EVIDENCE-BASED MANUAL THERAPY AND SELF-CARE TECHNIQUES Utilizing - - PowerPoint PPT Presentation

EVIDENCE-BASED MANUAL THERAPY AND SELF-CARE TECHNIQUES

Utilizing Hands-on Treatment to Efficiently Restore Function

1

Bill Meritt, PT, OCS, Cert. DN, FAAOMPT

Board Certified Clinical Specialist in Orthopaedic Physical Therapy Certified in Dry Needling Fellow, American Academy of Orthopaedic Manual Physical Therapists

bill@catalystathleticrehab.com @catalyst_rehab

2

Course Objectives

 Discuss the concepts behind manual therapy (specifically joint

mobilization and manipulation) and the proposed mechanisms for why it works

 Identify which patients will most likely benefit from hands-on

treatment

 Utilize components of regional interdependence to identify

anatomical areas that warrant manual intervention

 Apply appropriate joint mobilization and manipulation

techniques to various areas for pain relief and movement enhancement

 Implement effective post-mobilization exercises to promote

continued improvement

 Develop efficient home exercise programs and self-care

techniques to increase patient compliance and maintain gains 3

Today’s Schedule

 Utilization of manual therapy  Regional interdependence  Treatment of the neck, shoulder, and

thoracic spine

 Lunch  Treatment of the lumbar spine, hip, and

knee

 Review and wrap-up 4

Disclaimer

 You are responsible for:

฀ knowing what your state practice act legally

allows you to do as a provider

฀ performing on patients only the techniques

that you are competent to perform

฀ finding opportunities to practice with co-

workers, family, and friends

฀ seeking out more in-depth learning

• pportunities

5

Lab Ground Rules

 Safety is our primary concern  Participation is voluntary  Give quality feedback to lab partners  Develop soft therapeutic hands that are

comfortable to your lab partner

 Practice therapist position, patient position,

communication, handling, set-up comfort, angle

• f thrust

6

UTILIZATION OF MANUAL THERAPY

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Types of Manual Therapy

 Massage  Soft-tissue mobilization  Instrument-assisted soft tissue mobilization (IASTM)  Myofascial release  Muscle energy techniques  Acupressure  Dry needling(?)  Joint mobilization  Joint manipulation  Guru-related philosophies  And the list goes on and on….

8

History of Joint Mobilization and Manipulation

 Its use dates back over 4000 years

฀ Ancient Egyptians, Greeks, and Romans

 Been utilized by PTs since the 1920s  Well-known names associated with its use:

฀ Mennell ฀ Cyriax ฀ Kaltenborn ฀ Maitland ฀ Paris ฀ Mulligan

9

Biomechanics Review

10

Osteokinematics vs. Arthrokinematics

 For our purposes today, we are dealing in

arthrokinematics, not osteokinematics

 Arthrokinematics is the general term used to

describe specific movements of joint surfaces

 Three general movements:

฀ Rolling ฀ Gliding (or sliding) ฀ Spinning

 Critical for understanding movement created

during a joint mobilization

11

Articular Surface Movements

GLIDE ROLL

 One point on one surface

comes in contact with a new point on another surface

 A new point on one

surface comes in contact with a new point on another surface

12

Convex-Concave Rules

CONCAVE ON CONVEX CONVEX ON CONCAVE

 Rolling and gliding

• ccur in same direction

 Rolling and gliding

• ccur in opposite

directions

• steodoc.ru

13

Joint Play

 Involuntary movement that is present in all

synovial joints (Mennell)

 Short, straight-lined passive bone movement

(Kaltenborn)

 Amount of joint play is less than 1/8th inch  Voluntary movement is dependent on the

integrity of joint play

14

Joint Dysfunction

 Loss of joint play (Mennell)  A state of altered mechanics, either an increase

• r decrease from the expected normal, or the

presence of an aberrant motion (Paris)

15

Causes of Joint Dysfunction

 Four causes of joint dysfunction

฀ Trauma (macrotrauma or repeated microtrauma) ฀ Sustained postures ฀ Immobilization ฀ Following the resolution of a more serious

pathological condition

 Pathology affecting the musculoskeletal

system will lead to joint dysfunction

16

How Do We Deal With Joint Dysfunction?

 Muscles cannot restore joint play  It must be restored for the patient  It is a mechanical problem requiring a

mechanical solution

17

What Does Joint Mobilization and Manipulation Do?

18

Mobilization/Manipulation Defined

 Agreed upon definition from Orthopedic Section of

the APTA, AAOMPT, and the APTA used in the Guide to Physical Therapist Practice published in 2000:

■ A manual therapy technique comprised of a

continuum of skilled passive movements to joint and/or related soft tissues that are applied at varying speeds and amplitudes, including a small-amplitude/high-velocity therapeutic movement.

19

Mobilization/Manipulation Defined

 Definitions provided by Virginia Chiropractors Association

to Spinal Manipulation Study Task Force, Virginia Board of Medicine (1999)

◼ Spinal manipulation  Passive movement of short amplitude and high-

velocity which moves the joint into the paraphysiological range. This is accompanied by cavitation or gapping of the joint that results in an intrasynovial vacuum phenomenon thought to involve gas separating from fluid.

