Joints Treatment MT3 Flashcards
what should be treated?
signs and symptoms (info from subj assess and PE) and not diagnosis
1st distinguish the problem stucture ( prim and secondary joint) = differential diagnosis
e.g of treatment protocol when the patient has OA of the knee?
NB- dont focus on OA but go back to individual pt in front of you
?main problems?
?what bothering the patient?
?main complaints about condition affecting him?
overall:
what is S&S that pt present with at that moment
might change each session
what is the focus of the treatment theme?
treatment of the primary joint structures
by: using manual joint mobilisation i.e moving the joint
What are the primary joint structures?
capsules ligaments cartilage articulation surfaces =present at prim site of joint
treatment process:
mobilise the capsule & associated structures
facilitate the gliding & sliding & rolling of jnt structures
in context treatment:
cannot be isolated to joint alone, it will always, to greater or lesser extent, influence muscle/ nerve tissues
(seldom found that only joint structures are affected, therefore attention must be given to all the subsytems of body during the eval- clinical reasoning is very NB)
e.g which struct affected when do AP on fibula head?
popliteal nerve
hamstring
gastrocnemius
what is main AIM of mobilisation?
to ensure maximum and painfree function of the NMS system
-within the abilities of the client
you want to get your pt to point where he/she can do what they really want to do (FN is main aim)
Fn goals between people will differ/ between age
=need to change treatment plans according to fn goals
treatment based on ICF
1. Impairment pain, stiffness, spasm treat these to influence: 2. (Dis) ability/ function e.g cannot drive car/ cant step up or down 3. participation e.g cannot perform work or play soccer
so we want to re-edu the fn to influence his participation & facilitate participation= reach max potential for the pt
What is the 5 pillars of health care?
prevention promotion treatment rehabilitation referral
what is the role of joint mobilisation within the 5 pillars of health care?
- Accurate evaluation
ID: impairments, disabilities, participation restrictions of specific pt
1.1 prevention
assist to find methods to prevent injury or ways to chnage the way the person using the device
1.2 promotion
e.g advice pt to lose weight/ ergonomics
1.3 treatment
joint mobilisation techniques
1.4 rehabilitation
appropriate exercises, to return to everyday activities
1.5 referral
What can be faulty at the joint?
pain hypomobility muscle spasm hypermobility instability abnormal resistance abnormal quality of movement
what are the causes of joint abnormality?
capsular stiffness abnormal biomechanics pain muscle spasm muscle weakness muscle stiffness muscle imbalance
pathology (degeneration, inflammation)
cant be treated with MT but can be indirectly treated with MT
what are the AIMS of treatment?
to decrease abnormal joint factors (PRS) to increase joint mobility to improve tissue fluid dynamics (reduce swelling) to correct muscle imbalances to reduce postural stress aids in functional recovery to advice and educate
muscle imbalance and postural stress treated?
e.g shoulder and thorax
losen the thorax to provide the R for scapular muscles to re-align T.
the m contract better after the joint has been mobilised by correcting proprioceptive input and optimal jnt position aid in opt correc recruitment of the m surrounding the joint
therefore the scapula m will have improved fn on scapula & aid/ assist shoulder move
what do you have in your basket/toolbox to achieve these treatment aims:
EPT immobilisation exercise advice and educate re-education (HOL) strengthening mobilisation :soft tissue Mobilisation
techniques chosen specific to individual pt
what is manual joint mobilisation?
(he who works with his hands is a laborer; he who works with his hands and his mind is a craftsman; he who works with his hands and his mind and his heart is and artist.
consider the pt and their life & environment & what are your trying to achieve for them
what are the different philosophies of joint Rx
- Maitland
2. Mulligan
types of techniques for joint mobilisation:
- Active movement (assisted or not)
could be physiological movement =osteokinematic move
-bone move through range around axis of joint
e.g Fl, Ext; abd/add & internal/ ext rotation - passive movement
PAM= access/ arthrokinematic- occur at any joint: small movement (roll, glide, slide)
PPM - combination of the above
NB consider the rhythm when applying these techniques
what are the types of techniques for joint mobilisation?
