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MSM Ch 11

DPT 757 ch 11

If a joint surface is convex what is the direction of the glide? glide occurs in the direction opposite to osteokinematic motion.
If a joint surface is concave, what direction is the glide? glide occurs in the same direction as the osteokinematic motion.
What are the Correct Application of Manual Therapy Techniques Knowledge of jt surfaces (convex-concave)Duration, type and irritability of sxsPatient and clinician position Position of jt to be treatedHand placementDirection of forceAmount of forceSpecificity (exactness of procedure)
Knowledge of jt surfaces (convex-concave) If the jt surface is convex; glide occurs in the direction opposite to osteokinematic motionIf the jt surface is concave; glide occurs in the same direction as osteokinematic motion
Position of jt to be treated Resting position (for the particular pt/injury; not classic/loose packed resting position) in acute condition or with inexperienced clinician
Hand placement Maximize contact areaGentle and confident
Specificity Exactness of procedure
Direction of force Direct-toward the motion barrier or restrictionIndirect-away from the motion barrier or restriction
Amount of force Depends on the intent of the procedure and Age, Sex, General health statusBarrier to motion and end-feel (stage of healing) Type and severity of movement disorder
Reinforcement of any gains made Gains from man ther techniques will be lost in 48 hours, if the motions gained are not reinforced.Therefore, motion gained must be reinforced by both the mechanical and neurophysiological benefits of active movement.
Indications for Manual Therapy 1. mild musculoskeletal pain2. nonirritable musculoskeletal condition, demonstrated by pain that is provoked by motion but that disappears very quickly-Intermittent musculoskeletal pain-Pain reported by the patient that is relieved by rest
Pain reported by the pt that is relieved or provoked by particular motions or positions Indication for Manual Therapy
Pain that is altered by changes related to sitting or standing posture Indication for Manual Therapy
Kisner and Colby Indications for Jt Mobilizations 1. Pain, muscle guarding and spasm2. Reversible jt hypomobility3. Positional fault/subluxation4. Progressive limitation5. Functional immobility
1. Pain, muscle guarding and spasmA. Neurophysiology Effects Small oscillatory movements or distraction inhibit transmission of nociceptive stimuli
1. Pain, muscle guarding and spasmB. Mechanical Effects Small amplitude distraction or glides cause synovial fluid motion which brings nutrients to the avascular portion of cartilagePrevents painful and degenerative effects of stasis when a jt is swollen and painful and can’t move through ROM
Indications for Jt Mobilizations: 2. reversible jt hypomobility Progressively vigorous jt play stretching tecniques to elongate hypomobile capsular and ligamentous CT
Jt Mobilizations: 3. positional fault/subluxations Malposition of one bony partner with respect to the other may result in limited motion or painCan occur with traumatic injury, after periods of immobility, or with m. imbalancesattempt to realign jt surfaces while pt actively moves through the motion—
Absolute Contraindications to Manual Therapy Bacterial infectionmalignancysystemic localized infectionsutures over the treatment siterecent fxcellulitisfebrile statehematomaacute circulatory condition
More Absolute Contraindications to Manual Therapy an open wound to the tx siteosteomyelitisadvanced diabeteshypersensitivity of the skininappropriate EF (spasm, empty, bony)constant severe pain incluidng pain that disturbes sleep (indicates acut condition/cancer)extensive radiating pain
More, more Absolute Contraindications to Manual Therapy pain unrelieved by rest (cancer)severe irrritability (pain that is easily provoked and that does not go away within a few hours)
RELATIVE Absolute Contraindications to Manual Therapy joint effusion or inflammationrheumatoid arthritispresence of neurological signsosteoporosishypermobilitypregnancy, if a tech is applied to spinedizzinesssteroid or anticoagulant therapy