◼ Spinal mobilization  Passive movements within physiological joint range of

motion without cavitation or the popping sound inherent to manipulation.

20

Mobilization/Manipulation Defined

 The International Federation of Orthopaedic Manual

Physical Therapists (IFOMPT) definitions:

฀ Manipulation

 A passive, high velocity, low amplitude thrust

applied to a joint complex within its anatomical limit with the intent to restore optimal motion, function, and/or reduce pain.

฀ Mobilization

 A manual therapy technique comprising a

continuum of skilled passive movements to the joint complex that are applied at varying speeds and amplitudes, that may include a small- amplitude/high velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function, and/ or to reduce pain.

21

Maitland’s Five Grades of Oscillations

I.

Small amplitude movement performed at the beginning of the range

II.

Large amplitude movement performed within the range but not reaching the limit of range

III.

Large amplitude movement performed up to the limit of the range

IV.

Small amplitude movement performed at the limit of the range

V.

Manipulation – high velocity thrust at end-range of movement (HVLA – high velocity/low amplitude)

I III II IV

22

Current Theoretical Mechanisms

 A mechanical force starts a chain of

neurological, physiological, and/or psychological responses, which in turn produces the outcomes associated with manual therapy (Evans 2002; Pickar 2002; Bialosky 2009)

 Interaction of three elements:

฀ Biomechanical ฀ Neurophysiological ฀ Psychophysiological

23

24

Possible Biomechanical Effects

 Restore joint play and ROM  Stretch out tight joint capsules  Stretch out adhesions  Snap adhesions

25

Biomechanical Effects in the Spine

Fibrous adhesions develop Thrust separates Z-joints Gapping

• f Z-joints

breaks up adhesions Now Z- joints can move normally

26

Research on Biomechanical Effects

 Only transient biomechanical effects are

supported by studies that quantify motion, no lasting positional change (Gál 1997; Tullberg 1998; Hsieh

2002)

 Cavitation is an incidental side effect? (Evans 2002;

Flynn 2003)

 Techniques/forces are not necessarily specific to

a segment, they can spread throughout a large area, and vary among clinicians (Ross 2004; Ngan 2005)

 Choice of technique does not seem to affect

• utcomes (Cleland 2006)

27

Neurophysiological General Effects

 Neurophysiological effects likely more

influential than biomechanical effects

 Allows for facilitation of movement through

inhibition of pain

 Varying effects on Type I, II, and III

mechanoreceptors

 Increased activity in proprioceptors  Adjustment of nociceptor receptor pattern  Reduced overall central sensitization  Autonomic nervous system effects

28

Neurophysiological Effects – Peripheral Mechanisms

 Type I – Ruffini receptor endings

฀ Function – informs about static and dynamic position of

joint; regulation of postural muscle tone; pain inhibiting

฀ Activated by Gr. I and II mobilizations

 Type II – Pacinian corpuscles

฀ Function – informs about acceleration and deceleration of

joint movement; pain inhibiting

฀ Activated by Gr. I and II mobilizations

 Type III – Golgi tendon organ-like endings

฀ Function – reflex inhibition of muscle tone ฀ Activated by manipulation

29

Neurophysiological Effects - Peripheral Mechanisms

 Peripheral inflammatory response initiated by

musculoskeletal injury, influences healing and pain processing

 Observed blood level changes in the following

after manual therapy:



‐endorphin

 endogenous cannabinoids  serotonin  anandamide  substance-P

30

Neurophysiological Effects - Central Mechanisms

 Central mechanisms include both spinal and

supraspinal effects

 Manual therapy may exert an effect on the

spinal cord, suggested to act as a counter- irritant to modulate pain (Boal & Gillette 2004)

 Bombardment of central nervous system with

sensory input from muscle and joint proprioceptors (Pickar & Kang 2006)

31

Neurophysiological Effects - Central Mechanisms

 in pro-inflammatory cytokines after thoracic

manipulation suggests down-regulation of inflammatory-type responses (Teodorczyk-Injeyan

2006)

 Sympathetic nervous system excitatory response

฀ skin conductance/sweat and vasoconstriction from

mechanical stimulus at cervical or thoracic spine, associated with immediate  in pain and mechanosensitivity, and  ROM during ULNTs (Chu

2014)

 Increased muscle strength (Keller 2000; Cleland 2004,

Libeler 2001, Suter & McMorland 2002)

32

Neurophysiological Effects - Central Mechanisms

  dorsal horn sensitization and  afferent

discharge = immediate  in pain (George 2006;

Sterling 2001; Maduro de Camargo 2011; Mohammadian 2004)

 Alters muscle tone via α motor neuron pool

activity (Sterling 2001; Dishman 2002; Dishman 2002; Fryer

2012)

 Immediate change in functional connectivity

between brain regions that process and modulate pain (Gay 2014)

 Effects on the descending pain inhibitory system

(DPIS) discussed in pain science research

33

Psychophysiological Effects

 Placebo is a psychobiological phenomenon

• ccurring in the brain

 Higher expectation/beliefs for treatments =

significantly greater function/less disability

(Kalauokalani 2001; Bishop 2013)

 The “pop” from a manipulation and laying-on

• f skilled hands creates a psychological event

 Not the reason we use manual therapy, but it

has an effect

34

Mechanisms Summary

 Decreases pain

฀ May be short-term immediate relief

 Reduces muscle tone  Increases motion  Improves sensorimotor integration  Improves motor control

35

When is it Appropriate to Use Mobilization and Manipulation?