active movement (assisted or not) -mulligan PAM -maitland, mulligan PPM -maitland, mulligan combinations of above -maitland, mulligan
the usefulness of PPM
local circulation joint nutrition pain relief ROM= improve and maintenace Relaxation
e.g
paralysis= have some effects on bone health & contracture at the joint (quadriplegia/ paraplegia)- immobility/ lack of move: soft tissues can start to contract & use PPM to maintain ROM, prevent contraction at joints
diabetes= may develop diabetic neuropathy: nerve damage-> cause dec in ROM in ankle (tighten collagen of soft tissues in this area- painful movements) =PPM: pain relief, improve or maintain ROM
immobilisation in bed (cones callipers)= PPM: maintain joint range, prevent stiffness, help relaxation
joint pain= PPM help with circulation & jnt nutrition & relieve of pain
what is the usefulness of PAM
improve joint mobility (ROM) improve joint play (arthrokinematics) pain relief joint nutrition confirm/ refute joint involvement (Assessment)
e.g
stiff knee post immobilisation (can glide patella to relieve joint pain)
tennis elbow (change grip or strengthen muscles)
cervical pain (facet) - locked or stuck; use PAM
nerve root injuries (targets nerve space/ neural dynamics) ; pain relief
usefulness of PAM in more detal:
joint play (arthrokinematics) = if the joint cannot glide effectively, limit jnt ROM; capsule stiff and m weaken compression of joint surfaces can increase intra articular joint pain: graded compression can be used to treat pain distraction of joint surfaces can decrease intra articular joint pain: distraction can thus be used as treatment for pain
What is the treatment plane of the joint?
is an imaginary line that runs through the joint; parallel with the concave surface & at 90 deg angle to the axis of rotation of the convex surface
NB as it influences your treatment direction/ angle
this means that if the concave surface moves, the treatment plane moves
how does the treatment plane influence the treatment direction?
if apply a PAM e.g glide= it will be parallel with the treatment plane
e.g knee= lateral or medial glide
if do compression or distraction= it will be perpendicular to treatment plane
why is the concave-convex rule NB?
it influences your choice of technique
choice of technique is dependent on the biomechanics of the joint
direction of the glide:
when the convex surface moves, the direction of the glide is opposite to the direction of the moving lever arm
e.g the treatment plane does not move
because the concave part of joint is not moving
convex-concave rule carried on:
If the concave part of the lever arm moves= the direction of the glide within the joint is in the same direction as the moving lever arm
in this e.g
the treatment plane moves, because the concave surface of jnt moves
means that when apply treatment= you will also have to change direction of treatment according to how concave jnt arm is aligned
- why is the concave-convex rule NB?
we use it to work out which glide we should use for treatment by manual mobilizations
for treatment, we use the direction of glide that is associate with the problematic movement
thus
work out which PAM is needed from the restricted physiological movement
& then use that glide as 1st choice to treat
Knee Fl
the pt can only do 60 deg of knee fl because it is painful
therefore we use post glide on tibia to treat it
because when doing knee flexion the tibia which is the concave surface moves in a post direction
so treat at 60 deg for stiffness by applying a glide
shoulder abduction
if painful at 100 deg we use inferior glide on the humeral head, because the moving lever arm is convex
MAITLAND key aspects
patient centeredness way of thinking- reasoning specific evaluation techniques assessment
what MAITLAND concept?
not mechanics of technique, But in it’s approach to the patient and his particular problem. Attention to detail in exam, treatment and response.
concepts/guidelines of assessment and treatment
sound foundations of basic biological knowledge
the necessity of high level of skill
the evolution of the concepts:
the necessity for detailed exam
and for the exam/ treatment/ re-exam approach
evaluation (need a thorough)
subjective (interview) assessment
objective (physical) assessment
techniques of MAITLAND
a technique is the brainchild of ingenuity:
- dynamic =need to progress as the pt progresses
- techniques for Ev vs Rx
- adaptation of techniques (can use exam tech as treatment tech when modified)
- PAM & PPM as Rx
- always evaluate your technique efficacy
what is unique to MAITLAND concept?
oscillatory/ repetitive method of technique application
rhythm of technique
grades of movement
compression as treatment technique
what does Oscillations: rhythm mean?
reps of same technique= e.g AP glide of tib on femur- should be smooth & uniform, even rhythm
slow come up and then down
(up & down movement; equal in size; time of each wavelength is the same)
rhythm of the techniques?
rhythm can be (slow, fast, sustained) -> smooth, staccato/flicking, broken
oscillations: amplitude of technique?
