1.4 Manual Therapy – Flashcards
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T/F: manual therapy can be included in the objective part of an exam and used in assessment and treatment of a patient as well
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true
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Define Manual Therapy (3 purposes)
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skilled hand movements to mobilize soft tissue and joints for the purpose of: -pain modulation -inc in ROM -dec in soft tissue inflammation
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Define mobilization/manipulation (general):
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manual therapy techniques comprised of skilled passive movements to joint that are applied at varying speed and amplitudes
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Define mobilization (specific):
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a passive movement technique performed by an operator in a manner that is at all times *within the ability of the patient to prevent the movement*
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Define manipulation (specific):
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a passive movement technique performed at the limit of the available passive range at a *speed that is beyond patient control*
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Define thrust manipulation:
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*high velocity, low amplitude* therapeutic movements applied within or at the end range of motion
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REVIEW OF TERMS (read)
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velocity = speed amplitude = distance thrust = force
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What are examples of mobilization techniques?
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Passive physiological movement (PPM) Passive accessory movement (PAM)/joint play
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Osteokinematics is associated more with ________ (PAM/PPM) whereas arthrokinematics is more associated with _______ (PAM/PPM)
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PPM - osteo PAM - arthro
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Describe PPM:
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-movement of bones -movement you see -voluntary
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Describe PAM:
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-movement of joint -movement you feel -involuntary
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Manual therapy techniques involve what joint kinematic motions?
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glide and distraction (roll and spin are accessory movements and are considered part of joint play)
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What are some characteristics that create variability in joint play?
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-person to person -joint to joint -w/in same joint depending on ROM available (close and loose packed) -trauma, muscle tension, pain, laxity, inflammation etc.
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Limitation in motion can be due to either osteokinematics or athrokinematics. What is the #1 reason why each would limit motion?
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osteo: *muscle strength* main cause of limited motion (may also be joint capsule or ligaments) arhtro: *ligaments* main cause of limited motion (may also be joint congruency or integrity of cartilage/menisci)
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Summary of difference b/w chiropractic and PT manipulation techniques (read):
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-PT philosophy is different (why we perform it) -chiropractors perform more often, PTs perform only when needed -techniques are different (PT use min force, chiro use max force)
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Why do PTs perform manipulation when chiropractors are more skilled in this?
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it is within our scope of practice, because we are educated on it and are knowledgeable about when it is/isn't useful it would be unethical if we determined it beneficial for a patient and didn't use it
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T/F: every state in the US allows for PTs to use manipulation as part of our treatment plan
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*False* (WA, AR, WV do not allow performance of manipulation by PTs) *it is important to know your state practice act for legal purposes*
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Is there evidence to support the use of manual therapy in PT practice?
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"Manual therapy is beneficial for certain people (only) when performed with exercises"
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What are 3 possible mechanisms which explain the effectiveness of manual therapy?
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-neurophysiological/chemical -mechanical -psychological/placebo (don't underestimate)
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What is the neurophysiological/chemical explanation for the effectiveness of manual therapy? (4)
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-descending pain inhibitory system -endogenous opioid release -gate control theory -change in reflex excitability
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What is the mechanical explanation for the effectiveness of manual therapy?
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-free up entrapped/torn meniscoid -mechanical disruption to intra-articular adhesions -stretching of joint capsule (mechanical effect difficult to prove)
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T/F: the placebo effect plays a large part in the effectiveness of manual therapy
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true "take advantage of the placebo effect" -could be beneficial in finding a window to dec pain and perform exercise
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What are categories of absolute contraindications of manual therapy?
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-malignancy -neurological -vascular -bone diseases -inflammatory conditions -infections -acute symptomatic disc herniation -*undiagnosed pain*
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What are the neurological contraindications for manual therapy?
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-cauda equina syndrome -spinal cord compression -motor nerve root compression
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What are the vascular (& skin) contraindications for manual therapy?
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-vertebral artery insufficiency -hemophilia -hx of anticoagulant therapy -acute infection -open wound
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What are the bone pathologies that are listed as contraindications for manual therapy?
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-fracture -spondylolisthesis (could be precaution) -foraminal encroachment
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What inflammatory conditions are a contraindication for manual therapy?
