Principles of Orthopaedic Manual Physical Therapy

OMPT is a way of thinking

Built on strong knowledge of anatomy and kinesiology and sound clinical reasoning

Therapist as an instrument

The therapist uses entire body to constantly take in information about the patients status and how it is or is not changing

Patient as part of the examination and evaluation

Understand the condition from the patient’ perspective. Patients often tell you what is going on, you just have to be able to hear it. Also, findings have to be interpreted within the context of the specific patient

OMPT examination is a series of questions not a set of techniques

Everything you do in the examination should help provide answers to very specific clinical questions. You first have to know what question you are asking before you can determine the best technique to answer it. Not all questions are answerable and not all answers are equal.

• what questions does this answer

• how confident can i be in the answer

The patient’s condition does not begin and end in the clinic

Patients had a life before they came into the clinic and will have one when they leave. It is important to understand how this life may have influenced the onset of the condition and how it may influence the degree of recovery.

what are the predisposing and perpetuating factors

The OMPT examination and evaluation are ongoing

You are constantly assessing the patients status, how it is changing, and what needs to be done next

Assess, treat, reassess

OMPT techniques require constant evaluation

The information you are constantly collecting influences your ongoing clinical decision-making and results in immediate modifications to diagnosis, prognosis, and plan of care. OMPT cannot be delegated to a PTA

OMPT techniques require considerable contact

Maintaining as much contact as possible helps the patient feel secure and better able to all you to perform passive motions

• hug it like you love it

Hand contact should be firm but not tight and should include adequate surface area.

Proper hand contact is key to patient comfort, your ability to, sensing the response to your techniques, and your ability to perform techniques appropriately.

• moldy hands

• grip down to the bone and no further

• hands are grippers and sensors, no pushers or pullers

Hands should be close to the joint line

Important to be as close to the joint lines as possible in order to reduce creating levers and producing torque during techniques

Use your body to generate force

The force used to create motions in the desired joints comes from your trunk or your legs, not your arms or hands. Using arms and hands is less comfortable for the patient and reduces your ability to sense the response to your technique

• lock and rock

Joint mobility assessment is always done in the resting position

This is the position of least capsular tightness and bony congruency. In order to truly assess joint mobility you have to start in a standard position that is least restrictive.

Assessments and joint glides are performed in the plane of the joint

The plane of the joint is defined as being parallel to the concave surface of the joint being assessed or treated

One end of the segment should be stable and the other end (generally more distal end) is mobilized

When both sides of a joint are moving it becomes difficulty to 1) assess for normal/abnormal mobility and 2) generate enough force to produce plastic changes

History - aspects to include

• onset/mechanism of injury

• location of symptoms

• description of symptoms

• pain/symptom rating (current & worst/least in last 7 days)

• frequency/duration of symptoms

• aggravating/relieving factors

• patient’s perspective of what is wrong

History - onset/mechanism of injury

• sudden trauma

• gradual decline/overuse

• recurrent

History - location, description, frequency and duration of symptoms

ask patients to

• draw a diagram or point

clarify and quantify

• boundaries

• quality (ache, burning, tingling)

• quantity (0-10 scale)

• frequency (how long it lasts or time since onset)

• differentiate when multiple symptoms present

• ask about additional areas of pain

History - frequency & duration of symptoms

• mechanical - on and off

• inflammatory - up and down, gets worse every time

• sensitization - increasing worse

Screenings

Emergent

• Patient needs emergency medical attention

• Ex: acute stroke, heart attack, loss of consciousness

Urgent

• Urge patient to seek medical attention soon, call referring MD

• Ex: change in symptoms of known red flag conditions, very high blood pressure without symptoms

Important

• Monitor nearly every treatment session

• Ex: neurologic symptoms, moderately high BP, reports of dizziness

Screenings - Emergent

Patient needs emergency medical attention

Ex: acute stroke, heart attack, loss of consciousness

Screenings - Urgent

Urge patient to seek medical attention soon, call referring MD

Ex: change in symptoms of known red flag conditions, very high blood pressure without symptoms

Screenings - Important

Monitor nearly every treatment session

Ex: neurologic symptoms, moderately high BP, reports of dizziness

Review of Systems

head to toe questions

Red Flags:

signs and symptoms that raise suspicion of serious underlying pathology

• Neurological conditions

• Tumors

• Infection

Yellow Flags:

psychosocial and occupational factors that may affect patient presentation and treatment

• Expectation of a poor treatment outcome

• High anxiety

• Fear avoidance

Systems Review

• A brief or limited examination of the anatomical and physiological status of the 5 components, specifically noting any affects the ability to initiate, sustain, and modify purposeful movement for performance of an action, task, or activity that is pertinent to function.