Contraindications and Precautions of Jt Mobilization Techniques (Kisner/Colby) 1. Hypermobility2. Joint Effusion3. Inflammation
Contraindications of jt mobilization1. Hypermobility Jts with potential necrosis of ligaments/capsule should not be stetchedPainful hypermobile jts may benefit from gentle jt-play techniques if within jt limitations (no stretching)
Contraindications of jt mobilization2. Joint Effusion Do not stretch a swollen jt with mob or passive stretch techniques; the capsule is already on stretch by being distended to accommodate the extra fluid. The limitation in motion is from the extra fluid and response to pain; not from shortened fibers.Gen
Contraindications of jt mobilization3. Infalmmation Stretching will increase pain and guarding resulting in greater m. damageGentle osillation/distraction movements will temporarily inhibit pain response
PRECAUTIONS for stretching (jt mobs are safer) malignancybone disease detectable on radiographsUnhealed fxExcessive painHypermobility in associated jts (must have appropriate stabilization of hypermobile jt)Total jt replacements (mobilization techniques may be inappropriate)
Newly formed or weakened connective tissue (immediately after surgery, injury, disuse, corticosteroids)Systemic connective tissue diseasesElderly with weakened connective tissue and diminished circulation PRECAUTIONS for stretching (jt mobs are safer)
Soft Tissue TechniquesTransverse Friction Massage Developed by CyriaxRepeated cross grain massage to muscles, tendons, tendon sheaths, ligamentsIncreases mobility and extensibility of soft tissue structures
Soft Tissue TechniquesTransverse Friction MassageIndications: Acute or subacute ligament, tendon, or muscle injuriesChronically inflamed bursaAdhesions in ligament or m. or between tissuesPrior to manipulation or strong stretch to desensitize area
Soft Tissue Techniques Transverse Friction MassageContraindications: Acute inflammationHematomaDebilitated or open skinPeripheral nervesAreas of diminished sensation
Soft Tissue TechniquesTransverse Friction Massage Therapeutic effects: Traumatic hyperemiaPain reliefDecreasing scar tissue
TFM Traumatic hyperemia: Increases flow of blood and lymph which removes chemical irritant by-products of inflammation
TFM Pain relief: Stimulates type I and II mechanoreceptors (pre-synaptic anaesthesia)However, if too aggressive in acute stage , the stimulation of nociceptors will override the benefit of mechanoreceptors (pain increase)
TFM Decreasing scar tissue: Following a ligament sprain, Cyriax recommends immediate use of TFM to prevent adhesion formation between tissue and its neighbor
TFM technique Begin with light pressureUse reinforced finger (middle finger over index) or thumbMove the skin over the identified lesion back and forth in a direction perpendicular to fiber orientationRate should be at 2-3 cycles/second(usually 3-5 min)
How to you know if TFM is working? Conditions that improve with TFM should do so in 6-10 sessions over 2-8 weeksShould choose alternate technique, if no benefit in 3 sessions
Augmented Soft Tissue Mobilization (ASTM) Deep massage that uses specific hand held devices to assist in the mobilization of poorly organized scar tissue in and around muscles, tendons, myofascial planesLongitudinal strokes are applied parallel to the fiber alignment Immed bruising typical
What follows an ASTM treatment? the tissue undergoes a stretching/strengthening program to maintain flexibility and reestablish m. balance around the area that is being treated tissue matrixICE 5-10 min
Myofascial Release (MFR) Theory: Releases restrictions in myofascial tissueTrauma or structural abnormalities may create innappropriate fascial strainThese strains cause slow tightening of the fascia; causes body to loses adaptive properties
MFR Purpose Provide gentle sustained pressure to release fascial restrictions and restore normal pain-free functionNot unusual for pt to experience soreness afterwardBenefits are mostly anecdotal.