36

Indications for Joint Mobilization/Manipulation

 In the presence of joint dysfunction  Neurophysiological effects for pain relief  Lack of contraindications

37

Absolute Contraindications

(Dunning)

 Vascular

 Coronary artery disease; aortic aneurysm; severe

hemophilia; vertebral artery disease

 Bone

 Tumor; TB infection; metabolic disease; congenital

dysplasias; long-term corticosteroid use; inflammatory disease (RA); fracture; ligamentous (upper cervical instability)

 Neurological

 Cauda equina; cervical myelopathy

38

Absolute Contraindications

(Dunning)

 Excessive or extreme pain  Lack of a clinical diagnosis  Lack of patient consent

39

Absolute Contraindications

(Kroon and Kruchowsky)

 Relative to skill and experience  Unremitting, severe non-mechanical pain  Unremitting night pain (preventing patient

from falling asleep)

 Worsening neurological function  Empty end-feel and severe multi-directional

spasm, which can be the result of various serious pathological findings

 Post-surgical

40

Relative Contraindications

(Dunning)

 Disc herniation or prolapse

 HNP present in 49-63% of individuals that have

never had a significant bout of LBP

 Pregnancy

 Do not thrust between 12th-16th weeks (3rd and 4th

month) of pregnancy, coincides with risk of miscarriage

 HVLAT has never been shown to cause a

miscarriage

41

Relative Contraindications

(Dunning)

 Osteoporosis, rheumatoid arthritis  Spondylolisthesis

 Avoid extension

 Advanced DJD, spondylosis

42

Precautions for Manipulation

(Kroon and Kruchowsky)

 Hunch/feel  History of neoplastic disease: risk of recurrence  Patient unable to relax  When you sense that the joint will not “give”  Adverse reactions to previous manual therapy  Physique  Children  When spinal movements or palpation

reproduces distal symptoms

 Pain with psychological overlay

43

Manipulation Guidelines

 Manipulation is a treatment option, an

intervention that we clinicians (may) have the authority and privilege to use

฀ Beneficial for some – some of the time – not for all ฀ May be part of an overall plan ฀ Use a multimodal approach ฀ Not a stand alone treatment or philosophy of care

 Do so only after informed, planned, and

individualized assessment

44

General Rules for Joint Manipulation

 Patient relaxed  Perform in resting position of joint – never

mobilize/manip in close-packed position of joint

 Use good body mechanics  Visualize joint surfaces/mechanics  Techniques must suit body type of

patient/therapist or be modified

 Use the minimal force needed  Speed is key!

45

Post-Manual Therapy Treatment

 The lasting effect of a single session of HVLA

thrust ranged from no effect up to a maximum

• f 5 hours (Coronado 2010)

 Manipulation works fast

฀ Changes in sensory processing (reset) gives us a

window into the nervous system and a chance to alter motor control with the ultimate goal of a better expression of movement

฀ Tells the nervous system that movement is OK

46

Post-Manual Therapy Treatment

 Re-establishing and then maintaining normal

movement is critical

 Clinical and home exercises should target the

nervous system to further modulate sensory input and motor control to regain normal movement patterns

47

GET THEM MOVING… AND KEEP THEM MOVING

48

REGIONAL INTERDEPENDENCE

“A Musculoskeletal Examination Model Whose Time Has Come”

49

Regional Interdependence (RI)



“RI refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.” (Wainner 2007)



Likely includes musculoskeletal factors, as well as a neurophysiological component (Bialosky 2008)



UPDATED “The concept that a patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s).” (Sueki 2013)

50

Regional Interdependence (RI)

 RI represents the musculoskeletal manifestation

• f a larger interdependent process by which
• ther systems may be involved in eliciting these

MSK changes (Sueki 2013)

51

Regional Interdependence (RI)

The redefined concept from 2013 (Sueki) proposes:

 Response(s) to a disorder or condition and the

associated clinical outcome(s) are not limited to local and adjacent regions of the body but can involve a neuromusculoskeletal response that may be more widespread.

 Multiple systems respond to impairment and

may influence the function of the neuromusculo-skeletal system and associated symptoms.

