Functional Mobilization 1 Flashcards
1
Q
Functional Mobilization Treatment Strategies
A
- Identify mechanical articular/soft tissue hypomobility
a. Trace and isolate to greatest restriction
b. Localize restricted barrier to depth, angle, direction - Dynamic localization of restriction
a. Spinal- flexion, extension, then diagonal directions
b. Extremity localize in diagonal
c. Limiting folding or lengthening - Treatment hand applies a localizing sustained pressure to identified restrictions
a. Sustained pressure with gradual increase with release following path of release
b. Not resolving with 10 sec. alter technique (unlocking spiral or direct oscillations) - Mobilization of restriction
-superimpose specific sustained contraction “don’t treat through dirty lever” - Directions of sustained contraction - direct vs indirect. Can use either for tissues lacking lengthening
A. Direct - Resistance in direction of restriction.
- Use for: articulations do not fold
B. Indirect - - Progression to COI or Isotonic reversals
- Neuromuscular Reeducation
8.Motor control - Prolonged holds through phasic shakes
a. ROM improvement utilize COI to new ROM (phasic shakes)
b. PNF for pain
- Direct: directly to painful region
- indirect: Use irradiation and antagonistic contractions
c. Increase ROM improving neuromuscular control-COI
d. Reeducation of dysfunctional components of Characteristics of Neuromuscular Control
9.Training pt participation in treatment process
a. Active relaxation
b. Active movement
c. Resisted Movement
d. Communication/self-awareness- change in symptoms, discomfort guide treatment - PNF to perform efficient posture and body mechanics (CFS) and development of HEP
2
Q
Hypervigilant nervous and immune system characteristics
A
- Pain beyond typical healing time
- Painful motion changes
- Pain location and laterality changes
- Painful area progressively enlarges
- Sensitivity is disproportionate to tactile pressure
- Painful in many areas at the same time
3
Q
Self-limiting process
A
Acute pain experience
4
Q
Trauma occurs -> nervous system evaluates/orchestrates -> immune system responds -> Area is prepped -> fibroblasts get busy / local inflammation (and pain) cycle down
A
Acute pain experience
5
Q
Pain should stop when
A
No longer has biological value
6
Q
Acute processes fail to cycle down/pain becomes protracted
Inflammation becomes systemic
A
Sustained pain experience
7
Q
Chronic hormone and immune activity can lead to
A
Auto-immune responses in the body that can cause pain
8
Q
multisystem approach to down regulating chronic central and systemic inflammtion
A
Re-educating brain on the pain process
Regulating stress
Replenishing nutrients
enhancing antioxidant and anti-inflammatory nutrition
Restoring hormonal balance
Achieving sleep
healing GI system
Restoring efficiency throughout the body’s structures and functions
9
Q
Lumbar pathology patient education
A
- education about problem and self care
- Understanding the basic science of their injury or pathology
- Mechanisms underlying their pain experience
10
Q
Knowledge for controlling degenerative cascade
A
a. Anatomy
b. Genetics (variation in spinal foramen)
c. Natural progression of degeneration
d. Nutrition
e. Inflammation and its many causes
f. Alignment, responsiveness, strength, mobility, motor control
g. Body mechanics and usage
h. Employment and recreational stresses
11
Q
Training for degeneration
A
a. training to alter symptom generating habit patterns of posture and movements
b. treating the existing mechanical dysfunctions that are contributing to symptoms, dysfunction postures, and movements
c. addressing the neuromuscular dysfunction of core: initiation, strength, endurance
d. Enhancing motor control, balance, and coordinated movement
e. developing patient management skills for self care and conditioning
12
Q
Methods of supporting neutral sitting position
A
Active sitting-sacral roll using towel roll, clothing, better backs pillow, or foam wedge
-sacrum block to help stab sacrum
-Towel roll for pelvic tilt support
-Pillow behind back for neutral sitting
Drop one leg off side of chair
Back support sitting
Resting sitting-reclined or restful sitting using pillow to support spine against backrest
13
Q
Standing posture self evaluation
A
Body scan
weight bearing (feet, one side)
Effort (calves or Anterior tibialis)
Knee bend
Pelvis tilt
Lumbar spine positioning
Thoracic spine positioning
Shoulder girdle positioning
Arm positioning
Neck positioning
Head positioning
14
Q
Self correction of posture
A
- Balance through center of feet
- Tense and then soften your knees
