Transcript Manual Therapy

Orthopedic Manual
Therapy
An Introduction to Joint Mobilizations
Brenna M. Barzenick, P.T.
Manual Therapy
Definition:
A clinical approach utilizing skilled, specific hands-on techniques,
including but not limited to manipulation/mobilization, used by the
clinician to diagnose and treat soft tissues and joint structures for the
purpose of modulating pain; increasing range of motion (ROM);
reducing or eliminating soft tissue inflammation; inducing relaxation;
improving contractile and non-contractile tissue repair, extensibility,
and/or stability; facilitating movement; and improving function.
1,2 (Definition from American Academy of Orthopedic Manual Physical Therapy
(AAOMPT) and American Physical Therapy Association (APTA).
Types of Manual Therapy
•
Joint Mobilization/Manipulation*
•
MET (Muscle Energy Techniques)
•
Soft Tissue Mobilization/Myofascial Release
Muscle Energy Techniques
(MET)
•
Defined as a "direct manipulative procedure that uses a voluntary contraction
of the patient's muscles against a distinctly controlled counterforce from a
precise position and in a specific direction.”
•
MET is an active technique compared to a passive technique where only the
clinician does the work.
•
In contrast to joint mobilization, this technique engages the joint restriction
barrier but does not stress it.
•
MET may also be used to lengthen shortened muscles, reduce localized
edema, and mobilize restricted joints.
•
Successful technique for sacroiliac joint dysfunction
Source: Fred L. Mitchell, Sr., D.O., FAAO and T. J. Ruddy, D.O; Eugene Physical
Therapy
Soft Tissue Mobilization and Myofascial Release
STM:
•
restoration of med/lat muscle play, breaking fascial restrictions
between muscles and decreasing hypertonus that is associated
with muscle tightness. Specific directional manual force is used in
the direction of fascial restriction. Functional STM combines active
lengthening of the muscle tissue with manual work at the same
time.
MFR:
•
similar to STM, but a larger area of tissue is targeted as opposed
to very localized primary restrictions. Fascia is continuous
throughout the body.
Source: Eugene Physical Therapy
Joint Mobilization
Definition:
The AAOMPT, APTA, and IFOMT (International Federation of Orthopedic
Manual Therapy) define this as "a manual therapy technique comprised of a
continuum of skilled passive movements to joints and/or related soft tissues
that are applied at varying speeds and amplitudes, including a small
amplitude/high velocity therapeutic movement."
It is described by Grieves as "the attempt at restoration of full, painless joint
function by rhythmic, repetitive, passive movements within the patient's
tolerance and within the voluntary and accessory range, and graded according
to examination findings." Mobilization may affect a whole vertebral region or
may be localized to a single segment.
Manipulation is associated with a high velocity, low amplitude therapeutic
movement. (Source: Eugene Physical Therapy)
Fundamentals
•
Fundamentals of joint kinematics are necessary
to understand before using joint mobilizations as
a treatment method
•
You must know anatomy and how joints move
against one another (joint kinematics)
Joint Kinematics Accessory Joint Motion
•
Joints have accessory motions that are not controlled voluntarily and
are necessary for normal motion to occur
•
Accessory motion describes how joints surfaces move against one
another due to bony structure/shape
•
Examples:
•
Glide (ex. femoral condyles on tibial plateau)
•
Spin (ex. medial rotation of the femur on the tibia @ end range of
extension)
•
Distraction (ex. vertebral facet joints during rotation of the trunk)
•
Compression (ex. vertebral facet joints - opposite side as above)
Joint Kinematics Loose & Closed Packed Positions
•
Loose-packed position - joint surfaces are in a
resting position; joint surfaces are loosely
contacting each other; ligaments/capsule is loose
•
Closed-packed - maximum congruency of joint
surfaces; “locked position”; ligaments/capsule are
taut (ex. shoulder abd 90/ER 90; ankle full DF)
full ext
flex 25 deg
Example: Knee
Joint Kinematics Concave/Convex Principles
•
When a concave member is moving on a fixed
convex mate, the accessory motion occurs in the
same direction as physiologic motion (what you
can see)
•
When a convex member is moving on a fixed
concave mate, the accessory motion occurs in
the opposite direction as physiologic motion.
conCave
on
conVex
(same direction)
conVex
on
conCave
(opposite direction)
Convex Joint Surfaces
Concave Joint Surfaces
humeral head
glenoid fossa
proximal radial head
ulnar notch
metacarpal head
phalangeal base
femoral head
acetabulum
femoral condyle
tibial plateau
dome of talus
ankle mortise (distal tib/fib)
Joint Mobilizations
Why?
•
relieve pain
•
decrease muscle spasms
•
lengthen tissue
•
reduce intra-articular derangement
•
neurophysiological effects (can be inhibitory to
pain pathways)
Joint Mobilization
Techniques
•
FIRST: a thorough evaluation (medical history,
mechanism of injury, surgery, MD protocols),
inspection and physical examination; the clinician
must determine if joint mobilizations are indicated
•
If mobilizations are indicated; check accessory
motion (done passively, of course)
•
Checking accessory motion: one segment is
stabilized while the other is moved passively
*checking joint play
Accessory Joint Movement
Grade
Joint Status
0
ankylosed
1
considerable hypomobility
2
slight hypomobility
3
normal
4
slight hypermobility
5
considerable hypermobility
6
unstable
Contraindications (Absolute)
STOP do not mobilize
• Malignancy in area of treatment
• Infectious Arthritis
• Metabolic Bone Disease
• Neoplastic Disease
• Fusion or Ankylosis
• Osteomyelitis
• Fracture or Ligament Rupture
Contraindications (Relative)
(proceed with caution)
•
Excessive pain or swelling (intolerance to movement)
• Arthroplasty (joint replacement)
• Pregnancy (ligaments are lax during pregnancy)
• Hypermobility (chronic subluxation/dislocation)
• Spondylolisthesis
• Rheumatoid arthritis
• Vertebrobasilar insufficiency (cervical spine)
Treatment
•
Explain to the patient what you are about to do and why
(joint surfaces must be able to freely move on one another
to restore normal function)
•
Get patient in a comfortable position
•
Use good body mechanics
•
Keep hands close to the joint you are working on
•
Start slow; keep treatment short; assess tolerance next visit
•
Know that “feel” is developed through time and experience
Grading of Mobilizations
Grade
Description
1
small amplitude at the beginning
of the ROM; good for pain control
2
large amplitude within the range;
doesn't bump into resistance
3
large amplitude at mid-end
range; used to increase mobility
4
small amplitude at end range;
bumping into restriction
5
sharp thrust beyond
pathological limitation
Treatment
•
REMEMBER the concave/convex principles. This tells you what direction to
mobilize.
•
Indications:
•
Grade 1: pain exists at rest or is provoked at the beginning of the ROM
•
Grade 2: oscillations are larger in amplitude and can be helping if muscle
guarding occurs
•
Grade 3: pain and resistance from spasm or tissue tightness limit motion near
the end range
•
Grade 4: use when pain has decreased; used to increase ROM by moving
into the tightness/resistance
•
Grade 5: Do Not Use unless highly experienced and properly trained
Demonstrations
•
I need a volunteer!