Manual Tehrapy


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details of the Manipulation as well as Mobilization skills
A basic introduction

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Manual Tehrapy

  1. 1. 11/26/2008 DEFINITION • Mobilizations: these are passive movements performed by therapist at a slow speed enough that the patient can stop the movement. • Manipulations: these are sudden movements performed with a high velocity, short amplitude motion such that the patient cannot prevent the B.ARUN.,MPT,CMPT,COHS motion. ORTHOPEDIC PHYSIOTHERAPY 26-11-2008 2 Terminology Terminology • Mobilization – passive joint movement for increasing ROM or decreasing pain • Self-Mobilization (Automobilization) – – Applied to joints & related soft tissues at varying self-stretching techniques that specifically use speeds & amplitudes using physiologic or accessory joint traction or glides that direct the stretch motions force to the joint capsule – Force is light enough that patient’s can stop the movement • Mobilization with Movement (MWM) – concurrent application of a sustained accessory mobilization applied by a clinician • Manipulation – passive joint movement for & an active physiologic movement to end increasing joint mobility range applied by the patient – Applied in a pain-free direction – Incorporates a sudden, forceful thrust that is beyond the patient’s control Terminology Terminology • Physiologic Movements – movements done • Arthrokinematics – motions of bone surfaces within the voluntarily joint – 5 motions - Roll, Slide, Spin, Compression, Distraction – Osteokinematics – motions of the bones • Muscle energy – use an active contraction of deep muscles that attach near the joint & whose line of pull can • Accessory Movements – movements within the cause the desired accessory motion joint & surrounding tissues that are necessary for – Clinician stabilizes segment on which the distal aspect of the normal ROM, but can not be voluntarily performed muscle attaches; command for an isometric contraction of the muscle is given, which causes the accessory movement of the joint – Component motions – motions that accompany active motion, but are not under voluntary control • Thrust – high-velocity, short-amplitude motion that the • Ex: Upward rotation of scapula & rotation of clavicle that occur patient can not prevent with shoulder flexion – Performed at end of pathologic limit of the joint (snap adhesions, stimulate joint receptors) – Joint play – motions that occur within the joint – Techniques that are beyond the scope of our practice! • Determined by joint capsule’s laxity • Can be demonstrated passively, but not performed actively 1
  2. 2. 11/26/2008 Joint Surfaces of Ovoid and Sellar Joints KINEMATICS • Physiological Movements & Accessory movements. • Also called as • Osteokinematics (Physiological movements) • Arthrokinematics. (Accessory movements 26-11-2008 8 Osteokinematics ARTHROKINEMATICS • Deals about the movement present in the joint • Also termed as Accessory movements • Helps to find out the amount of Motion • Movements occurs inside the joint. available in particular joint • Responsible for improving Physiological • Can be visualized movements. • Can be measured • Restriction in accessory motion results in • Also called as Physiological movements decrease of physiological movements. 26-11-2008 9 26-11-2008 10 Arthrokinematics Roll • Roll • Glide / Slide • Spin • Compression • Distraction 26-11-2008 11 2
  3. 3. 11/26/2008 Slide Spin Compression Distraction CONCAVE AND CONVEX RULE 26-11-2008 18 3