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-RA (could be precaution) -active inflammation -ankylosing spondylitis
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What are relative contraindications for manual therapy? (12) (use clinical judgement to decide)
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-RA -osteoporosis -spondylolisthesis -gross degenerative changes -hypermobility/instability -pregnancy -previous malignancy -acute trauma -protective spasm -psychological pain -severe nerve root pain -steroid or anticoagulant
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What are contraindications/precautions for peripheral joint manipulation?
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-recent trauma -ligament injury -immediate post op -empty end-feel or muscle spasm -acute inflammation
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What are indications for manual therapy?
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-mild or moderate neuromusculoskeletal pain -joint hypomobility -a non-irritable, mild/moderate irritable condition -remodeling stage of recovery (subacute) -acute spinal pain w/o neurological symptoms
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What are the 2 grading scales for distractions? What type of motion is involved with each?
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Kalternborn - static hold Maitland - oscillatory motion
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What grading system is used for accessory glides?
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maitland (oscillatory)
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accessory glides can be performed parallel or _________ to joint surfaces
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perpindicular
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In the Kaltenborn distraction grading system, what does a grade 1 distraction accomplish? (3) Which patient population is this beneficial for?
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-unloads and decompresses joint surfaces -neutralizes pressure in joint *w/o actual surface separation* -produces pain relief by reducing compressive forces Grade 1 = loosen -used with *acute conditions* for pain relief
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In the Kaltenborn distraction grading system, what does a grade 2 distraction accomplish? (4)
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-*separation* of joint surfaces -eliminates play w/in joint capsule -used initially to determine joint sensitivity -pain relief Grade 2 = tighten/take up slack
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In the Kaltenborn distraction grading system, what does a grade 3 distraction accomplish? (3) What patient population can this be beneficial for?
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-joint capsule and ligament stretch -increases mobility in hypomobile joint -can be used w/ joint mobilization for hypomobile joints Grade 3 = stretch -beneficial for patients with chronic conditions (assessing flexibility of joint capsules and ligaments)
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The maitland grading system is graded based on _________ of movement and ________ application at a specific point in range
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amplitude of movement force application
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How many grades are there in the Maitland grading system?
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5 1-4 = oscillatory 5 = non-oscillatory
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T/F: the Maitland grades are progressive as you move from 1-5 and are in continuum
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false
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T/F: the Maitland grades will fall in the same place of a patient's available ROM whether they have a pathology or not
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false, the grades will change where they fall in the patient's available ROM, (shorter ROM based on the abnormal restriction)
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In the Maitland grading system, where does grade 1 fall within the available ROM? Large or small amplitude?
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first 25% small amplitude (in resistance free range)
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In the Maitland grading system, where does grade 2 fall within the available ROM? Large or small amplitude?
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middle 50% large amplitide (in resistance free range)
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In the Maitland grading system, what are grades 1 and 2 used for? What type of effect do they have?
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used for pain control have a neurophysiological effect
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In the Maitland grading system, where does grade 3 fall within the available ROM? Large or small amplitude?
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last 50% large amplitude (up to or into resistance)
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In the Maitland grading system, where does grade 4 fall within the available ROM? Large or small amplitude?
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last 25% small amplitude (into resistance)
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In the Maitland grading system, what are grades 3 and 4 used for? What effect do they have?
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-used for treatment of joint restriction and pain -have neurophysiological and mechanical effects -selectively activates muscle and joint mechanoreceptors
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Describe a grade 5 Maitland manipulation
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-high velocity -low amplitude -thrust movement to the limit of available or mid-range
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What is a grade 5 Maitland manipulation used for? What effects does it have?
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-used for pain control (spinal) and restoration of joint mobility -decreases pain, restores joint motion, breaks adhesions and remove loose bodies -has neurophysiological, mechanical, and placebo effects
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What might help determine if you need to use manipulation over mobilization technique?
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when progress plateaus or symptoms do not improve with the use of mobilization
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For grades 1-5 for the Maitland system, which are used for assessment or treatment?