- Pelvic oscillations to attain neutral
- Adjust thoracic cage over pelvis
- Both hands on sternum, breath in and out
- Pivot prone
- Axial elongation
15
Q
Principles of soft tissue mobilization
A
Manual contact
Application of STM
Mobility (Contractile tissue-myofascial)
Position of tissues being tested
Position of tissues being treated
Depth of palpation
Force of application
Rhythm-perpendicular strumming
Speed-parallels
Duration
16
Q
Manual contact types
A
Direct/indirect
General (forearm)/specific (finger/thumb)
17
Q
Application of STM
A
a. Sustained (prolonged) pressure into barrier: Perpendicular vs parallel
b. Unlocking spirals into direction of ease
c. Direct oscillations
- unidirectional direct oscillations
- perpendicular strumming
d. Association oscillations with any of the above
e. Active or resisted contraction during application of STM
18
Q
Mobility of ST
A
a. Physiological - functional excursion
b. Accessory - muscle play
19
Q
Precautions/Contraindications for STM
A
- Malignancy
- Inflammatory skin condition
- Fracture
- Sites of hemorrhage
- Obstructive Edema
- Localized infections
- Aneurysm
- Acute Rheumatoid arthritis
- Osteomyelitis
- Advanced Osteoporosis
- Advanced Diabetes
- Increased symptoms
- Fibromyalgia - during exacerbation
- Pregnancy (precaution)
20
Q
Vertical Compression contraindications- sitting
A
- Pt is highly irritable to loading
- Increase in painful symptoms with just placing hands on shoulders
- Do not add more force after beginning to produce symptoms. Do not continue to add force after segmental displacement occurs
- Anyone with delayed onset of symptoms after being treated.
- Symptoms, fracture, etc. of upper quadrant may be exacerbated with application of vertical compression
21
Q
Vertical compression contraindication - standing
A
Same as sitting
1. Acute lumbar shift (derangement). Correct derangement first
2. Lower extremity dysfunction may be exacerbated by compression
22
Q
Standing elbow flexion test contraindications
A
- Upper Extremity problem- Elbow/shoulder fracture or pain which may be exacerbated by compression
- TOS symptoms which are increased by minor elbow flexion resistance
- Irritable cervical symptoms
23
Q
Standing LPM contraindications
A
- Highly irritable patient- or if increased symptoms are experienced
- Pt must be supported or test avoided if marked balance disturbance exists
- If mild VC increased symptoms, only test in corrected position
24
Q
Superficial fascia finger glide contra
A
Through friable or irritable skin (Fresh incision, burn, grafted area, psoriasis, elderly; easily bruising, PVD, or denervated regions
-use skin slide (Except for recent skin graft)
Never stretch incision linearly as it will stimulate hypertrophy
25
Sacral sulcus precautions/contra
Too much force to hypermobile sacrum could exacerbate symptoms. Use less force and cascade of techniques
26
iliac crest precautions/contra
1. Caution with hypermobile innominate into anterior torsion
2. Acute nerve root pain or cuneal nerve pain may be exacerbated with firm pressure to iliac crest. (slow down and use cascade of techniques to facilitate normalization of tissues and protect vulnerable structures
27
12th rib precautions/contra
1. Steriod use, osteoporosis, fracture
2. Caution with kidney and spleen problems and all transplant patients
3. Caution with unstable thoracic lumbar region
28
Associated Oscillation precautions/contra
1. Vestibular symptoms or vertigo
2. Contraindicated on side of nerve root pain
3. caution with hypermobility
4. Caution with highly irritable articular or myofascial structure in region used for oscillation
29
Groove of spine precautions/contras
1. Suspect or confirmed fracture of spine; work superior to inferior direction first to avoid lymph stasis in upper thoracic region
2. Osteoporosis
3. Caution to maintain neutral during RX of acute hypermobile segment and acute nerve root
30
Strumming precautions/Contras
1. Touch sensitive patients who cannot relax during strumming
2. Caution in nerve root patients since oscillating motion may exacerbate peripheral symptoms
3. If vestibular or vertigo symptoms
31
Direct oscillations Precautions/contras
1. If oscillation exacerbates symptoms
2. If vestibular or vertigo symptoms are elicited
32
Unilateral Parallel mobilization precautions/contras
Avoid long passes along border with friable skin or over adipose tissue
33
Central Parallel on paraspinals/general lumbar spine Precautions/contras
1. Caution to maintain neutral, especially with any disc or nerve root involvements
2. Unilateral treatment may increase pain in hypermobile segment
3. Osteoporosis of rib cage
