MSK 2 - Week 1 - Introduction

What are relative contraindications to manipulation?

1) Active, acute inflammatory conditions
2) Significant segmental stiffness
3) Systematic diseases
4) Neurological deterioration
5) Irritability
6) Osteoporosis (depending on the intent and direction of movement)
7) Condition is worsening with present treatment
8) Acute nerve root irritation (radiculopathy)
When subjective and objective symptoms don't add up
9) Any patient condition (handled well) that is worsening
10) Use of oral contraceptives (if cervical spine)
11) Long-term oral corticosteroid use (if cervical spine)
12) Immediately postpartum (if noncervical spine)
13) Blood-clotting disorder

What is a Dural sleeve?

An extension of the dura mater covering the nerve root.

What is the pain pattern for nerve root related pain?

Pins and needles that are relieved as soon as pressure is released. If the pressure is significant enough, then numbness may develop.
-There will be no specific edge to the pins and needles, which will help differentiate the issue as being related to a nerve root as opposed to a peripheral nerve issue which would be very precise.
-there will be no increase in pins and needles as you move the limb around which helps differentiate it from a nerve trunk issue.

What is the pain pattern for spinal cord related pain?

-Bilateral extra segmental pins and needs, often in the LE.
-no edge or aspect, no effect of limb movement, no effect of stroking the skin
-long track signs such as Babinski, clonus, and Hoffman

How does the sequencing of pain relate to irritability?

Pain before resistance = high irritability

Pain with resistance = moderate irritability

Resistance before pain = low irritability

How do you know what level the SNAG should be applied?

Begin with pressure on the SP of the level above the problem or on the TP side with limitation or pain.

Do not use press and guess approach. You should be able to identify the problematic segment based on your exam.

What is the clinical prediction algorithm for acute low back pain?

1) Does the patient centralize with 2 or more movements in the same direction? or do they centralize with movement in one direction and peripheralize with movement in the opposite direction? if so -> they fall into the specific exercise group

2) If non of the above, does the patient have a recent onset of symptoms (less than 16 days) and no symptoms distal to the knee? If so -. they fall into the manipulation group.

3) If non of the above, does the patient have at least three of the following?:

-Average SLR greater than 91 degrees

-Positiveprone instability test

-Positive aberrant movements

-Age <40

If yes -> stabilization Group.

What are 3 patient specific modifiable factors?

-Load (compression sensitivity)
-Position
-Tension (neural, muscular, CTs)

What provocative and alleviating factors would suggest a patient with chronic LBP may be position sensitive?

Provocation: sitting or standing, repeated motions toward the provocative direction

Alleviation: changing positions, repeated movements away from the provocative direction.

What is chronic widespread pain?

Greater than or equal to 20% pain surface area as indicated on a pain location diagram.

What is chronic widespread pain correlated to? (4)

-Severe or extremely severe anxiety scores
-Greater than or equal to 5 psychosocial stressors
-Greater than or equal to 5 significant life events
-Has used more than or equal to 7 pain management strategies

What is the difference between an absolute contraindication and a relative contraindication?

An absolute contraindication involves any situation
in which the movement, stress, or compression placed on a particular body part involves a high risk of negative consequences.

A relative contraindication involves a situation that requires special care. The presence of a relative contraindication suggests there is risk of injury associated with a selected treatment and considerable reflection should occur prior
to use.

What are relative contraindications for active movement?

1) Active, acute inflammatory conditions
2) Significant segmental stiffness
3) Systematic diseases
4) Neurological deterioration
5) Irritability
6) Osteoporosis (depending on the intent and direction of movement)
7) Condition is worsening with present treatment
8) Hamstring and upper limb stretching on acute nerve root irritations

What is the general idea behind osteopathic manual therapy?

Use of manipulative therapy to address postural faults and restrictions of motion. Uses concepts including asymmetry, movement restriction, and palpation (less helpful for us now) to dictate treatment.

What are key concepts of Cyriax?

Diagnosis of soft tissue lesion and isolation of contractile vs non contractile components. Also every pain of must have a source and the treatment should reach and address the source of the pain to be effective. Birth of:
-STTT
-End feel classification
-Capsular patterns (less helpful for us now)

What is the common distribution of referred pain?