52

RI Examples in Literature (Sueki 2013)

UPPER QUARTER LOWER QUARTER

 Thoracic spine – Cervical

spine

 Thoracic spine –

Shoulder

 Thoracic spine – Upper

extremity

 Cervical spine – Upper

extremity

 Hip – Lumbar spine  Hip – Knee  Knee – Lumbar spine  Foot/ankle – Lumbar

spine

 Ankle - Knee

53

TREATMENT OF THE NECK, SHOULDER, AND THORACIC SPINE

54

Thoracic Spine Anatomy Review

 Thoracic vertebrae shorter anteriorly than

posteriorly

฀ This combined with wedge shape of discs creates

thoracic kyphosis

 Increase in size from superior to inferior as the

spine transitions from the smaller cervical vertebrae to the larger lumbar vertebrae

 Spinal canal is more narrow, particularly from

T4-T9

฀ Tension point at T6 – vulnerable site in nervous

system

55

Thoracic Vertebrae Characteristics

 T2-T9 are typical thoracic vertebrae

฀ Facets angled at 60 degrees in the transverse plane ฀ Allows for lateral flexion and rotation ฀ Spinous processes angle inferiorly

 T1 shares similarities with cervical vertebrae

฀ Uncinate processes ฀ Spinous process larger and more horizontal

 T12 shares similarities with lumbar vertebrae

฀ Inferior articular processes oriented in sagittal plane

like lumbar facets, restricting rotation

56

Lateral View of Thoracic Vertebra

johnthebodyman.com

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Spinal Facet Orientation

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Thoracic Facet Orientation

 Superior articular facets

฀ Face posterior,

lateral, and superior

 Inferior articular facets

฀ Face anterior,

medial, and inferior

Mulliganconcept.com 59

Thoracic Arthrokinematics

 Flexion

฀ Inferior facets of superior vertebrae glide up and tilt

forward

 Extension

฀ Inferior facets of superior vertebrae glide down and tilt

backwards

 Right sidebending

฀ Inferior facet of superior vertebrae on the right glides

down and tilts backwards

฀ Inferior facet on the left glides up and tilts forward

 Right rotation

฀ Inferior facet of the superior vertebrae on the right glides

down and tilts backwards

฀ Inferior facet on the left glides up and tilts forward

60

Shoulder Anatomy Review

 Glenohumeral joint  Acromioclavicular joint  Sternoclavicular joint  Scapulothoracic “joint”

61

Glenohumeral Joint Anatomy

 Convex humeral head on concave glenoid fossa

฀ Humeral head much larger surface than glenoid fossa

Think golf ball on a tee Glenoid fossa deepened by the labrum

฀ Glenoid fossa angled to face anteriorly approx 30o

 Joint capsule

฀ Attached to the circumference of the labrum and the

glenoid fossa

฀ Axillary recess allows for abduction to occur ฀ Glenohumeral and coracohumeral ligaments blend

into the capsule

62

adamdziemianko.blogspot.com stjohn-clarkptc.com

Glenohumeral Joint Anatomy

63

Glenohumeral Arthrokinematics

 Flexion

฀ Rotational spin with posterolateral glide of the

humeral head

 Abduction

฀ Inferior glide of the humeral head

 External rotation

฀ Anteromedial glide of the humeral head

 Internal rotation

฀ Posterolateral glide of the humeral head

64

Regional Interdependence Implications Involving the Thoracic Spine

65

Thoracic Spine Treatment for Cervical Pain

Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial (Cleland 2005)

 36 subjects with mechanical neck pain  Randomized into 2 groups: thoracic spine manipulation or

placebo manipulation

 Outcome measure was immediate (short-term) change in VAS

pain scale

 Thoracic spine manipulation group demonstrated clinically

significant immediate improvements in perceived level of neck pain compared to placebo manipulation group 66

Thoracic Spine Treatment for Cervical Pain

Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial (González-Iglesias

2009)

 45 participants with acute mechanical neck pain <1 month  Control group – electro/thermal therapy over 5 visits  Experimental group – electro/thermal + thoracic spine thrust

manipulation added at 3 of 5 visits

 Outcome measures included pain rating, cervical range of motion,

and disability rating (NPQ)

 Experimental group experienced greater improvements in pain,

cervical range of motion, and disability at 5th session and at 2- week follow-up

 Pain reduction in experimental group continued at 1-month

follow-up 67

Thoracic Spine Treatment for Cervical Pain

Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: a randomized clinical trial (Masaracchio 2013)

 64 participants with mechanical neck pain <3 months  Control group – 2 sessions of c-spine Gr. III mobilizations

and HEP

 Experimental group – 2 sessions of c-spine Gr. III

mobilizations, HEP, and 2 thrust manipulations each to upper and middle thoracic spine

 Outcomes measures included NPRS, NDI, and GROC  Experimental group demonstrated better overall short-term

(<1 week) outcomes in NPRS, NDI, and GROC than control group 68

Thoracic Spine Treatment for Shoulder Pain

The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome (Boyles 2009)

 56 patients with shoulder impingement syndrome in a one

group pre-test/post-test study

 Group received thoracic spine manipulation after shoulder

examination

 Outcome measures included NPRS, SPADI, and GROC  At 48-hour follow-up, decrease in NPRS during various

shoulder impingement tests was statistically significant

 Also significant reduction in SPADI and GROC

69

Thoracic Spine Treatment for Shoulder Pain

The immediate effects of thoracic spine and rib manipulation on patients with primary complaints of shoulder pain (Strunce 2009)