MFR Techniques J strokeVertical StrokeTransverse StrokeCross-Hands Technique
Soft Tissue Mobilization (STM)CONCEPT: tissue restrictions occur at different layers ranging from superficial to deepTreat superficial layers prior to deep layersForce is applied in the direction of maximal restrictionconsider discomfort irritability
Soft Tissue Mobilization (STM)TechniquesSustained Pressure Technique is applied to the center of restricted tissue at the exact depth, direction and angle of maximal restriction
STM Techniques- Sustained PressureModifications Clockwise/counter-clockwise movements (while sustaining pressure)Perpendicular/parallel movements while sustaining pressure
STM techniquesIschemic Compression Theory: ischemic compression deprives trigger point of oxygen; rendering them inactive and breaking the cycle of pain-spasm-painPressure is applied 8-12 seconds
STM techniquesGeneral Massage Definition: systemic therapeutic and functional stroking and kneading of the bodyStudies have shown that deep massage increases the circulation and skin temperature of the massaged areas due to dilation of capillaries
General Massage Techniques:Effleurage General stroking technique applied to muscles and soft tissues from distal to proximal to enhance relaxation and increase venous and lymphatic drainage
General Massage TechniquesStroking Applied superficially along the whole length of the surfacePrior to deeper techniques to enhance relaxation
General Massage TechniquesPetrissage Describes a group of techniques that involves compression of soft tissue structuresInclude, kneading, wringing, rolling, picking up techniques
Purpose of petrissage: to release areas of m. fibrosis and “milk” the muscles of waste products that collect from trauma or abnormal inactivity
How to Effleurage: Use the palm of the hand, firm contact, at end of stroke lift the hands and replace them at starting position
General Massage TechniquesStrumming Perpendicular strumming involves the application of repeated, rhthymic deformations of a m. belly
STM techniquesAcupressure Manual pressure over the acupuncture points of the body
STM techniques AcupressureWestern scientific research has proposed the following mechanisms for the effect of acupressure in relieving pain The gate control theory of painDiffuse noxious inhibitory control-noxious stimulation modulates the pain sensationStimulation of production of endorphins, serotonin and acetylcholine (which enhances analgesia)
Soft Tissue Techniques: MUSCLE ENERGY Combine the precision of passive mobilization with the effectiveness, safety and specificity of reeducation therapies and therapeutic exerciseRequire the active participation of patientUtilize muscular facilitation and inhibition
Soft Tissue Techniques: MUSCLE ENERGYUses- Mobilize jtsStrengthen weakened musclesStretch adaptively shortened mm. and fascia Most effective in acute or subacute stages of healing
Soft tissue techniques Muscle EnergyLewit’s Postisometric Relaxation Effect of subsequent reduction in tone experienced by a m./group off mm. after an isometric contraction
Soft tissue techniques Muscle EnergyJanda’s Postfacilitation Stretch Hypertonic m. is placed midrangePt performs isometric contraction at maximum effort and holds 5-10 secondsPT resists movement completelyWhen the pt relaxes, the PT applies a rapid stretch to the muscle and holds for at least 10 seconds
Soft tissue techniques Muscle EnergyReciprocal inhibition acute and subacute stages of healinginvolved m. is placed in midrange pos, pt contracts toward restriction barrier, DPT completely resist motion [] held 5-8 sec, pt relax then PT passively lengthens
Soft tissue techniques Muscle EnergyStrengthening IsometricConcentricEccentricIsolytic
Soft tissue techniques Muscle EnergyStrengthening: Isometric Equal resistance so that no motion occursContraction is held 30-60 seconds to increase the tone and strength of the m. or m. group
Soft tissue techniques Muscle EnergyStrengthening: Concentric PT applies resistance so that it is less than that of the pt, so that the pt moves the jt is the desired direction and through the desired range at a speed controlled by the PT Repeated 5 times
Soft tissue techniques Muscle EnergyStrengthening: Eccentric The DPT provides resistance to jt motion that is greater than that of the pt.the pt is unable to move the jt in the desired direction, but also unable to fully resist the DPT.the jt moves in the opposite direction of the desired movement.x5 times
Soft tissue techniques Muscle EnergyStrengthening: Concentric PURPOSE: Purpose is to increase concentric strength of agonist m. and relaxation of the antagonists
Soft tissue techniques Muscle EnergyStrengthening: Eccentric PURPOSE: : increase eccentric strength and length of agonist m.
Soft tissue techniques Muscle EnergyStrengthening: Isolystic Involves the use of a contraction bythe PT to overcome the resistance of the pt’s contraction (an isotonic eccentric contraction) in order to stretch/break down fibrotic tissueCan be uncomfortable for the ptNot to be used in the acute/subacute phase
Soft Tissue Techniques: Strain Counterstrain (positional Release) Myofascial tender points are located and then monitored while a position of comfort is established to evoke a therapeutic effectAlso thought to improve blood flow to the area through a circulatory flushing of previously ischemic tissues
Soft Tissue Techniques: Strain Counterstrain (positional Release)For extremities: , the body part is placed in a position of relaxationThis position of ease, which involves a shortening or folding of the tissues around the myofascial tender point, usually corresponds to the point of maximum relaxation
Soft Tissue Techniques: Strain Counterstrain (positional Release) how long do you hold? Hold the position of ease for 90-120 seconds before pt slowly returns to the normal positionOnce the tender point has been removed, need to lengthen and strengthen the involved m.