• Obtained through physical examination using selected tests and measures

• (Note. Be able to list all 5 components and provide a few examples of the type of information collected in each one)

Systems Review - cardiovascular/pulmonary

Heart rate, respiratory rate, blood pressure, & edema

Systems Review - integumentary

Pliability, scar formation, color, & integrity

Systems Review - musculoskeletal

Gross - symmetry, range of motion, strength, height, & weight

Systems Review - neuromuscular

Gross – coordinated movement and motor function

Systems Review - Communication, affect, cognition, language, and learning

Consciousness, orientation, emotional & behavioral responses, learning barriers & needs

Dermatomes - Instructions

• Provide clear instructions to patient including what responses you are looking for (presence of sensation and comparison side to side)

• Sweep your finger over the assessment zone one or two time

  • Perform bilaterally (at same time or corresponding spots one after the other)

• Ask patient:

  • “Do you feel it?”

  • “Is it the same on each side?”

• Move through exam in systematic order (see next slide for order and locations)

• Graded as: Increased – Normal – Decreased – Absent

  • If abnormal, identify borders/distribution to determine if:

  • Radiculopathy (nerve root)

  • Mononeuropahy (single peripheral nerve)

  • Polyneuropathy (multiple peripheral nerves)

Dermatome - c2

dorsal lateral scalp

Dermatome - c3

behind ears

Dermatome - c4

lateral neck (priest collar)

Dermatome - c5

anterior lateral shoulder

Dermatome - c6

dorsal thumb

Dermatome - c7

dorsal aspect of the proximal phalanx of the middle finger

Dermatome - c8

medial aspect of the hand (hypothenar eminence)

Dermatome - t1

medial (ulnar) proximal forearm

Dermatome - L1

groin

Dermatome - L2

medial thigh

Dermatome - L3

medial knee

Dermatome - L4

medial malleolus

Dermatome - L5

dorsal foot/great toe

Dermatome - S1

lateral malleolus

Dermatome - S2

medial calf

myotome - grading

0 = total paralysis.

1 = palpable or visible contraction.

2 = active movement, full range of motion (ROM) with gravity eliminated.

3 = active movement, full ROM against gravity.

4 = active movement, full ROM against gravity and moderate resistance

5 = (normal) active movement, full ROM against gravity and full resistance

myotome - c1

craniocervical flexion

myotome - c2

craniocervical extension

myotome - c3

cervical lateral flexion

myotome - c4

scapular elevation (shrug)

myotome - c5

shoulder abduction

myotome - c6

elbow flexion or wrist extension

myotome - c7

elbow extension or wrist flexion

myotome - c8

thumb adduction or extension

myotome - t1

finger abduction

myotome - L1-2

hip flexion

myotome - L3

knee extension

myotome - L4

ankle dorsiflexion

myotome - L5

great toe extension

myotome - S1

hamstrings

myotome - S1-2

plantarflexion

Deep Tendon Reflexes - Grading

0: Absent reflex, no reaction (generally not pathological if bilateral)

1: Small reflex, less than normal, or obtained with reinforcement

2: Lower half of normal reflex

3: Upper half of normal reflex

4: Increased reflex. Clonus may be present, and it is always pathological

Note. May use a (+) after number to distinguish from MMT. This does not indicate a slight increase in response.

Interpretation

• Hyporeflexia (0-1) may indicate lower motor neuron pathology

• Hyperreflexia (4) may indicate upper motor neuron pathology

Deep Tendon Reflexes - C5 - 6

biceps

Deep Tendon Reflexes - C6

brachioradialis

Deep Tendon Reflexes - C7-8

triceps

Deep Tendon Reflexes - L2-4

patellar tendon

Deep Tendon Reflexes - S1-2

achilles tendon

Observation

• Patient’s posture and gait when not expecting to be observed

• Static posture

• Gait

• Spontaneous movements

• Specific movements

What to observe more

• Skin abnormalities

• Sympathetic changes (see next slide)

• Edema

• Postural alignment

• Structure & symmetry

• Muscle bulk

• Movement patterns

• Compressive & tensile loading

• Aberrant movements

Goals of Palpation

• Identify structures of interest

• Gain information about:

  • Tissue type (bone, tendon, muscle belly, skin, subcutaneous tissue)

  • Tissue condition (warmth, edema, pliability, mobility)

  • Tissue position (appropriate anatomical alignment)

  • Tissue integrity (deficits, guarding, deformity)

  • Tissue reactivity (irritability, tissue tolerance)

• Build trust and rapport with patients

How do I palpate?

