Accessory Motion Testing: Stiffness

Question 1

Accessory Motion Testing: Stiffness

Answer 1

Choose direction based on Assessment/biomechanical theory first

Determine if it contributes to loss of motion

Joint accessory motion hypomobility without ROM impairment does not need to be treated

Question 2

Accessory Motion Testing: Pain

Answer 2

Choose direction based on Assessment/biomechanical theory first

Determine if it reproduces symptoms

Question 3

Basic principles of Accessory motiontesting:

Answer 3

1. Patient (subject) is maximally relaxed.
2. Usually test from “resting position” (or loose or open pack position) of joint.

3.Palpate to find appropriate landmarks

4.Good bone contact for good fixation

5. Hands as close as possible to joint line
6. Place yourself in good position and work with gravity whenever possible/needed
7. Stabilize one segment while mobilize other segment

Question 4

What are you testing for?

Answer 4

Hypo- Early Tissue Resistance
Normal
Hyper- Late Tissue Resistance
Pain

Question 5

Glenohumeral joint: distraction

Answer 5

the force is perpendicular to the T.P. in the glenoid fossa

Question 6

Glenohumeral joint: caudal glide

Answer 6

the distraction force is applied by the hand in the axilla, and the caudal glide force is from the hand superior to the humeral head

Question 7

Glenohumeral joint: posterior glide

Answer 7

patient supine

pushing posterior

Question 8

Glenohumeral joint: anterior glide

Answer 8

patient is prone or supine

pushing anterior

*Caution with suspected laxity or instability

Question 9

Acromioclavicular joint:

Answer 9

patient seated

anterior glide of the distal clavicle on the acromion

left hand on clavicle, right on on lateral shoulder

Question 10

Sternoclavicular joint: anterior and inferior glides

Answer 10

A) Pull the clavicle upward for an anterior glid

(B) Press caudalward with the curled fingers for an inferior glide

Question 11

Sternoclavicular joint: posterior and superior glides

Answer 11

A) Press down with the thumb for posterior glide

(B) Press upward with the index finger for superior glide

Question 12

Scapulothoracic articulation:

Answer 12

elevation, depression, protraction, retraction, upward and downward rotations, and winging

patient is sidelying, facing you

left hand on scapula, right on clavicle

Question 13

Common Stiff Shoulder Diagnosis

Answer 13

Post-operative Care
Post-immobilization Care
Adhesive Capsulitis
GHJ OA

Question 14

____ is the most frequent complication following shoulder surgery

Answer 14

Residual shoulder stiffness

> Limits function, but may also lead to early degeneration

Question 15

Causes of Stiffness

Answer 15

Immobilization

Lack of Movement (pain, fear avoidance)

Poor patient adherence

Synovitis

Surgery

Complex regional pain syndrome (CRPS)

Question 16

Step 1: Garner Trust

Answer 16

Patients after shoulder injuries and surgery have a very difficult time relaxing

Commonly afraid, get them to trust you

If they are guarding during your manual techniques, you will irritate their shoulder

Patient understanding and consent imperative

Question 17

Step 2: Catch it Early

Answer 17

“ounce of prevention = pound of cure”

Early recognition of patient prone to stiffness or becoming stiff early = Success more likely

Post-op: Contact surgeon, develop plan

Measure frequently, objectively track

Question 18

Step 3: Motion is Lotion

Answer 18

Early active and passive motion

Movement = cycling of synovial fluid = lubrication/joint nutrition

Post-op: Whatever you can do within surgical precautions/restrictions

Question 19

Step 4: How Long?

Answer 19

Creep occurs in most tissues after 2 min

Cumulatively exceed 2 min

Low Load Long Duration Most Effective = Assess and reassess

Question 20

Step 5: Toe the Line
Step 6: Use Your Bag of Tricks (adjuncts)

Answer 20

Warm up essential = Exercise is best to raise core temp

TENS during treatment

PNF contract-relax

Set aside pride, whatever gets the patient moving

HEP Imperative to keep the motion gained

Know when to slow down, speed up, or call for help

Question 21

Where is the stiffness coming from?

Answer 21

Joint
Muscle length
Pain
Muscle strength

Question 22

Therapeutic oscillatory or sustained hold techniques

Answer 22

Beginning of the range: pain relief

End of the range: improve restricted motion

High Velocity Thrust / manipulations for quick stretch to the tissues

Question 23

beginning of available range

Answer 23

small amplitude
low velocity oscillations
within resistance free range

Question 24

middle of available range

Answer 24

large amplitude
low velocity oscillations

Slow speed oscillations 1 or 2 minutes to relax muscle guarding

Question 25

end of available range

Answer 25

small amplitude
low velocity oscillations
into tissue resistance

use 6+second stretch force, followed by partial release back to beginning of range (but not releasing the tissue ‘slack’), then repeat with slow intermittent stretches, 3-4 seconds between each

Question 26

before anatomical limit

Answer 26

high velocity
small amplitude thrust
beyond tissue resistance

Question 27

Grades of movement

Answer 27

Low amplitude high speed oscillations can be used to inhibit pain

slower oscillaitons to relax muscle guarding

Alternatively, for painful joints, use sustained joint accessory motion, distraction 7-10 seconds, few seconds between, re-assess after a few cycles

Question 28

Grade I

Answer 28

small amplitude oscillations within resistance free range

rapid

Question 29

Grade II

Answer 29

large amplitude oscillations within resistance free range

smooth, regular

Question 30

Grade III

Answer 30

large amplitude oscillations up to the point of resistance

smooth, regular

Question 31

Grade IV

Answer 31

small amplitude oscillations at point of tissue resistance

rapid

Question 32

Grade V

Answer 32

small amplitude high velocity thrust beyond tissue resistance but before anatomical limit

Question 33

Accessory Motions:
GH
ST
AC
SCJ

Answer 33

GH: Distraction/Ant/Post/Inf glides

ST: Distraction/Sup/Inf/Protr/Retract

AC: Anterior

SCJ: Ant/Post/Sup/Inf