and has excessive or limited ROM in some directions... what is most likely affected

local dysfunction (local capsular adhesion, ligament sprain) *abnormal

when performing MMT a pt presents painful and weak. what is most likely wrong

major lesion of a muscle or tendon

when performing MMT a pt presents painful yet strong. what is most likely wrong

minor lesion of a muscle or tendon

if a joint is hypomobile, how should you proceed with the joint

mobilize the joint

when performing MMT a pt presents painless and weak. what is most likely wrong

neurological lesion or complete rupture of muscle or tendon

if a joint is measured a 3 for quantity of movement the joint is considered to be

normal

if a pt is described to have pain free, full ROM movement... their quality of movement would be described as _______________

normal

when performing MMT a pt presents painless and strong. how would you describe their movement

normal

Define mobilization

passive, skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes; non-thrust

active physiologic movement identifies a _____________ barrier

physiological

manual therapy is used to...

restore maximal, pain-free movement of the musculoskeletal system in postural balance

examples of normal end feels are...

soft: soft tissue approximation firm: capsule or ligamentous stretching hard: bone to bone *pain free

if a joint is hypermobile, how should you proceed with the joint

stabilize the joint

if a pt's quality of movement is painful and limited ROM in every direction... what is most likely affected

the entire joint (arthritis, capsulitis) *abnormal

the treatment plane is parallel to the ___________ bony partner

the treatment plane is parallel to the concave bony partner **labeled T.P. in the picture

what is the main difference between thrust and non-thrust manipulation

thrust: all or nothing, doesn't allow for the patient to back out if the force is too much non-thrust: allows the pt to say when the force is too much and allows the PT to back off the pressure

an "audible" or a joint sound (pop, snap, click) is also referred to as

tribonucleation or cavitation

with non-contractile dysfunction... •Resisted movements are _____________________(symptomatic or asymptomatic) •Passive joint play movements ____________ (reproduce or don't reproduce) symptoms and are ______________ (restricted or not restricted

•Resisted movements are asymptomatic •Passive joint play movements reproduce symptoms and are restricted

with contractile dysfunction •Resisted movements ____________ (reproduce or do not reproduce) symptoms •Passive joint play movements are _________________ (normal or abnormal) and _____________ (symptomatic or asymptomatic)

•Resisted movements reproduce symptoms •Passive joint play movements are normal and asymptomatic

what are 2 possible reasons someone may have an adverse reaction to a joint mobilization

◦Too much mobilization ◦Too much force