Referred pain that arises from a central disorder will produce central or bilateral pain. However, most often, referred pain is unilateral, does not cross the midline, and is referred distally on a segmental basis. For example, if the source of the pain is on the right (like a R facet) than the referred pain will only be on the right.

Can palpation of an irritable tissue identify if the tissue is directly at fault or if it is a referred pain?

No, palpation is not good for identifying referred pain. Palpation could easily lead you down the wrong path but you still need to clear the spine.

What is the pain pattern/distribution for dura mater pressure?

-Causes central pain with distal reference (extrasegmental pain/dishonext tissue) that does not extend past the buttock for lumbar, and not past the scapula for cervical.
-Most frequent site of pain is the buttock area (for lumbar)
-Can produce many trigger points
-Will produce pain only, no pins and needles.

What is extra segmental pain?

referred pain that doese not follow a dermatome.

What is the pain pattern for pain related to the dural sleve?

If the pressure is light, then you produce pain only with no pins or needles (unilateral?).

If the pressure is sufficient to impact the underlying nerve root, than pins and needles can develop and the pain may or may not persist.

What is the pain pattern for nerve trunk related pain?

-No local pain
-Distal pins and needles that develop as pressure is released
-could develop numbness and motor less with sustained pressure.
-pins and needs will have some edge or aspect to it and it will increase with limb movement and stroking of the skin.

Why is there a less distinct aspect or edge to numbness and tingling with nerve root and trunk related pain?

The closer the structure to the spine, the less cortical resources there are that are dedicated to those tissues so the brain is not as good at knowing exactly where it is. But it will still follow dermatomal distributions.

What is the pain pattern for peripheral nerve related pain?

-numbness is primary symptom, possible to have some pins and needles.
-very well localized
-clear edge and aspect to symptoms that are always distal to the site of the lesion.

What is the capsular pattern for the spine?

-Limited extension
-equally limited side bending and rotation
-minimally limited flexion

Anything else is a non capsular pattern.

When discussing the spine, what would a capsular pattern potentially indicate? and what would a non capsular pattern potentially indicate?

Capsular pattern could be caused by arthritis or following prolonged immobilization.

Non capsular pattern could be caused by derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion.

What are some of the essential ideas of kaltenborn? (5)

-assessing joint play and joint glides with graded movements
-concave-convex rule
-treatment should follow the findings of the assessment.
-the idea of open and closed packed joint positions.
-expanded views on end feels and pathologic end feels

What essential contributions did Maitland provide? (3)

The use of passive accessory motions to treat pain and dysfunction
-PA mobs and oscillatory mobs.

patient centered approach that monitored patient symptoms and responses to treatment.

Concordant sign

Examining the quality, quantity, and symptom provocation of functional movements (both active and passive with overpressure)

PPIVMs and PAIVMs

What are PPIVMs and PAIVMs?

Passive Physiologic Intervertebral Movements (PPIVMs) are defined as passively producing movements in directions that can be performed actively.

Passive Accessory Intervertebral Movements (PAIVMs) are defined as producing movements in directions that can not be produced actively in isolation but nonetheless need to be available for active movements to occur.

How is joint play assessment documented?

-patient response (pain vs stiffness)
-Quality of motion (onset of stiffness, end feel, feelings through the available range for example crepitus)

When doing JPA, how can you determine if the patient is pain dominant or stiffness dominant?

Pain dominant: Pain felt before R1, likely will not be able to reach R 2 due to pain.

Stiffness dominant: R1 and R2 are very close together, if painful, pain is felt at R2.

What would be characteristic of a pain dominant joint? (5)

-Diffuse pain
-Constant pain
-Guarded movements
-May have spasms
-Repeated movements aggravate pain

What would be characteristic of a stiffness dominant joint? (5)

-Localized pain
-Intermittent pain
-Limited movements
-Rarely has spasms
-Repeated movements increase range

In general, what would be indicated for a patient who has hypomobility with limited pain?

Higher grade joint mobs (Grades 3 and 4) to get it moving.

In general, what would be indicated for a patient who has hypomobility with pain?

Joint mobs at grades 1, 2, and 3 depending on irritability with working toward higher grades as pain and irritability come down.

In general, what would be indicated for a patient who has no pain and hypermobility?

No manual therapy, instead work on stabilization through exercise.

In general, what would be indicated for a patient who has Hypermobility with pain?

