PT 805: lecture three manual therapy intro

What two concepts of PT have the most scientific back up?

- Manual therapy

- Exercise

Musculoskeletal aberrations in normal motion can be from...

- Too much movement (hypermobile)

- Too little movement (hypomobile)

What two things are most used in PT exams and treatment

- Passive movement and palpitation

Types of manual techniques in this class

- Pain provocation or symptoms change test.

- Muscle length test

- Stability test

- Passive physiologic movements

- Passive accessory movements

Pain provocation or symptoms change test.

- Passive movement intended to load or unload structures to determine if they are mechanically sensitive.

o May not be informative of the cause of the problem.

Muscle length test

- Determine length of muscle tendon units

- Complementary testing: not a basis for diagnosis

o Often just classified as normal or abnormal

Stability test

- Passive movement to stress joint stabilizing structures.

- Test for magnitude of motion and quality of barrier

- Directionally specific

What is an example of a stability test?

Manual therapy to test for ACL tear

Passive physiologic movements test

- Passive movement at a joint or multiple joints (PROM)

- Includes osteokinematics and arthrokinematics.

o Flexion, extension, abduction, adduction, internal rotation, and external rotation

What two things can limit passive physiologic movements

- Musculotendinous units

- Articular and peri articular structures (joints)

Passive accessory movements test

- Passive movement at a joint that includes SPECIFIC arthrokinematics and NONSPECIFIC accessory motions.

Passive accessory movements are limited by ________ only.

- Articular or peri articular structures

What manual therapy technique is used often for PT evaluation and treatment?

- Passive accessory movement

Active vs passive movement skills analysis (during evaluation)

- Active: composite movement and joint physiologic (AROM)

- Passive: osteokinematic and arthrokinematics

What is the BIG different between physiologic motion and arthrokinematics motion

- PHYSIOLOGIC MOTION CAN BE MEASURED

ARTHOKINEMATIC MOTION CAN ONLY BE EVALUATED USING MANUAL THERAPY

Components of osteokinematic motion

- Bone on bone movement

- Usually, angular motion

- Can control voluntarily.

Components of accessory motions

- Accompany osteokinematic motions.

- Movement of one surface onto another (arthrokinematics)

- Not under voluntary control (passive movement)

Relationship between osteokinematics and arthrokinematics (not normal motion)

- If motion is reduced, can be cause by the loss of osteokinematic motion with or without loss of arthrokinematics motion.

Roll (arthrokinematics)

- Multiple points on one surface hit multiple points on another.

- Usually in same direction as movement

Spin (arthrokinematics)

A single point on one surface rotates on a single point of another surface.

Examples of spins that occur within the body.

- Hip flexion and extension.

- Radial head on capitulum during pronation

glide (arthrokinematics)

A single point on one surface contacts multiple on another surface

Why are rolls and glides usually combined?

- To prevent one joint surface from gliding off the other

________ motion + _______ motion = physiologic motion

Arthrokinematic + osteokinematic

Joint compression (description)

- Decreases the space and volume between to joints.

- Adds stability (less glide in joint)

- Can occur due to muscle contraction or external force.

Joint distraction (distraction)

- Increase the space and volume between joints.

- Joint capsule and accessory ligaments are tensioned.

- Only occur from external forces

End feel of a passive movement.

- Quality of resistance during and at the end of a motion

- Provides information about the extensibility, irritability, and presence of inflammation.

Relationship between pain and end- feel

- Pain before end feel: high mechanical sensitivity

- End feel before pain: low mechanical sensitivity.

Normal capsule or ligament barrier (end-feel)

- Firm with small elastic yield

Shorted capsule or ligament barrier (end-feel)

- Very firm with little to no elastic yield

o After a cast

lengthened capsule or ligament barrier (end-feel)

- Soft and less resilient with greater elastic yield

o Torn ligament or capsule

Soft tissue interposition barrier (end-feel)

- Soft and visible barrier

Bone to bone (end- feel)

Hard

Edema and effusion (end-feel)

- Soft (boggy)

Pain (end-feel)

- NONE

o Huge problem

Relationship between mobility and end feel

- Increased mobility = soft end-feel

- Decreased mobility = hard end feel

Force displacement curve of passive accessory motion

- Relationship between force and displacement regarding end-feel and capsule length

R1 vs R2 (Force displacement curve of passive accessory motion)

- R1: initial resistance still moves.

