2c - HVT Manip Flashcards
what is a thrust joint manipulation (TJM)
high velocity, low amp therapeutic mvmt w/i or at end ROM
- w/i normal anatomical range
what is the significance of Freddy Kaltenborn’s nordic approach to manips in 1961
first to relate manip to arthrokinematics
what were Geoffrey Maitland’s significant contributions to PT manips
treats “reproducible signs”
oscillatory techniques
- grades I-V
what were James Cyriax significant contributions to PT manips
clinical reasoning and diagnostic system
he focused on transverse friction massage
what is the goal of TJMs in PT
reduce pain and restore motion as part of a comprehensive multimodal POC
what profession has a similar procedure to PT and what profession has a varying procedure
osteopath
chiropractor
describe when PT hit most of its legislative challenges w manips and why
1990s
PT profession mvmt toward direct access and doctoral ed
how long has manip been part of PT’s practice and why is this relevant
since inception of profession
vital part of scope of PT
what is the role that state licensing play in PT manips
in place to assure PTs practice w/i scope of practice and protect the public
-> thrust and non-thrust manips included in NPTE
what are the 3 components to a PT’s scope of practice
professional
jurisdictional (legal)
personal
what is the significance of state practice acts and TJMs in PT
have to check state practice rights to see if allowed to do a TJM per legal guidelines
- some states need a MD referral for a PT manip
a lot of practice acts are silent, if don’t list it as prohibited, then implied we can do it
what state is spinal TJM by PTs prohibited
arkansas
what is the APTA’s guidance on TJMs
spinal and peripheral joint mobs/manips only to be performed by PT
bc these are considered interventions which require immediate and cont exam and eval throughout intervention
how can adverse reactions to TJMs be avoided
appropriate screening
adverse reactions/events to TJMs vs side effects (& ex)
adverse reactions are sequelae that are:
- med to long term duration
- mod to severe sx
- serious, distressing, and unacceptable to pt
side effects:
- short term, mild in nature
- non serious
- transient, reversible
ex: inc neck pain, HA, fatigue
what is the most common type of adverse event from a cspine TJM? what are specific examples?
neurovascular injury
- cervical a. dissection
- vertebral a. dissection
positive findings for VBI
5D’s And 3N’s
Diplopia
Dizziness
Dysarthria
Dysphagia
Drop attack
Ataxia of gait
Numbness
Nausea
Nystagmus
concentration problems
metallic taste
tinnitus
unconsciousness
hemiparesis/hemiplegia
(+) CN signs
sudden onset of severe neck pain/HA
who are cervical/vertebral dissecting vs non-dissecting more common in
dissecting
- young pt w trauma
non-dissecting
- older pts w CV risk factors
what is the key point if you are trying to do a physical exam for a cervical vascular disorder
there isn’t a single test that can screen for them
- and they have moved away from positional testing
how is the decision made for implementing a manipulation on the pt
shared decision making
- is pt comfortable?
is there a greater benefit than the risks
- risk is often low
- higher risk from NSAID use, injections, surgeries
what are 6 adverse events/complications from thoracic/lumbar spine manip
cauda equina syndrome
SCI
lumbar pedicle fx
lumbar/thoracic compression fx
rib fx
lumbar/thoracic disc herniation
what is cauda equina syndrome
bilateral sciatica
severe or progressive bilateral neurological deficit of legs
what are s/sx of cauda equina syndrome
major motor weakness w knee ext, ankle eversion, foot DF
saddle anesthesia/paresthesia
laxity of anal sphincter
difficulty initiation micturition, impaired sensation of urinary flow
-> untreated can lead to irreversible urinary retention w overflow urinary incontinence
loss of sensation of rectal fullness
-> untreated can lead to irreversible fecal incontinence
what is a consideration of TJM technique and the risk of a fx
unlikely to cause a fx w a small amp thrust
- if too large amp then could cause a fx
what are red flags to screen for prior to a TJM
significant trauma
wt loss
hx of cancer
fever
IV drug use
steroid use
pt >50yo
severe, unremitting night pain
pain worse w lying down
what are 4 general types of absolute contraindications for TJMs (and examples)
bony issues - any path that may lead to a bony compromise
- tumor, infection
- inflammatory, trauma
neuro issues - any path impacting the neuro system
- myelopathy, SC compression
- nerve root compression w inc neuro deficits
- sudden n/v & vertigo