Soft Tissue TechniquesFunctional Techniques Indirect techniquesUse positional placement away from the restrictive barrierFocus is on moving the jt being treated away from the restrictive barrier
Soft Tissue TechniquesFunctional Techniques Theory: there is a dynamic balance point located between the restrictive barrier and the opposite physiologic barrier this is the point where the tensions in the soft tissues around the jt become balanced equally in all 3 planes
Soft Tissue TechniquesFunctional Techniques Theory- what occurs when balance is achieved? When this balance is achieved; the clinician feels a sense of “ease” in under his/her palpating fingers If motion in any plane is initiated away form the dynamic balance point, increased sense of tension
Soft Tissue TechniquesFunctional Techniques Theory- why it works medically The afferent input from the proprioceptors is inhibited, which suppresses the local protective cord reflexes The techniques stimulate the mechnaoreceptors sufficiently to inhibit the pain receptors, allowing the tissues to relax
Soft Tissue Techniques (functional techniques)Once correct position is assumed; 2 intervention options Active-The clinician initiates movement along the path of least resistance until the restrictive barrier is no longer detectable and normal motion is regainedPassive-clinician follows the articular unwinding
Soft Tissue TechniquesCraniosacral Therapy "VOODoo" Based on the assumption that cranial bone movement occurs through a respiratory mechanism comprising the brain, CSF, intracranial and instraspinal membranes, cranial bones, spinal cord and sacrum
Joint Mobilizations Low to high velocity passive mov within or at the limit of jt range of motion, to restore any loss of accessory jt motion as the consequence of jt injuryMob techniques that utilize accessory motions and distractions are used primarily on inert tissues
Joint Mobilizations: what tissues? applied in which directions Physiologic movements are used to mobilize both contractile and noncontractile tissuesJt mobs are applied in a direction that is either perpendicular or parallel to the treatment plane
Joint Mobilizations- Benefits Restore physiologic articular relationship within the jointDecrease painDecrease m. guardingLengthen tissues around a jtIncreased proprioceptive awareness
3 types of mobs Active-pt exerts a forcePassive-clinician exerts a forceCombined-pt and clinician work together
Joint Mobilizations: Methods Direct-engagement is made against a barrier in several different planesIndirect-disengagement from the barrier occurs and a balance of ligamentous tension is soughtCombined-disengagement is followed by direct retracing of the motion
Joint Mobilizations: Kaltenborn Techniques Slack-amount of jt playPlane of motion-imaginary line lying across the joint surfacesall jt mobilizations should be parallel or perpendicular to plane of motionCombination of traction and mobilization to reduce pain and mobilize hypomobile joints
Joint Mobilizations Kaltenborn3 grades of traction Grade I-piccolo (loosen)Grade II-slack (take up the slack)Grade III-stretch
Grade I-piccolo (loosen) Traction force that neutralized pressure in the jt, without actually producing separation of the jt surfacesReduces compressive forces on the articular surfaces
Grade II-slack (take up the slack) Separates the articular surfaces and eliminates the play in the jt capsule
Grade III-stretch Actually stretches the jt capsule and soft tissue surrounding the jt to increase mobilityGrade III traction is used along with mobilization glides to treat hypomobility in the remodeling stages of healing
Joint MobilizationsAustralian Techniques primarily introduced by MaitlandROM is defined as available range (not full range)Point of limitation-short of the anatomic limit and reduced by pain and/or tissue resistance
Joint Mobilizations (Australian Techniques)Grades I and II Grades I, II are solely for pain relief; no direct mechanical effect on the restricting barrierEffective in pain relief by improving jt lubrication and circulation of tissue surrounding jt
Joint Mobilizations (Australian Techniques)Grades III and IV Grades III, IVStretch the barrier and have a mechanical as well as neurophysiologic effectMay activate inhibitory joint and m. spindle receptors which aid in reducing restriction to movement Jt to be mob is first in the open packed position
Jt. Mobilizations (Australian Techniques)Convex If the jt surface is convex relative to the other surface, the slide occurs in the opposite direction of bone movement (angular motion).
Jt. Mobilizations (Australian Techniques)Concave If the jt surface is concave, the slide occurs in the same direction as bone movement (angular motion)
Jt. Mobilizations (Australian Techniques)POSITION OF JT The position of the jt to be treated must be appropriate for the stage of healing and the skill of the clinicianStart in the resting positionMay be progressed to other positions in non-acute stages and if clinician is experienced
Jt. Mobilizations (Australian Techniques)STABILIZATION OF JT One half of the jt should be stabilized; the other half should be mob; both mob and stab hands should be as close to the jt line as possible. Should make max contact with the patient to spread out forces.
