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.