 21 subjects with primary c/o shoulder pain using test/re-rest

design

 Subjects received HVLA manipulation to upper thoracic spine

and/or ribs based on impairments found during examination

 Primary outcome measures were pain VAS and shoulder AROM  Statistically and clinically important improvements for the

entire group were demonstrated in post-treatment shoulder ROM measurements and VAS pain scores immediately following manual therapy

฀ One or more thoracic and/or rib impairments were identified in

each subject, including CTJ restrictions in 71%, upper thoracic restrictions in 100%, and unilateral rib restrictions in 79%

70

Thoracic Spine Treatment for Shoulder Pain

Effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy (Muth 2012)

 30 subjects with signs of RC tendinopathy received thoracic

spine manipulation

 Pre- and post-manipulation measurements of scapular

kinematics, scapular muscle activity, shoulder pain, and function (PSS and SPAM-DASH) were assessed

 No significant changes were observed in scapular range of

motion or kinematics; did observe small but significant increase in middle trapezius muscle activity, but no other muscles

 Subjects did demonstrate decreased pain with various

shoulder impingement tests, decreased pain with shoulder flexion, and improved shoulder function

 Conclusion: immediate improvements in shoulder pain and

function post-thoracic manipulation are not likely explained by alterations in scapular kinematics or shoulder muscle activity

฀ Outcomes support the likelihood of other neurophysiological

processes at play

71

Other Thoracic Spine Articles of Interest

 Prevalence of pain and dysfunction in the cervical

and thoracic spine in persons with and without lateral elbow pain (Berglund 2008)

 Joint manipulation in the management of lateral

epicondylalgia: a clinical commentary (Vicenzino 2005)

 The effectiveness of thoracic spine manipulation for

the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials (Walser 2009)

 Regional interdependence and manual therapy

directed at the thoracic spine (McDevitt 2015)

72

Thoracic Spine and Shoulder Manual Therapy Interventions

73

Common Reasons for Treating the Thoracic Spine

 Pain(!)

฀ Thoracic, cervical, or shoulder (and maybe even

elbow)

 Limited range of motion

฀ Thoracic, cervical, or shoulder

 Shoulder impingement signs

฀ Pain and limited ROM combined, painful arc, etc.

 Poor scapular muscle motor recruitment  Absence of contraindications

74

Supine Thoracic Manipulation



Patient crosses arms across chest (arm towards PT goes inferior), tightly to take up slack



Roll patient towards PT



Flat hand with fingers facing patient’s head, spinous process between thenar and hypothenar eminences, adduct arm to stay medial to scapula



May also use a closed fist, with loose MCP flexion



Roll patient back over hand so they are flat; therapist’s mid- section should be over patient’s elbows, head over opposite shoulder



Flex spine to the level to be manipulated with the other arm across the patient’s arms, then place your trunk on top to hold them in place



Provide compression via body contact, but keep chest up – may help to look out in front of you instead of down



Short, quick thrust anterior to posterior

75

Supine Thoracic Manipulation

76

Prone Thoracic Rotational Mobilization/Manipulation

 Patient in prone, arms over side of table  Therapist stands on side to be mobilized  Hypothenar eminence of caudal hand on same side TP  Hypothenar eminence of cranial hand on opposite TP,

but at same level

 “Screw home” so fingers of cranial hand point caudally

and fingers of caudal hand point cranially – not part of the mobilization

 Mobilize caudal hand in cranial/anterior direction,

and cranial hand in caudal/anterior direction

 If performing manipulation, thrust towards end of

patient exhalation

77

Prone Thoracic Rotational Mobilization/Manipulation

78

Glenohumeral Joint Inferior Glide

 Patient in supine with shoulder in resting

position (55o abd, 30o hor add)

 PT stands at side of table facing pt, with caudal

hand under upper arm and cranial hand on superior lateral border of humeral head

 Use your arm and body to hold/support

patient’s arm and facilitate relaxation

 Use caudal hand to gently distract the joint  Use cranial hand to glide humerus inferiorly  Used to increase elevation of shoulder

79

Glenohumeral Joint Inferior Glide

80

Glenohumeral Joint Posterior Glide

 Patient in supine with shoulder in resting position (55o

abd, 30o hor add)

 Can place towel under scapula to help stabilize  PT stands at side of table facing patient, with cranial

hand on superior anterior aspect of humeral head, and caudal hand on medial side of arm

 Use your arm and body to hold/support the patient’s

arm and facilitate relaxation

 Use both hands to gently distract the joint, then glide

posteriorly

 Used to increase internal rotation and flexion  Also used to help glenohumeral joint function in

neutral position (in presence of anterior laxity or anterior humeral head position)

81

Glenohumeral Joint Posterior Glide

82

Thoracic Spine Exercise Interventions

83

Supine Longitudinal Thoracic Spine Self-Mob on Foam Roller

 Foam roller running

length of spine, supporting head and buttock

 Knees bent to reduce

strain on lumbar spine

 Duration dependent

• n tolerance

 Flex elbows to avoid

median nerve irritation

84

Supine Shoulder Flexion with Dowel Rod on ½ Roller

 Use ½ roller, pool

noodle, etc.

