Manual Therapy Flashcards
What is manual therapy?
mobilization, manipulation, massage, stretching, deep pressure via skilled hand movements
What are two components of manual therapy? What is the purpose?
Joint techniques- increase joint mobility
Soft tissue techniques- increase soft tissue mobility
When is manual therapy indicated?
- motion impairments at joint
- motion impairments via weak/shortened muscles
- used in combo w/ exercise to improve function
What is joint play?
a movement that cannot be produced by the action of voluntary muscles
-compression, distractions, slides, rolls, spins at a joint
Is manual therapy always passive?
No. Most of the time it is but it can be extrinsic forces (therapist or gravity) or intrinsic forces (muscle contraction or breathing) acting on a patient’s body
What are the 4 different types of manual therapy?
1) Joint manipulation-
2) Joint mobilization-
3) Muscle energy-
4) Soft Tissue-
What is joint manipulation?
passive, high velocity, low amplitude. Joint beyond physiologic barrier and creates distraction or translation. Does not exceed anatomic barrier.
Can be direct or indirect- contraindicated if untrained
What is joint mobilization?
passive, slow motions, physiologic ROM.
1) graded oscillation
2) progressive loading
3) sustained loading
Direct- patient feedback
What is muscle energy?
active mm contraction after jt is taken passively to restricted motion. Post-isometric relaxation principles
Direct-contraindicated for people w/ severe heart disease
What is soft tissue?
enhancing status of mm activity and/or extensibility in tissues. Can effect mm, nn, lymph and circulatory systems.
Indirect- demands high degree of palpatory skill
What is the difference between physiologic barrier and anatomic barrier?
Physiologic barrier- point at which voluntary ROM in articulation limited by soft tissue tension.
Anatomic barrier- PROM is limited by bone contour or soft tissue. Final limit to motion in a joint and anything beyond causes tissue damage.
What are direct manual techniques?
movement and force are in the direction of the motion restriction- allows for maximal restoration of movement, however it may be painful when pain and mm guarding are present
What are indirect manual techniques?
movement and force are not both in the direction of the motion restriction- indicated for acute stages
What is the difference between general and specific manual therapy techniques?
General- the force is transmitted to a number of joints that have been determined to be hypomobile. Can increase motion to previously unstable joint
Specific- force is localized to one joint, force transmission is minimized through the uninvolved joints
Is there evidence that specific manipulation techniques are delivered accurately to the targeted segment?
No. Spinal manipulation is only accurate about 50% of the time due to multiple pops. ** The clinical success of spinal manipulation is not dependent on the accurate delivery of that therapy to the target spinal joints**
What is the pop?
generation/collapse of gaseous bubble in synovial fluid. Increase in CO2 levels and joint space is mechanism to increase ROM. Also causes reflex relaxation in surrounding mm. Doesn’t need to pop to be effective.
What is the 5 level grading system for joint mobilizations under Maitland?
1) slow, small, beginning of range (pain,
2) slow, large, do not reach end of resistance (oscillation, pain)
3) slow, large, to limit of range (increase mobility)
4) slow, small, to limit (oscillation, increase mobility)
5) fast, small, high velocity beyond pathological endpoint (thrust, resistance limits movement, absence of pain in that direction)
Is there evidence that manual therapy is effective in the treatment of spinal conditions? Low back pain?
- spinal manip/mob provides similar/better pain outcomes short term/long term when compared w/ placebo, McKenzie, back school etc. for acute and chronic (systematic of RTC)
- manipulation followed by exercise achieved most significant benefits, then manipulation, then exercise (high quality RTC)
- matching the individual patients with correct intervention
- CPR- accurate id LBP who are to benefit can benefit 50% improvement in disability
- 5 predictors of success 1) short symptom duration 2) low treatment apprehension levels 3) lumbar hypomobility 4) adequate hip IR 5) no symptoms past knee (4/5 of these 45-95% success rate)
- combo of manual therapy w/ exercise and appropriate intervention seem to increase manual therapy effects
Is there evidence that manual therapy is effective in the treatment of spinal conditions? Thoracic pain?
limited evidence intense rehab program decreased pain intensity in young patients w/ Scheurmann’s disease
Is there evidence that manual therapy is effective in the treatment of spinal conditions? Neck pain?
- for mechanical neck pain w/ no radicular symptoms
- spinal manipulation superior to general practitioner mgmt for short term pain reduction in pt’s w/ chronic sx’s(systematic review)
- mobilization is superior to PT/family physician care (moderate)
- No evidence to support manipulation versus mobilization for patients w/ neck pain
- T spine interventions have been shown to cause immediate decrease in pain/increase in neck ROM because they are intertwined biomechanically
- limited evidence- Tspine manipulation and intermittent cervical traction w/ patients w/ cervical compressive myelopathy/disc/radiculopathy show decreased pain improved function
Is there evidence that manual therapy is effective in the treatment of cervicogenic headaches?
