SP7058 Manual Therapy - Semester 2, Week 7 Notes

Session Plan

  • Recap of ascending pathway, gate control theory, descending pathway, and modulation.
  • Discussion of Maitland’s Philosophy.
  • The Biopsychosocial (BSP) model, subjective history, and communication.
  • Physiological Mobilisations: Elbow.
  • Accessory Mobilisations: Elbow.

Main Themes

  • Patient-centered approach: Focus on the individual's experience and needs.
  • Permeable brick wall concept: Understanding the layers of factors influencing a patient's condition.
  • Identifying and maximizing movement potential: Aiming to restore optimal movement.
  • Science and art of assessment: Combining evidence-based practice with clinical expertise.
  • Clinical reasoning is crucial; it's not just about treatment.
  • In-depth examination and assessment are vital.
  • Treatment decisions must consider the interaction between neural, muscular, and skeletal factors.
  • Psychosocial factors are important.
  • Reference: Hengeveld and Banks (2014) - Maitland Philosophy.

The Biopsychosocial (BPS) Model

  • Acknowledges that health conditions have biological origins but impact individuals physically, psychologically, and socially.
  • Long-term health conditions can't be treated solely through the biological medical model.
  • Bio: Pathology, disease, symptoms, science, treatments, doctors, tests.
  • Psycho: Depression, guilt, anxiety, tears.
  • Social: Hobbies, stress, family, isolation, money, identity, career, friends, burden.
  • Quote: "The medical support keeps me alive, but it is the psychological and social support that enables me to live."

Therapeutic Alliance and Patient-Centered Care

  • Key Components:
    • Patient: Values, context, experience, preferences.
    • Clinician/Therapist: Evidence, clinical experience, therapeutic relationship (rapport, trust). Insight, honesty, persistence, motivated to change, empathy, genuineness, confidentiality, unconditional positive regard.
  • Interaction:
    • Conversation, deliberation, encounter.
    • Shared decision-making tools.
  • Research focus: Most research covers what we do, but less on how we do it.

Application to Subjective History

  • Important questions to ask:
    • How does the patient's perception and knowledge of their issue affect them and their behaviors? "What do you think is going on?"
    • How does the injury affect their work and family life? "What are you most worried about?"
    • What are their perceived implications for the future?
    • How confident are they to return to sport or activity?
    • How motivated are they to engage in rehab or treatment? "What do you want to get from/achieve during this treatment/session?"
  • Focus on the person, their engagement and embodiment in the world, not just breaking down pain 'drivers'.
  • Listen to and discuss their beliefs, understandings, and fears

Communication

  • O’Keeffe et al., 2016: Clients book appointments for a reason; they have something to tell you.
  • Pain can be a source of worry; enable patients to talk about it.

The 4 Rules of Effective Communication

  • Listening.
  • Understanding.
  • Open-ended questions/Socratic style.
  • The ability to remain silent.
  • Quote: "If you can’t communicate, it doesn't matter what you know" (Gardener 1982).
  • Communication unlocks all other tools a Sports Therapist possesses.

Understanding Works Both Ways

  • Clients need to understand you and the information you provide, just as you need to understand them and their story.
  • Avoid ambiguity, making sure to be clear and concise.
  • The Assumption Dilemma: Don’t assume others understand what you are talking about.
  • Consider the use of language, terminology, and the references you make.

Non-Specific Effects

  • Current evidence suggests successful outcomes in Manual Therapy (MT) depend on identifying individuals likely to respond, rather than identification of a specific injury (Bialosky et al., 2009).
  • Specific Effects: Peripheral, Spinal, and Supraspinal.
  • Nonspecific Effects: Placebo.

Nonspecific Mechanisms

  • Variables like placebo, expectation, and psychosocial factors are relevant in the mechanisms of MT (Bialosky et al., 2009; Bishop et al., 2015).
  • These variables influence the neurophysiological descending pathways and endocrine system.
  • MT may assist in acquiring a new painless memory by exposure to new and less threatening stimuli, removing aversive memories previously associated with that stimulus.
  • MT acts to desensitize the CNS both physically (through exposure to nonthreatening mechanical stimuli) and cognitive-emotionally (through patient education), helping to remove acquired aversive memories of pain (Zusman, 2004).

Placebo and Nocebo

  • Key factors influencing placebo and nocebo effects:
    • Therapist-patient relationship.
    • Treatment environment.
    • Desire, motivation.
    • Modulation of anxiety, somatic focus.
    • Personality traits and genetics.
    • Observational social learning.
    • Reward-learning.
    • Memory and prior experience.
    • Expectation.
    • Conscious conditioning.
    • Unconscious classical conditioning.