 Position roller so it is

perpendicular to thoracic spine

 Foam roller can be

placed at most restricted level, but may have to start elsewhere

 Encourage shoulder

movement through tolerate range

85

Seated Thoracic Extension on Chair Using Dowel Rod

 Similar to supine

shoulder flexion, but now uses chair back as a fulcrum

 May need pillow or

roll for lumbar support

 Encourage minimal

cervical spine movement

86

Ball Walks on Wall with Thoracic Extension Emphasis

 Alternative to wall

climbs

 Encourages increased

thoracic extension as part of overhead movement

 Can also utilize for

retraining of scapular protractors and upward rotators

87

Other Thoracic/Shoulder Exercise Considerations

 Scapular muscle motor control/strength

฀ Serratus anterior ฀ Lower trapezius ฀ Middle trapezius

 Rotator cuff motor control/strength  Cervical deep neck flexor motor

control/strength

88

TREATMENT OF THE LUMBAR SPINE, HIP, KNEE, AND ANKLE/FOOT

89

Lumbopelvic-Hip Complex

Strengthphysio.com

90

Lumbopelvic-Hip Complex

 Refers to the biomechanical relationship between

the low back and hips

 Pelvis/SI joint interface  Multiple shared muscles

฀ Iliopsoas ฀ Quadratus lumborum ฀ Erector spinae ฀ Gluteus maximus ฀ Gluteus medius

 Contraction of these muscles can affect motion at

the spine, pelvis, and hips

91

Lumbar Spine Anatomy Review

 Multiple muscle and ligament attachments  Articular processes

 2 superior and 2 inferior to form the facet joints

 Predominant motion is in the sagittal plane due

to the orientation of the facet surfaces

 Flexion and extension dominate movement

availability

 Sidebending somewhat limited  Rotation is the most limited (happens primarily at

upper lumbar segments)

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Lumbar Vertebrae

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Lumbar Facet Joints

 Formed by inferior articular process of the superior

vertebra and the superior articular process of the inferior vertebra

 Nearly 90o orientation to the transverse plane  Principle guiding and restraining mechanism of the

segment

 Protect disc from excessive strain and keep the joint

stable

 Surrounded by a fibrous capsule

฀ Thick dorsally, reinforced by multifidus fibers ฀ Anteriorly replaced by the ligamentum flavum

 Have intra-articular meniscoid structures that protect

the joint and keep the joint surfaces lubricated during movement

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Lumbar Facet Orientation

 Superior articular facets

฀ Face medial and superior

 Inferior articular facets

฀ Face lateral and anterior

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Hip Anatomy Review

 Ball and socket joint formed by femoral head

and acetabulum

฀ Femoral head faces anterior, medial, and superior ฀ Acetabulum faces anterior, lateral, and inferior

 Stability improved by the labrum, which

deepens the socket

฀ Also allows for mobility

by virtue of its elasticity

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Hip Anatomy Review

 Joint capsule shaped like a cylindrical sleeve

฀ Inserts medially onto acetabular ring, transverse

ligament, and peripheral surface of the labrum

฀ Inserts laterally into base of the femoral neck ฀ Strengthened anteriorly by fibers of the rectus

femoris

 Hip joint ligaments

฀ Ligamentum teres ฀ Iliofemoral ligament ฀ Pubofemoral ligament ฀ Ischiofemoral ligament

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Hip Joint Arthrokinematics

 Flexion

฀ Femoral head rolls anteriorly and glides posteriorly

 Extension

฀ Femoral head rolls posteriorly and glides anteriorly

 Abduction

฀ Femoral head glides inferiorly

 Internal rotation

฀ Femoral head glides posteriorly

 External rotation

฀ Femoral head glides anteriorly

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Regional Interdependence Implications Involving the Lumbopelvic-Hip Complex and Lower Quarter

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Hip-Spine Syndrome (Offierski 1983)

 Concept of a biomechanical link between

the hip joint and the lumbar spine

 Specifically depicts the influence of a

pathological hip joint on the alignment of the spine and subsequent muscle length and joint forces

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Relationship Between LBP and Decreased Hip Mobility

 Multiple studies suggesting a link between

limitations in hip mobility with low back pain in patients

฀ Ellison 1990 ฀ Chesworth 1994 ฀ Cibulka 1998 ฀ Sjolie 2004 ฀ Vad 2004 ฀ Coplan 2002 ฀ Mellin 1988 ฀ van Dillen 2008

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Relationship Between LBP and Decreased Hip Strength

 Multiple studies investigating effects of hip

strength on low back pain

฀ Nadler 2000 ฀ Nadler 2001 ฀ Nadler 2002 ฀ Kankaanpää 1998 ฀ Nourbakhsh 2002

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Effects of the Hip and Pelvis on Spinal Alignment

 Studies investigating relationship between the hip/pelvis

and spinal posture

฀ Offierski 1983 ฀ Murata 2002 ฀ Nakamura 2003 ฀ Yoshimoto 2005 ฀ Takemitsu 1988 ฀ Sato 1989 ฀ Itoi 1991 ฀ Watanabe 2002