Mob/manip is effective for patients w/ cervicogenic headaches.
-Exercise and manual therapy worked better than control group, cervical manip/mob, strengthening deep neck flexors, scapular muscle strengthening after 7-12 weeks (systematic review)
Is there evidence that manual therapy is effective in the treatment of extremities? Hip?
Yes. 81% improvement w/ manual therapy, 50% improvement w/ exercises after 5 weeks tx for OA of hip. Manual had better pain, stiffness, hip fxn, ROM. (RCT).
Is there evidence that manual therapy is effective in the treatment of extremities? Knee?
Manual therapy and exercise group worked best by pain, stiffness, and function. Manual group were mobs to lumbopelvic region, hip, knee, ankle. Control group didn’t change.
Is there evidence that manual therapy is effective in the treatment of extremities? Shoulder?
- MT alone or combo w/ exercise has shown to be effetive
- 12/52 weeks after tx the manipulation group reported better outcomes
- shoulder impingement supervised flexibility and strengthening vs group w/ exercise and manual showed significantly more improvement in pain/function(RCT)
Is there evidence that manual therapy is effective in the treatment of extremities? Elbow?
-lateral epicondylitis mob w/ movement can help reduce painful movements and improve grip(limited evidence)
Is there evidence that manual therapy is effective in the treatment of other conditions?
- TMJ OA and fibro indicate MT decreased pain(less rigorous)
- cervical radiculopathy, cervicogenic dizziness, carpal tunnel and TOS MT may have positive effects
- few studies use mm energy or soft tissue
What are the side effects with spinal manip?
-61% complain of postmanip reaction show up w/i 4 hours and go away 24 hours, more common w/ women
-20% stiffness
15% local discomfort
-12% headache
12% radiating discomfort
12% fatigue
6% mm spasm
4% dizziness
2% nausea
Is there any evidence for the use of craniosacral therapy?
No single study to support craniosacral therapy as an effective therapeutic intervention
Does manual therapy affect visceral organs?
Little evidence- joint dysfunction can excite neural components and supress/attenuate visceral complaints
Can MT restore spinal curvature?
Loss of spinal curvature/lateral lumbopelvic list/straightened cervical spine due to mm spasm, nonaggressive manipulation techniques cand decrease spasm and increase movement
Can MT straighten a spinal deformity?
Scoliosis/hyperkyphosis manipulation cannot straighten the curves
How does manual therapy help to increase range of motion and decrease pain and disability?
- unknown in vivo effects
- MT moves mechanical impediment permitting movement and halting nociceptive input and reflex mm spasm
- ROM improvement helps relieve pain
- MT ruptures or stretches periarticular scar tissue
- MT improves nerve conductivity and circulation by increasing space where nerves/vessels exit/cross
- MT improve mm function and decrease stress on bones and ligaments by improving joint force/lever distribution
- MT affect neural activities as a result of afferent stimulation
Should joint hypomobility be treated in the absence of symptoms?
No. this will not prevent dysfunction
When is MT contraindicated?
- fracture
- infectious arthritis
- tumors
- joint anklylosis
- acute inflammatory disorders
- lack of diagnosed joint lesion
- pathological end feel
What is an end feel?
resistance felt at end PROM
- normal
- pathological- hard when soft, soft when hard, can be spasm, mushy, springy, severe pain, empty
What is cyriax end feel classification?
- bone to bone- stop, two hard surfaces (elbow ext)
- capsular- stop w/ some give (shoulder flex)
- tissue approx- tissues touch (knee flex)
- empty- pain w/o stop (inflammation, articular lesions)
- springy block- rebound (displacement of intraarticular structure)
- spasm-mm kick in(acute or subacute condition)
What is kaltenborn end feel classification?
- hard- bone on bone (elbow ext)
- firm- capsular or ligament (ER GH)
- soft- mm or stretch (knee flex)
What are the contraindications for thrust techniques?
- cranial nerve signs
- dizziness of unknown origin
- sacroperenial numbness, loss of B/B
- painful movements in all ranges or just one degree of painful range freedom
- B/multisegmental neurologic signs/symptoms
- paralysis in nonperipheral distribution
- hyperreflexia or + pathological reflexes
- emotional disorders
- anticoagulant meds/steroids for long time
- not proficient in indicated technqiue
What is the convex on concave rule?
convex on concave- the roll and slide are opposite, so mob in opposite direction of restriction
concave on convex- the roll and slide are same direction, so mob in same direction of restriction
What is loose and closed packed?
loose- least congruity of joint, position to do mobs
closed- most secure position, most contact.