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Grades 1-4: -assessment and treatment Grade 5: -treatment only
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T/F: Manipulation techniques are more effective than mobilization techniques
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False, there is nothing saying that one is more effective than the other necessarily, but depending on the patient's characteristics one may be more/less indicated than another
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What information can be gathered as part of the subjective exam that may help determine if a patient will benefit from manual therapy?
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*age* -bone maturity level, bone density, pain sensation etc. *psychological status* *special questions* -contraindications *SINS* -has manual therapy worked/not worked in the past? Did they have a good experience? *History*
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What information can be gathered in the objective exam that may help determine if a patient will benefit from manual therapy?
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*AROM* *PROM* -overpressure and end feel *CPR* -present/absent? *joint integrity/mobility* -accessory glides (and joint distraction?) *# of joints involved* *neurological findings*
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When assessing joint glides as part of the objective exam, what are 3 possible results you could have, and what does each indicate?
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*un-restricted* -motion limitation due to contractile tissues *excessive* -ligament or severe degeneration of joint surfaces *restricted* -joint restriction or limited by connective tissues
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Which type of accessory joint glide provides an indication for the use of manual therapy as part of a patient's POC?
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restricted accessory glide
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When assessing joint distraction during an objective exam, what are the possible results you could have and what does each indicate?
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*Pain w/ traction* -connective tissue tear (decrease pain with compression) *Restricted motion w/ traction* -connective tissue restriction *Relief of pain w/ traction* -joint surface problem (pain inc w/ compression = articular surface pathology)
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T/F: joint mobility is easy to assess
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false difficult to assess, graded in milimeters by "end feel" -poor intra/intertester reliability -MUST compare to un-involved side
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T/F: as part of your objective exam in determining if you should use MT, you should assess grades 1-4 of Maitland
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true
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What should you include in documentation of your assessment of Maitland grades 1-4?
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Quantity and quality of motion -normal -limited or stiff -hyper/hypomobile Reproduction of symptoms -inc or dec pain -muscle spasms present/absent
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What should be considered in the assessment of a patient to determine if manual therapy may be used as part of the treatment plan?
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-knowledge of joint surfaces and biomechanics -irritability of symptoms -working hypothesis -focus of treatment (pain and/or resistance)
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Which mobilization technique(s) should you utilize in a patient's treatment if pain control is your main priority? *know this*
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Maitland oscillation *grade 1 and 2* (1-2 bouts of 20-30 secs) Kaltenborn distraction *grade 1 and 2* (1-2 bouts of 10-20 sec static hold) *Grade 5* manipulation (spinal pain)
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With pain control as your focus in treatment, you should chose a least painful technique with _____ (high/low) speed, and a _________ (shorter/longer) treatment
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low speed shorter treatment
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Which mobilization technique(s) should you utilize in a patient's treatment if resistance is your main focus?
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Maitland oscillation *grade 3 and 4* (3-5 bouts of 45-60 sec) Kaltenborn distraction *grade 3* (3-5 bouts, 30-60 sec) *Grade 5* manipulation
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With resistance as your focus in treatment, you may start mobilization with more _______ of range techniques, or _________ (inc/dec) vigor as patient tolerates. You also want a ________ (shorter/longer) treatment
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end range increase vigor longer
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What manual therapy technique might you utilize for a muscle restriction?
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muscle stretching hold/relax
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What manual therapy techniques might you utilize for a joint restriction?
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manipulation grade 3 or 4 mob PPM
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What manual therapy techniques might you utilize for capsular restriction?
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*grade 4 mob* *prolonged stretch* distraction w/ or w/o movement Note: if two *bold* are combined, patient irritability must be low
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What manual therapy techniques might you utilize for extreme hypomobility or pain through ROM?
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PPM distraction
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What are some mobilization treatment variables?
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-joint position -direction of technique -type of mobilization -intensity of mobilization
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For mobilization techniques, some approaches advocate preliminary _______ therapy or _________ therapy prior to using these techniques. Australian approach utilizes ______ to determine this
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soft tissue modality SINS(S)
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Examples of peripheral joint and spinal joint manipulation techniques (read)
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Peripheral: cuboid whip ankle - TCJ Hip Wrist MCP Spinal: -SIJ -Lumbar Thoracic (No cervical)
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Remember to include appropriate ________ program following manual therapy
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exercise