4. Chronic steriod use (transplant and asthmatic patients)
5. Labor symptoms of pregnancy
6. Abdominal malignancy
34
Elbow at iliac crest Precautions/Contras
Caution to not put pressure on 12th rib and cluneal nerves
35
Hip external rotators Precautions/Contras
Caution with
1. end of range hip motion with hypermobile innominate
2. Osteoporotic hip
3. Sciatic nerve inflammation
36
Hip Capsule Precautions/Contras
Avoid excess force when stabilizing on the femur- osteoporosis
37
Muscle tone Precautions/Contras
Sustained pressure to a local point
1. Acute caution in fibromyalgia
2. Muscle tears acute
38
Forward bending in sitting Precautions/Contras
1. flexion sensitivity - nerve root involvement
2. Pregnancy
3. Cervical nerve root or flexion sensitive TOS
4. Respiratory problems with are exacerbated by full flexion
5. Anterior rib cage problems such as fracture or osteoporosis
39
Hip flexion with knee extension Precautions/Contras
1. Caution with patients with positive straight leg raising test
2. caution and need to stabilize if hypermobile innominate into posterior torsion or lumbar flexion sensitivity
3. Caution with resistance below the knee for ACL lesions
40
Hip extension in Thomas test position Precautions/Contras
1. Hypermobile SI - be sure to have opposite leg in full flexion and localize your mobilization to the hip joint
2. Nerve root involvement or hypermobile lumbar spine - caution and support in neutral
41
Half prone knee flexion hip extension Precautions/Contras
1. caution needed with hypermobile or nerve root involvement. Stabilize pelvis with strap (due to end range stress to innominate)
2. Patella femoral or ACL injury
42
Rib cage mobility Precautions/Contras
1. Osteoporosis or fracture
2. If side-lying causes exacerbation of symptoms utilize another position
3. General mobility - caution if pressure places strain on hypermobile and easily irritated lumbar or thoracic segment.
43
Hyper- and hypomobile spine treatment Precautions/Contras
Therapists should already be aware of contraindications / precautions of joint mobilization
44
Disinhibition series Precautions/Contras
1. Any resisted motion that increases pain is contraindicated
2. Flexion test- contraindicated in flexion sensitive patient or with LE peripheral symptoms
45
Lumbar and cervical home programs Precautions/Contras
Individual exercises should not be painful while being performed and not exacerbating symptoms after they are performed. Some exercises are not appropriate but should be sure that the exacerbation is not stemming from improper performance or too many repetitions.
46
Anterior chest Precautions/Contras
Osteoporosis, fracture, and breast cancer - caution in region and lymphatic drainage area
47
Abdominal Precautions/Contras
Pregnancy, malignancy, aneurysm, and abdominal problems, such as endometriosis, ulcers, pelvic or intestinal bleeding, or inflammatory diseases
48
Cervical Precautions/Contras
1. Caution with relation to patients with positive vertebral artery
2. Any bilateral anterior treatment is contraindicated
49
Soft tissue evaluation
skin sliding (general and specific)
Finger gliding
50
Soft tissue Treatment
Sustained pressure
Strumming
Unlocking spirals
Direct Oscillations
Tone reduction
Direct or indirect tensioning from assisting hand
Associated Oscillations
51
Tissue shortening
Try first (switch to lengthening if does not release within 10 sec)
Typically better for acute conditions
52
Used if restriction is not responding to sustained pressure and assisting hand
Unlocking Spiral
53
Unlocking spirals
apply clockwise and counter clockwise motion against restriction using forearm pronation and supination (turning a screwdriver)
Treatment in direction of ease until restriction begins to release. Then take up slack and follow release
54
Cascade of techniques
Sustained pressure on restriction
Assisting hand shortening or lengthening of tissues
Unlocking spiral in direction of ease
55
Body mechanics for spinous and transverse process groove
Staggered stance
56
caution with spinous/transverse process grove STR
Do not push facets into backward bending in lumbar region by using posterior pelvic tilts
57
Bony contours
Groove between spinous and transverse process
Sacral Sulcus
Coccyx
Iliac Crest
Lower border of 12th rib
Greater trochanter
Spine of scapula
Borders of the scapula
Occipital line
58
Cluneal nerves positioning in L/S
7 cm from midline on top of iliac crest
- avoid aggressive compression
59
Associated Oscillations
Assisting hand: apply passive oscillatory motion to pelvis
Treatment hand: maintains sustained pressure on restriction