What is capsular pattern?
limitation of joint movement or a pattern of pain that occurs in a predictable fashion
What is the loose packed? Closed packed? Capsular pattern of TMJ?
Loose-midway
Closed-teeth clenched
Capsular-opening
What is the loose packed? Closed packed? Capsular pattern of Cspine?
Loose-neutral
Closed-max extension
Capsular- all motions, except flexion
What is the loose packed? Closed packed? Capsular pattern of Sternoclavicular?
Loose-resting at side
Closed-max shoulder elevation
Capsular-full elevation, end ranges
What is the loose packed? Closed packed? Capsular pattern of Acromioclavicular?
Loose- resting at side
Closed- abd to 90
Capsular-full elevation, pain at end ranges
What is the loose packed? Closed packed? Capsular pattern of Glenohumeral?
Loose-55 abduction, 30 h adduction, 70 flexion
Closed- full abd/ER
Capsular- ER>ABD>IR
What is the loose packed? Closed packed? Capsular pattern of Humeroulnar?
Loose-70 flex, 10 supination
Closed-full extension, full spination
Capsular-flexion>extension
What is the loose packed? Closed packed? Capsular pattern of Humeroradial?
Loose-extension and supination
Closed-90 flexion, 5 supination
Capsular-flexion > extension
What is the loose packed? Closed packed? Capsular pattern of Radioulnar- proximal?
Loose- 70 flexion, 35 supination
Closed- 5 supination, full extension
Capsular- pronation=supination
What is the loose packed? Closed packed? Capsular pattern of Radioulnar- distal?
Loose-10 supination
Closed-5 supination
Capsular-pronation=supination
What is the loose packed? Closed packed? Capsular pattern of Radiocarpal?
Loose-neutral, slight UD
Closed-full extension, radial deviation
Capsular- flexion = extension
What is the loose packed? Closed packed? Capsular pattern of Midcarpal?
Loose-neutral , slight flexion and ulnar deviation
Closed- full extension
Capsular- all directions equal
What is the loose packed? Closed packed? Capsular pattern of Trapeziometacarpal?
Loose-neutral
Closed-full opposition
Capsular- abduction>extension
What is the loose packed? Closed packed? Capsular pattern of Carpometacarpal?
Loose-neutral
Closed-full opposition
Capsular-abduction>extension
What is the loose packed? Closed packed? Capsular pattern of Metacarpophalangeal?
Loose-slight flexion, ulnar deviation
Closed-full flexion
Capsular-
What is the loose packed? Closed packed? Capsular pattern of Interphalangeal?
Loose-slight flexion
Closed-full extension
Capsular-flexion> extension
What is the loose packed? Closed packed? Capsular pattern of Thoracic spine?
Loose-neutral
Closed-max extension
Capsular-side bend and rotation >extension > flexion
What is the loose packed? Closed packed? Capsular pattern of Lumbar spine?
Loose-neutral
Closed-max extension
Capsular- sidebend=rotation > extension >flexion
What is the loose packed? Closed packed? Capsular pattern of Hip?
Loose-30 flexion, 30 abduction, slt ER
Closed-full ext/abd/IR
Capsular-flex/IR > abduction > adduction > external rotation
What is the loose packed? Closed packed? Capsular pattern of Tibiofemoral?
Loose-25 flexion
Closed- full extension and ER
Capsular- flexion >extension
What is the loose packed? Closed packed? Capsular pattern of Talocrural?
Loose-10 plantar flexion, neutral inversion/eversion
Closed-full dorsiflexion
Capsular-plantarflexion > dorsiflexion
What is the loose packed? Closed packed? Capsular pattern of Subtarsal?
Loose- 10 plantarflexion, neutral inversion/eversion
Closed- full inversion
Capsular-limitation in varus
What is the loose packed? Closed packed? Capsular pattern of Midtarsal?
Loose- 10 plantarflexion, neutral inversion/eversion
Closed- full supination
Capsular- supination > pronation
What is the loose packed? Closed packed? Capsular pattern of Tarsometatarsal?
Loose-neutral supination and pronation
Closed- full supination
Capsular-
What is the loose packed? Closed packed? Capsular pattern of Metatarsophalangeal?
Loose-neutral
Closed-full extension
Capsular- extension> flexion
What is the loose packed? Closed packed? Capsular pattern of Interphalangeal?
Loose-slight flexion
Closed- full extension
Capsular-limited extension
Which is not a consequence or intention of manual therapy? A: mobility B: create lasting positional changes C) improve strength D) reduce pain
B create lasting positional changes
What is not an absolute contraindication to the application of manual therapy?
A) no consent
B) no competence of clinician to perform technique
C) long term anticoagulant
D) bone insufficiency
C: is a relative contraindication
Risk of cervical manipulation w/ serious complications is A) 1 in 100 mil B) 1 in 400,000 C) 1 in 1 mil D) 1 in 4,000
??