Jt. Mobilizations (Australian Techniques)DIRECTION OF MOB direction of the mob is almost always parallel or perpendicular to a tangent across the jt surface and is appropriate for the arthrokinematics of the jt surface being treatedThe mob shouldn't move into or through the point of pain.
Jt. Mobilizations (Australian Techniques)When should intervention be discontinued? intervention should be discontinued for the day when a large improvement has been obtained or when the improvement ceasesM. Reeducation is essential after mobilization or high-velocity thrust techniques; results in reduced post-treatment soreness.
Joint MobilizationsMobilizations with Movements (MWM)Mulligan Combine a sustained manual gliding force to a joint with concurrent physiologic motion of the joint, either actively performed by the patient, or passively performed by the clinicianIntent is to reposition “so-called” bony positional faults
Jt Mobilizations, MWMDescribe glide The glide is performed parallel to the plane (there are a few exceptions) of motion and sustained throughout motion until jt returns to its starting position
Jt Mobilizations, MWMMulligan's guidlines when treating hinge jts The patient is placed in WBPWhen treating hinge jts; the sustained glide should be at right angles to the glide that usually occurs with movement.
Jt Mobilizations, MWMMulligan's guidlines when treating long bones When jt movements involve adjacent long bones, it is often necessary for the clinician to adjust the relative positions of the long bones to enable pain-free jt movement to occur
Jt Mobilizations, MWMMulligan's guidlines pt is placed in WBPThe glide-mobilization is always successful in one direction only. It is applied 10 times before re-assessing joint motion. Overpressure should be applied at the end range of the available AROM
High Velocity Thrust Techniques The jt is briefly forced beyond restricted ROM (whereas jt mobs are applied within or at the physiological range)Technique: first find the restriction through the end-feel, engage the barrier, and then apply the thrust
High Velocity Thrust TechniquesLong lever techniques— exert forces on a body at some distance from the jt being treated
High Velocity Thrust TechniquesShort lever techniques— forces directed specifically at an isolated jt
High Velocity Thrust Techniques Cavitations Clicking or popping soundsThought to be due to release of synovial gasThe gas is reabsorbed by the jt for about 30 minTherefore, jt can only be “re-cracked” every 20-30 min
Goal of High Velocity Thrust Techniques Is NOT to produce cavitationIs to produce a temporary hypermobility that restores normal jt play
High Velocity Thrust TechniquesHarmful effects may occur with excessive force or failure to localize a force. Possible harmful effects include: FRACTURESPINAL CORD COMPRESSIONVERTEBRAL A. COMPROMISECEREBRAL ISCHEMIADEATHThrust techniques increase jt motion and therefore negate the effects of jt adhesions, soft tissue contracture and degenerative joint disease
Neurophysiologic Techniques 1. PNF2. Myofascial Trigger Point Therapy
Neurophysiologic Techniques1. PNF *Contract relax/Hold relaxManual contactSlow reversal hold relaxtraction
PNF theory Theory is that the m. system is a diagonal and spiral arrangement and that when mm. contract in proper sequence, the stressed m. group overcomes the demand made on it with optimal effectiveness Promotes motor learning in synergistic m. patterns
Neurphysiologic Techniques, PNFTwo fundamental neurophysiological principles 1. Postcontraction inhibition—after a muscle contracts, it automatically relaxes for a brief latent period2. Reciprocal Inhibition—when one m. is contracted, its antagonist is automatically inhibited
Neurophysiologic Techniques 2. Myofascial Trigger Point Therapy Myofascial trigger points-tender areasGoals-relieve pain and tightness of the involved mm, improve jt motion, improve circulation, and eliminate perpetuating factors
Neurophysiologic Techniques, Myofascial Trigger Point TherapyTECHNIQUES: Stretch and spray or stretch and iceM. strippingMassage therapyMyofasical releaseIschemic compressionStretchingJt mobilizations
Neurophysiologic Techniques, Myofascial Trigger Point Therapy:NONMANUAL INTERVENTIONS: ThermotherapyCryotherapyTrigger point injectionsElimination of causative or perpetuating factors, if anyBiofeedback and m. relaxationExerciseCombination therapy-ultrasound, trigger point injections, stretchingelectrotherapy
Created by: NicoleB