- R2: end resistance: no movement

Causes of hypomobility

- Shorted muscle and tendon units

o Loss of ostetokinematics only

- Loss of articular and periarticular tissue length

o Loss of osteokinematics and arthrokinematics

Causes of hypermobility

- Excessive osteokinematic motion only due to ligament tear or rupture

Causes of instability

Excessive arthrokinematics motion due to ligament tear or rupture

Concave surface on convex surface

- Roll and glide in the same direction as physiologic movement.

Convex surface on concave surface

- Roll and glide in opposite directions.

- Glide is opposite direction of physiologic movement.

Loose packed joint position

- Position of least tension of capsule and periarticular tissue

- Allows for maximal joint volume.

- Greatest availability for glide

Closed pack joint position

- Maximal joint congruency and stability

- Maximal tightening of ligaments and capsule

- Least available for traction and glide

Capsule pattern

- Pattern of movement loss of a joint

- Shortening of joint capsule

Capsule pattern example

FOZEN SHOULDER patients loose external rotation first then other motions

Contractile tissues and how they are tested for tension.

- Muscle, tendon, TMJ, bursa, and bone

- Isometric contraction

Why are contractile tissues tested via isometric contractions?

- TO NOT MOVE THE JOINT

noncontractile tissues and how they are tested for tension.

- Ligaments, capsule, bone, synovium, bursa, fascia

- Passive motion (stress and stretch test)

Mobilization or a non- thrust manipulation

- In the available motion or to the barrier

o Oscillations and stretches.

Manipulation or thrust manipulation.

- High velocity and small amplitude thrust through the barrier.

o Grades 1-5

Mobilization technique grades

- Grade 1: small amp at the begging of a motion

- Grade 2: large amp at the begging and middle of a motion

- Grade 3: large amp at the middle and end of a motion

- Grade 4: small amp and end

- Grade 5: manipulative thrust

Cavitation vs tribonucleation (cracking noises)

- Cavitation: collapse of gas bubbles or voids in liquid (popping fingers)

- Tribonucleation: creation of small gas bubbles by breaking contact between solid surfaces emerged in liquid.

Three effects of manual therapy

- Biomechanical

- Neurophysiologic

- Psychological

Biomechanical effects of manual therapy

- Realignment

- Breaking adhesions

- Reduction of hypomobility (increased motion)

- Increased fluid exchange

Neurophysiologic effects of manual therapy

- Change in central pain processing.

- Change in muscle recruitment.

- Reduced temporal summation (chronic pain)

- Biochemical changes

Psychological effects of manual therapy

- Placebo effect of POP noise

- Perception of benefits

Which of the three effects of manual therapy is greatest in magnitude

- Neurophysiologic effects

Pain definition (KNOW)

- An unpleasant sensory and EMOTIONAL experience associated with or resembling an association with actual or potential tissue damage.

Are pain and nociception the same phenomena?

- NO

o Pain involves perception, and nociception are pain signals in the body.

Three types of pain

- Peripheral nociceptive pain

- Neuropathic pain

- Nociplastic pain (central sensitization)

Peripheral nociceptive pain and example

- Input to the brain from a peripheral structure which may be interpreted as pain.

o Sprained ankle

Neuropathic pain and example

- Nerve root and peripheral nerve injury

o Carpal tunnel

Nociplastic pain/ central sensitization pain and example

- Predominantly central mechanisms

o Brain interoperates input signals as pain.

Pain dominate patients.

- Patients with joint limitations and pain that that is easily provoked and elevated.

- Pain is disproportional.

Stiffness dominate patients.

- Patients with joint limitation and pin that is rapid but returns to baseline.

Indications vs. contradictions vs. precautions

- Indications: probability of benefit

- Contradictions: probability of negative result or harm

- Precautions: may or may not contribute to positive and negative outcome and require clinical reasoning