• Pointy sticks - stick out your index finger and simply poke the structure you are palpating

• Cold fish are when you have cold clammy hands

• Wet mops are when you have limp, floppy hands that just sort of drag around on the patient

• Anvils - heavy hands that have no sense of tenderness or finesse.

• Popcorn hands - placing your hands on and off the patient. Your hands go up and down like popcorn in a kettle.

• Poking the dog occurs when you find a structure that is painful and then you just keep palpating it over and over until the structure, and more importantly the patient, is extremely irritated

Active Range of Motion (AROM)

Movement under full control of the patient

Assesses willingness TO move

Assesses ability TO move

Passive Range of Motion (PROM)

Movement under full control of the therapist

Assesses willingness TO BE moved

Assesses availability of motion

ROM assessment

• A more comprehensive examination and evaluation of the ability of one body segment to move or be moved relative to another

• Includes both quantitative and qualitative aspects

• Is more dynamic in nature

Goniometry

• A specific method of measuring the angle created by two adjoining body segments

• Is purely quantitative

• Is static in nature

Muscle performance

indicates we are talking about a functional quality of a muscle, the specific quality should be identified:

• Motor control – ability to contract and ability to control motion

• Force generating capacity – how much force

• Endurance – ability to sustain force over time

• Power – ability to generate force with speed

Motor control

ability to contract and ability to control motion

Force generating capacity

how much force

Endurance

ability to sustain force over time

Power

ability to generate force with speed

Muscle Performance - what to assess

• Can the muscle contract?

• Can the muscle (or group of muscles) control the intended motion?

  • Concentric vs. eccentric

  • Simple vs. complex

  • Slow vs. fast

  • Low vs. high inertia

Muscle Performance - how to assess

• Palpate muscle activation

  • Ability to contract

  • Timing of contraction

  • Consistency of contraction

• Observe movements

  • Complete range or motion

  • Smooth start/stop & throughout movement

  • Able to smoothly and quickly adjust speed

  • Able to perform above with reasonable range of weight

  • Able to respond appropriately to perturbations

    • Feedforward & feedback

Resisted Testing (Gross Muscle Strength)

General screen for a group of muscles that act together

Grading is less specific (Strong or Weak)

Manual Muscle Testing (MMT)

• Specific procedures in defined positions

• Targets specific (generally 1 or very few) muscles

• Very specific definitions for 0-5 grading system

Maximal voluntary isometric contraction (MVIC)

Quantification of either resisted testing or MMT

Requires a dynamometer

1 Repetition Max Testing

• Absolute measure of concentric force production capacity (weight that can be lifted 1x before failure)

• Function of motor unit activation & cross-sectional area of muscle

• Generally not recommended in presence of pathology

Repetition Max Testing

• Approximate measure of concentric force production capacity (number of times a given weight can be lifted before failure)

• Able to estimate 1RM using Holten curve

• Better estimate of force generating capacity if 15 reps or less is achieved

To assess endurance you would use

• repetition max testing

• sustained isometric hold

to assess power, you would use

• 5x sit to stand

• time to complete 10 heel raises

Time to Complete 10 heel raises – (unstandardized)

• Measure of time required to perform 10 full range heel double or single leg heel raises in standing. May use fingers on wall for balance support.

• Function of ability to move body (force) from lower to higher position (displacement) 10x as quickly as possible (time)

5x Sit-to-Stand Test – (standardized)

• Measure of time required to perform 5 sit-to-stands from a standard height chair (17 inches) without using hands.

• Function of ability to move body (force) from lower to higher position (displacement) 5x as quickly as possible (time)

Joint Mobility Testing

• How much unrestricted joint glide is available in a particular direction?”

• Amount of pressure is VERY gentle

• Performed in the resting position for the joint

Special Tests

Used to increase or decrease confidence that a condition of interest is present

Confidence that a condition is PRESENT

• 20% - rule out

• 80% - ruled in

HOW

• Ideally using tests with known psychometric properties.

• Other times using deductive reasoning strategies

Special Tests - Known Diagnostic Utility

Sensitivity (Sn)

Specificity (Sp)

Likelihood ratios (LR+/LR-)

Special Test - Deductive Strategies

Selective tissue testing (STT)

Response to treatment

Functional Testing Performance-based testing

• Assess patient trying to perform specific functional movement patterns

  • Try to correlate test/measure findings to functional performance

    • May assist in prioritizing interventions

    • Provides baseline data to create goals from

• Functional tests can be standardized or non-standardized

What makes a good test or measure?

Purpose (good for what?) - validity

Performance (how consistent are the results?) - reliability

Properties (how confident are you in results?) - diagnostic accuracy

Validity

The degree to which an instrument measures what it is intended to measure.