*Produce whole body oscillations
60
Bony contours HEP
Lateral Shear
Dynamic bracing
-Unilateral
-Bilateral knee above 90 (ABD stab)
Pelvic clock
61
Tone with STM
either an area of increased contractility within the muscle belly (due to central reasons or local response)
-Muscle belly density can also be due to internal "Play" loss
62
Strumming
To identify muscle bellies with increased density which have increased resistance to passive movement
63
Causes of increased belly density (tone)
Protective and reflex spams
subconscious holding patterns (associated with emotion/mental responses)
Habitual patterns of misuse
Neurological deficit
Mechanical intra and inter fiber connective tissue adherence
fluid stasis
64
Muscle bending
Direct: medial/lateral mobilizing
Bending: bringing elbows together and apart
65
Perpendicular Assessments
Perpendicular strumming
Perpendicular Deformation
66
Perpendicular strumming
To evaluate and treat loss of muscle play and increased tone in myofascial tissue
*Don't treat spot for longer than 2 min if not releasing
Applied to regions of increased tone or decreased play beginning superficially and proceeding deeper as myofascial elements relax and release
Top 50% of soft tissue
67
Body mechanics for perpendicular strumming
1. One hand can be used to set up associated oscillation
2. Use heel of hands to assist with the oscillation
3. Position one leg against table to assist by oscillating the table
68
Perpendicular strumming application
Perpendicular pressure against border of the muscle belly or tissue structure, deforming until EOR attained and allow muscle to spring back under contact surface
69
Perpendicular deformation (transverse deformation)
Eval and treat restrictions limiting muscle play (accessory mobility) of a muscle or soft tissue structure
Deeper 50% of soft tissue
70
Perpendicular deformation application
Perpendicular pressure against the border of muscle belly or tissue structure, deform until EOR attained but DO NOT allow muscle to spring back under contact surface
71
Unilateral parallels (longitudinal deformation)
Eval and treat restrictions of a muscles accessory mobility in relationship to surrounding structures
72
Unilateral parallels application
Angled pressure directed parallel to muscle belly or seam between it and surrounding tissues
73
General mobilization Principles
1. Apply with as gentle a pressure as possible in the proper layer and direction of restricted mobility
2. Adjust direction and depth of technique through angle of hand and forearms. With superficial tissues, the force is utilized in a more horizontal position. For deeper layers, direction should be more vertical
3. Use proper body mechanics and maintain a neutral spine. Use staggered foot position
4. Utilize assisting hand to shorten or lengthen surrounding tissue, or stabilize the superficial fascia as you treat deeper layers
5. Guide patient in breathing and relaxation
6. Possible contact surfaces
a. thumbs
b. heel of hand
c. proximal posterior phalanges
d. Knuckles
e. Forearm
f. Elbow
g. Mobilization tools
74
Centralized parallels (ironing)
paraspinals
To reduce muscle belly dysfunction-decreased fiber on fiber play or increased tone
75
Tips for pt relaxation with treatment
1. unlocking spirals or Localized strumming
2. Breathing toward pressure-sustained pressure
3. SP while breathing into pressure (dolphin technique)
4. SP while attempting to decrease discomfort
5. SP while trying to relax and let go
6. SP while utilizing visualization (color change)
7. Imagery (imagine softening of the tissues)
8. SP while attempting to selectively contract the muscle underneath the pressure
76
Forward Bending in Sitting (FBS) purpose
Treat shorted tissue of the extensor surface in lengthened range
77
Emphasize lumbar region with forward bending in sitting
place small pillow or rolled up towel in abdominal region to create fulcrum
78
HEP for muscle play and general techniques
Lower trunk rotation
Extensor stabilization strengthening
Lateral stabilization (Basking seal)
79
Lower trunk rotation variations
Dropping legs to one side
Crossed legs
Upper trunk flexion
80
Extensor stabilization and strengthening
Multifidi stabilization
Prone off edge of table
Single or bilateral lower extremities extension
81
Multifidi stabilization
Uses bracing and intrinsic control to stabilize spine with selective extremity movement
Facilitate unilateral multifidi with finger pressure, same side LE ext, head rotation to same side
82
Thoracic extension - supine
Increase thoracic extension
Resting over fulcrum with L/S protection