Modulate pain with low grade joint mobs and stabilize through exercise.

When should CPAs be used to treat a patient?

CPAs should be used to address central or bilaterally distributed symptoms when the accessory motions are the concordant sign, or are more concordant than physiologic motions.

When should UPAs be used to treat a patient?

UPAs should be used to address unilaterally distributed symptoms when the accessory motions are the concordant sign, or are more concordant than physiologic motions.

Can you use a UPA to improve physiologic motion in the spine?

No, you cannot use a UPA to change physiologic motion. Accessory mobilizations (PAIVMs) are to be used only when the accessory mobilization is the concordant sign. If the physiologic mobilization is the concordant sign, more so than the accessory mobilization, than you should use a passive physiologic intervertebral mobilization (PPIVMs).

When should traction be used?

-Primarily when symptoms are relieved by distraction and/or by unloading.
-When you want to open neural foramina but the patient cannot tolerate a physiologic or accessory technique.
-gradual onset of discogenic symptoms that may have radiculopathy components

When should neural mobilization be used?

When there is an issue with the nerve itself. Not when the problem is with the nerve interface/ root. Neural mobilization in the presence of foraminal stenosis is not going to help.

What are the three syndromes of the McKenzie method?

-Derangements
-Dysfunction syndrome
-Postural syndrome
-"Other" category

What are derangements?

Derangement refers to an abnormality or disruption in the normal function or structure of a joint, often involving the internal components such as the cartilage, menisci, or ligaments. In the spine this can refer to the intervertebral disc and issues associated with that.
-McKenzie identified anterior derangements (which are rare) and posterior derangements

What is dysfunction syndrome?

Refers to pain which is a result of mechanical deformation of structurally impaired tissues like scar tissue or adhered or adaptively shortened tissue.
-McKenzie identified flexion dysfunction (meaning loss of flexion) and extension dysfunction (meaning loss of extension.

What is postural syndrome?

Refers to pain which occurs due to a mechanical deformation of normal soft tissue from prolonged end range loading of periarticular structures. The pain arises during static positioning of the spine (for example sustained slouched sitting) The pain disappears when the patient is moved out of the static position.

What falls under McKenzie's "Other" Category?

• Patients who fail to classify in to the other categories
• Red flag symptoms
• Non-mechanical symptoms - cauda equina, malignancy, fracture, systemic inflammation
• Specific diagnosis - stenosis, hip pathology, SI dysfunction,
spondylolisthesis, etc.
• LBP due to pregnancy
• LBP post-op

How does McKenzie propose patient conditions should be classified?

By the level of pain or limitation that results from certain movements or positions utilizing pain questions, observation, and repeated motions.

How does McKenzie propose treating patients?

Based on the classification.

How does McKenzie propose treating derangements?

Reduce the disc, maintain reduction, restore full

movement. Use centralization to direct treatment

-Prolonged positioning into a directional preference

-For example: posterior derangements will be the prone press up progression

How does McKenzie propose treating dysfunction?

Remodel adaptively shortened tissues. Move in to the
painful direction. (can add MT to increase effectiveness though not strictly part of the McKenzie method)
-Repeated end range movements into the painful direction

(for dysfunctions, not derangements)

How does McKenzie propose treating postural syndrome?

Remove abnormal stress from the normal tissues. Focus on
secondary impairments.

What is the theory behind the mulligan concept?

That there is a positional fault (which is an articular malalignment that results in altered kinematics and joint dysfunction), and that glides in the frontal and transverse plane can be applied to restore motion in the sagittal plane. If the mobilization reduces pain or improves motion in the exam, it is
indicated for treatment

What is the goal of the meulligan concept?

PILL effect
-Pain free
-Immediate
-Long Lasting

How is the mulligan mobilization with movement performed?

-Mobilization is applied as close to the joint as possible
-Force is parallel to the treatment plane
-Use the minimal amount of force needed
-The mobilization is sustained throughout motion
-The patient performs active movement in weight bearing
-Overpressure is applied

How many reps should be used for the mulligan mobilization with movement?

5-10 reps, though could begin with fewer reps if the patient is highly irritable of if you want to be cautious with your first application in order to not over dose.

What are SNAGs?