how big the wave is
grades of movement?
not only decision making tool but also communication tool & determined by: -determining the resistance (R) -the amplitude (A) of the movement performed
types if passive movement
physiological/ accessory or combined -PPM -PPM &PAM -PAM
when doing MAITLAND treatment
PPM or PAM or combinations
grade of movement
rhythm of movement
with or without compression/ distraction
compression vs distraction for Rx
there is a time in Rx when joint surfaces should be kept apart (avoid contact) -> while still being able to Rx by PM
to avoid aggravation (e.g. joint very irritable/ SIN/ severe P
very small distraction (<1mm)
equally (and more commonly) there is a time for moving a joint while compressing the joint surfaces
- for ‘chronic’ symptoms (‘chronic’ i.t.o current Sx’s i.e. not necessarily ‘long term’ problem)
e. g shoulder P where P is provoked by lying on affected shoulder (so the longer before pain starts= the longer the compression force applied)
which factors influence your choice of treatment?
- patient diagnosis (e.g RA, OA, post #)
history, stability of the condition, stage of healing
symptoms and signs (pain vs spasm vs stiffness)
response during/ after treatment
what are the phases of conditions of Maitland?
Phase 1: pain and stiffness
phase 2: intra-articular, peri-articular
phase 3: arthritic conditions
phase 4: impacted #
phase 5: hypermobility
phase 6: loose fragment in joints (e.g meniscus/ cartilage)
MAITLAND phase 1:
pain and stiffness
-patients with readily recognizable combinations of signs and symptoms can be divided into FOUR main clinical groupings for the purposes of selection and progression of mobilization techniques
phase 1 has 4 groups:
group 1: pain
group 2: stiffness
group 3: 3(a) P>S; 3(b) S>P
group 4: momentary pain
Group 1: pain dominant factor
movement is limited by pain only
key features: pain present with rest pain starts early in ROM pain limits the movement early in ROM if SIN-> take precautions not to cause flare up during Ev and Rx
Group 2: stiffness
key features:
stiffness limits the movement
pain be present only at the end of ROM (stretch)
Group 3: pain & stiffness occur simultaneously and is related each other
key features: pain intensity inc proportional to inc in stiffness (felt as resistance) 3(a) P>S 3(b) S>P joint factors occurs together TROM
Group 4: pain is dominant, but pain is momentary
key features:
no observable dec ROM with general movement
pain is associated with certain movements/ positions (only)
sudden ‘bite/jab’ of P-> reproduced with combination movements/ sustained combination movements (quadrant positions)
Rx guidelines- group 1: pain
general:
NB
determine SIN (get from interview)
determine P1 or point where pain increases
correct positioning of painful joint is imperative
too much movement may even lead to pain after stopping the movement (latent pain)
Rx needs to be ‘gentle’
choice of rhythm:
slow & smooth
what are the group 1 treatment rules?
- P1< 60% of normal ACTIVE mvmt
- P>60% of normal ACTIVE mvt
- P1>75% of normal ACTIVE mvt
If, P1 <60% of N act mvt:
Rx in p-painfree position/neutral
joint well supported while treat
outside (not in) P
do only PAM’s or shaft rotation (spin) where possible, i.e joints that can spin)
choose one direction of movement (as a start)
big amplitude movements- Gr2 and progress to Gr 3
If, P1>60% of N act mvt:
Rx in a painfree position (but more than neutral)
Rx in a painfree ROM (outside of pain)
can do PAM’s: Gr II or *III
can do PPM: Gr II or *III
*if possible can start in resistance
progress: choose joint position to treat further in ROM
P1>75% of N act mvt:
Rx in 10-20% of pain (=in discomfort)
Rx near to the EOR
can do:
PAM: Rx in R (even do GrIII+ or IV+, if indicated)
PPM: Rx in R(even do GrIII+ or IV+, if indicated)
combination: PAM in a passive physiological position
-e.g GH PA in 150 deg fl)
therefore bring up arm to 150 deg fl & then a PA glide on GH joint to help with last part of movement
dosage for Group 1 conditions:
dosage is time contigent (depend on time)
If SIN/ if irritable
= 3 sets of 10 sec each
(10 sec of oscillations & you will repeat 3 times= more or less 1 oscillation per second)
if not SIN
=3 sets of 30 sec each
more or less 1 oscillation per second
re-evaluate after each set
Rx Guidelines- group 1: Pain
choice of technique:
- choice of direction of glide (PAM) -> acc to biomechanical rule (convex-concave rule)
- choose most limited PAM
- at later stages-> progress to most painful PAM
Rx Guidelines - Group 1: Pain
where in the ROM should I do the moblisation?
