Manual therapy & theraputic exercise for the lower quarter: clinical decision making
Clinical Decision making: joint based
AROM PROM Accessory mobility ~Hypomobile ~Hypermpobile ~Painful ~Normal ~~Make treatment decisions based on these mechanical findings
Manual therapy soft tissue based
Effleurage Petrissage Transverse friction massage Manual stretching
Therapeutic exercise: stretching
Muscle length Reciprocal inhibition Active Passive
Therapeutic exercise: neuromuscular control
Muscular balance Timing Coordination Endurance
Clinical Decision making: nerve based
Neural-dynamic Tension Tests ~ULTT I-V ~SLR I-V Findings supporting adverse neural tension ~Peripheral nerve distribution ~Irritability of the patient's condition ~Test/Re-test
Therapeutic exercise: strengthening
Open chain Closed Chain Plyometric Functional
True or false: tendinopathy rarely improves with passive treatments such as massage, utrasounds, and injections
exercise is the bast treatment for tendinopathy, modalities on their own are probably not going to work
Regional Interdependence
"the concept that a patient's primary musculoskeletal symptom(s) may be directly or indirectly influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s)"
Biomechanical Responses to Stress/Load
*varies based on tissue type Uncrimping Elastic Deformation Creep Stress relaxation Stress reaction
Treatment strategies: manual therapy
1. Identifying hypo-mobility during accessory motion testing. ~Correlating this with decreased osteokinematic motion. ~Treating the hypo-mobility with mobilizations into the direction of the restriction. ~Assessing patient response and adjusting the technique accordingly ~Grades ~Approximating end range of osteokinematic motion 2. Identifying the painful accessory motion, then treat with graded oscillatory mobilizations in the painful direction. ~Grades I,II, III, IV, &V ~Assess irritability of the condition with goal of reduction in pain vs. exacerbation. ~Establish a comparable sign (concordant sign) to reassess the effectiveness of intervention 3. recognizing signs and symptoms that form a pattern that might be responsive to a certain technique or techniques. ~Treatment based classification systems ~Regional Interdependence ~Mulligan MWM ~~~Combining accessory glide with osteokinematic motion, based on response.
Creep
Continued deformation of tissue in response to a maintained load. When a load is applied for a long period of time the tissue elongates often resulting in permanent deformation. It is the continuous or viscous deformation or "plastic flow" in a tissue in response to a maintained constant load. Example: forward posture creep of posterior structures.
Stress relaxation
Decreased force is required to maintain a tissue at a constant length over time. inverse of creep when stretching someone's ham...after a while you don't have to push as hard to hold it in the same stretch position
soft tissue based: 1. Swedish massage 2. deep tissue massage 3. trigger point massage 4.shiatsu
Definition: 1. stroking & kneading skin & underlying soft tissue 2. Deep stroking & pressure across muscle & soft tissue 3. Deep pressure to areas of local tenderness 4. varying rhythmic pressure from fingers Goal: ~improve circulation ~decrease muscle spasm ~relaxation ~Re-allign soft tissue ~break adhesions ~increase ROM ~Release muscle spasm ~remove cellular exudates
Nerve biased: neural dynamics
Definition: passive, combined movement of the spine & extremities w/in their normal ROM in ways to elongate or tension specific nerves Goal: ~improve ROM ~decrease pain
Joint biased technique: manipulation & mobilization
Definition: ~passive movement of a joint beyond normal ROM ~pattive movement of a joint within its normal ROM Goal: ~improve ROM ~decrease muscle spasm ~decrease pain
Clinical decision making: soft tissue based
Diagnosis ~Comorbidities ~Tissue integrity Stage of injury ~Acute ~Sub-acute ~Chronic ~Acute on chronic ~"scar" Palpation ~Tissue density/"feel" ~Type ~Tendon ~Muscle ~Ligament ~Fascia
True of false Tendon pathology on imaging usually correlates with pain
False
Stress Reaction
How tissues respond to repeated stresses to improve ability to respond to those stresses. Wolf's Law: Bones and collagen will respond to the physical demands placed on them resulting in remodeling and realignment along the lines of tensile force. Fatigue from cyclic loading can lead to overuse injury.
Therapeutic exercise: specific loading
Isometric Eccentric Heavy slow concentric/eccentric
Manual therapy Joint based
Joint mobilization Muscle energy techniques
Effects of joint mobilization
Mechanical Neurophysiological
effects of immobilization
Specific to Connective Tissue ~Decrease in water content ~~~3-4 % decrease in water content ~Muscle atrophy ~Diminished motor unit efficiency ~Tissue becomes less elastic more brittle (shifts the stress strain curve to the left. ~Unorganized laying down of collagen secondary to no stressors
Elastic Deformation
Stress applied to a tissue resulting in deformation into the elastic region generally results in the return of the tissue to its original rest length when the stress is removed. The amount of deformation within the elastic region will be dependent on the amount of collagen tissue present. Allows about a 4% stretch in collagen but varies depending on the amount of elastic tissue present.
Muscle strain classification
Stress strain curve Grade I-II : plasticity range Grade III: failure point
Muscle strains
common locations: Hamstring Adductors Iliopsoas Quadriceps Gastroc Classification: Grade I Grade II Grade III Location: Muscle belly Musculo-tendinous junction
ham string strain
often biceps femoris during running swing phase: hams active, stretched, & absorbing energy from decelerating swing limb lengthening contraction injury
True of false, tendinopathy does not improve with rest?
rest as a treatment does not help with tendinopathy rest may help with symptoms, but when they go back to activity pain returns rest in a vacuum does not improve tendinopathy, but it will improve tendinitis
Regional Interdependence
the concept that a patient's primary musculoskeletal symptoms may be directly or indirectly influenced by impairments in other non-symptomatic regions of the body region of body with impairments w/ out symptoms could cause symptoms elsewhere
Crimp
~The relaxed state of collagen fibers seen microscopically. ~1st response to stress or strain. ~Seen primarily in ligaments, tendons, and capsular tissue. ~Uncrimping is the "taking up of slack" in the toe region of the stress/strain curve. When a tissue is at rest, there is usually a slack in its length that can be thought of as crimp. Allows collagen to stretch by about 2% without structural change in other words "taking up the slack". This is a concept that we will talk about in joint assessment and mobilization. Remember from the last lecture that when assessing a joint we will place it in its resting position & either move one surface parallel or perpendicular to the treatment plane to form our assessment. Well we will always start off by "unweighting the tissues" which is similar to taking some of the crimp put of the capsule. ***grade 1 distraction before a joint mob.