Sustained natural apophyseal glides. They are a type of mobilization with movement that is based on the positional fault theory.
-Sustained facet glide with movement in weight bearing position
-Mobilization with active movement progressing to having passive overpressure applied.
-Pressure follows the treatment plane of the facet
-Motion must be painless

What are NAGs?

Natural apophyseal glides
-They consist of an oscillatory mobilization applied to facet joints between C2 and C7.
-Mid to end range mob that is applied along the treatment plane of the facet joint.
-Must be pain free

What is the dosing for NAGs?

Perform six times and allow for several sets.

What are reverse NAGs?

• The inferior facet glides up on the superior facet (similar to passive head retractions)
• Applied to lower cervical and upper thoracic vertebrae
• Oscillatory with the direction and force (same as the NAG)

What are the groups for treatment based classification of acute low back pain?

-Manipulation
-Stabilization
-Specific Exercise
-Traction

When using the treatment based classification system for acute LBP, what is recommended for patients who fall into the manipulation category?

-Manipulation of lumbopelvic region
-AROM exercises

When using the treatment based classification system for acute LBP, what is recommended for patients who fall into the stabilization category?

-Promoting isolated contraction and co-contraction of the deep stabilizing muscles (multifidus, transverse abdominis)
-Strengthening of large spinal stabilizing muscles (Erector spinae, oblique abdominals)

When using the treatment based classification system for acute LBP, what is recommended for patients who fall into the specific exercise category - Lateral shift?

-Exercises to correct lateral shift
-Mechanical or autotraction (but not until shift has been addressed)

What provocative and alleviating factors would suggest a patient with chronic LBP may be compression sensitive?

Provocation: Upright postures, carrying extra weight, impacts

Alleviation: Unloading, recumbency, avoiding impact.

What provocative and alleviating factors would suggest a patient with chronic LBP may be Tension sensitive?

Provocation: Stretching

Alleviation: Shortening

What are three different potential sources of symptoms for patients with chronic LBP?

-Nociception
-Peripheral neuropathic
-Central sensitization

What is indicative of central sensitization?

Pain that is disproportionate, non mechanical, unpredictable, and diffuse.
-dont forget about the strong association with maladaptive psychosocial factors (negative emotions, maladaptive behaviors, etc.)

What is central sensitization strongly associated with?

There a strong association with maladaptive psychosocial factors, such as: negative emotions, poor self-efficacy, and maladaptive beliefs and pain behaviors.

What is the pain outside the body sign?

When patients depict pain locations outside of the body on a pain location diagram that indicates psychological distress.

What is suggestive of peripheral neuropathic pain?

-Pain referred in a dermatomal or cutaneous distribution.
-History of nerve injury, pathology, or mechanical compromise
-Symptom provocation with mechanical testing (think SLR or ULTT).
(high levels of classification accuracy, Sp 0.96, Sn 0.863)

What is suggestive of nociceptive pain?

-Pain localized to the area of injury/dysfunction.
-Provocation/alleviation is clear, proportionate mechanical/anatomical nature
-Symptoms are usually intermittent and start onset with movement/mechanical provocation
-Quality may be a more constant dull ache or throb at rest.
-Absence of:
•Pain in association with other dysesthesias.
•Night pain/disturbed sleep.
•Antalgic postures/movement patterns.
•Pain variously described as burning, shooting, sharp or electric-shock-like.
(high levels of classification accuracy, Sp 0.91, Sn 0.909)

What is the take home point of the regional interdependence model?

The initial examination and treatment should focus on the patient's local area of complaint. However, it is just as important to screen the regions above and below the area of primary dysfunction. For example, when examining a patient with a primary complaint of knee pain, it is also important to screen the ankle and the hip, and even the lumbar spine.

How does MT promote pain reduction?

It is suggested that manual therapy demonstrates pain reduction through inhibition of nociceptors, dorsal horn, and inhibitory descending pathways of the spinal cord. It may also improve chemical alterations secondary to injury and CNS thresholds. Could also be impacted to a certain degree by a placebo effect.

When performing STTT, what would a result of all motions being painful indicate?

Once all sinister pathologies are ruled out the therapist should consider that the affective component may be the
chief generator of pain. Additionally, this could be a gross lesion lying proximally; usually capsular and produced
with joint movement is not fully restrained.

When performing STTT, what would it indicate if the motion is painful on repitition?