Resting EMG activity may be present in which of the following? A) TBI B) poorly controlled stress/anxiety C) 2 days post op TKA D) all
UML, anxiety, nociceptive can contribute to resting tone
What is a consequence of increased hyaluronan in the extracellular matrix according to the Fluid Dynamic Theory?
A) altered tissue extensibiity
B) increased nociceptive activity
C) stimulation of perioaqueductal gray
D) secretion of neurogenic pro-inflammatory neuropeptides
ABD all. PAG is supraspinal component of neurophysiologic pain generation and control. It responds to stress and to oxytocin (released in response to touch or pleasant tactile input)
Which of the following describes Gate Control Theory?
A)A-beta activation fibers leading up to regulation of interneuron activity at the dorsal horn and inhibition of projection neuron depolarization
B) down regulation of IL_1beta and TNF alpha to reduce inflammation
C) stimulation of periaqueductal grey in the brainstem leading to 5HT secretion and inhibition of substance P production
D) restoration of restricted glide component of arthrokinematic motion
??
The concept that seemingly unrelated impairments in a remote antatomical region may contribute to or be associated with, a patients primary complaint is referred to as A) the rule of the nerve B) biomedical model C) regional interdependence D) The australian approach
C)regional interdependence-
A therapist utilizes an AP, rapid, oscillatory mob to talocrural. What type of receptor would this manual therapy technique have the most significant effect on? A) type 1 B) type II C) type III D) type IV
C) type II
type 1- slow adapting tone at proximal joints
type 3-fire extreme ranges of joint
type 4- nociceptors
type 2- fast adapting and affect tone at distal joints
Pt w/ dx of knee OA, mild, difficulty extending. which direction to increase knee extension ROM. A) II PA of tib B) III AP of tib C) II AP of tib D) III PA of tib
D)
According to the convex concave rule which glide of clavicle at SC would improve retraction? A) ant B) post C) superior D) inferior
B posterior
clavicle is concave w/ retraction, convex w/ elevation and depression
Which is not considered a principle foundation of EBP A) best evidence B) clinical expertise C) patient values or expectations D) all above
D) all
With respect to answerable research questions, foreground question consists of which of the following
A) prediction, indep variable, comparison, outcome
B) patient/pop, intervention, comparsion, outcome
C) placebo, intervention, comparison, outcome
D) patient/population, intervention, comparison, opinion
B PICO
Which is considered the highest level of evidence for tx? A) case control sudty B) expert opinion C) systematic review of RCTs D) systematic review of cohort studies
C) systematic review of RCTs
Which of the following is not an example of primary research? A) RCT B) case series C) systematic reviews D) all of the above
C systematic reviews
reviews, systematic reviews, metaanalysis complite present data from primary
Statistical analysis, probability that someone with positive test actually has the condition is which of the following? A) + likelihood ratio B) - predictive value C) + predictive value D) - likelihood ratio
C) PPV true positives/ (true positives + false positives)
What is the MDC of the patient reported outcomes?
A) smallest change that might be considered important by a patient or clinician
B) smallest change in outcomes that ensures change is not due to error
C) degree of consistency that an outcome measures an attribute
D) The degree to which the outcome is measuring what it is intended to
?
The NINT of an intervention is
A) the number of patients that would need to receive treatment in order to gain one additional favorable outcome
B) the number of participants that are required in order for a RCT to be conducted
C) the probability that subjects with a positive screening test truly have the disease
D) porportion of the population without the target disorder who test negative for the disorder
?
Reseachers have chosen to include only data from individuals who have completed their clinical trial. The type of analysis is called A) intention to treat B) per protocol C) participation bias D) case control series
B) per protocol- should be suscpicious failing to acct for participants that dropped out of the study may skew the reported results
In a recent study, researchers iD that 80% of a group receiving a novel manual therapy technique reported clinically significant improvement in low back pain severity. Meanwhile, 30% of the control group reported improvement in symptoms. What is the absolute risk reduction or absolute benefit increase in this study? A) 40% B) 50% C) 166% D) 63%
ARR= CER-EER
.5= .3-.8
The Ottowa knee rules are if you need xrays. Sensitivity findings of 1.0 for the Adult and peds population tested, specificitity was reported to be the .49-.56 in for their adult population and .43 for their pediatric population. What do these stats indicate to the screener? A) any highly likely fx is present B) any, highly unlikely fx is present C) none, highly likely D) none, highly unlikely
D:
What are the Ottowa Knee rules?
- > 55 years old
- tenderness at head of fib
- tenderness of patella
- cant flex > 90
- can’t bear weight immediately and in ER more than 4 steps
