12/3/2012 5 th ed. Education Competency TI-15 Perform joint - PDF document

12/3/2012  5 th ed. Education Competency TI-15 Perform joint mobilization techniques as indicated by examination findings. Lynn Matthews, ATC, PT, DPT, COMT Daemen College Athletic Training Program Director  The participant will be to explain the grades of  Hanrahan, S. et al “The Short-Term Effects of mobilization. Joint Mobilizations on Acute Mechanical Low Back Dysfunction in Collegiate Athletes” J Athl  The participant will be able to explain when to Train 2005;40(2):88-93 use each grade of mobilization.  “Grade I and 2 joint mobilizations reduced  The participant will be able to perform selected subjects pain and increased force production in mobilizations for pain and increasing range of the short-term stages of mechanical low back motion. pain.  5 th ed. Education Competency TI-13  Defined: a type of passive movement of a skeletal joint. It is usually aimed at a 'target' Describe the relationship between the synovial joint application of therapeutic modalities and the incorporation of active and passive exercise  Activates mechanoreceptors and/or manual therapies, including therapeutic massage, myofascial techniques, and muscle energy techniques.  5 th ed. Education Competency TI-14 Describe the use of joint mobilization in pain reduction and restoration of joint mobility. 1

12/3/2012  Hippocrates 5 th century BC..manipulation Certified Orthopedic Manual Therapist  England bone setters 17 th century Adapted from Google Images Adapted from Google Images  Mulligan- NAGS and SNAGS, MWM  Dr. James Cyriax : “Father of Orthopedic  The Mulligan Concept courses are intended for Medicine” only licensed physical therapists and other  Dr. Stanley Paris clinicians whose scope of practice includes mobilization/manipulative therapy. (PT, MD,  Robin McKenzie DO, DC, OT) In order for PTA's or ATC's to  Brian Mulligan attend, your state must allow you to perform  Geoffrey Maitland: my training mobilization/manipulative therapy.  Other coursework: International Academy of Adapted from Google Images Orthopedic Medicine-US info@iaom-us.com McKenzie: Minimal Criteria to complete Full Program of Certification   ATCs (who are not PTs) can take 2 courses but cannot (Parts A-D and Credentialing Examination) : become Certified Healthcare practitioner with at least a Bachelors Degree in the field of  study AND current licensure in the state of practice, or registration by the appropriate state or national regulatory organization.  2 courses that certified ATs can take: In addition to having completed the four part course series, eligible  practitioners must have had at least two years of postgraduate clinical  SIJ http://www.ozpt.com/course_info.php?id=MT-S experience to take the Credentialing Exam.  STABS http://www.ozpt.com/course_info.php?id=MT-ST (Approved healthcare providers: PT, DC, MD, DO, NP, and PA; and in  some cases ATC, OT, RCEP (by ACSM), and RN). Depends on the state. Regardless, still able to complete Parts A-C.  This policy has been set in accordance with APTA and AAOMPT Policies 2

12/3/2012 Increase ROM   Mechanical  David Ruiz, MS, Decrease Pain: Stimulates Mechanoreceptors.  Mechanoreceptors are believed to alter the Diagnosis and ATC Cert. MDT pain-spasm cycle through the pre-synaptic Therapy inhibition of nocioceptive fibers in associated  Practical structures and the inhibition of hypertonic Applications in muscles, which ultimately improves functional Sports Medicine abilities. (Colloca, CJ, Keller, TS 2001) June 1-3, 2012  Audible “pop” Not necessary for pain reduction. Thought to be the result of “cavitation” in a synovial joint. Adapted from Google Images  Many hypothesis by researchers, chiropracters,  Know precautions and contraindications PTs, osteopathic and massage based fields  Know your limitations  Include-  Know the patients limitations  Movement of nucleus pulposus  Be sure to estimate and respect irritability  Activation of gate-control mechanism  Move inflamed tissue gently  Neuromechanical and biomechanical responses  Use your trunk-avoid white knuckles, blanched  Reduction in muscle hypertonicity fingernails, tense muscles, remote control, and awkward positions  Hypomobility- leads to decreased synovial  Assess (examine) -- assess the effects of the fluid and decreased ground substance which examination --treat --assess the effects of the leads to joint stiffness. treatment.  Focus on the comparable (reproduction of symptoms) sign  Additional causes of hypomobility:  Assess the Uninvolved side first  derangement  Let every patient help you refine your skills. Get their response first! Listen! 3