  4. 4. 11/26/2008 Maitland Joint Mobilization Grades of Movement in a Grading Scale Normal and a Restricted Joint • Grading based on amplitude of movement & where within available ROM the force is applied. • Grade I – Small amplitude rhythmic oscillating movement at the beginning of range of movement – Manage pain and spasm • Grade II – Large amplitude rhythmic oscillating movement within midrange of movement – Manage pain and spasm • Grades I & II – often used before & after treatment Adapted by permission from G. Maitland 1991. with grades III & IV • Grade III – Large amplitude rhythmic oscillating movement up to OSCILLATION MOBILIZATION point of limitation (PL) in range of movement – Used to gain motion within the joint – Stretches capsule & CT structures • Grade IV – Small amplitude rhythmic oscillating movement at very end range of movement – Used to gain motion within the joint • Used when resistance limits movement in absence of pain • Grade V – (thrust technique) - Manipulation – Small amplitude, quick thrust at end of range – Accompanied by popping sound (manipulation) Beginning Pathologic Normal – Velocity vs. force range of al limit of limit of – Requires training movement movement movement 26-11-2008 22 Kaltenborn Traction Grading SUSTAINED MOBILIZATION • Grade I (loosen) – Neutralizes pressure in joint without actual surface separation – Produce pain relief by reducing compressive forces • Grade II (tighten or take up slack) – Separates articulating surfaces, taking up slack or eliminating play within joint capsule – Used initially to determine joint sensitivity • Grade III (stretch) – Involves stretching of soft tissue surrounding joint – Increase mobility in hypomobile joint 26-11-2008 24 4
  5. 5. 11/26/2008 CONTRAINDICATION INDICATIONS • Inflammatory arthritis ( RA, AKS) • Pain • Malignancy • Muscle spasm • Bone disease • Decreased ROM • Bone Fracture • Hypomobile Joints • Vascular disorder • Reduce Functionally Mobility. • Unskilled manipulator 26-11-2008 25 • Joint effusion 26 • Pregnancy • Rubbery end feel of the CAUSES FOR COMPLICATIONS • TKR, THR joint. • Practioner — Related complications • Closed pack position • Evidence of involvement of 2 adjacent nerve root Diagnostic error • Cauda equina lesion. • Undiagnosed pain in lumbar spine Lack of skill • Lower limb neurological Lack of interprofessional consultation • Protective muscle symptoms due to spasm cervical or thoracic • Inability of the patient dysfunction. to relax. 27 26-11-2008 28 Patient — Related complications • Patient in whom uncomplicated sciatica becomes a unilateral radiculopathy with distal Patient with psychological intolerance of pain. paralysis of limb, sensory loss. Patient involved in litigation • These patients usually doesn’t respond to Patient recently undergone treatment to any manipulation & should be considered as practioners. surgical emergency. Patient develop psychological dependence on manipulation. 26-11-2008 29 26-11-2008 30 5
  6. 6. 11/26/2008 JOINT POSITIONS RESISTING POSITION: • The position in which the joint capsule & JOINT PLAY ligaments are relaxed. • Each joint in the body has positioned to • Helps in evaluation of the joint make maximum amount of motion. • Treatment done for hypomobile joints • Joint should be positioned in a Relaxed position. • Placing the joint in resting position allows the joint to assumes a Loose pack position 26-11-2008 31 26-11-2008 32 TREATMENT PLANES Closed pack position: • Direction of movement is either parallel or • Here maximal contact of articular surface of Perpendicular to the treatment planes. bones with capsule & ligaments are tense or • Joint traction – Perpendicular to the tight. treatment plane • No movement is seen. • Glides — Parallel to the treatment planes. 26-11-2008 33 26-11-2008 34 TREATMENT FORCE SPEED OSCILLATIONS: • It should be close to the opposing joint surface, • Grade I & IV are usually rapid oscillations • Either Gentle or Strong. • Grades II & III are smooth, regular oscillations at • Large contact area will be more comfortable than two or three per second for 1 to 2 minutes. small surfaces.. • Vary the speed of oscillation for different effects • Like use of Hand is advised than Thumb for such as low amplitude and high speed to inhibit mobilizing larger joint or Surface. pain or slow speed to relax muscle guarding. 26-11-2008 35 26-11-2008 36 6
