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"
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) 2. accessory (intra-articular)
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
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)
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)
define end feel
Feeling which is experienced by an examiner as a barrier to further motion at the end of a passive ROM.
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 during joint mobilizations
Geoffrey Maitland
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 types of things should you be looking out for / doing during a musculoskeletal examination
LISTEN TO THE PATIENT!!! Previous/past medical history (PMH) Social/family history/occupation Current injury history* Systems review Identify any 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 in standing, sitting, reclined, supine, etc. Presence of deformities (Structural vs. functional vs. dynamic) Contours of bony tissue and soft tissue Limb positions Color, texture, temperature of the skin Scars, callosities, blisters, ulcers, etc. Crepitus, snapping, clicking, etc. Edema, erythema, heat Attitude of the patient Willingness to move, patterns of movement Presence of fear-avoidance
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
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)
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 springy empty muscle spasm hard capsular
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
T or F: capsular patterns tend to be unpredictable
false they tend to be predictable
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
if a joint is measured a 0-2 for quantity of movement the joint is considered to be
hypomobile
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)
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
mobilization
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/manipulation
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 firm hard
if a joint is hypermobile, how should you proceed with the joint
stabilization
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)
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
a physical examination should consist of...
vital signs posture analysis gait analysis scanning examination (upper and lower quarter scan) joint examination (AROM, PROM, MMT) neurologic tests functional assessment special tests joint play palpation
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