12/3/2012  Progress treatment by increasing grade, time of each bout, number of bouts and/or position in  Need normal Accessory (Arthrokinematic) range movement for normal physiological  Let the features of the examination fit a pattern (osteokinematic) movement of presentation, do not force a bias fit  Most Arthrokinematic movements are beyond  Add a second technique or procedure when voluntary control you know the effect of the first..KISS  Use least amount of force  Assess over 24 hours  Avoid paralysis by analysis  Do not hold too long at end range Biomechanical analysis approach- coupling 1. motions of the spine, convex-concave rules  Do not be greedy- brief treatments early, over treat later if you must to increase range Patient response approach- movements and 2. treatments based on pt’s reports of symptoms  Start active exercises once have passive provocation and resolution movements under control Combination of both 3.  Preset outcomes not grades of movement, if  Mac Conaill (1969) used mechanical models in treating pain then preset outcome is reduction describing Roll, Spin and Glide in G/H joint and elimination of pain; if treating stiffness, the  Kaltenborn (1980) used MacConaill’s work “in outcome is increase in range vivo” studies refute the concave convex rule  If you make a pt. worse own up and do Poppen & walker (1976), Howell et al (1988), opposite Harryman et al (1990) Adapted from MT 1  4

12/3/2012  “Assessment of pain provocation during an  Grade I - Small amplitude, short of Resistance accessory motion test (PAIVMS) tends to be  Activates Type I mechanoreceptors. more reliable than assessments of motion or  Indications: Pain type of end feel”  Potter, N., Rothstein, J. (1985) “Intertester- reliabilty for selcted clinical tests of the Sacro- iliac joint” Physical Therapy 65:1671-1675  “ PAIVMS demonstrate that an OMT’s  Grade II – Large amplitude, short of Resistance manual examination when accompanied  By virtue of the large amplitude movement it will affect Type II mechanoreceptors to a by verbal subject response is highly greater extent accurate in detecting the lumbar segment level responsible for a subjects complaint”  Phillips, D. and Twomey, L (1996) “A comparison of manual diagnosis with diagnosis established by uni- level spinal block procedure” Manual Therapy 2:82-87  Grade III – Large Amplitude to 50% of R1-R2.  Selectively activates more of the muscle and joint mechanoreceptors as it goes into resistance, and less of the cutaneous ones as the slack of the subcutaneous tissues is taken up. 5

12/3/2012  Grade IV – Small amplitude to 50% of R-R2  Constant pain or severe intermittent pain  With its more sustained movement at the end  Easily provoked of range will activate the static, slow adapting,  Long time to settle Type I mechanoreceptors, whose resting  Examples: discharge rises in proportion to the degree of  Acute RA change in joint capsule tension.  Severe trauma  Inflamed chemical pain  Grade V - This is the same as joint  Rest important manipulation. Small Amplitude, High Velocity  Appropriate movement can lessen the chance thrust at end of available range. for post inflammatory excessive scar formation  R1- when first feel resistance  Grade I and II  R2- limit of the resistance  Brief bouts  In general 30 second bouts x 3 times per  Few Bouts second= 90 exercises  Short of the barriers  Position in comfort  Preferred direction 6

12/3/2012  Grade III, IV, and V  Longer bouts  Numerous bouts  Into barriers  End of range  Standard of biomechanical assessment methods  Concave surface rotates about a convex surface rolling and gliding occur in same direction  Convex surface rotates about a concave surface rolling and gliding occur in opposite direction 7

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