Strategies to Enhance Placebo in Physiotherapy (Testa & Rossettini, 2016)

  • Physiotherapist's and Patient's Features: Improve professionalism, reputation, training and expertise. Use a laboratory coat or tailored clothing. Be optimistic. Clear diagnosis, prognosis and explanation. Explore the patient's disease and illness. Encourage questions. Investigate expectation, preferences and the patient's previous experiences. Consider the phase of the musculoskeletal condition, gender and age of the patient.
  • Patient-Physiotherapist Relationship: Be warm, confident, friendly, relaxed and open during the clinical encounter. Use verbal expressions of empathy, support, sympathy and language reciprocity. Adopt psychosocial talk, partnership statements and paraphrase. Use positive messages associated with treatment for pain relief. Use eye contact, smiling, caring expressions of support and interest. Use affirmative head nodding, forward leaning and open body posture. Interpret patient's nonverbal body language expressions.
  • Treatment Features: Show and tell the patient that a therapy is applied. Boost the patient's willingness to talk to other patients who undergo the same treatment with positive results. Use patient-centred care, personalize the treatment. Deliver the treatment by the same physiotherapist in a clean and private environment. Set appointments with adequate length, punctuality, frequency, follow-up. Use touch to assist, prepare, inform, care of, perceive and treat patients.
  • Healthcare Setting Features: Combine positive distractors as light, music, temperature and aromas. Adopt supportive indications to facilitate access to physiotherapy service. Decorate the therapeutic environment with artworks and ornaments.

Beliefs and Attitudes – Psychosocial Factors

  • Patient expectations of MT are formed by their social environment, knowledge, and previous experience.
  • A treatment technique is perceived as positive if its characteristics align with the individual’s understanding and if care is delivered in an informative and reassuring manner.

Manual Therapy Effects

  • Shared error.

  • Nonspecific effects.

  • Specific treatment effect.

  • Natural history.

  • We give too much credit to specific effects (mechanisms). They likely change outcomes the least.

  • Non-Specific mechanisms are called Common Factors. They are likely more powerful than specific effects.

  • Most Musculoskeletal Disorders have a Favorable Natural History. In many cases, their recovery Occurs Naturally. Most tend to get better with No intervention.

Addressing Limitations of Patient-Reported Outcome Measures

  • Chad E. Cook, PT, PHD, FAPTA; Marco Barbero, PT PHO; Alexis Wright PE PO Jocelyn Wittstein, MO; Yannick Tousignant-Laflamme, PL PRO
  • Five Recommendations to Address the Limitations of Patient-Reported Outcome Measures

Objective Markers

  • Important to gain an objective marker PRIOR to treatment.
  • REMEMBER to RETEST the OM post treatment – was your treatment effective?
  • Objective Markers:
    • Pain = VAS
    • Range = RoM

Accessory Mobilisations: Elbow

Passive Physiological Mobilisations at the Elbow

  • Elbow:
    • Flexion.
    • Extension.
    • Pronation.
    • Supination.

Passive Accessory Mobilisations at the Elbow Joint

  • Movement:
    • Elbow – HUJ/ HRJ: Caudad.
    • Elbow - SRUJ: AP (Pronation), PA (Supination).

Elbow Articulations

  • 3 articulations:
    • 1- Humero-ulna Joint (HUJ) (Trochlea of Humerus & Trochlear Notch of Ulna – flexion/ extension).
    • 2 - Humero-radial Joint (HRJ) (Antero-inferior surface of Capitulum & Head of Radius – flexion/ extension) – Often not considered a “true” joint.
    • 3 - Superior Radio-Ulna Joint (SRUJ) (head of the radius & radial notch of ulna – pronation/ supination).

HUJ/ HRJ: Passive Accessory Mobilisations

  • CCR: Trochlea of Humerus is convex & the Trochlear Notch of Ulna is concave.
  • Direction: Caudad (a distraction of the proximal radius and ulna from the distal humerus) – Flexion/ Extension.

SRUJ: Passive Accessory Mobilisations

  • CCR: head of the radius is circular/ convex & the radial notch of ulna is concave.
  • Direction: AP – Pronation, PA – Supination.

Physiological Mobilisations: Wrist

Passive Physiological Mobilisations at the Wrist

  • Wrist:
    • Flexion
    • Extension
    • Radial Deviation
    • Ulnar Deviation

Accessory Mobilisations: Wrist

Passive Accessory Mobilisations at the Wrist Joint

  • Movement - Wrist:
    • RCJ : AP (Flexion), PA (Extension), LG (Ulnar Deviation), MG (Radial Deviation) + Distraction
    • IRUJ: AP (Supination), PA (Pronation)

RCJ : Passive Accessory Mobilisations

  • CCR: The proximal row of carpals (together) are convex, the distal end of the radius is concave.
  • Direction: AP (Flexion), PA (Extension), Lateral Glide (Ulnar Deviation), Medial Glide (Radial Deviation) + Distraction

IRUJ : Passive Accessory Mobilisations

  • CCR: The distal head of the ulna is convex, and the ulnar notch of the radius is concave.
  • Direction: AP (Supination), PA (Pronation)