*lumbar spine must be in full flexion (one or both legs flex) for protection and localization
Fulcrum: foam roll, folded towel, one with a dowel rolled up, tennis or racquetballs taped together
Advanced: performing sit ups to level of fulcrum and relaxing
83
Posterior FMI STM
Superficial fascia
Bony contours
- pelvic girdle (Coccyx, iliac crest, Ischial tuberosity)
- Groove of spine
Paraspinals
- Iliocostalis
- Longissimus
- Sacrospinalis
Hip
- Glute max and med
- ER
Lower Extremity
- Hamstring
- Posterior border of IT band
Scapula Bony contours
- Medial and lateral borders
- Spine of scapula
Scapula muscles
- Rhomboids
- Infraspinatus
- Teres Major and Minor
- Upper Traps
- Levators
- Supraspinatus
- Quadrates Lumborum
Lateral border of Latissimus
Serratus anterior
Mobilization of rib and spine
84
Forwards bending % back vs LE
50% low back; 50% LE
85
Functional soft tissue excursion
Supine Tri-planar straight leg raise
Supine Thomas test
Prone with one leg off table with foot on floor
86
Prone with one leg off table foot on floor variations
Knee flexion with hip extension: rectus femoris
Adduction: IT band
Hip internal and external rotation: Hip rotators (general techniques)
Dorsiflexion with knee flexion: Soleus
Hip extension: Psoas
87
Functional excursion HEP
Single knee to chest
Hamstring SLR
Hip flexors and adductors stretch
-1/2 kneel
-standing rectus
88
Rib cage evaluation
Side bending
shoulder abduction
EFT
Ribs with breathing
-lower ribs
-axillary
-apical
First and second rib
Sternum and T/S with flexion/extension/Cervical rotation
Side bending of rib cage for even gapping
Rib cage rotation
89
Stabilize pelvis to spring test ribs for
Functional mobility
90
Internal Obliques are under (deeper) to _________ with a ________ direction
External obliques; Superior lateral to medial
91
External obliques are superficial to _________ with a ___________ direction
Internal obliques: Inferior lateral to medial
92
Rib cage side lying muscle play evaluation
obliques
serratus
Latissimus
Intercostals
93
Rib Cage NMRE
Resist lateral rib cage pulling down with inhale, upward with exhale
94
HEP for rib cage
Arm circles
Basking seal FMP
95
Disinhibition series identifies
Peripheral weakness vs inhibited response
Initiation, strength, ability to hold (not push), ability to produce irradiation, and endurance
Lumbar or cervical pathology causing peripheral weakness
What type of UQ or LQ activity or stress inhibits the system
96
Break test
the amount of resistance needed to overcome the contraction
97
Home program tips
Type of individual
- Inactive individual: organize and develop to their goals/agreement
- Avid exerciser: set limits and meet endorphin needs
Primary goal
- Core contraction
- Strengthening
- Neuromuscular control
- Improving ROM
Inflammatory patients: less motion, slow progress, develop control, utilize ice, use taming pain techniques
Number of exercises
- initially exercise to little tired then progress to fatigue
- Effect and sensation
*don't overload with new exercises at one time
98
Anterior chest and rib cage evaluation
Rib cage and diaphragm expansion and inspiration (6 directions)
Cervical ROM
UE flexion
supine Shoulder retraction/PD spring test
Seated scapula and clavicle spring test
Supine acromion height
99
anterior chest and rib cage treatment
*for limited inspiration or limited expiration
Sternum and manubrium
Sternal costal joints
lower border of the rib cage
Diaphragm
NMR resisted sternal breathing
Coracoid process
Clavicle
Pectoralis major and minor
Subscapularis
Teres major/minor
Infraspinatus
Serratus anterior
Latissimus dorsi
Postural training
100
Anterior chest / rib cage HEP
Doorway stretch
Pivot prone
101
Abdomen pelvis lower rib cage evaluation
posture
VCT
Forward bending, backward bending, pelvic shear, thomas test, ilium height
Lumbar spine height supine
102
Abdomen pelvis lower rib cage treatment
Scar tissue
Superficial fascia
Lower border of the rib cage
Iliac crest
Pubic ramus
Rectus abdominus
Umbilicus
Lateral abdominals
Abdominal contents mobility
Iliacus
Psoas
Anterior bodies
Forward bending in sitting
103
Cranial and cervical treatment
Cranial superficial fascia
Temporalis
Masseter
posterior and submandibular bony contours
Medial Pterygoid
Hyoid bone, lyrynx, thyroid, cricoid cartilage
longus coli
Sternocleidomastoid
Anterior, medial, and posterior scaleni
Axial extension for posterior mobility of vertebra
Suboccipitals
Occipital frontalis
Mastoid process
Posterior neck soft tissues, articular pillars
Upper trap, levator scap, deep cervical fascia
Posterior superior serratus
First rib mob- AP PA
Upper extremity generals
104