 Although these studies demonstrate a relationship

between the hip and spine, there is a lack of evidence demonstrating the significance of its effect on low back pain

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Common Hip Dysfunction Findings – Hip Flexion

 Limited and/or painful hip flexion

฀ Decreased posterior glide of hip, possible tight

posterior capsule

฀ Femoral acetabular impingement (FAI) ฀ Labral tear ฀ Can be associated with internal rotation deficit ฀ Poor iliopsoas strength/motor control ฀ Potentially worse with prolonged sitting

 Effects on the lumbar spine

฀ Decreased hip flexion can be compensated for with

excessive hip hiking/lumbar sidebending/lumbar flexion

฀ Often seen in cyclists

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Common Hip Dysfunction Findings – Hip Extension

 Limited and/or painful hip extension

฀ Decreased anterior glide of the hip, possible tight anterior

capsule

฀ Tight anterior chain muscles (iliopsoas and/or rectus

femoris) – check with Thomas Test

฀ Poor gluteus max strength/motor control

 Effects on the lumbar spine

฀ Decreased hip extension can lead to compensatory lumbar

extension and/or rotation

฀ Lumbar extension-rotation syndrome (Sahrmann)

 Potential role in distal lower extremity pathology

฀ Hamstring pain/tightness ฀ Calf pain/tightness or Achilles tendinopathy ฀ Plantar fasciopathy

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Lumbar Spine Intervention CPRs

 Two different clinical prediction rules (CPRs)

developed for classifying treatment of patients with low back pain

฀ Lumbopelvic manipulation (Flynn 2002) ฀ Lumbar stabilization (Hicks 2005)

 The presence of adequate hip range of motion

was a common finding for increased likelihood

• f success in both CPRs

฀ Hip IR >35o in 1 or both hips (Flynn 2002) ฀ SLR >91o (Hicks 2005)

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The Use of Manual Therapy to Improve Hip ROM Deficits

 Manual therapy (thrust and nonthrust techniques

directed at hip) and exercise in patients with hip OA decreased hip pain, increased function, and increased hip ROM (MacDonald 2006)

 Hip mobilization and stretching group achieved

greater increases in hip ROM, decreased pain, and improved function compared to exercise group in patients with hip OA (Hoeksma 2004)

 Manual therapy to hip resulted in increased

composite hip ROM (hip flexion, functional squat, and FABER ROM) in patients with knee OA (Cliborne

2004)

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The Use of Manual Therapy to Improve Hip Strength Deficits

 Patients treated with Gr. IV mobilizations

addressing anterior hip capsule demonstrated immediate improvement in gluteus maximus strength (Yerys 2002)

 Patients treated with Gr. IV mobilizations

addressing inferior hip capsule demonstrated immediate improvement of hip abductor strength (Makofsky 2007)

 These findings are relevant because the muscles

• f the pelvic girdle that are most commonly

affected with hip pathologies are the gluteal muscles (Paquet 1994)

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Hip Treatment for Low Back Pain

The effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip (Ben-Galim 2007)

 Purpose of study was to assess clinical application of hip-spine

syndrome (Offierski)

 25 patients with hip OA and at least moderate LBP and spinal

disability prior to having THR

 Outcomes measures included VAS for hip, VAS for lumbar

spine, Oswestry, and Harris Hip Score

฀ Collected pre-op, at least 3-months post-op, and 2 years post-op

 Findings showed significant improvement in LBP and

function after treatment of hip OA (via THR)

฀ Authors recommend treating hip OA first in patients that

present with both hip OA and LBP

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Impairment-Based Treatment for Low Back Pain - Stenosis

A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial (Whitman 2006)

 58 patients with lumbar stenosis randomized to one of two

groups:

฀ Manual therapy, exercise, and walking group ฀ Flexion exercise, ultrasound, and walking group

 Manual therapy treatments were impairment-based, and

included treatment of the thoracic spine, lumbar spine, pelvis, and LEs

 GROC was primary outcome measure, also used Oswestry,

SSS, NPRS, and walking tolerance test, with primary follow- ups at 6-weeks and 1-year

 Both groups benefited from interventions, but manual

therapy group reported greater rates of perceived recovery than flexion exercise group at 6-weeks (79% vs. 41%) and 1- year (62% vs. 41%) 110

Effects of the Hip on the Knee

 Females with unilateral knee pain had significantly less

gluteus medius and gluteus maximus strength on the involved side (Rowe 2007)

 Females with PFPS had significant hip weakness but

not altered kinematics compared to non-symptomatic controls during stair descent (Bolgla 2008)

 Females with PFP demonstrated increased peak hip

internal rotation motion and decreased hip muscle strength during running, drop jump, and step-down compared to non-painful controls (Souza 2009)

 Hip strengthening improved symptoms and function in

patients with medial knee OA, but did not affect medial knee load (Bennell 2010)

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Lumbopelvic and Hip Manual Therapy Interventions

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Common Reasons for Treating the Lumbar Spine, Hip, and Lower Quarter