If the movement is strong and painless but hurts after several repetitions, the examiner should suspect intermittent
claudication.

During a medical screening, what are some findings that would be considered red flags that warrant immediate medical attention?

• Pathological changes in bowel and bladder
• Patterns of symptoms not compatible with mechanical pain
(after physical exam)
• Blood in sputum
• Numbness or paresthesia in the perianal region
• Progressive neurological deficit
• Pulsatile abdominal masses
• Neurological deficit not explained by monoradiculopathy
• Elevated sedimentation rate

During a medical screening, what are some findings that would be considered red flags that require subjective questioning or are contraindications to selected manual therapy techniques?

• Impairment precipitated by recent trauma
• Writhing pain
• Nonhealing sores or wounds
• Fever
• Clonus (could be related to past or present CNS disorder)
• Gait defects
• History of cancer
• History of a disorder with predilection for infection or hemorrhage
• Long-term corticosteroid use
• History of a metabolic bone disorder
• Recent history of unexplained weight loss
• Age > than 50
• Litigation for the current impairment
• Long-term worker's compensation
• Poor relationship with the employment supervisor

During a medical screening, what are some findings that would be considered red flags that require further physical testing and differentiation analysis

• Bilateral or unilateral radiculopathy or paresthesia
• Unexplained significant lower or upper limb weakness
• Abnormal reflexes

What are absolute contraindications for active movement?

1) Malignancy of the targeted physiological region
2) Cauda equina lesions producing disturbance of bowel or bladder
3) Red flags including signs of neoplasm, fracture, or systemic disturbance
4) Rheumatoid collagen necrosis
5) Coronary artery dysfunction (unless active movements involve stabilization procedures) with signs including:
-Drop attacks, blackouts, loss of consciousness
-Nausea, vomiting, and general lack of wellness
-Dizziness or vertigo
-Disturbance of vision including diplopia
-Unsteadiness of gait and general feelings of weakness (intermittent)
-Tingling or numbness (especially dysaesthesia, hemianaesthesia, or facial sensation)
-Dysarthria or difficulty swallowing
-Hearing disturbances
-Headaches
6) Unstable upper cervical spine (unless active movements involve stabilization procedures)

What are absolute contraindications for passive movements such as mobilizations, stretching, and manually assisted movements?

1) Malignancy of the targeted physiological region
2) Cauda equina lesions producing disturbance of bowel or bladder
3) Red flags including signs of neoplasm, fracture, or systemic disturbance
4) Rheumatoid collagen necrosis
5) Coronary artery dysfunction (unless active movements involve stabilization procedures) with signs including:
-Drop attacks, blackouts, loss of consciousness
-Nausea, vomiting, and general lack of wellness
-Dizziness or vertigo
-Disturbance of vision including diplopia
-Unsteadiness of gait and general feelings of weakness (intermittent)
-Tingling or numbness (especially dysaesthesia, hemianaesthesia, or facial sensation)

What are relative contraindications for passive movements such as mobilizations, stretching, and manually assisted movements?

1) Active, acute inflammatory conditions
2) Significant segmental stiffness
3) Systematic diseases
4) Neurological deterioration
5) Irritability
6) Osteoporosis (depending on the intent and direction of movement)
7) Condition is worsening with present treatment
8) Acute nerve root irritation (radiculopathy) when:
-When subjective and objective symptoms don't add up
-Any patient condition (handled well) that is worsening
-Use of oral contraceptives (if cervical spine)
-Long-term oral corticosteroid use (if cervical spine)
9) Immediately postpartum (if noncervical spine)
10) Blood clotting disorder

What are absolute contraindications to manipulation?

1) Malignancy of the targeted physiological region
2) Cauda equina lesions producing disturbance of bowel or bladder
3) Red flags including signs of neoplasm, fracture, or systemic disturbance
4) Rheumatoid collagen necrosis
5) Coronary artery dysfunction
6) unstable cervical spine
7) Practitioner lack of ability
8) Spondylolisthesis
9) Gross foraminal encroachment
10) Children/teenagers
11) Pregnancy
12) Fusions
13) Psychogenic disorders
14) Immediately postpartum

What is the difference between active movements and passive movements?

Active movements include all motions performed exclusively by the patient.

Passive movements include all motions performed by the clinician and may be physiological, accessory, or combined.