  7. 7. 11/26/2008 Sustained: LIMITATION • Painful joints : Apply intermittent distraction 7—10 sec • Few seconds of Rest in-between. 1. Can’t change the disease process of Disorders. • If no response Repeat correctly or Discontinue. 2. Like OA,RA manual therapy helps in Reducing • Resisted Joints : pain & mobilize joints. • Apply for 6 sec stretch force 3. Skill of therapist affects outcome. • Followed by partial release • Repeat with intermittent stretches for 3—4 sec intervals. 37 26-11-2008 38 PRINCIPLES OF MANUAL 5. All pain arise from lesion, so treatment should THERAPY focus on the lesion. • The principles are summarize by clinicians such as 6. Constant reassess to determine the effect of the Grieves, Maitland, Cyriax ect.. technique being used. 1. Remember the contraindications & conditions 7. Progress is governed by the response to previous require extra care. treatment. 2. Don’t harm the patient or yourself 8. Discontinue technique that are not productive 3. A through examination is necessary 9. Make the patient to relax, reduce anxiety & fear. 4. Make an accurate diagnosis as possible based on 10.Don’t force the protective muscle spasm. 39 40 solid knowledge of anatomy. Causes of Limited Range of 11. A slight alteration of joint position or angle of thrust often allows a technique much more Motion effective. • Loss of Extensibility of periarticular connective 12. Warm up patients of the potential for post tissue structures, ligaments, capsule & fascia. treatment soreness. • Deposition of Fibrofatty infiltrates acting as 13.Don’t over treat. intraarticular “Glue”. 14.Aim for restoration of normal , painless • Adaptive shortening of Muscles. technique. • Breakdown of articular cartilages. 41 42 26-11-2008 7
  8. 8. 11/26/2008 EFFECTS Pain & Muscle guarding • Mobilization showed that it helps in break down of Muscle shortening and reduce the fibroblastic • Wyke’s explained that Receptors nerve proliferations inside the joints. endings present in various periarticular • Forceful passive movements has shown to structures. rupture of intra-articular adhesion that forms during immobilization. 26-11-2008 44 26-11-2008 43 • Type I (postural) & Type II (dynamic) mechanoreceptors are located in joint capsule. • Type IV, (Pain receptors), are found in capsule, ligaments, Fat pads and Blood vessel walls. • They have low threshold and excited by repetitive movements including oscillations. • These receptors are fired by noxious stimuli as in trauma and have a relatively high threshold. • Type III mechanoreceptors are found in joint capsules and extracapsular ligaments. • Type IV are Slow conducting fibers, • They are excited in stretching & thrust • Type I & II are Fast conducting fibers. maneuvers. 26-11-2008 45 26-11-2008 46 EFFECT OF MANUAL EFFECTS OF MANUAL THERAPY THERAPY PAIN REDUCTION Pain Reduction • During Oscillatory glides, faster impulses Small amplitude Stimulate distraction, Oscillatory mechanorece overwhelm the slower impulses. movement ptors • It helps in closing of gate at spinal level. • Release of Endorphins from CNS. Inhibit Transmission Melzack R, Torgerson WS: On the language of pain, Anesthesiology, of Nociceptive stimuli 1971 26-11-2008 48 Wyke B: Articular neurology—a review, physiotherapy, 1958 8
  9. 9. 11/26/2008 Small Amplitude Muscle Relaxation Distractions & Glides • Type III receptors in joint & golgi tendon organ Stimulates Gentle Joint Synovial fire by stretching or thrusting of a joint result in play helps in Fluid maintain motion temporary inhibition or relaxation of muscle. Nutrient exchange • This itself cause an increase Range of motion Brings nutrition to Avascular and helps prepare the joint for further Articular cartilage stretching & mobilization. Prevent Painful Degenerati Paris SV: extremity dysfunction and mobilization . Institute Press, Atlanta 49 1980 on Wyke B: Articular neurology—a review, physiotherapy, 1958 IMPORTANT RULES FOR 3) Protect neighboring hypermobilities. If patient MOBILIZATION is having shoulder dislocation, following a Described by Stanley. V. Paris. anterior laxity, mobilization focused on 1. Identify the location and direction of the improving abduction and rotation. limitation. for e.g Ankle stiffness, posterior glide 4) Communicate with the surgeon, find out which of talus is restricted. tissue have been cut or scarified, and what 2. Prepare the soft tissue, (i.e) first reduce the motions should be avoided initially. swelling, pain, muscle guarding or tightness. 26-11-2008 51 26-11-2008 52 9
  10. 10. 11/26/2008 WHAT IS THE NAME OF A CROSS BREED BETWEEN THIS 26-11-2008 58 10