vascular issues - any path may lead to vascular compromise (more for cspine)
- VBI, aortic aneurysm, angina
- acute ab pain w guarding (AAA)
- bleeding diatheses (hemophilia, anticoags)
clinical issues - any matter that inc risk of harm to pt
- lack of subj/obj exam info
- lack of dx
- lack of PT skill
- lack of pt consent
what are ex of relative precautions for TJMs to thoracic spine
HTN
serious degen joint dz
growing children
serious kyphosis/scoliosis
herpes zoster on spine
vertigo
systemic infection
psych dependence on manip
pain w psych
no change/worse sx after multiple manips
what is the general consensus for safety w thoracic and lumbar TJM and what does the literature say for safety
impossible to determine precise risk
- no accepted standard reporting
- not all events published
clinical decision making based on exam and evidence-based approach
what does the research/CPGs say for TJM use
recommended in CPGs for acute and chronic LBP
what pts w LBP is the evidence not as strong for TJMs and what is the assumption
those w back pain and leg pain
- consider neuro involvement anyway
what does the evidence say about manip vs mob in chronic LBP
manip appears to produce larger effect than mob
what are considerations for sidelying lumbar manip
rotate upper body all the way down to level you want to manip and flex leg up to that level
short lever arm w arm on pelvis
what is a consideration of supine lumbar regional manip
very non-specific
- can have manip anywhere from lumbar to SIJ
what is the lumbar spine clinical prediction rule and what are the
classifies pts w LBP who demonstrate respond favorably to HVT (4 of 5 signs)
- duration of sx <16days
- no sx distal to knee
- LB hypomobility
- at least 1 hip >35deg IR
- FABQ work subscale <19pts
what are inclusion/exclusion criteria for lumbar HVT
18-60yo
red flags for manip
- OP, fx, CA, prolonged steroid use, RA, infection
- LMN involvement
- pregnancy
- prior lumbar surgery
what are the 2 most important factors of the lumbar spine clinical prediction rule
duration <16 days
not having sx distal to knee
CPGs recommend thoracic manip in:
pts w neck pain with:
- mobility deficits
- chronic HA
- chronic radiation pain
what do the CPGs say about thoracic manual therapy benefits depending on phase of recovery of neck pain
tends to be better in acute phase
- in subacute to chronic stage, benefit tends to dec
what do CPGs say about thoracic manip vs mobilization in neck pain
thoracic manip may not offer any benefit over mobilization
(and may be associated w temporary discomfort)
what is an important consideration for your set up with a supine segmental AP thoracic thrust technique
position their elbows under your xiphoid so you can get force from legs and be more effective
- bc you are going to be smaller than most pts
what is the overall consensus of what evidence is available for spinal HVTs
greater evidence available for it than other PT interventions
evidence for thrust manip for LBP
- clinical prediction rule may be of limited help to guide decision making in use of TJM for pts w LBP
evidence for mob/manip combined w exercise in neck pain
benefit to treating the thoracic spine
what is the proposed mechanical MOA for thoracic and lumbar spinal thrust techniques
realignment
breakdown of adhesions
dec acute joint locking
- meniscoid entrapment
joint cavitation
- audible click
what is the proposed neurophysiological MOA for thoracic and lumbar spinal thrust techniques
inc firing of mechanoreceptors
- inhibition of ms reflex contraction
- dec pain perception
stim of pain inhibition pathways
- PAG
how does manual therapy work per the mechanical and neurophysiological model
- mechanical force
- cascade of neurophys response (peripheral and central nervous system)
- clinical outcomes
how does the patient-provider interaction impact the outcome
a lack of confidence when PT does the technique can create less optimal outcomes
what are 5 indications for a HVT manip
- hypomobile segment
- acute facet joint locking
- mob technique showed benefit but didn’t achieve full effects
- criteria for clinical prediction rule -> L spine
- neck/shoulder dysfunction -> tspine TJM
what are important components of informed consent
explain nature, purpose, implications, risks, and alternatives for technique
document consent every time
what are the steps to the thrust manip technique
- isolate joint
- preposition, hold, reposition
- speed not force**
- re-assess
what are components to document about the HVT manip
pt position
direction of force
target/location of force
grade of manip