If SIN or if irritable- perform the technique far away from P1
if pain increases quickly with movement- perform the technique far away from P1
e.g: Act Sh F (L)= 0-60 deg (8/10 pain)
treat in neutral or 10 deg of fl
Rx Guidelines- Group 1: Pain
what amplitude should I choose?
where in the ROM P starts
how P inc (behaviour)
irritability
But in practice… “the larger the amplitude that can be performed when treating pain, the more effective it will be”
- SIN or irritable condition= small A
- when you mobilise closer to P1= small A
- when you mobilise further from P1= large A
Re-evaluation
How do you know that the pain (group 1) improved?
- Pain occurs later in ROM that before
- pain intensity dec (8/10 -> 7/10)
- speed with which pain increases is slower (dec)
so that they can do more move before the pain starts
then you will know pain improved & techniques are working
Re-evaluation
How do I adapt my technique after re-evaluation?
If Sx are better -repeat same procedure -progress to bigger A -progress to deeper in R If Sx are worse -decrease A (smaller) -decrease ROM (do earlier in ROM) No change -repeat procedure -or try another technique
Rx guideline- Group 2: Stiffness
General:
mobilise needed @ point of limitation
in all indicated directions
any PPM and all PAM that is limited may be used in EOR of physiological movements as stretching techniques
Rx Guidelines- Group 2: stiffness
Option 1:
identify limited physiological movement
take to EOR
whilst keeping joint @ limit, use PAM as stretch technique
perform small amplitude oscillatory stretching movements (GrIV+/GrIV ++)
choose PAM acc to biomechanics
Rx Guidelines- Group 2: stiffness
Option 2
identify limited physiological movement take it to EOR perform small amplitude oscillatory stretching movements (Gr IV+/GrIV++) smooth or staccato rhythm you are using the PPM as Rx treatment
Rx Guidelines- group 2: stiffness (dosage)
dosage=
4x60 sec OR
4x45 sec
(stretch the capsule)
Rx Guidelines- Group 2: stiffness
aftercare of joint after stretching it
treatment pain (Rx P) common due to stretching of structures
how to treat Rx pain? PPM in direction you stretched in gr III or Gr III- 30sec x 3 oscillations =to get rid of the pain metabolites can apply heat for the pain/ EPT
Group 3: Pain & Stiffness
determine which is dominant: pain or stiffness
determine the exact relationship between stiffness and pain (movement diagram)
Group 3(a): Pain > Stiffness
general: the movement is limited by pain But there are some underlying stiffness Usually not SIN therefore can treat in R Rx and progress with group 1 (pain) treatment direction of movement need to correlate with functional problem
BUT
dosage= 3x30 sec
if no change in Sx:
try active mobilisation (e.g Mulligan)
OR
Rx as Group 3(b) but consider pain- just touch on pain
Group 3(b) : Stiffness > Pain
treat almost like for Group 2
stiffness limits the movement, but there is pain not associated with stretching the tissues
treat 5-10 degrees short of EOR within R (always GrIII or IV) (and - or +) Rx focussed on addressing R Respect pain: can touch P1- but don't go into it dosage: 30 sec x 3
Group 3(b): Stiffness > Pain
progression:
when pain decreases- move further into ROM
may need to treat:
Rx Pain
muscle spasm
Group 3(b): Stiffness > Pain what if there is muscle spasm?
- evaluate:
joint well supported?
your handgrips correct and firm - dont force through spasm
do small A PPM against the spasm (can try with PAM also)
try to move further in ROM - Can use continuous stretch (stretch out the muscle in spasm)
Group 4: momentary Pain
must get a positive * sign (i.e must reproduce the pain)
usually a combination movement (e.g Quadrant)
can be a sustained position with compression (kneeling)
Rx:
use the combination movement that reproduced the symptoms (e.g knee fl/ add)
use Gr IV and Gr III (tot ++) (vary between the two grades)
Group 4: momentary
Dosage
1 x 60 sec
In pain
treat for treatment pain
