Clinical Reasoning, Manual Therapy and Concept of Healing

Question 1

Subjective Examination (Anamnesis) - Definition

Answer 1

Thorough and detailed subjective history and review of systems. To provide adaptable treatment depending on the patient.

Question 2

What information must be gathered for a subjective examination?

Answer 2

• Body chart (gender, height, weight, age)
• Location, quality, severity, irritability, and behavior of a patient’s symptoms
• Aggravates/Eases
• Functional incapacity: Professional life, personal life (daily activities/leisure…). What’s the most prominent change due to the pain (blue/black flags).
• Patient’s history of present pain: Nature of injury / pain / problem. How did it happen? Since when? Phase of healing. Acute, subacute, recurrent, chronic? Natural evolution of condition. AM/PM and 24 hour pain.

Question 3

What questions must be asked at the end of the subjective examination?

Answer 3

Suspicion of a serious condition that needs referral? Suspicion of psychometric factors that might interfere with the treatment outcome?

Question 4

Objective Examination

Answer 4

• Guided by subjective examination (hypothesis, do the features fit? relevant to present condition).
• Patient centered (concordant sign: pain or symptom for which the patient is seeking physical therapy).
• Screening examination (proximal to site of symptom, link with distal symptom?, A.ROM - overpressure, spring test).
• Region specific examination (narrowing on concordant vs. disconcordant sign, how specific movement affect symptom).

Question 5

Objective Examination - Tests

Answer 5

A.ROM (physiological movement, quality?, quantity?)
P.ROM (physiological movement, accessory movement, end-feel).
Specific tests (Pain provocation, neurodynamic, muscular, neurological).

Question 6

Rules of Application of Joint Mobilization Treatment

Answer 6

• Patient should be relaxed
• Explanation of the purpose of the treatment
• Comfortable room temperature with patient properly draped
• Remove watches and jewelry
• Secure ties, belt buckles, etc.
• Start in a resting position and then “chase” end range
• Allow gravity to assist to Avoid muscle guarding
• Large surface area of hand contact (confident, firm and
comfortable hand holds)
• Short lever arms and hands as close to joint as possible

Question 7

Absolute Contradictions

Answer 7

• Malignancy in area of treatment
• Infectious arthritis
• Metabolic bone disease
• Neoplastic disease
• Fusion or ankyloses
• Osteomyelitis
• Fracture or ligament rupture
• Herniated disc with nerve compression
• Hypermobile joint for grade III and IV

Question 8

Relative Contradictions

Answer 8

• Excessive pain or swelling
• Arthroplasty
• Pregnancy
• Hypermobility
• Spondylolisthesis
• Rheumatoid arthritis
• Vertebrobasilar insufficiency
When in doubt, don´t do it

Question 9

Manual Therapy - Definition

Answer 9

'’Hands-on’’ treatment. May include joint mobilization, manipulation, muscle stretching, passive movements of affected body part, patient moving body part against resistance to improve muscle activation and timing. Selected specific soft tissue techniques to improve mobility and function of tissue and muscle.

Question 10

Manual Therapy - James Cyriax

Answer 10

tension techniques, soft-tissue massage

Question 11

Manual Therapy - Freddy Kaltenborn

Answer 11

techniques incorporate the influence of muscle function

and soft-tissue changes, techniques are eclectic and very specific.

Question 12

Manual Therapy - Geoffrey Maitland

Answer 12

uses passive accessory movements to restore function,

history of the patient and objective assessment, oscillations

Question 13

Manual Therapy - James Mennell

Answer 13

joint play is the key, small accessory movements

Question 14

Manual Therapy - Stanley Paris

Answer 14

incorporates both chiropractic and osteopathic orientations.

Question 15

Manual Therapy Techniques

Answer 15

• Mobilisation!
• Massage!
• Soft-tissue mobilisation
• Neural mobilisation
• Trigger point release
• Myofascial release
• Proprioceptive neuromuscular facilitation
• Manual resistance
• Stretching
• Stabilisation

Question 16

Joint Mobilization - Definition

Answer 16

A manual therapy technique.
“skilled” passive movements at the joint complex, applied at varying speeds and amplitudes. May include small amplitude/high velocity therapeutic movement (manipulation) with the intent to restore optimal motion, function and/or reduce pain.

Question 17

What is the goal of joint mobilization?

Answer 17

Restore function and reduce pain.

Question 18

Joint Mobilization vs. Manipulation

Answer 18

• Joint mobilization is on a continuum with manipulation
• Both involve passive movements
• Mobilization is under patient´s control
• Manipulation is done at a speed where the patient cannot stop the motion (!)

Question 19

Physiological Joint Motion

Answer 19

Movement that patient can do voluntarily and can be analyzed for quantity, quality and symptom response.

Question 20

Accessory Motion

Answer 20

Necessary for normal joint motion but cannot be voluntarily performed or controlled.
Roll, spin and slide (convex or concave rule).
Examined passively to assess range and symptom response in the open pack position of a joint.

Question 21

Primary Healing

Answer 21

Separation of tissue is small, stump ends are close, bridge of cells binds ends together. Example: surgical incision.
Heals faster.

Question 22

Secondary Healing

Answer 22

Severe wounds, stump ends far apart, cannot be bridged by single cells, production of cells from the bottom. Example: second-degree sprain.

Question 23

Can we treat patients with inflammation?

Answer 23

Yes! if the patient does not have fever or other symptoms of infection.

Question 24

Signs of inflammation

Answer 24

Pain, swelling, redness, heat, function reduction.

Question 25

Factors Affecting Healing (physiological)

Answer 25

• Therapeutic modalities
• Drugs 
   - NSAIDs (nonsteroidal anti-inflammatory drugs)
   - Other drugs (pain medication)
• Surgical repair
• Patient’s age
• Systemic diseases (diabetes, do not heal as fast)
• Injury size
• Infection
• Nutrition
• Swelling

Question 26

Rehabilitation Techniques to Relieve Symptoms

Answer 26

Acute: Modalities; no exercise
Chronic: Identify causes

Question 27

Rehabilitation Techniques to Restore Deficiencies

Answer 27

Manual Therapy
ROM exercises
Strength-endurance exercises
Balance-coordination exercises

Question 28

Rehabilitation Techniques to Return to Function

Answer 28

Functional Exercises

Activity-specific exercises

Question 29

Role of Therapeutic Exercise in Healing

Answer 29

Clinicians influence on healing:
• Knowing how to apply treatment
• Knowing when to apply treatment, the intensity of application, and consequences or benefits.
Usually physiotherapy is done in the proliferation phase.
Exercise prescription during remodeling to reduce risk of re-injury.

Question 30

What does the treatment response depend on?

Answer 30

Severity of the injury, secondary effects resulting from the

injury, patient compliance and body part involved.