 Pain  Able to provoke lumbopelvic pain (or the patient’s

familiar pain) with hip assessment

฀ ROM/passive mobility ฀ Strength testing ฀ Special Tests

 Altered kinematics during movement assessment

฀ Gait pattern ฀ Squat ฀ Functional movements

 Absence of contraindications

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Hip Long-Axis Distraction Manipulation

 Patient in supine (use banana belt around groin

to stabilize patient to table if needed)

 Grab patient’s ankle with both hands just

proximal to malleoli

 Place hip in resting joint position (30o flexion,

30o abduction, 20o ER)

 Lean back to distract and then lock joint, then

thrust caudally

 Can also use to perform Gr. I-IV mobilizations

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Hip Long-Axis Distraction Manipulation

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Posterior Mobilization of Hip

 Biomechanically used to improve flexion and

internal rotation

 Patient in supine with body at edge of table, PT

standing on opposite side of hip to be mobilized

 Passively flex hip to near 90 degrees, then bring

towards you in slight adduction (patient’s tolerance determines starting point of mobilization)

 Gradually apply force through knee to glide

femoral head posteriorly

 Target area for patient response is deep buttock

(posterior hip capsule stretch?)

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Posterior Mobilization of Hip

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Anterior Mobilization of Hip (Neutral)

 Use to improve extension and external rotation  Patient in prone, knee in slight flexion  PT cradles patient’s knee and lower leg with

caudal arm

 PT’s cranial hand placed under gluteal fold

towards femoral head

 Apply force through proximal thigh to glide

femoral head anteriorly

 Vary amount of hip extension as needed

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Anterior Mobilization of Hip (Neutral)

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Anterior Glide of Hip (Figure 4)

 Use to improve extension and external rotation  Patient in prone with hip abducted and

externally rotated, knee flexed so foot rests on popliteal fossa of other leg (may need bolster between foot and knee)

฀ Knee may be slightly off of table for patient’s comfort

 Stabilize lower leg with caudal hand or leg  Cranial hand at gluteal fold  Apply force through proximal thigh to glide

femoral head anteriorly

 Can also direct force anteromedially

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Anterior Glide of Hip (Figure 4)

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Lumbopelvic, Hip, and Lower Quarter Exercise Interventions

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Cat-Camel Mobilization

 Good choice for

unloaded spinal mobility

 Help patient overcome

fear of movement

 Encourage pelvic

tilting to maximize spinal movement

 May require tactile

cuing

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Quadruped Rocking

 CKC movement used to

promote hip mobility without lumbar compensation

 Instruct pt to find

neutral spine

 Maintain neutral spine

as pt pushes butt towards heels to flex hips

 Use tactile cuing to give

pt feedback about spinal movement compensations

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Posterior Hip Self-Mobilization

 Set-up similar to

piriformis stretch

 Rotate lower body

away from side to be stretched

 Maintain 5-10 seconds,

then return to neutral

 Good HEP if pt

responded well to manual posterior hip mobilization

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Hip Flexor Stretch

 Pt at edge of table so

thigh can hang off in space

 Pull opposite knee to

chest to flatten lumbar spine (maintain proximal tension on psoas major)

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Anterior Hip Self-Mobilization

 Abduct hip and place

foot in popliteal fossa

 May need to place

bolster between foot and knee

 Pt performs isometrics

glute max contraction to anteriorly glide femoral head

 May need to place

bolster under knee to increase effect

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Anterior Hip Band Mobilization

 More aggressive

anterior hip mobilization

 Monster band around

proximal thigh

 Kneeling position with

lumbar spine maintained in neutral

 Posterior pelvic

tilt/glute max isometric to add stretch to anterior hip

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Bridges

 Emphasize glute max

activity to minimize hamstring and lumbar contribution

 Cue to push through

heels and squeeze glutes

 Can also increase knee

flexion to decrease hamstrings

 Only lift 6 inches off

table (really just stay below point of lumbar extension)

 Progress to single-leg

after mastery

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Hooklying Clamshells

 Aids with better

isolation and recruitment of hip external rotators

 Cue to engage core as

needed

 Use tactile cuing by

patient to feel appropriate gluteal engagement

 Add isometric

version for movement complexity

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Hip Thrusters

 Good progression from

bridges to involve posterior chain

 Encourage glute max

drive, but will require hamstrings and lumbar muscles to achieve full extension

 Emphasize ASIS as high

point vs. navel (minimize lumbar extension/rib flare)

 Add resistance as

needed

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Hip Hinge

 Dowel rod

touches occiput, mid-thoracic, and sacrum

 Emphasizes hip

movement with lumbar stabilization

 Start in sitting,

then progress to standing

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What Next?

 Look beyond the site of pain to find the “cause

• f the cause”

฀ Start looking at your current patients differently on

Monday

฀ Evaluate your new patients differently by assessing

• ther potential areas of dysfunction as indicated

 Start to use these manual techniques

฀ Practice the ones you are less comfortable with on

your colleagues and family members

 Seek out more in-depth manual therapy

learning opportunities (fellowship/residency)

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